Alcohol Intervention Study

RESEARCH REPORT

March – April 2009

Prepared for: National Public Health Service (Wales) Client Contact: Jo Menzies TERMS OF CONTRACT Prepared by: Beaufort Research Agency contact: Sarah O'Donoghue Unless otherwise agreed, the findings of this study remain the copyright of Beaufort 2 Museum Place Research Ltd and may not be quoted, Cardiff published or reproduced without the CF10 3BG company’s advance approval. Tel: (029) 2037 8565 Approval to quote or publish will only be Fax: (029) 2037 0600 withheld on the grounds of inaccuracy E-mail: [email protected] or misrepresentation. Website: www.beaufortresearch.co.uk

Any approved publication must detail: © Beaufort Research Ltd 2009 Beaufort Research Ltd as provider, B2913 / SO / 19th August 2009 sample size and field dates.

CONTENTS

EXECUTIVE SUMMARY 1

1. Introduction 3

1.1 Background and Objectives 3 1.2 Methodology 4

2. Profile of Drinkers 6

3. Awareness of Alcohol Units 12

4. Drinking Behaviour 17

5. Attitudes to Drinking 22

6. Perceptions of the Impact on Personal Health 35

7. Ideas for Helping People Reduce Alcohol Consumption39

8. Reactions to Intervention Concepts 43

9. Conclusions and Recommendations 51

Appendix 1 – Omnibus Survey Questionnaire 53 Appendix 2 – Focus Group Topic Guide 61 EXECUTIVE SUMMARY

 A total of 40% of men and 25% of women were drinking more than the recommended daily alcohol limit – of these, 24% of men and 13% of women could be considered binge drinkers (men drinking 9+ units and women drinking 7+ units in one day). There is a definite gender bias, with significantly more men than women drinking over the recommended daily guidelines.

 An age difference was also seen; younger people tended to be heavier drinkers, with 43% of people aged 16-24 and 41% of those aged 25-34 drinking above the guidelines – this compares to only 22% of those aged 55+. This difference is even stronger when looking a binge drinkers - around a third (34%) of 16-24 year olds were classified as binge drinkers, almost four times the proportion of those aged 55+ who fell into this category (9%).

 Half (50%) of the sample had drank alcohol at least once a week in the last 12 months; of these, 7% reported to have drunk alcohol every day, 13% said they had drank between 3 – 5 times a week and almost a third (30%) said they drank once or twice a week. Almost a fifth (17%) of the sample said they had not drunk any alcohol in the last 12 months.

 Over half (56%) of regular drinkers drank both during the week and at weekends, with 38% only drinking at weekends and a small minority (4%) drinking only during the week.

 When asked if they drank more on some days than others, 50% of regular drinkers said they did, whereas 47% said they drank roughly the same amount each day.

 For regular drinkers who drank more on some days than others, most drank more alcohol on the weekend (38% drinking more on Friday and 65% drinking more on Saturday than on any other day) – consumers in the focus groups tended to look forward to the weekends as a time for socialising and drinking was considered a key ingredient of the socialising process.

 The majority of the total sample (85%) were aware of the concept of ‘alcohol units’ but detailed knowledge of the daily limits for women and men was mixed –two fifths of the population (41%) knew the correct limit for women and around a half (47%) knew the correct limit for men.

 Consumers in the focus groups found it difficult to relate the guidelines to their own drinking behaviour – there were two main reasons for this; comprehension (do these apply whether you drink every day or only occasionally?) and that they appear too far removed from current drinking patterns (it was considered more realistic to measure consumption by drinks rather than abstract units).

 Two thirds of regular drinkers (64%) felt they had at least some idea of the number of alcohol units contained in different drinks; of these, 20% claimed to know a lot about the different units in different drinks.

 However, in the discussion groups it became apparent that the term ‘unit’ did not mean a great deal – most calculated how much they were drinking by the number of drinks consumed. This was corroborated by the quantitative research; 74% said they had a good idea of how much they were drinking, and of these, most (72%) counted the number or types of drinks consumed rather than alcohol units.

 The vast majority (80%) of regular drinkers did not want to cut down on their alcohol consumption. Only 16% said they did – this rose to 25% amongst those drinking over the recommended daily guidelines.

B2913 Alcohol Intervention Study 1 © Beaufort Research Ltd 2009 March – April 2009  Although half of the participants in the discussion groups wanted to reduce their alcohol consumption, the combination of the enjoyment associated with alcohol and a lack of willpower created powerful barriers to adopting any changes in drinking behaviour. Key factors challenging consumption reduction were that alcohol enhanced the social experience, alcohol was seen as a reward, alcohol had become engrained into routines and current drinking patterns had not resulted in any negative health / social consequences.

 Opinion was divided amongst regular drinkers about the impact of alcohol on long-term health, and those who were regularly drinking more than the recommended daily alcohol limits tended to down-play both the effects of drinking on long-term health and the seriousness of it. Heavier drinkers were also more inclined to se drinking alcohol as a positive enhancer of social situations.

 The majority of regular drinkers acknowledged the dangers of alcohol dependency, however in the focus groups, participants found it difficult to relate any of the more serious signs of drinking too much to their own behaviour. Key signals of drinking too much and the mild to serious behaviours that identified them included:

o Health (from a mild hangover to cirrhosis of the liver) o Dependency (from drinking more at home to drinking in the morning) o Behaviour (from doing something stupid to having a short temper) o Social status (from being in trouble with a spouse to having your family leave you).

 Most regular drinkers (77%) did not consider their drinking was impacting on their long-term health. However, those drinking over the recommended daily guidelines were more likely to admit their drinking could have a possible or likely impact on their long-term health (29% above the limit, 38% binge drinkers compared to 7% those drinking within guidelines). Participants of the discussion groups showed limited awareness of the long-term health implications of drinking over the recommended daily alcohol limit, and were more likely to consider diet and exercise as key contributors to a healthy lifestyle.

 Amongst regular drinkers who wanted to reduce their alcohol consumption, most popular methods for doing so were talking to a friend or family member (29%), reading information in leaflets, books or on the Internet, or doing it themselves with willpower (23% for each).

 Two key themes emerging from focus groups participants’ ideas for reducing the amount of alcohol people drink were education (raising awareness of the impact of heavy drinking) and breaking habits (including interventions in a more holistic overall health check).

 Reaction to the four intervention concepts (booklet / website, face-to-face discussion, telephone discussion or peer group meeting) was ‘luke-warm’. The majority of regular drinkers said, for each concept, that they would be unlikely to use it. Of the four, the booklet / website was the most popular, with 23% saying they would be likely to use it. This was followed by the short face-to- face discussion with a health professional (21% saying they would be likely to use it).

 In the focus groups, participants were also not particularly interested in the four proposed concepts. A major obstacle was their recognising a need for the service, as they were seen to be aimed at people with a drink ‘problem’. Relatively more interest was shown in the booklet / website, and to a lesser extent the face-to-face meeting, than in the group meeting and phone chat proposed services.

B2913 Alcohol Intervention Study 2 © Beaufort Research Ltd 2009 March – April 2009 1. INTRODUCTION

1.1 Background and Objectives

The Welsh Assembly Government has requested that the National Public Health Service for Wales scopes public reaction to a community-based intervention service aimed at reducing the amount of alcohol being drunk by people who are currently drinking more than the recommended daily amount. Part of the scoping exercise included market research amongst the general public, and more specifically amongst people drinking heavily on a regular basis.

The specific objectives of the research were as follows:

 Profile the current drinking behaviour of adults in Wales.

 Evaluate awareness of alcohol units in drinks.

 Ascertain attitudes towards hazardous and harmful alcohol consumption and its impact on health.

 Explore attitudes to health in general.

 Ascertain potential service users’ attitudes to various proposed alcohol intervention schemes.

 Determine potential users’ barriers to seeking advice and support to reduce their alcohol consumption.

This report contains the findings arising from the study - full data tabulations are available in a separate document.

B2913 Alcohol Intervention Study 3 © Beaufort Research Ltd 2009 March – April 2009 1.2 Methodology

A combined quantitative and qualitative approach was taken for the research.

Quantitative Survey

A total of 1,002 interviews were conducted using the Welsh Omnibus survey. The interviews were conducted in-home using CAPI (Computer Aided Personal Interviewing) technology in a cross section of Welsh homes sampled by electoral ward. A total of 68 sampling points were used across the whole of Wales.

The sample was designed to be representative of the adult population resident in Wales aged 16 and over and within each sampling point, interlocking quota controls of age and social class within sex were used for the selection of respondents. The quotas were set to reflect the demographic profile of Welsh residents and no more than one person per household was interviewed.

The resultant data was also weighted by age group within gender within Unitary Authority grouping to fine-tune any imbalances in the sample and ensure that it was representative of the Welsh population.

Parts of the questionnaire were asked of the total sample (e.g. awareness of alcohol units, awareness of recommend daily alcohol limits and whether respondents had drank any alcohol in the last 7 days). However, the majority of the questionnaire was targeted at regular drinkers. These were defined as:

 People who had drunk alcohol at least once or twice a week in the last 12 months  OR those who had drunk 2 or more units of alcohol in the last 7 days.

Fieldwork took place between 6th and 18th March 2009.

Qualitative Study

The qualitative research design consisted of six mini discussion groups (four to six participants) with consumers drinking more alcohol than the daily recommended guidelines. We proposed smaller groups given the nature of the discussion.

The design took into account a number of criteria, principally:

. Whether or not consumers wanted to reduce their alcohol consumption . Age . Gender . Socio-economic grouping

B2913 Alcohol Intervention Study 4 © Beaufort Research Ltd 2009 March – April 2009 The group composition is summarised in Table 1 below.

Socio- Reducing Table 1 Gender Age economic consumption group Group 1 Want to reduce Female 31-50 ABC1

Group 2 Do not want to reduce Male 18-30 C2DE

Group 3 Want to reduce Male 31-50 C2DE

Group 4 Do not want to reduce Female 18-30 ABC1

Group 5 Want to reduce Male 18-30 ABC1

Group 6 Do not want to reduce Female 31-50 C2DE

Fieldwork took place between 7th and14th April 2009 in Wrexham, Swansea, Newport and Cardiff. We convened an additional group as only three participants attended one group.

Discussion flow

The recruitment questionnaire used for the discussion groups included lifestyle questions so that it did not emphasise too strongly the alcohol focus of the study. As a result, we were able to begin the discussions on the general theme of health and wellbeing and establish the context within which attitudes to alcohol sit.

The discussion then focused on alcohol and alcohol consumption, which included a creative idea generation technique (‘Fast forward’, see Discussion guide in appendix) to generate ideas for helping consumers reduce their alcohol consumption.

The questionnaire and topic guide used for this study are appended to this document.

B2913 Alcohol Intervention Study 5 © Beaufort Research Ltd 2009 March – April 2009 2. PROFILE OF DRINKERS

Respondents of the Omnibus survey (a representative sample of the Welsh population aged 16+) were asked to estimate how frequently they had drunk alcohol in the last 12 months.

A fifth (20%) reported that in the last 12 months they had drunk alcohol between 3 – 7 days a week, including 7% saying they drank almost every day. Almost a third (30%) claimed to have drunk alcohol once or twice a week. A similar proportion (32%) said that in the last 12 months they had drank alcohol less frequently than this, and 17% said they had not drunk any alcohol in the last 12 months – see Figure 1 below.

Fig 1 - How Often had a Drink in Last 12 Months Amongst all respondents

10 9 9 7

Almost 5-6 days a 3-4 days a 1-2 times a 1-2 times a Once Once or Not at all every day weeks week week month every twice a couple of year Base: all respondents (1,002) months

Respondents were also asked on which day of the week in the last 7 days had they drank the most alcohol – almost half (47%) reported that they had not drunk any alcohol in the last 7 days.

Perhaps not surprisingly, weekends were when most people reported to have drunk the most alcohol; 11% drank most on Friday, 22% most on Saturday and 7% most on Sunday. Only 11% claimed they drank the most alcohol on a week day – see Figure 2 overleaf.

B2913 Alcohol Intervention Study 6 © Beaufort Research Ltd 2009 March – April 2009 Fig 2 - Day on Which Drank most Alcohol in Last 7 Days Amongst all respondents 47

2 3 3 3 2

Mon Tues Wed Thurs Fri Sat Sun Not drank DK in last 7 Base: all respondents (1,002) days

Respondents were asked to think back to the day in the last week when they had drunk the most alcohol and estimate how many units of alcohol they had consumed. To aid them with their calculation, they were presented with a showcard explaining the number of alcohol units in various types of drinks – Figure 3 below illustrates the showcard that was presented to respondents.

Fig 3 – Showcard of Alcohol Units in Drinks L G A N M O R R O T N S

1 pint of normal 1 pint of strong beer, 1 small (125ml) glass 1 large (175ml) glass Single spirit measure 1 alcopop strength beer, lager, lager, stout or cider of wine, sherry or of wine, sherry or (whisky, gin, vodka stout, cider, or shandy vermouth vermouth etc.) (excluding cans and bottles of shandy)

= 2 Units = 3 Units = 1.5 Units = 2 Units = 1 Units = 1.5 Units

B2913 Alcohol Intervention Study 7 © Beaufort Research Ltd 2009 March – April 2009 Based on the number of units of alcohol they had drank in the last 7 days, respondents were categorised as either drinking within the guidelines, drinking above the guidelines or binge drinkers (a sub-set of those drinking above the guidelines). The following explains the criteria used for defining the three categories:

 People drinking within guidelines: o Those people who have not had a drink in the last 7 days. o Women who drank between 1-3 units on the day when they drank the most. o Men who drank between 1-4 units on the day when they drank the most.

 People drinking above guidelines: o Women who drank between 4+ units on the day when they drank the most. o Men who drank between 5+ units on the day when they drank the most.

 Binge drinkers: o Women who drank between 7+ units on the day when they drank the most. o Men who drank between 9+ units on the day when they drank the most.

Firstly looking at the amount of alcohol drunk by men, 37% of men said that they had not consumed any alcohol in the last 7 days. Another fifth (20%) had drunk between 1- 4 units on the day when they drank the most alcohol, and therefore over half of the sample of men (57%) were drinking within the recommended daily limits.

However, two fifths (40%) reported to have drunk 5 or more units on the day when they drank the most, and of these, 24% could be considered binge drinkers as they had drunk 9+ units on the day when they drank the most – see Figure 4 below.

Fig 4 - Units Drunk on Day Consumed Most Alcohol 37 Amongst all MEN

Drinking within guidelines (0 - 4 units) = 57% 24 Drinking above guidelines (5+ units) = 40% Binge drinkers (9+ units) = 24%

8 8 7 5 4 4 3 1

0 1 2 3 4 5 6 7 8 9+ DK

Base: all men (458)

B2913 Alcohol Intervention Study 8 © Beaufort Research Ltd 2009 March – April 2009 Turning now to the amount of alcohol drunk by women, a significantly higher proportion of women were drinking within the recommended guidelines when compared to men.

Over half (55%) reported to have drunk no alcohol within the last 7 days, and a further 18% had drunk between 1-3 units, therefore nearly three quarters (73%) of women were drinking within the recommended guidelines compared to 57% of men.

Conversely, a quarter (25%) were drinking over the daily recommended units of alcohol, and 13% of these could be considered binge drinkers (consuming 7+ units on the day when they drank the most). This compares to 40% of men who were drinking over the recommended daily alcohol limit and 24% who were binge drinkers.

See Figure 5 below for more details on the amount of alcohol being drunk by women.

Fig 5 - Units Drunk on Day Consumed Most Alcohol Amongst all WOMEN 55

Drinking within guidelines (0 – 3 units) = 73% Drinking above guidelines (4+ units) = 25% Binge drinkers (7+ units) = 13%

10 8 5 5 5 5 2 1 2 2

0 1 2 3 4 5 6 7 8 9+ DK Base: all women (544)

Figure 6 overleaf gives shows the combined results of men and women, and illustrates the number of alcohol units being drunk on the day when respondents drank the most across the whole sample.

Almost half (47%) said they had not drunk any alcohol within the last 7 days, 21% had drunk up to 4 units and 28% had drunk 5 or more units, with 16% saying they had drunk 9+ units on the day when they drank the most alcohol.

B2913 Alcohol Intervention Study 9 © Beaufort Research Ltd 2009 March – April 2009 Fig 6 - Units Drunk on Day Consumed Most Alcohol

47 Amongst all respondents

6 5 6 6 4 4 3 1 1

0 1 2 3 4 5 6 7 8 9+ DK

Base: all respondents (1,002)

Table 2 overleaf shows the demographic profile for people in each of the three categories of drinker:

 People drinking within guidelines  People drinking above guidelines  Binge drinkers.

As noted earlier, there is a clear gender difference for people drinking within the recommended daily limit and those drinking above the limit; significantly more men than women were drinking above the daily recommended limit.

The results also show that younger people tend to be heavier drinkers – around two fifths of those aged 16-24 (43%) and those aged 25-34 (41%) were drinking above the guidelines – this compares to only 22% of those aged 55+.

It is when considering binge drinking levels that the pattern of age related drinking is even stronger – around a third (34%) of 16-24 year olds were classified as binge drinkers, almost four times the proportion of those aged 55+ who fell into this category (9%).

B2913 Alcohol Intervention Study 10 © Beaufort Research Ltd 2009 March – April 2009 Table 2 - Alcohol Consumption by Demographics Amongst all respondents

Bases in brackets Drinking within Drinking above Binge drinkers guidelines guidelines (175) (657) (317) ALL 67 33 18 Gender Male (458) 57 40 24 Female (544) 73 25 13 Age 16-24 (154) 57 43 34 25-34 (125) 59 41 26 35-54 (313) 63 37 18 55+ (382) 78 22 9 Social Class ABC1 (444) 64 36 19 C2DE (530) 70 30 18

B2913 Alcohol Intervention Study 11 © Beaufort Research Ltd 2009 March – April 2009 3. AWARENESS OF ALCOHOL UNITS

Prior to establishing the number of alcohol units being consumed by respondents, we asked them whether they were aware of the recommended maximum daily units for men and women.

A significant minority were not aware of the concept of alcohol units (15%).

Around half (47%) of the population knew that the correct daily limit for women was 2-3 units. The remainder were either unable to state a number (21%), chose a number too high (10%) or chose a number too low (7%).

Women were no more likely than men to be aware of the correct daily limits for women (47% for both - see Figure 7 below.

Fig 7 - Perceptions of Recommend Max Daily Alcohol Units for Women Amongst all respondents 34

CORRECT = 47% WOMEN = 47%

MEN = 47% 21

7 4 3 1 1 1

Not 1 2 3 4 5 6 7 8 9+ DK aware

B2913 Alcohol Intervention Study 12 © Beaufort Research Ltd 2009 March – April 2009 A slightly lower proportion of respondents were aware of the correct recommended maximum daily units for men (41% saying 3-4 units), however men were more aware of the limits for their own gender (43%) compared to women (38%) – see Figure 8 below.

Fig 8 - Perceptions of Recommend Max Daily Alcohol Units for Men Amongst all respondents

24 21 20 CORRECT = 41% WOMEN = 38% 15 MEN = 43%

7 5 4 1 2 1

Not 1 2 3 4 5 6 7 8 9+ DK aware

The remainder of the quantitative questionnaire focussed on regular drinkers – these were respondents who had previously stated that they had drunk alcohol at least once or twice a week in the last 12 months or had drunk two or more units of alcohol in the last 7 days.

Regular drinkers were asked if, prior to the interview, they knew how many alcohol units were contained within various different drinks. Most claimed to have at least some knowledge – a fifth (20%) said they knew a lot about the units contained within different drinks, and another 44% said they had some idea.

However, almost a third (31%) of regular drinkers claimed that they had heard of units but didn’t really know how many were in different drinks, and a small proportion (3%) said that they had not heard about alcohol units before being interviewed by Beaufort – see Figure 9 overleaf.

B2913 Alcohol Intervention Study 13 © Beaufort Research Ltd 2009 March – April 2009 Fig 9 - How Much Knew About Alcohol Units Contained in Different Drinks Amongst regular drinkers 44

Knew a lot about Had some idea Heard of units but Hadn't heard of Don't know different units in about different units didn't really know alcohol units different drinks in different drinks how many in different drinks Base = all regular drinkers (579)

A similar picture emerged in the discussion groups. Participants were mostly aware of ‘units’ as a concept. But they tended not to be aware of the recommended alcohol consumption guidelines. Consumers normally guessed what it might be, in units, based on weekly consumption. For men, estimates ranged from six to eight units a week to 20-30 units a week, while for women, suggestions ranged from two to three units a week to four units a day.

All the estimates they provided were lower than the amounts they reported consuming.

It became apparent that the term ‘unit’ did not mean a great deal to consumers and posed a difficult challenge for them in trying to determine how many units, on average, they consumed. Most attempted to calculate the estimate by first thinking about how many drinks they consumed, and then what this might represent in units.

I don’t know what a unit involves. . . . . is it one pint equals one unit? (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

I’m not very aware of units to be honest. I’ve only noticed it on a bottle, say 1.8 for a Carlsberg, but for a shot or even a pint I’m not fully aware. (Male, want to reduce, 18-30, ABC1, Wrexham)

But what’s a unit? (Female, want to reduce, 31-50, ABC1, Swansea)

B2913 Alcohol Intervention Study 14 © Beaufort Research Ltd 2009 March – April 2009 I always get confused what a unit is. It loses me straight away. If it’s pints or how many, I could do that. (Male, don’t want to reduce, 18-30, C2DE, Cardiff)

When consumers in the discussion groups were shown the alcohol consumption guidelines, the information did not appear to have much of an impact on them. Some did find it informative in that it helped them to be more precise over how much they thought they drank. Indeed, a handful were surprised by the number of units in a drink, expecting it to be lower. Less often, those who did want to reduce the amount of alcohol they consumed paused for thought over the revelations of the unit to measurements ratio.

It’s made me wonder if I’m a binge drinker [9 shots at the weekend]. (Female, want to reduce, 31-50, ABC1, Swansea)

For the majority, however, it remained difficult to relate to these guidelines for two main reasons. First, in terms of comprehension: the idea of ‘daily’ guidelines proved hard to grasp, particularly when the guidelines state that ‘these daily amounts apply whether you drink every day, once or twice a week, or occasionally’. In consumers’ minds, drinking on a daily basis had to be more harmful than drinking less regularly. There was also uncertainty over calculating wine glass measurements at home and in the pub or bar. In addition, the impact of varying individuals’ body mass was raised: how did this affect recommended guidelines? Furthermore, some queried the guidelines themselves, wondering upon what evidence they were founded (for example, ‘the French drink all the time’).

I’d think about pints [per week] . . . bottles . . . definitely. (Male, want to reduce, 31-50, C2DE, Newport)

Having 2-3 units a day is very different from having it once a week. Surely it’s more damaging to drink continuously? (Female, don’t want to reduce, 18-30, ABC1, Newport)

The second main difficulty with the guidelines was that they appeared too far removed from consumers’ current drinking patterns. Although the guidelines sounded ‘sensible’, it was unrealistic for consumers to think in small, moderate volumes; and it was far more straightforward to measure volumes by pints, glasses, bottles, shots and weekly amounts. Some also acknowledged that they simply did not think in detail about how much they were consuming at the time they were drinking.

B2913 Alcohol Intervention Study 15 © Beaufort Research Ltd 2009 March – April 2009 Taking all these points into account, the guidelines were not informing consumers of why they should change their drinking habits.

It makes me stop and think . . . but even though I’m triple over the guidelines I know I’m OK when I go out [in control]. (Male, don’t want to reduce, 18-30, C2DE, Cardiff)

We know that if you drink lots it’s not good for you. (e.g. 6 bottles and some shots). Tell us something we don’t know. (Male, want to reduce, 18-30, ABC1, Wrexham)

It sounds sensible but it’s not practical. If you’re going for a night out, you wouldn’t just have one or two drinks. . . . it’s not going to make any difference to me. (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

Most people drink alcohol to get drunk, not to have a couple and chill out (Do you include yourself in that?) Yes, definitely. . . . There’s just no point in having that 3 to 4 [units] a day. . . if it was per week, it would be much more understandable. (Male, want to reduce, 18-30, ABC1, Wrexham)

B2913 Alcohol Intervention Study 16 © Beaufort Research Ltd 2009 March – April 2009 4. DRINKING BEHAVIOUR

When asked whether they drank during the week only, at weekends only or both, over half (56%) said they drank both during the week and at weekends.

Around two fifths (38%) said they only drank at the weekend, and a small proportion (3%) reported to drink alcohol only on weekdays – see Figure 10 below.

Fig 10 - Usual Weekly Drinking Behaviour Amongst regular drinkers 56

Drink during the Drink at Drink both during DK week only weekends only the week and at weekends Base = all regular drinkers (579)

There was a roughly even split between those regular drinkers who said they drank about the same amount of alcohol each day (47%) and those who drank more alcohol on some days compared to others (50%) – see Figure 11 below.

Fig 11 - Usual Weekly Drinking Volumes Amongst regular drinkers 50 47

I drink roughly the I drink more on some DK /Refused same each day days than others

Base = all regular drinkers (579)

B2913 Alcohol Intervention Study 17 © Beaufort Research Ltd 2009 March – April 2009 Those who drank more on some days than others were asked on which days they drank more.

A clear pattern of drinking more than usual on the weekends appears – 38% drank more on Friday and almost two thirds (65%) drank more on a Saturday than on any other day. A smaller proportion (14%) drank more on a Sunday and only 18% claimed to drink more during the week – 8% did not know, however, on what day they drank the most – see Figure 12 below.

Fig 12 - Day on Which Drink More Alcohol Amongst regular drinkers who drink more on some days than others 65

14 8 8 5 3 2

Mon Tues Wed Thurs Fri Sat Sun DK

Base = regular drinkers who drink more on some days than others (287)

The discussion groups demonstrated that consumers very much looked forward to the weekend most, primarily for socialising. It was also associated with family time / time spent with the children, ‘me time’ and hobbies. Alcohol often featured as an ingredient of the socialising process whether at the weekend or during the week.

I look forward to Saturday evenings, with my husband and all the family together, I love it. (Female, want to reduce, 31-50, ABC1, Swansea)

Going out! On a Saturday night, and sport, watching and doing it. (Male, want to reduce, 18-30, ABC1, Wrexham)

The weekend, partying in town. . . . £12 and you can drink as much as you want. It’s brilliant. (Male, don’t want to reduce, 18-30, C2DE, Swansea)

B2913 Alcohol Intervention Study 18 © Beaufort Research Ltd 2009 March – April 2009 It’s hard work with my daughter [who’s autistic]. She’s quite demanding. . . . so I enjoy time on my own or with my mate on a Saturday. (Male, want to reduce, 31-50, C2DE, Newport)

Examples of drinking behaviour are given below, ranging from just over the recommended guidelines to binge drinking:

Nerys: likes a couple of glasses of wine at the weekend with her husband; she’s careful with amount she drinks, and tries, but sometimes fails, to avoid drinking during the week; she doesn’t like feeling drunk.

Allie: when she manages to get a babysitter, she likes to make the most of it, going out with friends and having ‘a few too many’ bottles (eight bottles of Smirnoff Ice on her birthday recently).

Paul: on his last night out, he drank four pints of lager at his local pub with the boys before going into town; he then switched to shorts to avoid feeling bloated.

When asked whether they kept track of the amount of alcohol they were drinking in an average week or month, three quarters (74%) said that they had a good idea in their head. However, almost a quarter (23%) admitted that they didn’t really know how much they Figwere 13drinking,- Keeping and a further Track 2% ofcould Amount not comment of Alcohol – see Figure Personally 13 below. Consumed Amongst regular drinkers

I really don't know how much alcohol I drink in an average week 23 or month

I've a good idea in my head how much alcohol I drink in an average 74 week or month

I record / write down how much I drink in an average week or month

DK / Refused 2 B2913 Alcohol Intervention Study 19 © Beaufort Research Ltd 2009 Base = all regular drinkers (579) March – April 2009 B2913 Alcohol Intervention Study 20 © Beaufort Research Ltd 2009 March – April 2009 Keeping track of personal alcohol consumption varied according to the amount of alcohol people reported to have drunk on the day when they had drank the most.

Those drinking over the recommended daily limit, and especially binge drinkers were more likely to say they did not know how much they were drinking (27% and 35% respectively) compared to people drinking within the recommended limit (14%). Conversely, more people drinking within the limit said they had a good idea in their head how much they were drinking in an average week or month (82%) compared to those drinking over the limit (71%) and binge drinkers (62%) – see Figure 14 below.

Fig 14 - Perceptions of Amount of Alcohol Personally Consumed Amongst regular drinkers by Alcohol Consumption

I really don't know 14 how much alcohol I 27 Drinking within drink in an average guidelines week or month 35

I've a good idea in my Drinking above head how much 82 guidelines alcohol I drink in an 71 average week or 62 month Binge drinkers I record / write down how much I drink in an average week or month 1

4 DK / Refused 2 2

Bases vary: Within guidelines (234); Above guidelines (317); Binge drinkers (175)

Those regular drinkers keeping track of how much they drank were asked how they calculated this – was it by counting the number of drinks they consumed, the number of alcohol units or a combination of both.

On the whole, drinkers were thinking about the number and types of drink consumed rather than alcohol units – almost three quarters (72%) counted drinks whereas only 10% counted units; a further 12% counted both drinks and units. In addition, 5% said that they did not know how they kept track of the amount they drank, suggesting that their may be some overclaim for those people saying they know how much alcohol they consumed in and average week or month – see Figure 15 overleaf.

B2913 Alcohol Intervention Study 21 © Beaufort Research Ltd 2009 March – April 2009 Fig 15 - Keeping Track of Alcohol Drank Using Units vs. No. Drinks Amongst regular drinkers who know how much they drink 72

12 10 5

Number / types of Alcohol Units Both DK drinks

Base = regular drinkers who know how much they drink (431)

B2913 Alcohol Intervention Study 22 © Beaufort Research Ltd 2009 March – April 2009 5. ATTITUDES TO DRINKING

Regular drinkers in the Omnibus survey were asked whether they wanted to cut down on the amount they were currently drinking – the vast majority did not.

A total of 80% said that they thought it was fine to continue drinking at their current level. Only a fifth (19%) claimed that they would like to cut down on their alcohol consumption; 16% of these said they would like to reduce it a little, whereas 3% would like to reduce it a lot – see Figure 16 below.

Fig 16 - Attitudes to Personal Drinking Habits Amongst regular drinkers 80

I think its fine for me I'd like to reduce my I'd like to reduce my DK to continue drinking alcohol consumption alcohol consumption at my current level a little a lot

Even amongst those drinking over the recommended daily limit there is reluctance to consider cutting down on their alcohol consumption. Three quarters (74%) of those drinking over the limit, and 63% of binge drinkers reported that they thought it was fine for them to continue drinking at their current level.

Only a quarter (25%) of the people who were drinking over the recommended limit expressed an interest in reducing their alcohol consumption – these people therefore represent the core target audience of the intervention programme, and are equivalent to 8% of the Welsh population – see Figure 17 overleaf.

B2913 Alcohol Intervention Study 23 © Beaufort Research Ltd 2009 March – April 2009 Fig 17 - Attitudes to Personal Drinking Habits Amongst regular drinkers by Alcohol Consumption 91

Drinking within guidelines 74 8% of Drinking above guidelines 63 Welsh population Binge drinkers

6 6 1 3 2 1 1

I think its fine for me I'd like to reduce my I'd like to reduce my DK to continue drinking alcohol consumption alcohol consumption at my current level a little a lot

Although half of the participants in the discussion groups wanted to reduce their alcohol consumption, the combination of the enjoyment associated with alcohol and a lack of willpower created a powerful barrier to adopting any changes in drinking behaviour.

Four key factors emerged which made consumption reduction such a challenge:

. Alcohol enhanced the social experience: Frequently described as an essential ingredient, alcohol was helping consumers; to ‘fit in’ in various social contexts such as at work and the sports club, to feel more confident in social situations (for example in bars and nightclubs) and to have fun with drinks promotions.

You don’t mind being a prat. You can have a laugh with your friends. (Male, want to reduce, 18-30, ABC1, Wrexham)

Sometimes I wake up with a headache but it’s worth it! (Female, want to reduce, 31-50, ABC1, Swansea)

B2913 Alcohol Intervention Study 24 © Beaufort Research Ltd 2009 March – April 2009 I went out the other Thursday [was driving] and didn’t have a drink and I felt completely out of place. (Male, want to reduce, 18-30, ABC1, Wrexham)

I’d like to [reduce my alcohol consumption] but I still like my Friday nights out. (Male, want to reduce, 31-50, C2DE, Newport)

. Alcohol was a routine reward: Consumers could view a drink as compensation for a hard day or week at work, or as a marker of the change from children to ‘me time’ once the children were in bed. In short, something they deserved or, as one consumer described it, ‘part of my relaxation package’.

I would like not to have to drink . . . not ‘have to drink’, I sound like an alcoholic. I know it sounds ridiculous, I don’t need to have a glass of wine but it relaxes me and I look forward to it in the evening. (Female, want to reduce, 31-50, ABC1, Swansea)

By the time the kids are in bed it’s 9pm and I’m exhausted. A glass of wine then off to bed! . . . every night without fail. (Female, want to reduce, 31-50, ABC1, Swansea)

. Alcohol had become engrained into routines: Building on the routine-reward theme, some consumers acknowledged that their patterns of routine drinking had become difficult to disrupt, to the extent that some older male participants, who wanted to reduce their consumption, believed that they might be too set in their ways to be able to break the pattern.

I tend to drink more now as I’ve got older, met my partner, and bought a house. Maybe because at home I can have as much as I want. (Male, want to reduce, 31-50, C2DE, Newport)

When I’m away, there’s nothing else to do really in the evenings except have a drink [with colleagues]. (Male, want to reduce, 31-50, C2DE, Newport)

Having ‘hectic’, busy lifestyles and working long hours were also thought to make it difficult to consider reducing alcohol consumption.

B2913 Alcohol Intervention Study 25 © Beaufort Research Ltd 2009 March – April 2009 . Current drinking patterns were not resulting in any tangible wake-up call Drinking more than the recommended guidelines was not always taken very seriously; from time to time during the discussions, participants joked about their consumption (e.g. spending their discussion group incentive in the bar afterwards).

They were aware that drinking too much was not good for the body but, other than feeling unwell the next day, they were not – as far as they were aware – experiencing any physical or psychological conditions as a direct result of drinking more than the guidelines. A small number of younger participants felt that it was something to worry about later in life. This view was in contrast to opinions on the impact of a poor food diet, discussed later in this report.

I don’t think it’s having an impact on me, but maybe when I get older it will do. At the moment, I just don’t think about it. (Male, want to reduce, 31-50, C2DE, Newport)

I’d probably improve my food intake for healthiness compared to my drinking. I don’t see [drinking] as a big a problem to my health – even though it probably is. (Male, want to reduce, 18-30, ABC1, Wrexham)

Those who did not want to reduce their alcohol consumption, in the main, did not believe that they were drinking too much. They drank for the same reasons as those outlined above, in particular to enhance a social occasion or to relax at the end of the day.

I haven’t needed to [reduce consumption]. I haven’t felt like I needed to, either. (Female, don’t want to reduce, 18-30, ABC1, Newport)

I don’t know how this will sound to you but I don’t think I drink over the top [5-6 pints typical night]. (Male, don’t want to reduce, 18-30, C2DE, Cardiff)

I try to keep it for the weekends, but after a bad day at work it’s nice to have a glass of wine to relax. (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

No one likes dancing sober. (Male, don’t want to reduce, 18-30, C2DE, Swansea)

Taking into account all of the points described above, the discussion groups illustrated that consumers’ motivations for wanting to reduce alcohol consumption were not as compelling, or immediate, as the attraction of continuing to drink at their current levels.

B2913 Alcohol Intervention Study 26 © Beaufort Research Ltd 2009 March – April 2009 Those who did want to reduce their consumption focused on health as the primary driver. They acknowledged that alcohol could affect health but they did not demonstrate any great awareness of the impact alcohol could have on the body, other than damaging the liver. Occasional reference was made to the ageing effect alcohol was thought to have on a person’s appearance, such as affecting the skin, creating wrinkles and staining teeth. There were also isolated comments on the impact of alcohol on a friend or relative (for example, a friend dying from alcoholism, a relative having dialysis through alcoholism).

I don’t know what I damage when I do binge drink. (Male, want to reduce, 18-30, ABC1, Wrexham)

It’s probably too much [alcohol consumption]. But because we’re used to it, it seems all right. But health-wise it’s probably not a good thing. At the time, everyone’s doing it. (Male, want to reduce, 18-30, ABC1, Wrexham)

Less often, participants referred to other motivations. These included: o realising that their consumption had developed into too much of a habit, for example having a drink every night of the week. o the financial cost of a ‘big night out’ when they could not really afford it. o the impact of drinking on a relationship (for example arriving home very late and then being unable to lead family activities the next morning).

Regular drinkers in the omnibus survey were presented with a list of statements about drinking alcohol and asked to what extent they agreed with each.

Opinion was divided when it came to the statements about the impact of alcohol on health, although for all of these statements a few more people disagreed than agreed. Two fifths (38%) agreed that “you have to be drinking heavily each day before you can be classed as having a serious problem”, whereas nearly half (49%) disagreed with this statement.

A similar pattern was seen for the following statements:

 “Having a few too many once a week is unlikely to cause any long term health problems”

 “If you regularly exceed the daily limits, even by a small amount, you are unlikely to have long term health problems” (34%) – see Figure 18 overleaf.

B2913 Alcohol Intervention Study 27 © Beaufort Research Ltd 2009 March – April 2009 Fig 18 - Attitudes to Drinking Amongst Regular Drinkers

Agree strongly Agree slightly Neither Disagree slightly Disagree strongly Don't know

You need to be drinking heavily every day before you can be classified as having a 13 25 10 27 22 3 serious drinking problem

Having a few too many once a week is unlikely 11 29 14 27 16 3 to cause any long term health problems

If you regularly exceed the daily alcohol guidelines, but only by a small amount, you are 7 27 16 30 14 6 unlikely to have any long term health problems

Those regularly drinking more than the recommended daily alcohol limits tended to down-play the effects of drinking on long-term health and the seriousness of it; higher proportions of heavier drinkers agreed with all three statements than those drinking within the guidelines – see Figure 19 overleaf.

B2913 Alcohol Intervention Study 28 © Beaufort Research Ltd 2009 March – April 2009 Fig 19 - Attitudes to Drinking (continued) Amongst regular drinkers by Alcohol Consumption - % Agree

You need to be drinking heavily every 34 day before you can be classified as having a 43 serious drinking problem 44 Drink within guidelines Having a few too many 30 once a week is unlikely 49 Drink above to cause any long term guidelines health problems 49 Binge drinkers If you regularly exceed the daily alcohol guidelines, but only by 29 a small amount, you 41 are unlikely to have any long term health 42 problems

While most regular drinkers agreed that “you can enjoy a night out in the pub without drinking alcohol” (68%), most disagreed that “there is nothing wrong with people of my age getting drunk” (64%). Opinion on whether alcohol gives people more confidence around new people was more divided (33% agreeing compared to 47% disagreeing) – see Figure 20 below.

Fig 20 - Attitudes to Drinking (continued) Amongst Regular Drinkers

You can enjoy a night out in the pub without 34 34 10 11 10 1 drinking alcohol

I feel more confident around new people if I have had a few drinks 7 26 18 20 27 1 first

There's nothing wrong with people my age 5 15 12 23 41 3 getting drunk regularly

B2913 Alcohol Intervention Study 29 © Beaufort Research Ltd 2009 March – April 2009 People consuming more than the recommended daily alcohol limit were more inclined to see drinking alcohol as a positive enhancer of social situations. They were less inclined to agree that “you can enjoy a night out in the pub without drinking”; 64% drinking over the limit agreed with this, and only 56% of binge drinkers agreed, compared to 75% of people drinking within the limit who agreed with this statement).

Moreover, heavier drinkers were more inclined to agree that “they feel more confident around new people if they have had a few drinks first”; 41% of those drinking above the guidelines and 46% of binge drinkers agreed with this statement, compared to 24% of those drinking within the guidelines.

There was a starker contact between those drinking within and those drinking above the guidelines regarding the statement “There’s nothing wrong with people my age getting drunk regularly”; only 8% of those drinking within the guidelines agreed with this statement, compared to 30% of those drinking above the guidelines and 36% of binge drinkers.

Younger people were also much more likely to agree with this statement – 49% of 16-24 year olds agreed compared to 21% of 25-34 year olds, 18% of 35-54 year olds and only 7% of those people aged over 55. To a certain extent this is related to the fact that this group tend to be heavier drinkers – see Figure 21 below.

Fig 21 - Attitudes to Drinking Amongst regular drinkers by Alcohol Consumption - % Agree

75 You can enjoy a night Drink within out in the pub without 64 drinking alcohol guidelines 56 Drink above guidelines I feel more confident 24 around new people if Binge drinkers I have had a few 41 drinks first 46

16-24 years = 49% There's nothing wrong 8 with people my age 25-34 years = 21% getting drunk 30 regularly 36 35-54 year = 18% 55+ years = 7%

B2913 Alcohol Intervention Study 30 © Beaufort Research Ltd 2009 March – April 2009 The final two statements concerned the more serious aspects of drinking and alcohol dependency – nearly three quarters (71%) of regular drinkers agreed that “being dependent on alcohol was more difficult to admit than being dependent on nicotine”. A slight majority (52%) also regarded alcohol as causing as may problems as other drugs – see Figure 22 below.

Fig 22 - Attitudes to Drinking (continued) Amongst Regular Drinkers

Being dependent on alcohol is more difficult to admit than 32 39 15 5 4 4 being dependent on nicotine

I don't think that alcohol causes as many problems as 11 20 13 26 26 4 other drugs

The signals of drinking too much

Analysis of the discussion groups revealed four main dimensions upon which consumers identified the signals of drinking too much alcohol. In the main, they put forward signals that they did not report associating with themselves although the potential influence of the discussion group environment should be noted. This response correlates with the stigma attached to having an issue with alcohol, which became apparent when discussing the intervention concepts.

Health was a key dimension for signals and with the emphasis on ‘scares’ and the long-term impact, i.e. factors which most participants did not see as directly relating to themselves. Figure 23 overleaf summarises the perceived health signals, from short- term to long-term impact.

B2913 Alcohol Intervention Study 31 © Beaufort Research Ltd 2009 March – April 2009 Figure 23 – Perceived Health Signals

The signals to the left-hand end of the scale Consumers tended to focus on the signals to were those that consumers were more likely the right-hand end of the scale. to relate to, but were also not deemed so serious.

The dependency dimension was also readily voiced among consumers as a signal. As with the health dimension, example signals that consumers provided tended to be towards the extreme end of the scale (those that they did not report associating with themselves) see Figure 24 below.

Figure 24 – Dependency on Alcohol

Drinking more at home and having a drink Consumers tended to focus on the more to relax were both signals with which some extreme signals to the right-hand end of consumers could identify. the scale.

B2913 Alcohol Intervention Study 32 © Beaufort Research Ltd 2009 March – April 2009 Participants also identified the impact of alcohol on behaviour as a signal for drinking too much. In keeping with the other dimensions, their focus was on the more extreme behaviour. During the discussions, participants were less likely to mention any examples of where drinking had resulted in a particular change in their behaviour. Interestingly, the issue of violence did not come to the fore as a behavioural signal although it was on occasion highlighted as a point of difference when comparing alcohol with other substances (discussed later in the report) – see Figure 25 below.

Figure 25 – Behaviour Associated with Consuming Alcohol Consumers made only occasional Consumers tended to focus on the more references to the impact of drinking on extreme signals to the right-hand end of their own behaviour. the scale.

The final main dimension is labelled as social status. Of all the dimensions, the potential impact on social status was the least top of mind. Occasional examples given of experiences included letting the family down the morning after a night of excessive drinking, and a warning from an employer after sending inappropriate text messages while drunk – see Figure 26 overleaf.

B2913 Alcohol Intervention Study 33 © Beaufort Research Ltd 2009 March – April 2009 Figure 26 – Social Status and Alcohol Consumption Very few examples were voiced where Consumers tended to focus on the more consumers had experienced an impact on extreme signals to the right-hand end of their social status the scale.

Comparing alcohol with other substances, participants in the discussion groups focused on nicotine.

The general view was that alcohol is more socially acceptable, and causes no harm when consumed in moderation. It was therefore not as black and white as smoking, where smoking is bad for the individual (cancer) and can directly affect those in the smoker’s vicinity.

It’s a lot more socially accepted, drinking - it’s just a way of life. The health risks aren’t like they are on a pack of fags, and you see the baby breathing out smoke and you think oh my God. What do you see about alcohol? (Male, want to reduce, 18-30, ABC1, Wrexham)

Smoking is frowned upon more, and affects those around you as well. It’s looked upon as more of an evil [than drinking]. (Male, want to reduce, 31-50, C2DE, Newport

The Government’s position was clearer on smoking than on alcohol: consumers referred to the fact that there are fewer alcohol awareness advertising campaigns. Some anti-smoking campaigns were readily recalled (for example the campaign highlighting the effects on children of second-hand smoke). In addition, and unlike smoking, they were not aware of any high profile law changes in restricting where they could consume alcohol. Some smokers believed the law change had made smoking a more sociable activity as they gathered outside pubs.

B2913 Alcohol Intervention Study 34 © Beaufort Research Ltd 2009 March – April 2009 As alcohol consumption levels increase, however, some consumers perceived alcohol to be more of an issue than smoking. The heavier the drinking, the less socially acceptable the activity became. Some also remarked on its consequences: the impact on performance at work and the potential for violence. Some therefore viewed heavy smoking as the lesser of two evils from a social perspective.

I’d rather live with someone who smokes too much than drinks too much. (Female, don’t want to reduce, 18-30, ABC1, Newport)

In casualty you’ll see fights relating to alcohol [but not smoking]. (Female, want to reduce, 31-50, ABC1, Swansea)

B2913 Alcohol Intervention Study 35 © Beaufort Research Ltd 2009 March – April 2009 6. PERCEPTIONS OF THE IMPACT ON PERSONAL HEALTH

Regular drinkers in the omnibus survey were asked whether they thought that their drinking behaviour was having any impact on their long term health – most thought that it was not.

Almost three in five (57%) respondents reported that they had no concerns about the impact of their drinking on their long term health. A further fifth (22%) said that they thought it was unlikely that their drinking would have any impact on their long-term health.

A smaller proportion (15%) felt that their drinking behaviour could possibly affect their long-term health, and only a small minority (4%) thought it was likely to have an impact – see Figure 27 below.

Fig 27 - Perceptions of Drinking Habits on Personal Health Amongst regular drinkers

I don't have any concerns about its impact on 57 my long term health

I think its unlikely to have an impact on my 22 long term health

It possibly could affect my long term health 15

I think its likely to have an impact on my long 4 term health

Those people drinking over the recommended daily limit, especially binge drinkers were more inclined to acknowledge that their drinking behaviour may have an adverse effect on their long-term health.

Those people drinking above the recommended daily limit and binge drinkers were more likely to believe that their level of alcohol consumption could possibly or be likely to affect their long-term health (29% and 38% respectively).

B2913 Alcohol Intervention Study 36 © Beaufort Research Ltd 2009 March – April 2009 Although concern is greater amongst those drinking above the guidelines / binge drinkers, the majority of these people believe their health is likely to be unaffected - half (50%) of those drinking over the recommended daily alcohol limit, and 38% of binge drinkers said that they did not have any concerns about the impact of their drinking on their long-term health (79% of those drinking within the guidelines also selected this response) – see Figure 28 below.

Fig 28 - Perceptions of Drinking Habits on Personal Health Amongst regular drinkers by Alcohol Consumption

I don't have any 70 concerns about its 50 impact on my long 38 term health

I think its unlikely to 22 have an impact on my 23 long term health 23 Drinking within guidelines

It possibly could 6 affect my long term 20 Drinking above health 29 guidelines

I think its likely to 1 have an impact on my 9 Binge drinkers long term health 9

1 DK 1

The discussion groups with those drinking over the recommended guidelines highlighted the limited awareness of the impact of drinking too much, other than liver damage later in life. Some consumers admitted that the amount they drank was probably having some adverse effect on their health, but some believed that they were not drinking to an extent that would affect their health.

At the recruitment stage for the discussion groups, the recruitment questionnaire included more general health related questions to ensure the alcohol focus was not too explicit. This way, we were able to include health as part of the discussion without too much of an alcohol bias, before moving onto the topic of alcohol itself.

This approach demonstrated that alcohol rarely featured spontaneously among consumers’ health considerations. The focus instead was on reducing weight or improving physique by changing what they ate (especially reducing ‘junk food’ consumption), and taking more exercise.

B2913 Alcohol Intervention Study 37 © Beaufort Research Ltd 2009 March – April 2009 Older consumers, male and female, were less likely to be trying to improve their wellbeing although they often admitted that it was something they should do; however, some younger consumers were comfortable with their current lifestyles and did not feel that they needed to make any changes until perhaps they were older. Junk food could also be viewed as a type of reward.

You’re not going to work hard and then eat a bunch of lettuce leaves. . . . it’s a reward [to eat junk food]. (Male, want to reduce, 18-30, ABC1, Wrexham)

I know I need to do more [exercise] but I’m one of these people who always put it off until tomorrow. It’s something I should do a lot more. (Male, want to reduce, 31-50, C2DE, Newport)

Efforts to encourage consumers to reduce their alcohol consumption may benefit from tapping into the catalysts and desired outcomes expressed for improving general wellbeing; the catalysts for consumers were varied, for example:

. A New Year’s resolution . Reading, and being influenced by, magazine articles . Celebrity culture (women) . Being unable to fit into clothes . The approaching holiday season . Underperforming in sport . A health scare (for example of their own or within the family; diabetes, emphysema) . Receiving a warning from work (alcohol related; sending inappropriate text messages to colleagues when drunk)

Sometimes I’ll buy a men’s health magazine and it tells you [what food] improves this and that so, like, I want to my skin to look better. (Male, want to reduce, 18-30, ABC1, Wrexham)

B2913 Alcohol Intervention Study 38 © Beaufort Research Ltd 2009 March – April 2009 The end benefits they were trying to achieve were also wide ranging, for example:

. Improving self esteem - to feel good about yourself . Attracting the opposite sex . Improving sporting performance . Enjoying the ‘buzz’ of exercise or the ‘me time’ . Enjoying the activity itself . Belonging to a social group (part of a team) . Keeping a job after a warning for inappropriate behaviour . Wanting to live longer . Wanting to see their children grow up.

If you try to exercise, eat more healthily you feel better in yourself, more motivated. (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

You’ve got a lads’ holiday coming up and you want to look good on the beach. (Male, want to reduce, 18-30, ABC1, Wrexham)

Celebrities in general. They’re all stick thin, perfect. In magazines it’s all diets. If you want to look like this celebrity, here is the Beyoncé diet . . . (Female, don’t want to reduce, 18-30, ABC1, Newport)

Pilates – it’s my time, away from everybody else, I don’t have to think about anyone else. (Female, want to reduce, 31-50, ABC1, Swansea)

I don’t want to end up at 50 and telling my daughter I’ve got cancer [through smoking]. (Male, don’t want to reduce, 18-300, C2DE, Cardiff)

B2913 Alcohol Intervention Study 39 © Beaufort Research Ltd 2009 March – April 2009 7. IDEAS FOR HELPING PEOPLE REDUCE ALCOHOL CONSUMPTION

We previously saw at Figure 16 that 16% of regular drinkers reported that they would like to cut down the amount of alcohol they consumed. These respondents were shown a list of possible methods they could use to reduce the volume of alcohol they drank, and asked which they would consider using.

Consideration was highest (29%) for talking to a friend or family member. Around a quarter (23% for each) said they would read information in leaflets, books or on the internet, or do it themselves with willpower. A further 16% would visit either their GP or a Practice Nurse.

Consideration of other methods was lower – around one in ten (9%) said they would telephone a helpline, and around one in twenty would visit a counsellor or attend a peer support group (7% and 5% respectively). A small proportion (7%) said that they would consider none of the options given.

Heavier drinkers were slightly more inclined to talk to friends and family, and less likely to visit a GP or Practice Nurse when considering cutting down on their alcohol consumption – see Table 3 below.

Table 3 - Methods Would Consider to Reduce Alcohol Consumption Amongst people who want to reduce their alcohol consumption

All Within Above Binge (103) Guidelines Guidelines drinkers (14) (76) (59) Talk to a friend or family member 29 16 34 31 Read information on leaflets / 23 27 24 22 internet / books Do it myself / willpower 23 15 27 27 Visit a GP or Practice Nurse 16 19 9 9 Telephone a helpline 9 8 10 11 Visit a counsellor or other type of 7 8 10 therapist Attend a behavioural support 5 6 5 group Other 2 2 2 None of these 7 9 7 Don’t know 15 31 11 14

B2913 Alcohol Intervention Study 40 © Beaufort Research Ltd 2009 March – April 2009 The two key themes to emerge from participants’ ideas for reducing the amount of alcohol people drink were education and breaking habits.

In relation to education, the focus was on raising awareness of the impact of drinking more than the recommended guidelines. A popular suggestion was to highlight exactly what alcohol does to the body, both the ‘shock tactics’ approach (comparisons were drawn with anti-smoking campaigns) and also the less critical damage, for example to an individual’s appearance.

Not just your liver, they should go into all the different effects it can have on you. I didn’t realise until the other day about ageing, that red wine is worse for wrinkles. (Female, don’t want to reduce, 18-30, ABC1, Newport)

For women, it needs to highlight the effect on your looks, your skin, . . . ageing you. (Female, want to reduce, 31-50, ABC1, Swansea)

Education also included publicizing more widely the recommended guidelines, and providing more context to what a ‘unit’ means; for example, a sliding scale or axes showing units by impact on health.

What effect do the units have? . . . show me the impact of getting absolutely slaughtered once a month. (Male, want to reduce, 18-30, ABC1, Wrexham)

If we hadn’t had this discussion today we wouldn’t know anything about these units . . . it makes you think about it, but it is a habit at the end of the day. (Male, don’t want to reduce, 18-30, C2DE, Swansea)

We need to know why we should only have 2-3 units. . . . what makes it so bad for a woman to have more than 2-3 units? (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

B2913 Alcohol Intervention Study 41 © Beaufort Research Ltd 2009 March – April 2009 Further awareness and education suggestions included:

. Highlighting the calorific or sugar content within alcoholic drinks, and its impact on weight gain or loss if consumption is reduced . Using case studies showing the effect on other people’s lives of drinking more than the guidelines . Emphasising the benefits of drinking less . Linking consumption reduction to a desired outcome (e.g. better fitness) . Showing how much drinking more than the guidelines can cost an individual over time

Some days you feel sick – not with the hangover but with the amount you spent. (Male, want to reduce, 18-30, ABC1, Wrexham)

Consumers in the discussion groups acknowledged that the idea of breaking drinking patterns was difficult to achieve for all the reasons discussed earlier in this report. A common suggestion centred on positioning any intervention as help from a more ‘holistic’ point of view, that is, part of a ‘health check’. They also put forward:

. Using a more ‘realistic’ approach that is not simply opposed to drinking or looking to remove an activity that consumers enjoy. . Providing some kind of alternative social environment, rather than having to go to the pub for conversation or settling in each evening to drink and watch TV; this might involve someone similar to a ‘personal trainer’ spending time with an individual and ‘sussing out’ their lifestyle.

Like a personal trainer, who looks at your lifestyle and what can do together to move you out of that environment so you’re not having bottles of wine while you’re watching Corrie. Is there something else you could be doing? (Male, want to reduce, 31-50, C2DE, Newport)

B2913 Alcohol Intervention Study 42 © Beaufort Research Ltd 2009 March – April 2009 Inevitably, consumers felt that TV and mass media coverage would be the most effective way of conveying these messages and the support available. Some suggestions were more creative, including the following:

. Street campaigns with ‘canvassers’ handing out leaflets with ‘punchy headlines’. . Magazine articles in health or celebrity publications. . Images on bottles, health warnings on pumps; ‘show the damage’ of drinking more than the recommended guidelines. . Encourage GPs to talk to patients about the subject – ‘free health checks’. . Use pubs and supermarkets to raise awareness of how many units are contained in each drink; and what the guidelines are. . Hold meetings with individuals who have been affected by moderate drinking, for example attacked or raped as a consequence of having drunk too much (participants agreed that they would be unlikely to attend such an event and therefore suggested some kind of incentivisation to encourage participation.) . Target friends or members of families as the individuals who should talk to those drinking more than the recommended guidelines. . Develop a stand, or have a person available to talk to the public, in places such as the gym foyer.

If everybody got called into their local doctors so they could have a check, the doctor would tell you what will happen in 10 years – that’s good. (Male, don’t want to reduce, 18-30, C2DE, Cardiff)

If there was an article in a [men’s health] magazine, I’d read that. (Male, want to reduce, 18-30, ABC1, Wrexham)

Consumers advised that the tone of any communications on this subject should be educational rather than lecturing or ‘preachy’; they sometimes warned against anything which would suggest an attempt to ‘spoil people’s fun’ or imply a ‘nanny state’ stance. Some would also like communications to be in ‘layman’s terms’ and not units.

B2913 Alcohol Intervention Study 43 © Beaufort Research Ltd 2009 March – April 2009 8. REACTIONS TO INTERVENTION CONCEPTS

Regular drinkers interviewed in the omnibus survey were presented with a list of four concepts for community-based intervention programmes aimed at reducing alcohol consumption amongst people drinking above the recommended guidelines. The concepts were as follows:

o A telephone chat with a health professional, discussing the effects of drinking more than the daily recommended units of alcohol. o A short face to face discussion with a health professional on the health implications of drinking more than the daily recommended units of alcohol. o A booklet or website explaining the effects of drinking more than the daily recommended units of alcohol, tips on how to cut back, and the chance to keep an online drinking diary. o A meeting with other people (peer support sessions) to discuss the effects of drinking more than the daily recommended units of alcohol and how to cut back.

Reactions were luke-warm – for each of the concepts outlined above, the majority said they would be unlikely to use them.

Consideration was highest for the booklet / website option, with 23% saying they would be likely to use this. A similar proportion (21%) said they would be likely to take part in a short face-to-face discussion with a health professional.

Smaller proportions would be likely to use either the peer support sessions (17%) or the telephone chat with a health professional (14%) – see Figure 29 below.

Fig 29 - Attitudes to Intervention Concepts Amongst regular drinkers

Very likely Fairly likely Neither Fairly unlikely Very unlikely Don't know

Booket or website explaining effects of drinking more than 6 17 10 14 51 2 recommended daily units

Short face to face discussion with health professional 4 17 7 16 53 2

Peer support sessions 4 13 9 16 57 2

Telephone chat with a health professional 4 10 8 18 58 2

B2913 Alcohol Intervention Study 44 © Beaufort Research Ltd 2009 March – April 2009 There were no major differences in likelihood to use each type of service according to the volume of alcohol consumed – see Figure 30 below.

Fig 30 - Attitudes to Intervention Concepts Amongst regular drinkers by Alcohol Consumption - % Likely

Booket or website explaining effects 22 of drinking more than recommended 25 daily units 26

Drink within 20 guidelines Short face to face discussion with 24 health professional 24 Drink above guidelines 16 Peer support sessions 18 Binge drinkers 15

13 Telephone chat with a health 15 professional 15

On the focus groups there were some parallels between the proposed services and suggestions put forward by participants for helping consumers reduce the amount of alcohol consumed. However, when presented with the concepts, participants tended not to be very interested in them.

For the most part, participants found it difficult to envisage identifying with the proposed services in reality and what would prompt them to consider them in the first place. Even those who did want to reduce their consumption struggled to imagine themselves choosing to use these services.

A major obstacle was recognising that drinking more than the recommended guidelines might require this kind of intervention. In participants’ eyes, the proposed services were aimed more at individuals with a drink ‘problem’.

These [proposed services] are all geared for alcoholics. (Female, want to reduce, 31-50, ABC1, Swansea)

I haven’t got a problem so I wouldn’t look. (Female, don’t want to reduce, 18-30, ABC1, Newport)

B2913 Alcohol Intervention Study 45 © Beaufort Research Ltd 2009 March – April 2009 I’d take notice of them, but I don’t think I’d change anything. . . . if you know the facts then it’s at your own risk. You’d be informed. (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

Overall, relatively more interest was shown in the website / booklet and, to a lesser extent, the individual face-to-face meeting, than in the group meeting and phone chat proposed services.

In terms of the person providing the face to face and phone help, consumers would listen to their local GP or a practice nurse as trusted professionals. They would respect them and feel comfortable with them. As a professional, they would be well qualified to impart advice compared to an adviser who may only have ‘been on a two-week course’.

My local GP – he’s really good. (Male, don’t want to reduce, 18-30, C2DE, Swansea)

You tend to believe what a health professional is telling you. (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

Occasionally, consumers suggested involving people who had benefited from the service. When prompted with the phrase ‘health professional’, participants assumed this meant a GP or nurse. If the advice and support was provided by a ‘counsellor’, this would signal to consumers that ‘you’ve really got a[n alcohol] problem’.

The report now deals with each proposed service, broadly in order of relative interest.

A booklet or website explaining the effects of drinking more than the daily recommended units of alcohol, tips on how to cut back, and the chance to keep an online drinking diary.

Of the four concepts tested, this idea was the least likely to imply that the service user had an issue with alcohol and most interest was shown in the online version. Those who used the internet deemed it easily accessible and private and the concept as a whole came across as ‘non-threatening’.

Some consumers showed a degree of interest in obtaining tips on how to reduce their alcohol consumption and in learning more about alcohol and its potential effects.

Best one so far [shown 3rd]. . . . online I think I‘d do it. . . . . by far the best. . . . it’s private. (Male, want to reduce, 18-30, ABC1, Wrexham)

I’d definitely look at something on the Internet, to find out more about the recommended units [but not the online drinking diary]. (Female, want to reduce, 31-50, ABC1, Swansea)

B2913 Alcohol Intervention Study 46 © Beaufort Research Ltd 2009 March – April 2009 I’d look [online] for a clearer explanation of units, measurements and so on. Tips on how to cut back is a good idea. I’d probably do the online diary if it then totted it up for you. (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

The booklet version idea drew no strong opinions but some thought that they would read the leaflet if it came through the door and they noticed it.

Leaving aside the issue of lack of internet usage, some thought the idea of the online diary looked like too much hard work; it might be hard to remain motivated to complete the diary over a period of time, and a ‘hassle to log on each time they had a drink’. Some could not see how exactly the online service would help them. If a booklet was produced, consumers thought it would quickly end up in the recycling bin with all the other direct mail and flyers received.

I’m not going to log online and say ‘today I had ...... I don’t see how it could help. (Female, don’t want to reduce, 18-30, ABC1, Newport)

Improvements suggested by participants

Improvements centred on enhancing the functionality of the online service:

. As the user completes the diary, the site provides feedback on the impact on the drinker’s health of their current alcohol consumption levels. . As the user completes the diary, the site provides the estimated spend on alcohol. . Offer the facility to book via the website a face to face individual meeting with a GP / practice nurse.

It could also show you how much money you’ve spent. . . . we always try to work out how much we spent on a night out. . . . then you’ve got the financial and the health together. (Male, want to reduce, 18-30, ABC1, Wrexham)

Some consumers thought it would be useful and effective if the website covered the less serious health issues as well, for example the effect on skin and that alcohol ‘gives you spots’ etc.

B2913 Alcohol Intervention Study 47 © Beaufort Research Ltd 2009 March – April 2009 A short face-to-face discussion with a health professional on the health implications of drinking more than the daily recommended units of alcohol.

From a positive perspective, some consumers liked the fact that this proposed service was more personal than some of the other options. The user would be able to build rapport with the health professional (who they respected) and gauge the levels of sincerity and interest the professional was taking in them. It was also pointed out that it would not be so easy to opt out once a face-to-face appointment had been made, whereas a consumer could easily avoid making / receiving a phone call or going online

A handful also felt that this service could be aimed at anyone, and that it would be a good opportunity to find out information on the subject, especially if it formed the starting point for a health check.

Like a health check sort of thing. (Female, don’t want to reduce, 18-30, ABC1, Newport)

If they could then look into how much you drank and what it means. . . what it’s actually doing to my liver. (Male, want to reduce, 18-30, ABC1, Wrexham)

However, as with certain other proposed services, some participants felt quite strongly that this concept would be more appropriate for those with an alcohol problem or who were alcoholics – where their ‘health is at risk’. Some were also reluctant to attend this kind of meeting as they were concerned they might be lectured for drinking over the recommended guidelines.

That would only apply to alcoholics. (Female, want to reduce, 31-50, ABC1, Swansea)

It’s more if you think you’ve got a problem. (Male, want to reduce, 18-30, ABC1, Wrexham)

The reference in the service description to ‘short’ was noted which led to debate on how effective this (presumably ‘one-off’) intervention would be, especially for those who recognised alcohol consumption as a difficult pattern to break.

It’s not a bad idea but it needs to be a bit more than ‘short’ - to have a proper chat like today. (Male, don’t want to reduce, 18-30, C2DE, Swansea)

B2913 Alcohol Intervention Study 48 © Beaufort Research Ltd 2009 March – April 2009 Improvements suggested by participants

According to some consumers, the purpose of the discussion could be broadened to incorporate a conversation on general health and wellbeing – as part of a regular check-up, therefore removing the perceived stigma of having an issue with alcohol.

They also suggested:

. Including a question and answer session, and seeking the individual’s input on how they felt. . Looking at the individual’s lifestyle over a few weeks. . An open day at a local centre, for example at the local surgery where consumers could make an appointment, or in a gym or university foyer – ‘bring it out to people’.

It would need some kind of health check first, so the professional had some knowledge of that person and some evidence. (Female, don’t want to reduce, 31-50, C2DE, Wrexham

A meeting with other people (peer support sessions) to discuss the effects of drinking more than the daily recommended units of alcohol and how to cut back.

Consumers were most likely to associate the group meeting with Alcoholics Anonymous and therefore were mostly dismissive of the idea as it did not, in their minds, apply to them. Some also pointed out that it would be easy to sit back and not participate in the discussion, and that it might not be taken that seriously in the group environment.

That makes it sound like Alcoholics Anonymous. You’ve got to want to do it. . . . you’ve got to realise you’ve got a problem. (Male, want to reduce, 31-50, C2DE, Newport)

Sounds like an AA meeting. You’re not going to go are you? I don’t think I’d go. (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

On the positive side, some did acknowledge that they had learned something from the discussion group they were currently attending, and expected that they might also learn from such a meeting (for example about the effects of drinking more than the recommended guidelines, and from other people’s experiences). It might also be reassuring to realise that other people were in a similar position.

As with other proposed services, participants suggested the meeting should include the broader health context rather than only focus on alcohol. To overcome the issue of encouraging people to make the effort to attend, a small number of consumers wondered if the meetings could ‘come to them’, for example at work, university or even convened in pubs – ‘somewhere you were going to be anyway’. If they were to be at a central location, some kind of incentive for attending was suggested.

Rather than just the alcohol, if they incorporated it with other health issues. (Female, 18-30, don’t want to reduce, ABC1, Newport)

A telephone chat with a health professional, discussing the effects of drinking more than the daily recommended unit of alcohol.

One of the least popular concepts, consumers were put off by the impersonal nature of the medium for what was potentially a sensitive topic. It would be harder to develop a rapport and therefore to open up to the other person on the call. Some participants were further deterred by expectations of a ‘call centre’, with advisers following a script, and therefore lacking sincerity. A doubt was also raised as to how effective a phone chat would be, for this subject.

It’s more impersonal . . . when someone phones you up you always feel like they’re reading a script. (Female, don’t want to reduce, 31-50, C2DE, Wrexham)

I’d rather sit down in the surgery [for a chat] if I had to choose one or the other. (Female, don’t want to reduce, 18-30, ABC1, Newport)

Again, the concept suggested to some a service for people with a ‘serious’ alcohol problem.

I’d have to think I had a serious problem to phone that. . . . how would you know that you should be calling it? (Male, want to reduce, 18-30, ABC1, Wrexham)

There was, however, occasional interest in the idea, as it would be easy to access, could be used from home and potentially could be aimed at anyone. One participant who had found the discussion group a useful exercise thought that she would call it because of the convenient access.

Consumers tended to struggle to think how this proposed service could be improved but suggested the following:

. Make it clear that there is no automation involved with the call. . Involve people in the service who have managed to cut down their alcohol consumption (i.e. people to whom the caller can relate).

B2913 Alcohol Intervention Study 51 © Beaufort Research Ltd 2009 March – April 2009 9. CONCLUSIONS AND RECOMMENDATIONS

Any communications and interventions have to work through several stages of cognition for consumers:

1. Comprehension and front of mind of the concept of alcohol units.

2. Accuracy – finding a way for consumers to accurately calculate how many units they have had.

3. Persuading consumers to cut back on something that they associate with enjoyment, reward and relaxation.

4. Implications of cutting back – what does this say to the consumer about whether they are drinking too much.

5. Positioning the intervention as not being a service for alcoholics.

6. Consequences – what could happen to me if I don’t cut down?

The research has shown that consumers may struggle to work past Stage 3 of the process.

NPHS need to raise awareness of the health impact of drinking:

 Include a mix of serious and appearance-related consequences, as well as any more immediate issues (financial, social).

 Improve knowledge and understanding of the recommended guidelines.

 Educate without lecturing.

Focus on current desired outcomes for healthier living:

 Adopt a more holistic approach; incorporate alcohol awareness in a more general discussion on healthy living.

 Use as hooks those aspects that currently motivate consumers to act on improving their wellbeing (health, fitness, weight, appearance etc.)

 Help consumers achieve the end benefits (better figure, feeling healthier etc.)

 Consider how to minimise the implication of having a ‘drink problem’.

B2913 Alcohol Intervention Study 52 © Beaufort Research Ltd 2009 March – April 2009 Possible intervention programmes to pursue:

 Involve (local) health professionals – one-to-one rather than group sessions.

 Explore the potential to target a friend or relative to encourage participation.

 Trial an online intervention with an interactive diary / blog – consider developing the functionality of the diary to include alcohol unit counters and monetary cost of drinking.

 Explore the possibility of creating interventions that are more than a ‘one-off’.

 Review the findings from other research such as Stop Smoking Wales survey 2008 that back up the ‘You’re more likely to succeed with help’ message.

B2913 Alcohol Intervention Study 53 © Beaufort Research Ltd 2009 March – April 2009 APPENDIX 1 – Omnibus Survey Questionnaire

B2913 Alcohol Intervention Study 54 © Beaufort Research Ltd 2009 March – April 2009 National Public Health Service: Alcohol Intervention Research Questionnaire FINAL

Q1 How often have you had an alcoholic drink of any kind during the last 12 months?

SHOWCARD Almost every day 5 or 6 days a week 3 or 4 days a week Once or twice a week Once or twice a month Once every couple of months Once or twice a year Not at all in last 12 months

***************************************************************************************

Q2 Have you ever heard of the recommended maximum number of alcohol units that people should drink in a day?

Yes No Not sure / don't know Only know a weekly figure (Spontaneous only)

***************************************************************************************

FOR THOSE WHO ANSWER YES AT Q2

Q3a Can you tell me how many units per day is that for women?

WRITE IN NUMBER

***************************************************************************************

Q3b Can you tell me how many units per day is that for men?

WRITE IN NUMBER

***************************************************************************************

B2913 Alcohol Intervention Study 55 © Beaufort Research Ltd 2009 March – April 2009 INSERT AFTER ANOTHER CLIENTS QUESTIONS

Q4a In the last 7 days, on which day did you drink the most alcohol?

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Have not had an alcoholic drink in last 7 days

*************************************************************************************** ASK IF HAD AN ALCOHOLIC DRINK IN LAST 7 DAYS

SHOW CARD – ALCOHOL UNITS DESCRIPTION

Q4b Please look at this card which describes the amount of alcohol units contained in different types of drinks. Thinking about the day in the last 7 days when you drunk the most alcohol, how many units did you drink?

WRITE IN NUMBER

***************************************************************************************

REMAINING QUESTIONS (Q5-Q15) TO BE ASKED ONLY OF THOSE WHO HAVE DRUNK 2+ UNITS AT Q4B OR DRINK AT LEAST ONCE OR TWICE A WEEK AT Q1

Q5 And before today, how much did you know about the alcohol units contained in different drinks?

SHOW CARD I knew a lot about the different alcohol units contained in various drinks I had some idea of the different alcohol units contained in various drinks I’d heard of alcohol units but didn’t really know how many were contained in various drinks I hadn’t heard of alcohol units before today

***************************************************************************************

B2913 Alcohol Intervention Study 56 © Beaufort Research Ltd 2009 March – April 2009 Q6 Which of the following best describes when you drink alcohol?

SHOW CARD Drink during the week only Drink at weekends only Drink both during the week and at weekends

***************************************************************************************

Q7 And which of these best describes how you drink alcohol?

SHOW CARD On days that I drink….

I drink roughly the same amount each day I drink more on some days than others

*************************************************************************************** ASK IF DRINK MORE ON SOME DAYS THAN OTHERS

Q8 And which days do you tend to drink more alcohol?

SHOW CARD - MULTICHOICE Monday Tuesday Wednesday Thursday Friday Saturday Sunday

***************************************************************************************

Q9a Which of these best describes how, if at all, you keep track of the amount of alcohol you drink?

SHOW CARD

I don’t really know how much alcohol I drink in an average week or month GO TO Q9b I’ve got a good idea in my head how much alcohol I drink in an average week or month GO TO Q10 I record / write down how much alcohol I drink in an average week or month

***************************************************************************************

B2913 Alcohol Intervention Study 57 © Beaufort Research Ltd 2009 March – April 2009 ASK IF ANSWER ‘DON’T KNOW HOW MUCH AT Q9a

Q9b Is there anything that would prompt you to start keeping track of how much you drink? PROBE – Anything else?

RECORD VERBATIM ______

ASK IF ANSWER ‘GOOD IDEA IN MY HEAD’ AT Q9a

Q10 And when you’re thinking about the amount you’ve had to drink in an average week / month, are you thinking about the number / type of drinks you’ve had or the total number of alcohol units?

Number / type of drinks Alcohol units Both

***************************************************************************************

IF ANSWER ‘RECORD OR WRITE DOWN’ AT Q9a

Q11a And do you record / write down the number and type of drinks you’ve had or the total number of alcohol units?

Number / type of drinks Alcohol units Both

***************************************************************************************

Q11b Which of the following best describes how you feel about your own alcohol consumption?

I think its fine for me to continue drinking at my current level I’d like to reduce my alcohol consumption a little I’d like to reduce my alcohol consumption a lot

***************************************************************************************

B2913 Alcohol Intervention Study 58 © Beaufort Research Ltd 2009 March – April 2009 Q12 And thinking about the amount you drink, which of the following describes how you feel it might impact on your long term health?

I don’t have any concerns about its impact on my long term health I think it’s unlikely to have an impact on my long term health It possibly could affect my long term health I think it’s likely to have an impact on my long term health

*************************************************************************************** ASK IF WOULD LIKE TO REDUCE ALCOHOL CONSUMPTION A ‘LITTLE’ OR ‘A LOT’ AT Q11

Q13 Which of these would you consider as a way of reducing your alcohol consumption?

SHOW CARD - MULTICHOICE Visit to a GP or Practice Nurse Visit to a counsellor or other kind of therapist Attend a behavioural support group Talk to a friend or family member Telephone a helpline Read information on leaflets / the internet / in books Other (please specify)

***************************************************************************************

Very likely Fairly likely Neither likely nor unlikely Fairly unlikely Very unlikely

Q14 I’m now going to read out four descriptions of services that might be available to people who want to cut down on the amount they drink. Using this scale, how likely would it be that you would use each service?

A telephone chat with a health professional, discussing the effects of drinking more than the daily recommended units of alcohol

A short face to face discussion with a health professional on the health implications of drinking more than the daily recommended units of alcohol

A booklet or website explaining the effects of drinking more than the daily recommended units of alcohol, tips on how to cut back, and the chance to keep an online drinking diary

A meeting with other people (peer support sessions) to discuss the effects of drinking more than the daily recommended units of alcohol and how to cut back

***************************************************************************************

B2913 Alcohol Intervention Study 60 © Beaufort Research Ltd 2009 March – April 2009 Q15 I am now going to read out a number of statements that people have made about consuming alcohol. I would like you to tell me how much you agree or disagree with each one. There are no right or wrong answers – it just your personal opinion we are interested in. So firstly,……

….Having a few too many once a week is unlikely to cause any long term health problems

Agree Strongly Agree Slightly Neither agree nor disagree Disagree Slightly Disagree Strongly

….You need to be drinking heavily every day before you can be classified as having a serious drinking problem

….I don’t think that alcohol causes as many problems as other drugs

….Being dependent on alcohol is more difficult to admit than being dependent on nicotine

….If you regularly exceed the daily alcohol guidelines, but only by a small amount, you’re unlikely to have any long term health problems

… Most people with serious drinking problems only have themselves to blame.

… You can enjoy a night out in the pub without drinking alcohol.

… There’s nothing wrong with people my age getting drunk regularly.

… I feel more confident around new people if I have had a few drinks first.

B2913 Alcohol Intervention Study 61 © Beaufort Research Ltd 2009 March – April 2009 APPENDIX 2 – Focus Groups Topic Guide

B2913 Alcohol Intervention Study 62 © Beaufort Research Ltd 2009 March – April 2009 National Public Health Service for Wales (BQ2913)

FINAL TOPIC GUIDE (03/04/09)

Overall objectives:  Explore attitudes towards hazardous and harmful alcohol consumption  Elicit motivations to reducing alcohol consumption  Elicit barriers to reducing alcohol consumption  Obtain reactions to potential alcohol intervention schemes

A. INTRODUCTION (5 mins)

1. Thank participants for attending. Introduce self and Beaufort Research

2. Explain purpose of discussion is to allow them to express their own views – there are no right or wrong answers

3. Explain MRS Code of Conduct: reassure about confidentiality and obtain permission to record – purpose of digital recorder is to aid analysis

4. Explain aims of study – find out their views on health and lifestyle, and obtain their opinion on possible health related services

5. Introduce group members: family / work circumstances

Note: be mindful of any sensitivities within the group throughout the discussion

B. LIFESTYLE (20 mins)

Probe but do not prompt, subject and role of alcohol consumption

1. I’d like to begin by asking you to talk me through a typical week for you: roughly what hours you work and when; how you fill your time outside work and so on? Ask for brief description from each participant, but allow others to contribute as appropriate

2. Thinking about your time outside work, what do you particularly like doing?

 What do you look forward to most in a typical week? Why?  How do you like to unwind?

B2913 Alcohol Intervention Study 63 © Beaufort Research Ltd 2009 March – April 2009 3. How would you sum up your lifestyle?

Focus on health

4. Tell me (more) about your general wellbeing? Probe:

 What sort of things do you do to try and keep healthy? Probe.

 How long have you been doing this?  What’s led you to do this? Probe to understand any motivations  What specifically are you trying to achieve?

 How effective are these activities? Why?

 What are the advantages?  And what are the disadvantages?  How successfully do you keep to them?  How important are they to you?

5. What, if anything, are you not so happy about in relation to your lifestyle and wellbeing? Probe

 How long have you felt this way?  How do you want to improve things?

6. Is there anything you’ve tried to do in the past, but now stopped, in terms of trying to improve your wellbeing? If yes:

 What did you do?  What motivated you to do it?  What were you trying to achieve?  How come you no longer do this?

7. Overall, what are you concerned about most in relation to your general health? If not already covered, probe as appropriate:

 What’s prompted this concern?  What, if anything, are you currently doing to address it?  What’s preventing you from doing anything / more to address this issue?  What would have to happen for you to consider doing something about it?

1. I’d like to focus now on drinking. Tell me (more) about the role drinking plays in your typical week?

 Probe for habits, patterns e.g. drinking:  During the week  At weekends  When going out  At home

2. Tell me about the occasion in the last week or so when you’ve had the most to drink? Probe:

 What was the occasion?  Where were you?  Who were you with?  What was it like?  How much do you think you had to drink?

 What’s your view of that amount?  How regular a scenario is this for you?

3. If you repeated the same occasion but no one involved had anything alcoholic to drink, what would the occasion have been like?

4. Can I have a show of hands: who is aware of the recommended unit guidelines for men and women?

 How much is it for men / women?  Prompt recommended guidelines: Department of Health guidelines state that men can drink between 3-4 units of alcohol per day without serious risk to health. This amount is reduced to between 2-3 units per day for women. These daily amounts apply whether you drink every day, once or twice a week, or occasionally.

 What do you think of these guidelines?  How do you measure the amount you drink?  Probe in terms of weekly v. daily

5. What’s your view of these recommended unit guidelines?

 How much of an impact do they have on you?  How do they compare with the amount you typically drink?

B2913 Alcohol Intervention Study 65 © Beaufort Research Ltd 2009 March – April 2009 6. In your mind, what is an acceptable amount to drink on a typical occasion?

 At what point do you think alcohol starts to impact on a person’s health? In what ways?

Use flipchart – ask a participant to record on flipchart

7. At what point do you think people need to start thinking about the amount they drink overall? Allow light-hearted suggestions to help with group dynamics. Try sentence completion exercise e.g.:

‘You need to start thinking about the amount you drink when . . . . ‘

8. (If not already covered) Have any of you ever tried to cut down the amount you drink? Probe:

 What exactly prompted you to do this?  What was your strategy?  How successful were you?  What would have to happen for you to try to cut down again?

9. Those of you who haven’t tried to cut down before, what do you put this down to? Probe

 What would have to happen for you to try to cut down?  What do you think deters people you know from wanting to cut down?

Note: be aware of any sensitivities in group

10. How do you think alcohol is viewed when compared with other drugs? For example, compared with smoking?

 Probe perceptions of someone who smokes versus someone who drinks more than recommended guidelines

Use flipchart to list actions

11. We’re going to try something a little different now. I’d like you to imagine it’s now April 2010, and an organisation has won a prestigious award for helping people, who drink more than the recommended unit guidelines, to cut down the amount they drink.

 What exactly has the organisation done to win this award? Encourage participants to suggest actions, anything goes; probe, for example:

 What specific messages did they convey?

B2913 Alcohol Intervention Study 66 © Beaufort Research Ltd 2009 March – April 2009  How did they convince people to listen?  What was it about the service that motivated you to use it?  Who did they work with / involve? Etc.

12. Now let’s do the complete reverse. Again, I’d like you to imagine it’s now April 2010, and the same organisation has completely failed in its attempts to help people, who drink more than the recommended unit guidelines, to cut down the amount they drink.

 What exactly has the organisation done to get it wrong? Encourage participants to suggest actions, anything goes.

D. CONCEPT EVALUATION (25 mins)

1. I’d like to get your reactions to some ideas that a Welsh health organisation is considering developing to help people who want to cut down the amount they drink.

Rotate order of service concepts as follows

1. A telephone chat with a health professional, discussing the effects of drinking more than the daily recommended unit of alcohol.

2. A short face to face discussion with a health professional on the health implications of drinking more than the daily recommended units of alcohol.

3. A booklet or website explaining the effects of drinking more than the daily recommended units of alcohol, tips on how to cut back, and the chance to keep an online drinking diary.

4. A meeting with other people (peer support sessions) to discuss the effects of drinking more than the daily recommended units of alcohol and how to cut back

Group Number Rotation Order 1 1,2,3,4 2 2,3,4,1 3 3,4,1,2 4 4,1,2,3 5 1,4,3,2 6 2,4,3,1

B2913 Alcohol Intervention Study 67 © Beaufort Research Ltd 2009 March – April 2009 Show each concept on a card: read it out twice and then discuss:

2. What’s your reaction to this idea?

3. What do you like about it?

4. What do you dislike about it?

5. Who do you think it’s aimed at? Why?

6. How exactly would you improve this service to make it appeal to you?

7. Who would you prefer to have this information from? A GP, Practice Nurse, Health Professional, Counsellor?

8. On a scale of 1 to 10 where 10 means ‘extremely likely to use it’, how likely is it that you would use this service if it existed? Probe

Repeat for remaining three concepts

9. Ask participants to prioritise the four concepts based on which they would be most likely to use

E. SUMMARY (5 mins)

1. If you were responsible for encouraging people you know to reduce the amount they drink, what would you do?

2. Is there anything you’d like to add before we finish?

Thank and close