Alcohol and public health: culture, policy and delivery more

ACE alcohol culture exchange Exploring  drinking  cultures  in  the  South  West Alcohol  and  public  health Culture,  policy  and  delivery James  Nicholls Laura  Juett Rowan  Miller Culture,  policy  and  delivery The  Alcohol  Culture  Exchange The  Alcohol  Culture  Exchange  was  a  collaboration   between  Dr  James  Nicholls  (Bath  Spa  University)  and   the  South  West  Alcohol  Improvement  Programme.     It  was  funded  by  the  Arts  and  Humanities  Research   Council,  through  their  Knowledge  Transfer  Fellowship   scheme,  with  support  from  Calling  Time:  The  South   West  Alcohol  Improvement  Programme.     The  goal  of  the  ACE  was  to  bring  together   practitioners,  policymakers,  service  providers  and   academics  to  explore  the  links  between  drinking   cultures,  alcohol  policy  and  the  planning  of  service   responses.    Four  one-­‐day  workshops  took  place   between  January  and  March  2011.    Over  100   participants,  including  representatives  from  the  NHS,   licensing  authorities,  police,  alcohol  services,  planning   and  trading  standards  across  the  South  West  region   attended  the  workshops.    Discussions  centred  on   understanding  drinking  cultures,  adapting  to  new   policy  frameworks  and  supporting  partnerships  to   tackle  alcohol-­‐related  harm. The  following  guest  speakers  contributed  to  the   workshops:  (Department  of  Psychology,   University  of  Bath) Dr  James  Kneale  (Department  of  Geography,   University  College  London) James  Morris  (AERC  Alcohol  Academy) Rob  Andrew  (Cornwall  Council  –  Newquay  Safe   partnership) Iain  Loe  (Campaign  for  Real  Ale) Dr  William  Haydock  (Russell  Group  and   Bournemouth  University) Richard  Eastham  (Feria  Urbanism) Mick  Biggs  (Association  for  Sustainable  Night-­‐time   Economy  Development) The  workshops  were  facilitated  by: Dr  James  Nicholls  (Bath  Spa  University) Laura  Juett  (South  West  Alcohol  Improvement   Programme) Rowan  Miller  (South  West  Alcohol  Improvement   Programme) The  organisers  would  like  to  express  their  gratitude   to  the  guest  speakers,  who  brought  a  wide  diversity  of   expertise  and  a  range  of  perspectives  to  the  project.     The  conclusions  drawn  in  this  report,  however,  are   those  of  the  ACE  team  and  should  not  be  attributed  to   the  speakers,  other  participants  or  project  funders.   The  organisers  would  also  like  to  thank  the  following   participants,  who  agreed  to  take  part  in  follow-­‐up   interviews:   Jennefer  Bliss  (Criminal  Justice  Alcohol  Lead,  Devon) Ian  Carter  (Licensing  Manager,  Taunton  Deane   Borough  Council) East  Somerset  Council) Lisa  Lowndes  (Alcohol  and  Sexual  Health  Project  Lead,   Project  28) Jonathan  Martin  (Regulatory  Compliance  Unit  [Trading   Standards  and  Licensing]  Manager,  Bristol  City   Council) Martin  Worthington  (Licensing  Sergeant,  Devon  and   Cornwall  Police)   For  further  information  on  any  aspect  of  the  ACE   project  please  contact: Dr  James  Nicholls School  of  Humanities  and  Cultural  Industries Bath  Spa  University Newton  Park Bath  BA2  9BN 01225  876249 j.nicholls@bathspa.ac.uk Laura  Juett Regional  Alcohol  Manager Public  Health  Development  Unit 18  Catherine  Street Plymouth PL1  2AD   Tel:  07785  928517 laura.juett@nhs.net 2 Culture,  policy  and  delivery Introduction This  report  addresses  some  of  the  key  issues  that  emerged  in  the  ACE  workshop  discussions  and  subsequent   existing  knowledge  might  be  applied  effectively  at  a  local  level.    Drinking  cultures  are  complex,  diverse  and   could  be  further  developed,  it  is  clear  that  considerable  efforts  are  already  being  made  in  many  areas  to  sustain   existing  partnerships  and  extend  their  scope  effectively.     The  ACE  project  looked  at  drinking  cultures  in  the  round.    Therefore,  while  the  emphasis  was  on  tackling   alcohol-­‐related  harms,  many  participants  were  keen  to  stress  the  positive  aspects  of  drinking  both  in  terms  of   sociability  and  personal  wellbeing.      The  focus  on  harms  in  this  report  does  not,  consequently,  imply  that  all   drinking  is  problematic,  or  that  alcohol  consumption  should  only  be  construed  in  negative  terms.   While  national  statistics  give  a  broad  picture  of  consumption  trends,  drinking  patterns  and  behaviours  vary   diverse  range  of  cultural  drivers,  in  addition  to  macro-­‐economic  factors  such  as  affordability.    Therefore,  local   initiatives  have  a  unique  role  to  play  alongside  national  policy  in  targeting  harm.   Whereas  public  drinking  has  historically  been  the  focus  of  concern  over  alcohol-­‐related  harms,  supermarket     effective  ways  to  tackle  harms  associated  with  drinking  in  environments  other  than  pubs  and  clubs  is   a  key  challenge.     Forthcoming  amendments  to  the  2003  Licensing  Act  provide  a  number  of  opportunities  for  wider  community   involvement  in  licensing.    However,  they  also  pose  challenges,  especially  regarding  the  relationship  between   health  bodies  and  licensing  authorities.     Because  of  the  complex  nature  of  drinking  culture,  regional  partnership  working  is  key  to  developing  effective   multi-­‐dimensional  approaches.    A  number  of  successful  partnerships  (e.g.  Newquay  Safe)  exist  across  the   South  West  region  and  forums  for  sharing  experience,  knowledge  and  best  practice  should  be  supported  in  the   future. 3 Culture,  policy  and  delivery General  trends  in  consumption  and  harm In  the  mid-­‐2000s,  levels  of  alcohol  consumption  in   England  reached  historically  high  levels.    Between   1975  and  2005  per  capita  consumption  for  over-­‐ 15s  increased  from  9  litres  of  pure  alcohol  a  year  to   11.4  litres  –  a  rise  of  over  25%.1    Since  around  2005   however,  consumption  has  been  declining  steadily.     The  most  recent  data  shows  a  downturn  in  overall   consumption  among  men  and  women,  as  well  as  lower   reported  levels  of  drinking  frequency  and  amounts   consumed  on  single  occasions.2    Recent  data  on  youth   drinking  shows  both  fewer  under-­‐15s  having  drunk   alcohol  than  in  previous  years  and  lower  reported   drinking  frequency.    However,  the  amount  consumed   by  under-­‐15s  who  reported  drinking  remains   relatively  high  at  an  average  of  just  under  13  units  a   week.3     have  a  decisive  impact  on  trends  and  the  underlying   reasons  for  the  recent  decline  in  consumption  remain   unclear.7 too  is  the  wider  cultural  context  in  which  drinking   takes  place.    In  the  last  two  decades  a  number  of   factors  have  contributed  to  what  has  been  described   as  a  ‘new  culture  of  intoxication’.8    As  regards  alcohol,   these  have  included  the  widespread  development  of   ‘vertical  drinking  establishments’  as  a  response  to   the  rise  of  club  cultures  in  the  late  1980s,  new  youth   marketing  techniques  which  sought  to  associate   alcohol  with  partying  and  hedonism;  the  central  role  of   alcohol  in  the  development  of  the  nighttime  economy   in  British  cities,  aggressive  price  competition  driven   by  supermarkets,  and  the  rise  of  trends  in  tabloid   journalism  which  over-­‐emphasise  drunkenness  in  the   reporting  of  celebrity  lifestyles.9   In  the  main,  people  drink  because  it  is  pleasurable  and   social;  however,  research  into  problematic  drinking   among  young  people  often  shows  that,  alongside   Over  the  long  term,  however,  the  trend  since  the   the  pleasures  of  drinking,  consumption  is  driven  by   1960s  has  been  towards  increased  consumption.     boredom,  routine  and  perceptions  of  both  social  norms   factors  including  the  expansion  of  home  consumption,   and  tradition.10    Drinking  to  get  drunk  is  often  seen   increased  wine  sales,  and  higher  levels  of  consumption   as  a  natural  step  in  the  transition  to  adulthood  –  both   by  young  people  and,  in  many  cases,  adults.    However,   among  women.4    Despite  recent  declines  in  overall   consumption,  alcohol-­‐related  deaths  continued  to  rise   while  it  is  often  suggested  that  excessive  drinking  is  a   longstanding  behavioural  trait  among  the  British,  the   increasing  ‘normalisation’  of  public  drunkenness  in   drinking  levels  and  the  onset  of  chronic  alcohol-­‐ recent  decades  has  contrasted  strongly  with  cultural   related  disease.    However,  as  with  many  other  health   11    A   issues,  alcohol-­‐attributable  disease  is  proportionately   higher  in  areas  of  multiple  deprivation,  despite  overall   key  goal  of  cultural  approaches  to  the  reduction  of   consumption  levels  rising  with  income.    This  points  to   alcohol-­‐related  harm  may,  therefore,  be  to  challenge   misperceptions  regarding  the  inevitability  of  heavy   a  complicated,  and  not  fully  understood,  relationship   drinking  in  British  society.    Recent  data  suggests  that   between  social  deprivation  and  alcohol  harms. drunkenness  is  becoming  less  acceptable  among  some   Drinking  behaviours  vary  by  region,  age,  class  and   of  encouraging  this  trend.12 ethnicity.    The  South  West  region  has  lower  overall   consumption  than  areas  such  as  the  North  East  and   Drunkenness  itself  is,  to  a  large  degree,  shaped  by   North  West.5    However,  levels  of  both  consumption   culture.    How  drinkers  feel  about  drunkenness,  what   and  harm  in  cities  such  as  Bristol  and  Plymouth  are   comparatively  high,  and  the  issues  faced  by  authorities   their  expectations  are,  and  how  they  behave  after   and  services  across  the  South  West  vary  considerably.     and  attitudes  within  peer  groups.13    Drunkenness   implies  a  loss  of  self-­‐control,  but  it  also  involves  both   learnt  behaviours  and  the  expression  of  individual   and  group  identities.    Neither  the  decision  to  drink   It  is  widely  recognised  that  the  affordability  and   nor  attitudes  to  drunkenness  tend  to  operate  at  a   availability  of  alcohol  play  a  central  role  in  shaping   purely  individual  level.    Therefore,  a  focus  on  cultural   levels  of  consumption.6    However,  there  many   other  cultural  drivers  that  shape  both  attitudes  and   4 Culture,  policy  and  delivery individual  motivations  when  considering  interventions   hours’,  allowing  operators  to  sell  alcohol,  in  principle,   and  strategies  designed  to  reduce  problematic   24  hours  a  day.     consumption  or  behaviour. Lessons  from  the  past British  drinking  cultures  are  not  static:  both  levels  and   patterns  of  consumption  have  changed  over  time.14     While  notorious  episodes  of  high  consumption,  such   as  the  eighteenth-­‐century  ‘gin  craze’,  are  often  cited  as   evidence  that  drunkenness  has  deep  roots  in  British   Licensing  objectives  under  the  2003  Licensing  Act   Preventing  crime  and  disorder Securing  public  safety Preventing  public  nuisance Protecting  children  from  harm marked  by  many  decades  of  low  consumption  –  caused   The  2003  Act  was  implemented  in  November  2005.    At   not  only  by  increasing  costs  and  stricter  licensing   control  but  changing  fashions,  especially  among  the   don’t  bear  out  the  assumption  that  relaxed  licensing   15 young. inevitably  leads  to  increased  drinking.    However,  it   has  been  argued  that  population  trends  mask  regional   There  is  strong  historical  evidence  that  affordability   variations,  and  that  inadequate  monitoring  processes   were  put  in  place  by  the  government  when  the   for  affecting  pricing  at  a  local  level  is  limited.    The   legislation  was  enacted.18    Discussions  with  licensing   historical  evidence  for  the  impact  of  licensing   practice  on  consumption  is  mixed:  records  show   views  on  the  2003  Act:  some  felt  it  had  exacerbated   no  clear  trend  of  outlet  density  leading  directly  to   problems  of  clustering  and  public  drunkenness  in   16      However,  both  historical  and   higher  consumption. their  areas,  while  others  felt  it  facilitated  a  more   contemporary  evidence  suggests  that  clusters  of  high-­‐ productive  strategic  role  for  licensing  authorities.     volume  outlets  can  exacerbate  antisocial  behaviour   Nationally,  published  evaluations  of  the  2003  Act   and  more  harmful  patterns  of  consumption.17     Historically,  licensing  has  tended  to  focus  more  heavily   in  consumption,  crime  or  injuries,  though  a  Home   on  pubs  and  clubs  than  off-­‐licences;  however,  the  trend   Affairs  Select  Committee  found  a  strong  perception   over  recent  decades  has  been  towards  an  increase  in   of  increased  crime  among  some  police  forces.19    Many   home  drinking  driven  primarily  by  supermarket  sales.     of  the  developments  in  alcohol  retail  associated   Arguably,  this  was  aided  by  licensing  reforms  in  1961   with  public  disorder  –  clustering  in  high  streets,   that  allowed  off-­‐licences  to  retail  without  an  afternoon   competition  between  providers,  point-­‐of-­‐sale  offers,   gap,  thereby  enabling  supermarkets  more  easily  to   deep  discounting  in  supermarkets  –  were  already   sell  alcohol  alongside  other  consumables.    Because   established  by  the  late  1990s.20    Overall,  it  appears   of  its  focus  on  public  order,  licensing  has  historically   that  changes  in  accessibility,  affordability  and  retail   been  concerned  primarily  with  the  on-­‐trade,  but  this   practices  in  the  1990s  may  have  had  a  greater  role  in   imbalance  shows  signs  of  being  redressed  as  the  role   increasing  consumption  and  harm  than  the  provisions   of  supermarkets  in  driving  consumption  (including   of  the  2003  Licensing  Act.     preloading)  is  more  widely  recognised. In  2010,  the  Coalition  moved  responsibility  for   licensing  policy  back  from  the  DCMS  to  the  Home   The  2003  Licensing  Act  transferred  licensing  powers   from  local  magistrates  (who  had  been  responsible  for   licensing  since  1552)  to  local  councils.    It  established   four  licensing  objectives  against  which  objections  to   licence  applications  could  be  judged,  and  established   the  principle  that  licence  applications  should  be   accepted  unless  representations  were  made  by   ‘responsible  authorities’.    It  also  removed  ‘permitted   to  the  2003  Act  in  its  2010  Police  Reform  and  Social   Responsibility  Bill.   5 Culture,  policy  and  delivery Key  amendments  to  2003  Licensing  Act  (as   contained  in  the  Police  Reform  and  Social   Responsibility  Bill,  2011) Adding  licensing  authorities,  PCTs  and  local  health   boards  to  the  list  of  ‘responsible  authorities’  able  to   lodge  objections  to  a  licence  application Removing  the  ‘vicinity  test’  for  individuals  seeking   to  object  to  licence  applications Allowing  licensing  authorities  to  make  decisions   on  the  grounds  they  are  ‘appropriate  to’  (rather   than  ‘necessary  for’)  the  promotion  of  licensing   objectives Extending  ‘Early  Morning  Restriction  Orders’  to   cover  12am-­‐6am Establishing  ‘late  night  levies’  as  option  for  local   authorities   approach  promoted  in  the  Department  of  Health   White  Paper  Healthy  Lives,  Healthy  People.    Evidence   suggests  voluntary  agreements  can  at  best  only  form   part  of  a  wider  strategy  to  reduce  alcohol-­‐related   harm;  however,  it  remains  too  early  to  assess  the   effectiveness  of  the  Responsibility  Deal  in  contributing   to  this. Population  v  voluntarist  approaches The  withdrawal  of  support  for  the  Responsibility  Deal   among  key  lobby  groups.    Alcohol  health  campaigners   are  broadly  united  in  advocating  a  ‘population’   approach  to  alcohol  regulation,  which  asserts  that   the  State  has  a  duty  to  reduce  overall  levels  of   consumption  through  targeted  policies,  primarily   raising  prices  and  reducing  access  through  stricter   licensing.23    Alcohol  industry  bodies,  by  contrast,   generally  call  for  voluntary  agreements  based  on  harm   reduction  while  insisting  that  moderate  drinkers  have   the  right  to  be  protected  from  state  interference.     The  amendments  to  the  Act  not  only  strengthen  the   power  of  local  authorities,  but  create  opportunities   for  wider  involvement  in  licensing  from  both  local   communities  and  health  bodies.    A  number  of  ACE   participants  noted  that  a  key  challenge  will  be  to   Experience  in  Scotland,  for  instance,  shows  that  both   health  authorities  and  licensing  boards  have  struggled   to  effectively  apply  public  health  considerations  to   licensing  decisions,  and  this  issue  will  need  to  be   addressed  in  England  and  Wales  once  the  Police   Reform  and  Social  Responsibility  Bill  is  enacted. Historically,  alcohol  policy  has  exposed  differences  in   approach  between  government  departments.21    Under   strengthen  statutory  powers,  the  Department  of  Health   has  emphasised  voluntary  agreements  with  the  drinks   industry,  especially  through  its  Alcohol  Responsibility   Deal  (launched  in  March  2011).    The  Responsibility   Deal  has  the  support  of  most  major  drinks  producers   and  supermarkets,  but  support  from  the  six  major   public  health  bodies  involved  in  discussions  towards   the  Deal  was  withdrawn  shortly  before  it  was   launched.    In  July  2010,  a  House  of  Lords  Committee   questioned  whether  the  Responsibility  Deal  was   based  on  a  robust  model  of  behaviour  change.22    A   number  of  ACE  participants  also  expressed  scepticism   towards  both  the  Responsibility  Deal  and  the  ‘nudge’   6 level,  since  they  rely  on  changes  to  national  policy.    In   recent  years  government  policy  in  England  and  Wales   (unlike  Scotland)  has  consistently  rejected  population   approaches.    This  has  led  to  concerns  –  expressed   in  some  ACE  workshops  –  that  local  initiatives  can   only  have  a  marginal  impact  on  behaviour.    However,   most  research  accepts  that  tackling  alcohol  harm   requires  a  range  of  interventions  so  local  prevention,   harm  reduction  and  recovery  initiatives  continue  to   play  a  critical  role  in  parallel  to  national  legislation.   Furthermore,  research  into  local  alcohol  strategies   across  Europe  points  to  some  very  effective  projects.24  A  key  amendment  to  the  2003  Licensing  Act  will  be   the  inclusion  of  local  heath  bodies  as  ‘responsible   authorities’  able  to  raise  objections  to  licensing   applications.    During  the  ACE  workshops,  participants   raised  concerns  that  the  scope  and  capacity  of  health   bodies  in  this  role  was  unclear,  especially  if  the   protection  of  public  health  wasn’t  one  of  the  licensing   objectives  against  which  applications  were  evaluated.     In  Scotland,  where  the  protection  of  public  health  is  a   licensing  objective,  investigations  continue  into  how   this  provision  can  be  effectively  operationalized.25    One   key  strategy  appears  to  be  the  effective  use  of  data-­‐ Culture,  policy  and  delivery sharing  between  hospital  Emergency  Departments,   police  and  licensing.    The  so-­‐called  ‘Cardiff  Model’   provides  the  most  well-­‐known  example  of  how  this   can  work  in  practice,  and  a  number  of  ACE  participants   suggested  this  could  provide  useful  pointers  for   future  involvement  of  health  in  licensing  in  the  wider   region.    A  pilot  project  carried  out  in  Bristol  from   between  hospitals  and  the  police  could  be  a  powerful   manage  information.26     of  public  disorder  can  provide  secure  grounds  for   refusing  supermarket  licences  in  cumulative  impact   this.29    Again,  data-­‐sharing  projects  in  Cardiff  and   Bristol  have  shown  that  systematic  mapping  of   hospital  Emergency  Department  data  can  be  very   effective  in  demonstrating  links  between  outlets  and   health  impacts  (especially  accidents  and  emergencies).     However,  while  data-­‐sharing  projects  have   demonstrated  the  possibility  of  linking  problems  to   to  off-­‐sales  since  the  alcohol  may  be  purchased  and   consumed  at  some  distance  from  the  places  where   problems  arise.    Techniques  for  overcoming  this   problem  continue  to  be  explored  both  in  the  region   and  nationally,  though  no  solution  has  been  found  as   yet. A  number  of  initiatives  currently  target  supply  to   underage  drinkers.    Anecdotal  evidence  suggests  that   Challenge  21  and  Challenge  25  schemes  have  had  a   swift  and  demonstrable  cultural  impact,  with  young   people  now  routinely  expecting  to  be  challenged   on  their  age.30    The  role  of  Trading  Standards  is   clearly  critical  in  both  enforcing  the  law  on  underage   sales  and  educating  retailers.    Early  evaluations   of  Community  Alcohol  Partnerships  suggests  that   collaboration  between  Trading  Standards,  the  police   and  licensing  can  be  effective  in  reducing  underage   sales  –  though  it  remains  unclear  how  well  this  model   works  in  larger  towns  and  cities.31     Discussions  with  ACE  participants  demonstrated   that  developments  in  the  night-­‐time  economy  vary   report  that  the  on-­‐trade  have  stopped  competing   and  are  now  seeking  to  improve  the  variety  of  the   night-­‐time  offer  by  drawing  in  more  families.    In  other   places,  it  is  reported  that  the  impact  of  the  economic   downturn  has  led  to  increased  price  competition  and   a  continuing  culture  of  ‘dog  eat  dog’  among  retailers.32     There  is  however,  broad  agreement  that  in  many   town  centres  there  are  currently  ‘too  many  bars  and   not  enough  people’.33    A  key  problem  remains  the   clustering  of  ‘vertical  drinking  establishments’  in  town   centres.    Research  demonstrates  that  such  clustering   exacerbates  antisocial  behaviour,  though  impacts   on  levels  of  consumption  are  less  clear.    In  their   statements  of  licensing  policy,  many  authorities  in  the   region  specify  that  they  will  give  particular  regard  to   types  of  premises  in  relation  to  cumulative  impact   7 Until  very  recently,  both  public  concerns  and   government  policy  on  alcohol  tended  to  focus   primarily  on  the  night-­‐time  economy.    Issues  such   as  closing  times,  the  clustering  of  outlets  and   the  provision  of  effective  policing  and  transport   infrastructure  have  been  at  the  forefront  of  policy   debates.    However,  the  increasingly  dominant  role  of   supermarkets  in  alcohol  retail  has  drawn  attention  to   a  number  of  different  concerns:  the  long-­‐term  health   implications  of  domestic  drinking,  the  impact  of  pre-­‐ loading  on  disorder  in  town  and  city  centres,  and  the   question  of  supply  to  underage  drinkers.     While  alcohol  sales  in  pubs  have  declined  for  a   number  of  years,  consumption  in  the  home  and   purchase  from  supermarkets  continue  to  increase.     The  home  is  the  most  common  location  for  general   drinking  and  a  common  location  for  heavy  episodic   consumption.27    While  domestic  drinking  tends  to   raise  fewer  concerns  over  antisocial  behaviour,  it  is   increase  in  alcohol-­‐attributable  disease  since  1970.     Supermarket  sales  are  clearly  a  public  health  issue,   and  this  is  acknowledged  in  the  Alcohol  Responsibility   Deal.    However,  it  is  hard  to  correlate  long-­‐term  health   and  as  yet  unresolved,  questions  about  how  health   authorities  can  make  effective  representations  around   this  key  sector  of  the  alcohol  retail  market.   The  role  of  pre-­‐loading  in  youth  drinking  cultures  is   now  well  recognised,  and  cheap  off-­‐sale  promotions   not  only  facilitate  preloading  but  can  encourage  price   promotions  in  the  on-­‐trade  as  it  seeks  to  compete.28     Consequently,  off-­‐sales  have  a  potential  impact  on   public  order  as  well  as  long-­‐term  health.    A  recent   judgement  in  Brighton  suggests  that  the  prevention   Culture,  policy  and  delivery policies.      Published  studies  support  this  approach,   showing  that  tackling  harms  associated  with  outlet   of  given  social  clusters.40    One  conclusion  they  draw   density  is  more  effective  when  clustering  is  gauged  by   is  that  health  warnings,  which  are  widely  recognised   type  of  outlet,  rather  than  outlet  numbers  as  a  whole.34   as  having  limited  impact  on  young  drinkers,  can  be   effective  when  targeted  at  people  from  families  who   There  is  also  considerable  research  available  on   already  discourage  alcohol  use  for  cultural  or  religious   the  impact  of  design  and  management  of  behaviour   reasons.    Valentine  et  al.  highlight  the  importance  of   within  premises.    Some  studies  have  concluded  that   recognising  differing  attitudes  towards  drinking  in   drinking  environment,  on-­‐premise  entertainment  and   rural  and  urban  areas.41    As  ACE  interviewees  pointed   type  of  clientele  are  at  least  as  important  as  levels  of   out,  this  has  implications  for  the  effective  enforcement   intoxication  in  determining  antisocial  behaviour.35     of  regulations  around  underage  sales:  in  rural  areas   Attention  to  the  internal  design  of  premises  and  the   controls  on  sales  are  aided  by  the  fact  that  retailers,   nature  of  entertainment  on  offer  can,  therefore,  also  be   consumers  and  enforcement  agencies  may  know  each   important  in  tackling  harm.     other,  whereas  the  anonymity  of  urban  areas  makes   Server  training  is  generally  seen  as  most  effective   when  supported  by  monitoring  and  regulation.36    Bar   staff  are  often  young,  poorly  trained  and  on  casual   contracts  so  their  capacity  to  enforce  the  law  on   preventing  sales  to  drunk  or  underage  customers  can   be  severely  hindered  if  not  adequately  supported.     Interviews  with  ACE  participants  suggest  that  training   can  be  patchy,  with  some  operators  taking  their   responsibilities  more  seriously  than  others.37  A  2008   audit  of  local  alcohol  strategies  in  the  South  West   suggested  there  was  a  variable  emphasis  on  server   training.38    This  may  have  been  addressed  across  the   region,  but  encouraging  the  trade  to  take  seriously  its   responsibilities  in  this  area,  while  monitoring  uptake,   remains  important. Age  is  a  key  determinant  of  drinking  patterns.    Broadly   speaking,  drinking  frequency  tends  to  increase  with   age,  while  amounts  consumed  on  single  occasions   declines.42    Percy  et  al.,  however,  note  that  attitudes   to  drinking  change  as  young  people  progress  through   their  ‘apprenticeship’  of  drinking.43    They  also   suggest  that  ‘positive’  learnt  behaviours  –  such  as   knowing  how  to  ‘hold  your  drink’  –  are  an  important   feature  of  youth  drinking.    Indeed,  the  importance   of  acknowledging  positive  aspects  of  drinking  was   raised  by  a  number  of  ACE  participants.    Negative   motives  such  as  boredom  or  routine  are  widely   recognised  as  driving  much  drinking  behaviour;   however,  the  importance  of  understanding  ‘positive’   motives  for  drinking  remains  important  –  not  least   While  pubs  and  bars  are  often  the  places  where   because  evidence  suggests  that  simply  pointing  to  the   alcohol  harms  are  at  their  most  visible,  many  ACE   downsides  of  consumption  may  have  a  limited  effect.44     participants  emphasised  that  they  also  play  a  positive   Hard-­‐hitting  messages  can  have  an  impact  –  especially   social  role,  as  well  as  providing  a  safer  environment  for   if  they  tackle  short-­‐term  consequences.45    However,   drinking  than  streets  or  parks.    Again,  this  emphasises   a  recent  study  investigating  successful  public  health   the  point  that  domestic  drinking,  preloading  and  street   campaigns  across  the  world  found  that  empathy  and   drinking  –  all  predominantly  related  to  off-­‐sales,  and,   humour  could  also  be  very  effective  in  setting  the   to  a  large  extent,  unregulated  drinking  environments  –   ground  for  attitudinal  change.46     should  be  key  targets  for  intervention. One  of  the  key  strands  of  current  Department  of   Health  approaches  to  alcohol  is  the  development  of   social  norms  marketing  and  nudging.47    Social  norms   Diversity  of  drinking  cultures marketing  is  a  relatively  new  approach  to  promoting   culture  change  which  arose  from  efforts  to  tackle   A  number  of  recent  UK-­‐based  studies  have  considered   campus  drinking  in  America.    Evidence  suggested   the  cultural  drivers  which  shape  drinking  behaviours.39   that  new  undergraduates  tended  to  over-­‐estimate   Many  of  these  emphasise  the  need  to  both  understand   the  amount  that  their  peers  drank;  consequently,   the  diversity  of  drinking  cultures  and  to  develop   they  consumed  alcohol  to  a  level  that  matched  their   interventions  on  the  basis  of  that  knowledge.     expectations  rather  than  the  reality.    Social  norms   Hurcombe  et  al.  for  instance,  note  that  drinking   approaches  suggest  that  raising  awareness  of  actual   8 Culture,  policy  and  delivery drinking  levels  among  peers  can  encourage  greater   moderation,  since  lower  consumption  is  more  likely   to  be  perceived  as  normal  if  this  is  encouraged.    A   number  of  evaluations  have  been  carried  out  and   remains  mixed.48    In  ACE  workshops  and  interviews,   a  number  of  people  expressed  scepticism  towards   that  where  drinking  levels  are  demonstrably  high  a   correct  perception  of  drinking  by  peers  within  those   groups  may  encourage  excess.    Nevertheless,  there  are   examples  of  social  norms  interventions  which  have   been  successful  and  which  could  provide  guidance  for   good  practice.49 One  concern  surrounding  educational  and  social   marketing  initiatives  is  that  measuring  their  impacts   population  recognises  or  recalls  a  campaign  is   no  guarantee  that  it  has  been  effective.    Research   on  media  audiences  shows  consistently  that  the   interpretation  of  messages  can  be  unpredictable  and   there  is  evidence  that  despite  high  recall  of  NHS  ‘Know   Your  Limits’  campaigns,  they  can  be  ignored  or  even   read  as  humorous.50    Nevertheless,  carefully  designed   interventions  that  seek  to  address  concerns  from  the   cultural  perspective  of  young  drinkers  can  be  effective.     The  Project  28  drug  and  alcohol  service  in  Bath,  for   example,  has  developed  a  range  of  advisory  materials   which  target  the  known  concerns  of  their  clients.     These  form  part  of  a  wider  screening  and  treatment   service  which  has  produced  some  very  strong  results.51 while  Bellis  et  al  found  just  under  half  of  underage   drinkers  reported  parental  supply  –  though  with  a   similar  pattern  of  more  varied  sources  as  consumption   increased.53 A  number  of  recent  studies  have  investigated  how   attitudes  to  drinking  are  communicated  in  the  home.     Many  of  these  note  that  children  often  have  a  nuanced   understanding  of  drinking  styles  and  that,  before   the  age  of  thirteen  at  least,  they  anticipate  modelling   their  future  behaviours  on  their  parents.54    While  this   nevertheless,  powerful  and  important.55    Seaman   and  Ikegwuonu  argue  that  even  in  later  years  (when   drinking  to  get  drunk  becomes  the  ‘default  choice’  for   many  young  people)  responsible  parental  drinking  can   demonstrate  that  other  drinking  styles  exist.56   Many  ACE  participants  noted  the  lack  of  consistent   advice  available  for  parents.  In  2008,  the  Chief  Medical   access  to  alcohol  for  under-­‐15s;  however,  much  recent   research  argues  this  is  unrealistic.57    Nevertheless,   given  the  evidence  that  parents  do  have  a  meaningful   impact  on  attitudes,  Velleman  has  argued  that  parental   education  and  support  should  be  recognised  as  vital  to   tackling  alcohol-­‐related  harm.    Emphasising  the  degree   may  also  help  tackle  the  feeling  of  powerlessness   that  parents  often  report  in  the  face  of  wider  cultural   pressures  faced  by  their  children. The  ACE  events  drew  attention  to  the  range  of   The  role  of  parents  in  shaping  their  children’s  drinking   partnerships  operating  in  the  region,  but  also   behaviour  was  a  common  theme  in  ACE  workshops   suggested  areas  where  closer  working  could  be   and  interviews,  with  many  participants  noting  an   developed  in  future.    The  evidence  from  both   increased  willingness  among  parents  to  accept   ACE  participants  and  wider  research  is  that  while   underage  drunkenness  as  a  normal  part  of  growing  up.     interventions  to  tackle  alcohol-­‐related  harms  operate   According  to  the  most  recent  national  data,  parental   in  a  national  policy  context,  community  partnerships   supply  was  the  second  most  common  source  for   can  have  a  ‘considerable  positive  impact’.58     alcohol  among  underage  drinkers,  with  20%  reporting   being  given  alcohol  by  parents  and  12%  reporting   The  success  of  Community  Alcohol  Partnerships   taking  it  from  home  with  permission.    However,  the   has  led  to  a  concerted  effort  to  roll  the  model  out   more  widely  (there  are  currently  around  thirty  in   respondents  reported  drinking:  that  is,  the  more  they   place  across  England).    A  CAP  is  currently  running   drank,  the  more  likely  they  were  to  get  it  from  sources   in  Mid  Devon,  and  the  interim  report  suggests  it  has   59     other  than  their  parents.52    Research  carried  out  by   Torbay  PCT  also  found  that  parents  were  among   However,  CAPs  have  a  relatively  restricted  remit  (to   the  most  common  suppliers  of  alcohol  to  children,   reduce  underage  public  drinking)  so  are  only  one   9 Culture,  policy  and  delivery approach  to  reducing  overall  harms.    A  number  of  ACE   participants  and  interviewees  reported  comparable   initiatives  in  their  areas,  but  which  have  slightly   different  remits  than  the  CAP.    Taunton  Deane  Council,   for  instance,  convenes  a  Safety  Advisory  Group   comprising  of  responsible  authorities  under  the  2003   Act.    The  SAG  meets  to  discuss  wider  licensing  issues   In  Bristol  City  Council  a  Joint  Enforcement  Team brings  police  and  licensing  together  to  target   problematic  premises  and  promote  improved   compliance  across  the  licensed  trade.    An  Alcohol   Diversion  Scheme  is  now  in  place  across  Devon  and   recent  reviews  of  similar  schemes  elsewhere  in  the  UK   suggest  they  can  be  an  effective  strategy.60    A  number   of  other  workshop  attendees  stated  that  partnerships   between  enforcement  agencies  were  in  place  and  that   they  proved  effective.61 The  inclusion  of  health  bodies  as  responsible   authorities  under  the  forthcoming  amendments  to  the   2003  Act  raises  the  possibility  of  closer  partnership   working  between  licensing  and  the  NHS.    There  are   the  nature  of  input  from  health  bodies  should  be   (and  who  will  constitute  such  bodies  after  PCTs  are   wound  down),  but  the  ACE  workshops  demonstrated   the  extent  to  which  the  concerns  of  health  bodies   overlapped  with  those  of  other  services.    As  one   licensing  manager  observed  ‘the  best  thing  about  the   workshops  was  seeing  the  health  side  of  it  and  talking   to  them,  because  they’re  dealing  with  issues  that  are   very  similar  to  what  we’re  dealing  with.’62    Creating   further  opportunities  for  exploratory  discussions   between  licensing  teams,  enforcement  agencies,   service  providers  and  health  bodies  may  be  key  to   making  the  most  effective  use  of  the  new  provisions   regarding  public  health  in  the  amendments  to  the   2003  Act.     bodies,  alcohol  services  and  licensing.    However,   there  are  risks:  historically,  health  services  and  the   goals  –  health  promotion  and  the  sale  of  alcohol  –  can   seem  intractably  opposed,  and  the  future  the  role   of  licensing  authorities  in  mediating  between  the   two  will  be  complicated.    However,  the  ACE  project   demonstrated  that  there  was  much  common  ground   support  for  the  establishment  of  working  structures   and  the  development  of  mutual  understanding,  there  is   the  scope  for  productive  collaboration  in  the  future. It  is  recognised  that  achieving  sustainable  cultural   change  is  a  multi-­‐dimensional  and  long-­‐term  process.     As  a  number  of  ACE  participants  noted,  the  long-­‐ term  nature  of  cultural  change  runs  counter  to  the   often  short-­‐term  nature  of  political  decision-­‐making.     Interventions  that  may  take  years  to  produce  results   are  of  limited  attraction  to  politicians  facing  periodic   re-­‐election,  and  a  key  challenge  is  to  secure  political   and  economic  backing  for  projects  whose  impacts  may   not  be  immediate.    Nevertheless,  drinking  cultures   are  neither  monolithic  nor  static  –  nor  do  they  only   operate  at  a  population  level.    Therefore,  evidence-­‐ remain  important.    Developing  and  supporting   partnerships  and  collaborations  which  address  the   multi-­‐dimensional  nature  of  alcohol  harms  is  also   critical,  and  amendments  to  the  2003  Act  may  provide   the  opportunity  for  further  regional  development   in  this  area.    There  are  many  examples  of  good   practice  in  addressing  alcohol  harms  across  the  South   West.    However,  the  winding  down  of  the  Alcohol   Improvement  Programme,  as  well  as  the  trend  towards   localism,  may  limit  the  scope  for  sharing  knowledge  in   future  so  new  opportunities  to  encourage  the  exchange   of  ideas  across  organisations  and  services  should  be   sought.63     The  ACE  events  demonstrated  a  high  degree  of   commonality  in  the  concerns  and  approaches  of  a   range  of  stakeholders,  and  the  diversity  of  drinking   cultures  means  no  single  agency  is  able  to  address   associated  harms  in  isolation.    Therefore,  knowledge-­‐ sharing  and  partnership  working  will  remain  critical   to  promoting  safer  drinking  cultures  in  future.     Encouraging  and  facilitating  this  should,  therefore,   remain  a  key  priority  for  all  concerned  with  reducing   alcohol  related  harm. Despite  a  downward  trend  in  consumption  in  recent   years,  tackling  alcohol-­‐related  harms  remains  a   priority.    Public  health  campaigning  focuses  primarily   on  population-­‐level  approaches,  which  operate  a   national  level,  but  local  strategies  remain  important   given  the  degree  of  regional  diversity  which  shapes   drinking  behaviours  and  levels  of  harm.    Furthermore,   amendments  to  the  2003  Licensing  Act  will  provide   opportunities  for  greater  engagement  between  health   10 Culture,  policy  and  delivery 11 Culture,  policy  and  delivery References Where  sources  are  publicly  available  online,  the  web  addresses  have  been  included  below.     1  British  Beer  and  Pub  Association,  Statistical  Handbook  (BBPA,  2010) 2   http://www.statistics.gov.uk/downloads/theme_compendia/GLF09/GLFSmoking-­‐DrinkingAmongAdults2009.pdf 3   young_people_in_England_2010_Full_report.pdf 4   Memorandum  AL59,  2009):  http://www.publications.parliament.uk/pa/cm200910/cmselect/cmhealth/151/151we21.htm 5   http://www.nwph.net/alcohol/lape/ 6   7   8   9   10   11   12  Fuller,  Smoking,  Drinking  and  Drug  Use  Among  Young  People 13  The  classic  investigation  into  social  norms  of  drunken  behaviour  is  Edgerton,  R.,  MacAndrew,  C  and  Heath  D.,  Drunken  Comportment:   http://eprints.bournemouth.ac.uk/17420/1/LSA_Proofs_(pdf).pdf 14   http://www.publications.parliament.uk/pa/cm200910/cmselect/cmhealth/151/15102.htm 15   (HMSO,  1931)   12 Culture,  policy  and  delivery 16   to  establish 17   18   19   http://www.ias.org.uk/resources/nighttime/policy/2003act-­‐ http://www.publications.parliament.uk/pa/cm200708/ cmselectcmhaff/364/364i.pdf 20   21   22   http://www.publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/17902.htm 23   24   http://www.emcdda.europa.eu/publications/monographs/harm-­‐reduction 25  Details  of  this  work  can  be  found  on  the  Alcohol  Focus  Scotland  website:  http://www.alcohol-­‐focus-­‐scotland.org.uk/ 26   and  Research  Council,  2007):   27   28   (2009).    The  claim  regarding  impact  on  on-­‐trade  offers  was  made  during  an  interview  with  an  ACE  participant,  May  2011 29   30   13 Culture,  policy  and  delivery 31   32   33   34   Review  26  (2007) 35   36   Graham  and  Homel,  Raising  the  bar 37   38   39   can  be  found  at:   40   41   42   43   44   45   46       47   http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127424.pdf 48   and  Research  Council,  2010):   49   50   14 Culture,  policy  and  delivery 51  For  more  information,  visit  the  website  at:   52  Fuller,  Smoking,  Drinking  and  Drug  Use  Among  Young  People 53   54   55   Foundation,  2009) 56   57   58   Council,  2007):   59  A  report  on  this  CAP  can  be  found  here:   60  The  report  on  the  ADS  in  Hertfordshire  can  be  accessed  here:   http://www.druglink.co.uk/uploads/39EvaluationofHertsAlcoholDiversionScheme.pdf The  report  for  the  ADS  scheme  in  Derbyshire  can  be  accessed  here:   61   62   63   http:// www.alcohollearningcentre.org.uk/ further  information,  see  here:  http://www.alcoholacademy.net/ 15