Guidance

Chapter 12: Alcohol

Updated 9 November 2021

This guidance is issued jointly by the Department of Health and Social Care, the Welsh Government, the Department of Health Northern Ireland, Public Health England, NHS England and NHS Improvement and with the support of the British Association for the Study of Community Dentistry.

Delivering Better Oral Health has been developed with the support of the 4 UK Chief Dental Officers.

Whilst this guidance seeks to ensure a consistent UK wide approach to prevention of oral diseases, some differences in operational delivery and organisational responsibilities may apply in Wales, Northern Ireland and England. In Scotland the guidance will be used to inform oral health improvement policy.

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Alcohol misuse

In England, among people aged 15 to 49 years, alcohol is the leading cause of ill-health, disability, and death (1 , 2) . Alcohol misuse across the UK is a significant public health problem with major health, social and economic consequences, estimated at between £21 and £52 billion a year (3) . Each year there are over 1 million admissions to hospital for alcohol-related conditions (4) .

Alcohol consumption is a public health issue across Europe, which has the highest per capita consumption of alcohol of all regions globally, and the highest level of alcohol-related harms (5) . Harmful use of alcohol contributes not only to the burden of non-communicable diseases (NCDs), but also to the burden of communicable diseases, as well as violence and injuries (6) .

This chapter will highlight the extent of the problem and summarise the links between alcohol and oral health. It will outline brief advice and the use of a screening tool which dental team members can use to support their patients who drink alcohol, to lower their risk in relation to general and oral health.

Alcohol and health

The UK Chief Medical Officers ( CMOs ) advise that to keep the risk from alcohol low, adults should not regularly drink more than 14 units of alcohol per week. Alcohol adversely affects health in a range of ways and there is no definitively ‘safe’ lower limit – no level of regular alcohol consumption improves health. There is a significantly increased risk of oral cancers among drinkers, particularly when combined with smoking or any form of tobacco use. These behaviours are linked; it is therefore important to recognise that drinking alcohol during an attempt to stop smoking can potentially reduce the chances of effectively quitting and this needs to be considered carefully (7) . Alcohol has a wide range of health impacts including cardiovascular disease, cancers (breast, bowel, throat and mouth), and drinking during pregnancy can lead to long-term harm to the baby (3) .

For alcohol, frequency of consumption is more important than duration in years – higher consumption over a few years has a higher risk for oral cancer than a lower intake over many years (8) , although duration is still important as a risk factor for other chronic diseases like cardiovascular disease. There is some variation by site, with evidence by head and neck cancer sites that drink-years are associated with more pharyngeal/oral cavity site cancer when compared with laryngeal cancer (8) .

Alcohol consumption

Around 21% of the adult population in England and 24% of adults in England and Scotland, regularly drink at levels that increase their risk of ill health (increasing risk and higher risk drinkers) (9) . The latest health survey for England, in 2018, suggested that more than twice as many men than women drank at levels of increasing risk in a usual week (25% and 11% respectively); and, similarly at higher risk levels (5% of men drank over 50 units and 3% of women drank over 35 units) (10) . Adults living in the least deprived areas were more likely to drink over 14 units of alcohol in a usual week than those living in the most deprived areas (27% compared with 18%) (10) . Whilst younger adults are less likely to drink than any other age group, when they do drink, the evidence suggests that consumption on their heaviest drinking day tends to be higher than that of older people (9) . There is emerging evidence that people who have a dry month such as ‘Dry January’ subsequently reduce their drinking (11) .

What is a unit of alcohol?

One unit equals 10ml or 8g of pure alcohol, which is around the amount of alcohol the average adult liver can break down in an hour, although this will vary from person to person. If a wine label says ‘12% ABV’ or ‘alcohol by volume 12%’, it means 12% of the volume of that drink is pure alcohol (12) . To work out how many units there are in any drink, multiply the total volume of a drink (in ml) by its ABV (measured as a percentage) and divide the result by 1,000. Figures 12.1 and 12.2 provide visual representation of drinks in relation to their units of alcohol.

Figure 12.1. Alcohol unit reference. Source: (13)

One unit of alcohol is: one half pint of ‘regular’ beer, lager or cider, half a small glass of wine, one single measure of spirits, one small glass of sherry, one single measure of aperitifs. Drinks that are more than a single unit are: one pint of ‘regular’ beer, lager or cider (2), one pint of ‘strong’ or ‘premium’ beer, lager or cider (3), one Alcopop or a 275ml bottle of regular lager (1.5), one 440 ml can of ‘regular’ lager or cider (2), one 440 ml can of ‘super strength’ lager, one 250 ml glass of 12% wine (3), one 75cl bottle of 12% wine (9).

Figure 12.2. Alcohol unit guide. Source: (12)

The number of units you are drinking depends on the size and strength of your drink.

Wine	11% ABV wine	14% ABV wine	Beer	3.8% ABV lager	5.2% ABV lager
125ml glass	1.4 units	1.8 units	284ml half pint	1.1 units	1.5 units
175ml glass	1.9 units	2.4 units	440ml can	1.7 units	2.3 units
250ml glass	2.8 units	3.5 units	568ml pint	2.2 units	3 units
750ml bottle	8.2 units	10.5 units	660ml bottle	2.5 units	3.4 units

Guidelines on alcohol

The UK CMOs ’ low risk guidelines for alcohol consumption in 2016 provide clear recommendations on alcohol (15 to 17) .

All adults

To keep health risks to a low level, it is safest not to drink more than 14 units per week. For adults who drink as much as 14 units per week, it is best to spread this evenly over 3 days or more.

Young people

An alcohol-free childhood is the healthiest and safest option.

Pregnant women

The safest approach for women who are pregnant, or planning a pregnancy, is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk. The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.

Cutting down alcohol consumption

A good way to help achieve this is to have several drink-free days each week.

Drinking risk categories

The term low risk drinking implies that no level of alcohol consumption is completely safe. Furthermore, the context can determine the level of risk, for example drinking and driving, in conjunction with medication or where there is pre-existing chronic illness.

The guidelines state the following.

Low risk drinking

‘Low risk’ is not regularly exceeding 14 units per week, spread evenly over the week. This level of consumption represents a low risk of long term or short-term health harm for a healthy adult.

Increasing risk drinking

Increasing risk means drinking in a way that raises the risk of ill health from drinking alcohol. For both men and women, this means regularly drinking more than the low risk guideline of 14 units per week and up to 35 units for women and 50 units for men.

Higher risk drinking

Higher risk drinking for women is regularly drinking more than 35 units per week and for men regularly drinking more than 50 units per week. People in this group are likely to already be experiencing health damage from their alcohol use, even if it is not yet evident.

Binge drinking

Binge drinking really means drinking enough on a single occasion to get drunk (The technical definition of binge drinking is drinking 6+ units (women) or 8+ units (men) in a single session) (18) . Drunkenness can lead to risky behaviour and an increased risk of injury.

Sources: (15 , 19)

Alcohol dependent drinking

Alcohol dependence is a disorder of regulation of alcohol use arising from repeated or continuous use of alcohol (20) . The characteristic feature is a strong internal drive to use alcohol, which is manifested by impaired ability to control use, increasing priority given to use over other activities and persistence of use despite harm or negative consequences. These experiences are often accompanied by a subjective sensation or urge or craving to use alcohol. Physiological features of dependence may also be present, including tolerance to the effects of alcohol, withdrawal symptoms following cessation or reduction in use of alcohol, or repeated use of alcohol or pharmacologically similar substances to prevent or alleviate withdrawal symptoms. The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if alcohol use is continuous (daily or almost daily) for at least one month (20) . Adults identified as misusing alcohol encompasses a very wide pathology: people drinking above low risk but who are not dependent; and people with mild, moderate and severe dependence.

Interventions which most effectively support patients to reduce alcohol consumption

Supporting patients with brief interventions for alcohol is important in relation to the prevention of oral cancer and in particular, when combined with tobacco use ( Chapter 2: Table 4 ; Chapter 11 ). In addition to the benefits for general health, there is also some evidence that patients with periodontal disease may have the potential to benefit from reducing alcohol intake ( Chapter 5 ).

Identification and Brief Advice ( IBA )

A significant proportion of the healthy general population visit a dentist on a regular basis. There is evidence that identifying patients’ alcohol health risk, and feeding it back to them along with some advice on cutting down, is effective in reducing alcohol consumption (21) .

Behavioural counselling for adults

Whereas for non-dependent drinkers IBA is helpful in risk reduction ( 19 ), NICE guidance suggests that adults who are dependent drinkers require behavioural counselling using motivational interviewing or cognitive behavioural therapy ( CBT ) as part of a package of care (22) . There is moderate to low quality evidence that behavioural counselling interventions improve outcomes such as alcohol consumption, heavy drinking episodes, and drinking above the low risk threshold in adults who have been identified by screening in primary care settings as misusing alcohol (21) . The evidence for effectiveness of behavioural interventions amongst pregnant women is inconclusive (21) .

Brief interventions can reduce alcohol consumption for hazardous and harmful drinkers compared to minimal or no intervention (23) . Longer duration interventions probably have little additional benefit (23) .

Children and young adults

There is insufficient evidence currently on the role of behavioural counselling interventions in reducing alcohol consumption, heavy drinking episodes, and drinking above recommended amounts in adolescents who have been identified by screening in primary care settings as misusing alcohol (21) .

Dental teams are in a good position to identify people at risk and provide brief advice and support to those who are drinking above the low risk levels ( Figure 12.3 ).

The primary goal of IBA is to reduce alcohol consumption by showing the patient the following.

1. Their drinking might be putting their health at risk (they may be completely unaware).
2. What the patient can do about it.

Figure 12.3. Alcohol pathway: IBA .

Screening tool (Ask)

The AUDIT (Alcohol Use Disorders Identification Test for Consumption) screening tool was originally developed by the World Health Organization as a simple method of screening for excessive drinking and to assist in brief assessment (24) . Its shortened form, AUDIT-C, outlined in the previous version of Delivering Better Oral Health ( DBOH ) is now widely used as a screening tool and is shown in Figure 12.4. It is also available as a patient scratch card. There is evidence that this brief alcohol screening tool can be successfully used in general dental practice to identify patients at risk of harm from excessive alcohol consumption (25 , 26) .

Figure 12.4. Audit C scratch card. Source: (13)

Advise

Advise the patient of the level of alcohol health risk indicated by their score.

Provide feedback and information relevant to their level of risk, and give a patient information leaflet .

Score 4 or below

Low risk: it’s good practice to give positive feedback and encourage your patient to keep their drinking at low-risk levels.

Score 5 to 10

Increasing or higher risk: it’s suggested to give brief advice to highlight the risk of harms caused by alcohol and the benefits of cutting down. Feedback to the patient that their level of drinking is putting them at risk of developing a range of health problems (including cancers of the mouth, throat and breast) and this risk increases the more you drink and how frequently you drink (23) .

Highlight the recommendations from the CMOs . For example, you can say that:

• to keep health risks from alcohol to a low level, it is safest not to drink more than 14 units a week on a regular basis
• if you regularly drink as much as 14 units per week, it’s best to spread your drinking evenly over 3 or more days
• if you wish to cut down the amount you drink, a good way to help achieve this is to have several drink-free days a week

Score 11 or 12

Drinking could be becoming a problem, explore the option of referral to a specialist alcohol addiction service or to a GP. Do not merely advise these patients to stop drinking as they may require support to do so safely. They may need to be referred for a full assessment by a specialised service who can advise on appropriate support. It can be dangerous for some dependent drinkers to withdraw without medical supervision (19) .

Other relevant issues

Vulnerable people

Alcohol use is higher among certain groups in society, such as homeless people, who may also have other conditions or circumstances that exacerbate the risk from alcohol; they may therefore have additional support needs (27) .

Combined behaviours: tobacco and alcohol

Tobacco and alcohol are linked behaviours, whereby around one quarter of smokers drink above low risk guidelines (7) . Alcohol increases the level of ‘feel-good’ chemicals produced in the brain by nicotine. Nicotine changes how the brain responds to alcohol, which means more alcohol is needed before people get the same feel-good response as a non-smoker after a couple of drinks.

The available training suggests that there is no harm in talking to patients about both their smoking and alcohol consumption in one session (7) . The most important issue is to deliver person-centred advice and support and therefore the best option may be to offer the chance to explore both issues and let the patient decide which to start with. Some health professionals prefer to talk to their patients about smoking before raising the issue of alcohol consumption, while others will prefer to let their patient decide whether to talk about tobacco or alcohol use first. Both approaches are perfectly fine (7) .

It is worth being aware that if a patient is stopping smoking, they may need to think carefully about their alcohol consumption, as once they have had a few units of alcohol to drink, their willpower to maintain tobacco cessation may be reduced (7) .

Apps to assist with alcohol monitoring

There are now free apps that some patients may find useful for monitoring their alcohol consumption such as:

• Drink Free Days
• Dry January

Further evaluation is required on the effectiveness of using technology for reducing alcohol consumption.

Resources

E-learning for healthcare: Alcohol Identification and Brief Advice programme . This includes useful videos which demonstrate practising AUDIT-C.

E-learning for healthcare: Alcohol and Tobacco Brief Interventions programme .

Health Matters: tobacco and alcohol CQUIN . This includes links to infographics resources, the AUDIT-C scratch card and a structured alcohol advice patient information leaflet.

Screening and brief advice for alcohol and tobacco use in inpatient settings

Alcohol and drug misuse prevention and treatment guidance .

Alcohol use screening tests (includes the AUDIT-C tool) .

Alcohol Change UK : a leading UK alcohol charity formed from the merger of Alcohol Concern and Alcohol Research UK. This includes a dry January app and alcohol unit calculator.

One you: Drink less .

Local Alcohol Profiles for England .

References

1. Alcohol Change UK. Alcohol Statistics: Alcohol Research UK

2. Public Health England. The Burden of Disease in England compared with 22 peer countries: executive summary London: Public Health England; 2020 (updated 17 January 2020).

3. Public Health England. The public health burden of alcohol: evidence review. London: Public Health England; 2016.

4. NHS Digital. Statistics on Alcohol London: NHS Digital; 2020 (updated 4 February 2020).

5. World Health Organization. Alcohol in the European Union Consumption, harm and policy approaches. Copenhagen: WHO Regional Office for Europe; 2012.

6. World Health Organization. Time to Deliver in Europe Meeting noncommunicable disease targets to achieve the Sustainable Development Goals: Outcome report from the WHO European High-level Conference on Noncommunicable Diseases . Ashgabat, Turkmenistan, 9–10 April 2019 Copenhagen: WHO Regional Office for Europe; 2019

7. NHS England, Health Education England, Public Health England. Alcohol and Tobacco Brief Interventions Programme : NHS England; 2019

8. Lubin JH, Purdue M, Kelsey K, Zhang ZF, Winn D, Wei Q and others. Total exposure and exposure rate effects for alcohol and smoking and risk of head and neck cancer: a pooled analysis of case-control studies. American journal of epidemiology. 2009;170(8):937-47.

9. UK government National Statistics, Statistics on Alcohol, England 2020 .

10. National Statistics, NHS Digital. Health Survey for England: Adult health related behaviours. 2019.

11. de Visser RO, Robinson E, Bond R. Voluntary temporary abstinence from alcohol during ‘Dry January’ and subsequent alcohol use. Health Psychology. 2016;35(3):281-9.

12. NHS England. Alcohol Units London: National Health Services England; 2019 (updated 13 April 2018).

13. UK government. Alcohol use disorders identification test consumption (AUDIT C) . London: UK Gov; 2019.

14. NHS. STOPTOBER: quit smoking with Stoptober London: NHS; 2019 (updated 13.04.2018). Available from: https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/.

15. Department of Health England, Welsh Government, Department of Health Ireland, Scottish Government. UK Chief Medical Officers’ Low Risk Drinking Guidelines 2016. London: Departments of Health; 2016.

16. Donaldson L. Guidance on the Consumption of Alcohol by Children and Young People. London: Department of Health; 2009.

17. Mamluk L, Edwards HB, Savović J, Leach V, Jones T, Moore THM and others. Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently ‘safe’ levels of alcohol during pregnancy? A systematic review and meta-analyses. BMJ Open. 2017;7(7):e015410.

18. Office of National Statistics. Adult drinking habits in Great Britain: 2017. London: ONS; 2018.

19. NICE . Alcohol-use disorders: prevention PH24. London: NICE ; 2010 02.10.2010. Contract No.: PH24.

20. World Health Organization. ICD-11 for Mortality and Morbidity Statistics 6C40.2 Alcohol dependence. Geneva: WHO; 2020.

21. Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL and others. Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2012;157(9):645-54.

22. NICE . Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence CG115. London: NICE ; 2011 23.02.2011. Contract No.: CG115.

23. Kaner EFS, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N and others. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews. 2018(2).

24. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care, Geneva: World Health Organization; 2001.

25. Ntouva A, Porter J, Crawford MJ, Britton A, Gratus C, Newton T and others. Alcohol Screening and Brief Advice in NHS General Dental Practices: A Cluster Randomized Controlled Feasibility Trial. Alcohol and Alcoholism. 2019;54(3):235-42.

26. Venturelli R, Ntouva A, Porter J, Stennett M, Crawford MJ, Britton A and others. Use of AUDIT-C alcohol screening tool in NHS general dental practices in North London. British Dental Journal. 2021.

27. Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders. Cochrane Database of Systematic Reviews. 2016(11).