Healthy life expectancy in Scotland – 60 years for men and 62 for women – falls far short of actual life expectancy, 76 and 80 years respectively (Scottish Government, 2011a). With a predicted 26% rise in the number of pensionable-aged Scots by 2035 (Scottish Government, 2011b), this increase in chronic disease has led to a focus on the health risks associated with our behaviour (Dixon and Johnston, 2010).
Risk Factor: Excessive Alcohol Consumption
Alcohol has an irritant effect, contributing to arteriosclerosis, ultimately increasing the risk of hypertension, heart disease and stroke (Harrington-Dobinson and Blows, 2007a). It irritates the mucous lining of the gastrointestinal tract and accessory organs, predisposing to chronic inflammation, malnutrition (possibly leading to Wernicke’s encephalopathy and, if untreated, Korsakoff’s psychosis (Rassool, 2009)) and tumour development; the liver, due to its central metabolic role, is particularly susceptible to damage, cirrhosis, failure and cancer (Harrington-Dobinson and Blows, 2007a). Alcohol’s seemingly paradoxical stimulant and depressive effects, depending on amounts consumed (Harrington-Dobinson and Blows, 2006), are a significant factor in the complex cycle of co-morbidity between mental ill-health and alcohol misuse (Rassool, 2009). The numerous acute health risks (Harrington-Dobinson and Blows, 2007a) and social harms (NHS ISD, 2011) will not be discussed here.
Health Promotion: Towards Reduced Alcohol Consumption
The medical approach to health promotion (Scriven, 2010) involves preventing or treating alcohol-related harm through healthcare interventions, using a ‘stepped care’ method (Scottish Government, 2011c). NICE (2010 and 2011) outlines this process. Primary prevention includes screening tools – for example, the Fast Alcohol Screening Test (FAST) in primary care (SIGN, 2003) or the Paddington Alcohol Test (PAT) in emergency departments (NHS QIS, 2008) – and brief intervention (discussed below); secondary prevention may involve extended brief intervention through motivational interviewing (SIGN, 2003) and assisted withdrawal; tertiary prevention is provided by specialist services, and may include pharmacological relapse prevention (NICE, 2011). Scriven (2010) outlines four key strategies in the behaviour change approach: self-monitoring, cost/benefit/reward motivational systems, target-setting and coping strategies. A ‘drink diary’ is a useful self-monitoring tool (Harrington-Dobinson and Blows, 2007b). Targets appropriate to the individual – abstinence, reduction in consumption or merely harm reduction – should be agreed (NICE, 2011). Successful coping strategies have included implementation intentions, namely, “if (critical situation) occurs, then I will (behavioural response)” (Armitage, 2009). Alcoholics Anonymous or similar programmes, although not evidence-proven (SIGN, 2012), may still be appropriate for some individuals due to their wide availability (Scottish Government, 2011c). The education approach (Scriven, 2010) involves communicating the recommended guideline limits (see Appendix 1), and the risks of exceeding these, to the public. Although consumption appears to be reducing (see Appendix 2), this is not backed up by corresponding sales data (NHS ISD, 2011), nor the apparent increase in dependency (see Appendix 2). As people usually give an honest account of their consumption (SIGN, 2003), this suggests the government is right to be concerned over inconsistent drink labelling and the “drift towards larger ‘standard’ measures” (Scottish Government, 2009, at p.12). The beneficial cardio-protective effects of a moderate alcohol intake are, at best, limited to certain sub-groups and, at worst, inconsistent and misleading (Grønbaek, 2009); they are therefore, rightly, underplayed in public health education. Alcohol Brief Interventions – lying somewhere between the medical, the behaviour change and the education...
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