Summary of the impact

In 2007, consumption of alcohol by children and young people was made a priority in the Labour Government's National Alcohol Strategy, which acknowledged that whilst decreasing numbers of young people were drinking alcohol, those who were, consumed more alcohol more often. Given the association of high-risk behaviours with high-levels of alcohol consumption, this commitment was taken forward with the publication of the Youth Alcohol Action Plan in 2008.

This case study demonstrates the central role that the group's research has played in guiding and shaping coherent, evidence-based alcohol policy for children and young people, including the development of the first national guidance on alcohol consumption by children and young people in England.

Underpinning research

The group's research programme on alcohol and young people developed through initial work to support the development of alcohol policy in North West England, along with an on-going research programme into youth risk behaviours in nightlife environments. Building on this expertise, between 2006 and 2007 Jones and Bellis produced systematic reviews to support the development of National Institute for Health and Care Excellence (NICE) guidance on preventing alcohol misuse in young people. An epidemiological review provided evidence of associations between adolescent alcohol consumption and outcomes including risky sexual behaviour, injuries and violence. In 2008, Jones extended this work by conducting a comprehensive synthesis of international evidence on harms associated with alcohol in children and young people. Findings provided the evidence-based framework for the Chief Medical Officer for England's new guidance on alcohol consumption by children and young people (CMO guidance).

Epidemiological studies by the group also contributed to the CMO guidance. These included analyses of biennial surveys of school children in North West England (~10,000 per year) implemented by Trading Standards with support from the group to monitor trends in underage drinking. Bellis, Hughes, Wood and Morleo examined the extent and impacts of underage drinking in these samples, finding strong associations between alcohol-related harms and unsupervised alcohol use, drinking in public places and cheap alcohol access, and protective effects for parental supervision at low levels of alcohol use [1, 2]. The group's use of ecological analyses to examine the contribution of alcohol use to teenage pregnancies nationally also supported the guidelines; identifying, independent of deprivation, evidence of a significant relationship between teenage conceptions and alcohol-related hospital admissions in young people [3].

The group also characterised the burden of alcohol-related disease expected in a 2005 birth cohort through development of an evidence-based disease incidence model, which was extended in 2007-2008 by employing new methodologies to calculate England-specific alcohol-attributable fractions (AAFs) [4]. The AAFs were subsequently used by the group to estimate the national disease burden of alcohol consumption in England in 2005; showing that 3% of all deaths were attributable to alcohol consumption and that young people were disproportionally affected by alcohol use. Building upon the Local Alcohol Profiles for England (LAPE www.lape.org.uk) tool that was developed for the Department of Health, the group developed a measure of alcohol-related harm in young people that has been adopted by government as a national performance indicator for local areas in England.

Focusing on young people's alcohol consumption in nightlife environments, Hughes, Bellis and Quigg undertook a series of studies to examine quantities and patterns of alcohol use and associated harms, including the first UK study to identify the extent and impacts of preloading (that is, consuming alcohol in private settings prior to visiting pubs and nightclubs) [5, 6]. These studies show that more than half of young nightlife users preload and linked preloading to increased alcohol consumption and greater involvement in violence [5, 6].

Key members of the research group: Professor Mark Bellis (1999 to 2013); Professor Karen Hughes (Professor of Behavioural Epidemiology, from 1999), Ms Lisa Jones (Reader in Public Health Evidence Synthesis, from 2005), Ms Sara Wood (nee Hughes, Senior Public Health Researcher/Analyst, from 2004).

References to the research

Representative publications/peer-reviewed journal articles (citation information taken from Scopus, 20^th November 2013):

This report was a product of core Public Health Observatory funding. The findings were subject to rigorous in-house peer review by the Department of Health and adhered to their quality assurance processes. A copy of this document can be supplied by LJMU upon request.

A copy of this document (reference 4) can be supplied by LJMU upon request.

Research Grants:

i. Effectiveness and cost-effectiveness of interventions delivered in primary and secondary schools to prevent and/or reduce alcohol use by young people under 18 years old. National Institute for Health and Care Excellence; 2007-2008; £95,000. Bellis MA (PI).

ii. Focus on Alcohol Safe Environment (FASE). PHEA; 2008-2010; €216,154 (value to LJMU €54,910). LJMU (award holder).

iii. North West Public Health Observatory core funding; Department of Health; April 2008 - March 2009; £639,600. Bellis.

iv. Alcohol Measures for a Public Health Research Alliance (AMPHORA). European Commission; FP7, 2009-2013; €3 million (value to LJMU €98,438). LJMU (award holder).

Details of the impact

As the priority of alcohol policy in England increasingly focused on children and young people, the group's established profile for high-quality alcohol research afforded opportunities to stimulate, guide and shape debates about alcohol in local and national political agendas. For example, the group's research on underage drinking was cited in the initial 2008 Youth Alcohol Action Plan (corroborating reference 1), while Bellis was an invited keynote speaker at Westminster Health Forums (2008, 2009) that served to stimulate and inform debate on alcohol between policymakers in Parliament, Whitehall, government agencies, health bodies and key stakeholders (corroborating reference 2).

Based on the group's research and engagement with policy discussions, in 2008 Bellis was asked to support the production of CMO guidance on alcohol consumption by children and young people (corroborating references 3 and 4). Underpinning research by the group showed that unsupervised and heavy drinking were widespread in young people in England, yet there was no guidance on alcohol consumption available for young people, their parents or professionals. The new CMO guidance established a national evidence-based position on underage alcohol consumption and made the UK one of the few countries to establish such guidance. The group's evidence synthesis provided the framework for the CMO's five recommendations and, alongside the group's primary research, determined their direction. The following examples show how the group's research impacted on the wording and content of the recommendations:

• Recommendation 2, that if young people aged 15-17 drink alcohol, it should be with parental guidance and in a supervised environment, was based on the group's evidence synthesis and the group's research findings that parental supervision of child alcohol consumption was associated with lower levels of drinking in public places.
• Recommendation 3, that 15-17 year olds that drink should do so no more than once a week and never exceed adult daily limits, was based on the group's evidence synthesis which highlighted the greater vulnerability of young people to the harmful effects of alcohol, bolstered by the group's research findings that binge drinking among young people was associated with regretted sex and fighting.
• Recommendation 4, that parents and carers should be informed of their influence on child alcohol consumption and supported to respond to this, was informed by the group's evidence synthesis that showed the importance of parental influences on young people's alcohol consumption, including the group's research linking binge drinking and parental supply of alcohol.

The CMO for England is the most senior advisor on health issues to the Government and the guidance was therefore influential in progressing national and local public health policy for children and young people in the UK (for example, corroborating reference 5). The CMO recognised the group's contribution in the foreword to the guidance:

"The work to support us in producing this report [CMO guidance] has been carried out by Professor Mark Bellis and his team at the Centre for Public Health, Liverpool John Moores University. I am deeply grateful to them for their excellent contribution."

Alongside guidance development, Bellis and Jones sat on the Expert Panel (in 2008) established by the Department for Children, School and Families to review evidence on the impact of alcohol on children and young people and develop ideas for advice and information for parents and young people. While the impact of the CMO guidance on reversing harmful social norms on alcohol among young people requires longer term study, since publication numerous interventions have been initiated to tackle underage drinking. This includes information for parents and children on alcohol; awareness raising campaigns; and plans to tighten legislation around licensed outlets persistently selling alcohol to children. A specific example of how the guidance has been used to shape local policy is the Hampshire County Council's policy for children and young people in foster care (available at: http://www3.hants.gov.uk/10-4alcoholconsumption.doc).

The Department of Health also commissioned the group to undertake research into alcohol-attributable fractions for alcohol-attributable disease (Jones et al., 2008). This piece of work culminated in a measure of harm which was subsequently adopted by the Government as a national indicator (NI39 — admissions for alcohol-attributable conditions). Intelligence relating to children and young people, and adults and alcohol-related harms were incorporated into the following documents: the Cumbria Alcohol Strategy 2005-2008; Wirral Alcohol Harm Reduction Strategy 2007-2010; Shropshire Alcohol Strategy 2008; and Wigan Borough Alcohol Strategy 2009-2012. The findings of the group's research on drinking environments also contributed to a national debate on the association between alcohol use, nightlife, violence and alcohol pricing (for example, corroborating reference 6).

Sources to corroborate the impact

1. Department for Children, Schools and Families, Home Office and Department of Health (2008).Youth Alcohol Action Plan. London: TSO.
   http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publications/standard/Alcoholdrugssubstancemisuse/Page1/Cm%207387
2. President, UK Faculty of Public Health.
3. Donaldson L (2009). Guidance on the consumption of alcohol by children and young people. London: Department of Health.
   http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110258
4. Chair in Health Policy, Imperial College London.
5. Jewell, T. (CMO for Wales). You, Your Child and Alcohol. Guidance on the consumption of alcohol by children and young people. Welsh Assembly Government.
   http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CC4QFjAA &url=http%3A%2F%2Fwww.drinkwisewales.org.uk%2F__assets%2Fasset88.pdf&ei=fyeCUvf1No KBhAfMkYHoDg&usg=AFQjCNG9AVW4onQxOltsFzSJLJOnWGe3fA&bvm=bv.56146854,d.ZG4
6. Select Committee on Home Affairs, Seventh Report:
   http://www.publications.parliament.uk/pa/cm200708/cmselect/cmhaff/364/36407.htm#a19