Project objectives

The ATS aims to provide timely tracking data on key alcohol-related variables in England, and evaluate how these relate to national and local policies, campaigns and events. The evaluations will focus on trends and impact as a function of major socio-demographic variables. The ATS and the long-established Smoking Toolkit Study (STS) involve the same respondents and will thereby allow the assessment of associations between alcohol and tobacco use and corresponding time trends.

Changes to project objectives

We had originally planned to include the full 10-item AUDIT (a screening tool for risky alcohol use) questionnaire during only the first six waves of data collection, and thereafter use the 3-item version, the AUDIT-C. However, we subsequently requested additional funds to continue the assessment of the full AUDIT for another 12 months as we realised that having the full version of the AUDIT added substantial value as it includes items indicating harm and dependence relating to alcohol use.

The survey was also expanded to include a variety of additional questions until the end of 2017 on the new Drinking Guidelines. These questions were funded by NIHR PHRP and led by John Holmes at University of Sheffield. Public Health England (PHE) have also paid for additional items relating to the harm that alcohol does to other people.

The initial SPHR funding was due to end in March 2017, but we received funding for the AUDIT for a further five years from Cancer Research UK (CRUK) (£600,000). We have sought SPHR2 funding to support the other non-AUDIT questions relating to the population context for alcohol use for an additional 18 months. During that time, we will prepare further bids for non-SPHR funding to complement the remaining 42 months of CRUK-funded AUDIT data collection.

Brief Summary

Methods

The ATS consisted of cross-sectional household, computer-assisted interviews of representative samples of adults in England aged 16+. Each month a new sample of approximately 1700 adults completed the survey. All respondents who consented to be followed-up were asked to complete a telephone survey 6 months later. Questions covered alcohol consumption and related harm (AUDIT), socio-demographic characteristics, attempts to reduce or cease consumption and factors associated with this, and exposure to health professional advice on alcohol. The ATS complemented the STS, which has been tracking key performance indicators relating to smoking since 2006. As both the ATS and STS involved the same respondents, it was possible to assess interactions between alcohol and tobacco use.

For analyses involving prevalence estimates, the baseline sample was weighted to match the English population profile on the dimensions of age, social grade, region, tenure, ethnicity, and working status within sex. The dimensions were derived monthly from a combination of the English 2011 census, Office for National Statistics mid-year estimates, and an annual random probability survey conducted for the National Readership Survey.

We pre-registered our analysis plans and command files using Open Science Framework (OSF) (https://osf.io/). The exact analyses varied depending upon the research question.

Results & conclusions

The ATS has established a 36-month time-series of alcohol consumption and related behaviours in England, which has unique advantages over other large-scale surveys on alcohol use in the United Kingdom. These include the frequency of data collection and detailed contextual information relating to alcohol consumption.

Descriptive data on important trends were published monthly on a dedicated website: www.alcoholinengland.info. Additionally, key findings were published in peer-review journals and included: 

1. Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, <10% of those who drink excessively report having received advice on their alcohol consumption.
2. January is associated with moderate increased attempts to reduce alcohol consumption. However, we find little evidence of a change in alcohol consumption. In part, this may be due to temporal insensitivity of the AUDIT questions.
3. Different socioeconomic (SES) measures appear to influence whether the Alcohol Harm Paradox is observed as a linear trend across SES groups or a phenomenon associated particularly with the most disadvantaged. The paradox also appears more concentrated in men and younger age groups.
4. In England, the use of pharmacotherapy is prevalent for smoking cessation but not alcohol reduction. Other aids are used at a low rate, with face-to-face counselling being more common for alcohol reduction than smoking cessation.
5. Around a fifth of high-risk drinkers in England report trying to reduce their drinking, particularly older, high-socioeconomic female drinkers from the south of England. Attempts to cut down appear to be driven by a desire to improve health, advice from others and cutting down on the cost of drinking.
6. Smoking and high-risk drinking appear less common in ‘central England’ than in the rest of the country. Regional differences in smoking, but not those in high-risk drinking, appear to be explained to some extent by sociodemographic disparities.
7. Smokers who report starting a quit attempt in the last week also report lower alcohol consumption, including less frequent binge drinking, and appear more likely to report currently attempting to reduce their alcohol consumption compared with smokers who do not report a quit attempt in the last week.
8. Publication of new or revised lower risk drinking guidelines can improve drinkers’ knowledge of these guidelines within all sociodemographic groups; however, in the absence of sustained promotional activity, positive effects may not be maintained and social inequalities in awareness and knowledge of guidelines are likely to persist.

The articles have been influential: for example, one paper was among the top-10 most-read articles in the British Journal of General Practice in 2016. The ATS is now starting to generate adequate time series data with suitable sample sizes to assess population-level trends and evaluate the impact of population level interventions using sophisticated statistical methods (e.g., ARIMA, ARMIAX, VAR).

For example, a paper is currently under review which assesses the association at a population level between alcohol prevalence and related-behaviours with smoking prevalence. Eight further papers are also under review and in preparation, and findings have also been disseminated at 29 conferences as posters, presentations and symposia (details listed below).

The findings have been shared with practitioner and policymaker partners with real-time updates on trends in outcomes measures by our monthly mailing list and dedicated website. The Department of Health and PHE are supportive of the ATS, and have commissioned work based on the data it provides or paid to fund additional questions on specific topics of interest.

Plain English summary

Background

A detailed monthly national survey is needed to understand population-wide influences on alcohol use, and to inform and evaluate policies aimed at reducing alcohol-related harm. The Alcohol Toolkit Study (ATS) was established in 2014 with SPHR1 funding and involved monthly household surveys of representative samples of the adult population in England. The survey collected detailed information across 36 consecutive months from over 60,000 people on alcohol consumption and harm (AUDIT), which was contextualised by data on a range of alcohol-related behaviour and socio-demographic characteristics. The ATS has several advantages over other large-scale surveys on alcohol use in the United Kingdom. These include the frequency of data collection and detailed contextual information relating to alcohol consumption.

Findings

Key findings include that less than 10% of those who drink excessively and visit their GP in England report having received advice on their alcohol consumption whereas for smokers it is ~50%; January is associated with increased attempts to cut down alcohol intake but there is little evidence that these attempts translate into reduced consumption; the established paradox that lower socioeconomic status groups consume less alcohol but experience more alcohol-related problems appears to be influenced by the particular measure socioeconomic status and to be concentrated in men and younger people; just 14.8% of high-risk drinkers use aids to help them reduce their alcohol intake compared to 60.3% of smokers attempting to quit; at any one time around 1/5^th of high-risk drinkers in England are attempting to cut down; smoking and high-risk drinking appear less common in ‘central England’ than in the rest of the country; and that the publication of revised lower risk drinking guidelines can improve drinkers’ knowledge of these guidelines within all sociodemographic groups.

Conclusions & implications

The wide variety of questions on alcohol use and key-related behaviours has resulted in several important findings which have implications for policy and identify ways in which high-risk alcohol consumption may be reduced. For example, there is a clear need to increase the uptake of aids and behavioural support, to encourage GPs to broach the subject of excessive alcohol use and to decrease social-inequalities. In the future, the long-running nature of the ATS will allow for the evaluation of population level polices on health inequalities and the impact across different social groups and types of local authorities.

Dissemination

Journal articles (published)

Beard, E., Brown, J., West, R., Acton, C., Brennan, A., Drummond, C., Hickman, M., Holmes, J., Kaner, E., Lock, K., Walmsley, M., & Michie, S. (2015). Protocol for a national monthly survey of alcohol use in England with 6-month follow-up: ‘The Alcohol Toolkit Study’ BMC Public Health 2015, 15:230. http://old.biomedcentral.com/content/pdf/s12889-015-1542-7.pdf

Brown, J., West, R., Angus, C., Beard, Brennan, A., Drummond, C., Hickman, M., Holmes, J., Kaner, E., & Michie, S. (2016). Comparison of brief interventions in primary care on smoking and excessive alcohol consumption in England: a population survey. British Journal of General Practice. 66 (642): e1-e9. http://dx.doi.org/10.3399/bjgp16X683149

Beard, E., Brown, J., West, R., Angus, C., Brennan, A., Holmes, J., Kaner, E., Meier, P., & Michie. S. (2016). Deconstructing the alcohol harm paradox: A population based survey of adults in England. PLOS ONE. https://doi.org/10.1371/journal.pone.0160666

Beard, E., Brown, J., Michie, S., Kaner, E., Petra, M., & West, R. (2016). Use of aids for smoking cessation and/or alcohol reduction: A population survey of adults in England. BMC Public Health. 16:1237. http://link.springer.com/content/pdf/10.1186%2Fs12889-016-3862-7.pdf

de Vocht, F., Beard, E., Angus, C., Brennan, A., Michie, S., Campbell, R., & Hickman, M. (2016). Temporal patterns of alcohol consumption and motivation to reduce alcohol intake in England. BMC Public Health, 16: 917. http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3542-7

Brown, J., West, R., Beard, E., Brennan, A., Drummond, C., Gillespie, D., Hickman, M., Holmes, J., Kaner, E., & Michie, S. (2016). Are recent attempts to quit smoking associated with reduced drinking in England? A cross-sectional population survey. BMC Public Health. 16:535. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3223-6

Beard, E., Brown, J.,Kaner, E., West, R., &Michie, S. (2017). Predictors of and reasons for attempts to reduce alcohol intake: a population survey of adults in England. PLOS ONE. https://doi.org/10.1371/journal.pone.0173458

Beard, E., Brown, J., West, R., Angus, C., Kaner, E., & Michie, S. (2017). Healthier central England or North–South divide? Analysis of national survey data on smoking and high-risk drinking. BMJ Open. http://dx.doi.org/10.1136/bmjopen-2016-014210

Journal articles (under review or in preparation)

Shahab, L., Meads, C., Brown, J., Hagger-Johnson, G., & West, R. (under review). Sexual orientation and tobacco and hazardous alcohol use – findings from a cross-sectional representative population survey.

Buykx, P. Gillespie, D., Brown, J., Beard, E., Michie, S., Brennan, A. (in preparation, other authors TBC) Estimating the proportion of people with alcohol dependence who would be amendable to specialist alcohol treatment in England using the Alcohol Toolkit Survey data on past year motivation to cut down drinking.

Colin Angus, Jamie Brown, Emma Beard, Gillespie, D., Buykx, P., Kaner, E., Michie, S., & Petra, M. (submitted). Brief interventions as a tool for addressing health inequalities: Socioeconomic variations in delivery of brief interventions for smoking and drinking in primary care in England

Khadjesari, Z., Brown, J., Beard, E., Michie, S., (in preparation, co-authors to be confirmed). Drummond, C. Alcohol Screening and Brief Intervention and Help Seeking by Alcohol Use Disorder Identification Test (AUDIT) severity

Beard, E., Marsden, J., Stapleton, J., Brown, J., Michie, S., Tombar, I., & West R. (under preparation). Introduction to modern time series analysis in the addictions.

Beard, E., Brown, J., West, R., & Michie, S. (under preparation). Predictive validity, diagnostic accuracy and test-retest reliability of the Strength of Urges to Drink (SUTD) scale.

Beard, E., West, R., Michie, S., & Brown, J. (under review). Association between smoking and alcohol-related behaviours: A time-series analysis of population trends in England

Beard, E., Brown, J., Kaner, K., West, R., Boniface, S., Holmes, J., Michie, S. (under preparation). What are the independent associations of different components of socioeconomic status with drinking patterns: a cross-sectional study of adults in England

Dr Emma Beard, who is funded by the NIHR SPHR, has also authored a paper on e-cigarettes using data from the Smoking Toolkit Study (STS), which is conducted on the same participants and linked with the ATS. Emma has also contributed to a special issue of Trials on Stepped Wedge designs which will be used in the analysis of the ATS. Emma acknowledged the SPHR in all these publications:

Beard, E., Lewis, J. J., Copas, A. J., Davey, C., Osrin, D., Baio, G., Thompson, J. A., Fielding, K. L., Omar, R. Z., Ononge, S., Hargreaves, J., & Prost, A. Stepped wedge randomised controlled trials: systematic review of studies published between 2010 and 2014. Trials. https://link.springer.com/article/10.1186/s13063-015-0839-2

Baio, G., Copas, A., Ambler, G., King, M., Beard, E., & Omar R. Z. Sample size calculation for a stepped wedge trial. Trials. https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-0840-9

Davey, C.,Hargreaves, J., Thompson, J. A.,Copas, A. J., Beard, E., Lewis, J. J., & Fielding, K. L. Analysis and reporting of stepped-wedge randomised-controlled trials: a synthesis and critical appraisal of published studies, 2010-2014. Trials. https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-0838-3

Hargreaves, J., Copas, A. J., Beard, E., Orsin, D., Lewis, J. J., Davey, C., Thompson, J. A., Baio, G., Fielding, L., & Prost, A. Five questions to consider before conducting a stepped wedge trial. Trials. http://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-0841-8

Beard, E., Brown, J., McNeill, A., Michie, S., & West. Has growth in electronic cigarette use by smokers been responsible for the decline in use of licensed nicotine products? Findings from the Smoking Toolkit Study: A longitudinal cross-sectional survey. THORAX. http://thorax.bmj.com/content/70/10/974

Dr Jamie Brown, Dr Emma Beard, and Prof Susan Michie have also given a number of presentations on the ATS to members of the Department of Health and Public Health England, researchers and health-care professionals:

Oral presentation: Emma Beard. “‘The Alcohol Toolkit Study’: a national study of alcohol use in England”. UKSBM. Nottingham. 02/12/014

Symposium: Jamie Brown. “Evaluating public health approaches to reducing alcohol related harm in an English context”. UKSBM. Nottingham. 02/12/2014

Oral presentation: Jamie Brown. “Prevalence of brief interventions in primary care on smoking and excessive alcohol consumption in England: Findings from a population survey”. UKSBM Nottingham. 02/12/2014

Oral presentation: Emma Beard. “‘The Alcohol Toolkit Study’: a national study of alcohol use in England”. ARIG UCL. London. 15/12/2014

Oral presentation: Jamie Brown. “Prevalence of brief interventions in primary care on smoking and excessive alcohol consumption in England: Findings from a population survey”. ARIG UCL. London. 15/12/2014

Oral presentation: Jamie Brown. “The Smoking Toolkit Study: A population survey in England”. Harvesting Global Learning on ENDS to inform U.S. Research, Surveillance and Policy. Philadelphia, US. 28/02/2015

Symposium and discussion: Jamie Brown. “Developing content based on theory and evidence”. Harnessing Digital Technology for Health Behaviour Change. London, UCL. 23/02/2015.

Poster: Emma Beard. “’Alcohol Toolkit Study’: a national study of alcohol use in England. SPHR Conference. Sheffield. 22/10/2015

Oral presentation: Emma Beard. “The Alcohol Harm Paradox: Population survey of adults in England”. Health Psychology Research Group Seminar, UCL. 30/04/2015.

Oral presentation: Emma Beard. “A review of stepped wedge RCTs”. PRIMENT Clinical Trials Unit. 09/12/2014.

Oral presentation: Emma Beard. “Implementation of brief interventions in primary care for excessive alcohol consumption: a comparison with smoking”. Alcohol Academy Conference on Brief Interventions, Birmingham. 04/2015

Oral presentation: Emma Beard. “Plenary Debate and Q & A”. Alcohol Academy Conference on Brief Interventions, Birmingham. 04/2015

Oral presentation: Emma Beard. “The Alcohol Harm Paradox: Population survey of adults in England”. Health Psychology Research Group Seminar, UCL. 30/04/2015.

Oral presentation: Jamie Brown. “‘The Alcohol Toolkit Study’: a national study of alcohol use in England”.. The School for Public Health Research: Alcohol Programme, Meeting with DH, PHE & HMRC Alcohol Policy, 17-Sep-15

Oral presentation: Emma Beard. “‘Use of aids for smoking cessation and alcohol reduction: population survey of adults in England”. UK Society for Behavioural Medicine, Newcastle. 9-12-2015

Oral presentation: Colin Angus (December, 2015). “Characterising the Alcohol Harm Paradox: A population based survey of adults in England”. UK Society for Behavioural Medicine, Newcastle. 9-12-2015

Oral presentation: Frank de Vocht, F. “A seasonal analysis of alcohol consumption and motivation to cut down in England”. UK Society for Behavioural Medicine, Newcastle. 9-12-2015

Oral presentation: Jamie Brown Are recent attempts to quit smoking associated with reduced drinking in England? A cross-sectional population survey. UK Society for Behavioural Medicine, Newcastle. 9-12-2015

Oral presentation: Jamie Brown Are recent attempts to quit smoking associated with reduced drinking in England? A cross-sectional population survey. SRNT, Chicago. 5th-Mar-16

Oral presentation: Susan Michie. “The development and evaluation of a theory-based smartphone application”. NIHR School for Public Health Research Annual Scientific Meeting, 10-Mar-16

Oral presentation: Emma Beard. “The Alcohol Toolkit Study: Findings and future directions”. NIHR UCL Alcohol Event, London. 10-2016

Poster: Emma Beard. “Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time-series analysis of population trends”. Society for the Study of Addiction, York. 11-2016

Poster: Emma Beard. “Is the emergence of a healthier central England replacing the traditional North-South divide? Analysis of national survey data on smoking and high-risk drinking”. Society for the Study of Addiction, York. 11-2016.

Oral presentation: Emma Beard. “Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time-series analysis of population trends.” UKSBM, Cardiff. 12-2016.

Oral presentation: Emma Beard. “Is the emergence of a healthier central England replacing the traditional North-South divide? Analysis of national survey data on smoking and high-risk drinking”. UKSBM, Cardiff. 12-2016

Oral presentation: Emma Beard, “Association between smoking and high-risk drinking indices in England: A time-series analysis”. UKSBM, Cardiff. 12-2016

Oral presentation: Emma Beard. “Using time-series analysis to examine the effects of adding or removing components of digital behavioural interventions and associations between outcomes and patterns of usage”. 3rd Behaviour Change Conference: Digital Health and Wellbeing, London. 02-2017

Poster: Emma Beard. “Use of digital and non-digital aids for smoking cessation and alcohol 

reduction: a population survey of adults in England”. 3nd Behaviour Change Conference: Digital Health and Wellbeing, London. 02-2017

Poster: Emma Beard. “Use of digital and non-digital aids for smoking cessation and alcohol reduction: a population survey of adults in England”. NIHR SPHR conference, London. 03-2017.

The ATS website is now available – www.alcoholinengland.info; details of the ATS are already available on the UCL Health Psychology webpage (http://www.ucl.ac.uk/health-psychology/research/health-related-behaviours). We have met with stakeholders at PHE (organised by Matthew Walmsley) to feedback some of the early findings from the ATS. On the 12th October 2016 we held an event titled “Reducing alcohol consumption: guidelines, local government and smartphone apps” which brought together researchers and practitioners in the field of excessive alcohol consumption reduction.

Public involvement

The ATS has been welcomed by PHE who have paid for additional items relating to the harm that alcohol does to other people and have contributed data for a related NIHR Public Health Research Programme funded project being conducted by SPHR members (PI John Holmes, University of Sheffield) to evaluate the impact of the new drinking guidelines. The Department of Health commissioned SPHR members at University of Sheffield to use ATS data to estimate amenability to specialist alcohol treatment in England among people with alcohol dependence. The team have authored a public health evidence briefing disseminated by SPHR and hosted a SPHR alcohol event together with the UCL Centre for Behaviour Change attended by practitioners, public and policymakers (total attendance of over 75 people). We established a policymaker and public-facing website and mailing list, which is updated monthly with the latest trends in key alcohol indicators (www.alcoholinengland.info).

The UKCTAS is a leading inter-institution organisation in the UK of which the majority of named SPHR members are prominent members. The UKCTAS Drinkers Panel is an established and diverse PPI group consisting of ~40 adult drinkers who meet 2-3 times a year. We plan to attend two meetings to discuss results and at a first meeting in June 2017, we plan to involve two panel members to contribute more regular oversight to the project direction and focus. We have budgeted appropriate travel and incentive expenses for the relevant meetings.

Impact

The SPHR1 funded Alcohol Toolkit Study produced a range of successful outcomes (e.g., engagement with Public Health England (PHE), impactful publications and symposia, and leveraged further funding from NIHR and CRUK) and has established a 36-month time-series across a number of important indicators of population alcohol use and related behaviour. Such detailed surveillance of the population-level context of alcohol use will be necessary to evaluate and understand impact, particularly on health inequalities and across different social groups and types of local authorities. In fact, the availability of comprehensive and contextual data may even increase the likelihood of action: without confidence that the effects can be understood and evaluated, public health policymakers and practitioners may hesitate to pursue new policies. Moreover, the toolkit would allow interested policymakers, practitioners and researchers to add additional items to answer further questions relating to new policies, accruing benefit from existing variables and time series.

This will be particularly important as there is currently momentum and enthusiasm within the public health community and practice to address alcohol-related harm, underlined by recent reviews and guidance from PHE (10, 11). Although central government has no immediate plan to update its 2012 Alcohol Strategy, it is possible that new alcohol treatments and policies will be commissioned and delivered in response to these reports and guidance, while local authorities are likely to continue commissioning different services at a local level.

There was a growing collaboration between the research team, PHE and the Department of Health, which helped bring research findings closer to practice, and policy priorities closer to research design. The team organised a workshop at the PHE conference in September 2016, and have had several meetings as part of the wider alcohol programme with them and a variety of other stakeholders, including the Home Office and HMRC. PHE used the ATS to collect additional data to compile a report on the harm to others of alcohol, and Department of Health together with SPHR members at Sheffield used the routine ATS data to estimate the proportion of dependent drinkers amenable to treatment.

 

This project was funded by the National Institute for Health Research School for Public Health Research (SPHR-SWP-ALC-WP5)

 Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Public Health Research, NIHR, NHS or the Department of Health.