Introduction  

The detrimental effects of alcohol are well documented; in 2012 alcohol consumption was responsible for approximately 6% of deaths and 5% of disease burden globally.1 The focus has been on the harmful effects of alcohol on the drinker with less attention on the harms caused to others, including families, work colleagues and wider society. The WHO’s global alcohol strategy highlights the need to consider the harm alcohol causes to people other than the drinker,2 and it is these alcohol-related harms to others (AHTO) that are the focus of this study.

Health and social data provide insight into the potential harms caused by another’s drinking. Data from the Crime Survey for England and Wales, for example, show that in just over half of all violent crimes the victim perceived the offender to be under the influence of alcohol and that drinking was particularly implicated in violent incidents between strangers.3 Data from the Department of Transport show that in England during 2013–2015, there were almost 10 000 alcohol-related road traffic accidents in which at least one driver failed the alcohol breathalyser test (data are available at: https://fingertips.phe.org.uk/profile/local-alcohol-profiles), demonstrating a considerable potential harm to both the drinking driver and to others on the roads.

In the last decade or so, several studies have aimed to quantify and explore AHTO in more detail. These studies have provided widely varying estimates of the prevalence of harm, largely due to differences in the way harms are defined and the reference population. Studies which focus on identifying the sociodemographic and behavioural factors associated with being the victim of harm do not always provide consistent findings, suggesting the need for further research. While there is a relatively consistent finding across studies that younger age increases the likelihood of experiencing harm,4–6 the association of harm with other characteristics is less clear. For example, women have generally been identified as more at risk of harm from another’s drinking than men but this is not consistent across all countries and some authors report this association for certain types of harm only.4–7 Two studies identified that women were more likely to experience unwanted sexual attention/harassment/assault, whereas men were more likely to experience having their belongings or property damaged.4 6

When the impact of alcohol includes the effects to the individual drinker and wider society, the cost is considerable. A review of studies in high-income countries found the gross economic costs of alcohol to range from 1.4% to 2.7% of gross domestic product; in the UK in 2016, this would be equivalent to between £27 billion and £52 billion.8 There is a need to better understand AHTO and the characteristics of those affected in order to implement an effective response. To date there has been no national survey of AHTO in England, although surveys have been conducted in Scotland,9 Wales10 and Ireland.11 The objectives of this exploratory study were to estimate the prevalence of AHTO in England, identify factors associated with being the victim of harm, the frequency with which this harm occurs and the perpetrators of harm.

Method

Results

Perpetrators of harm

Respondents could select more than one perpetrator category per harm type. Overall, the most frequently reported perpetrators of harms were friends (23.4% of total perpetrator reports N=590) and strangers (22.9% of total perpetrator reports,  N=578), while work colleagues were the least reported perpetrators (3.7%, of total perpetrator reports, N=94,  figure 1). The perpetrator varied according to the type of harm (online supplementary table 3). Focussing on the most common harms experienced, being kept awake due to noise or disruption was predominantly perpetrated by strangers (49.5%, 95% CI 43.8% to 55.3%;  of the 370 people who were kept awake at night, 183 indicated a stranger perpetrated this harm),  while both strangers and friends were the most common cause of feeling uncomfortable or anxious at a social occasion (strangers 34.4%, 95% CI 28.5% to 40.7%; N=105/305 friends 32.8%, 95% CI 27.2% to 39.0% N=100/305). Serious arguments that did not include physical violence were predominantly perpetrated by friends (35.7%, 95% CI 29.5% to 42.6% N=93/260) or someone the respondent was in a relationship with and lived with (23.1%, 95% CI 17.6% to 29.6% N=60/259). Likewise, being let down by someone or being emotionally hurt or neglected were harm types perpetrated by people close to respondents.

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Figure 1

Perpetrators as a percentage of all reported harms to others, weighted data, weighted n=2522 (represents the total number of perpetrators across all harms).

 Strangers were most likely to be the perpetrators of two of the aggressive harms: of the 154 respondents who reported being physically threatened, 93 indicated a stranger perpetrated this harm (60.5%, 95% CI 51.2%– to 69.1%). Of the 83 people who reported being physically hurt, 26 said a stranger perpetrated this harm (31.5%, 95% CI 21.5% to 43.6%). While 19.0% (95% CI 6.5% to 44.2%, N=5/27) of respondents who reported being forced or pressured into sex or something sexual reported the perpetrator was a stranger, the most commonly reported perpetrator for this sexually aggressive harm was someone the respondent was in a relationship with and lived with (23.3%, 95% CI 9.8% to 46.0%, N=6/27; rising to 39.9% when also including people in a relationship who lived elsewhere).

Frequency of harm

Figure 2 reports information on the frequency with which harms were experienced. The majority of reported harms were experienced less than once a month (N=1536, 74.8%); 12.8% (N=262) of harms were experienced at least monthly but less than weekly, 7.2% (N=149) of harms were experienced weekly but less than daily and 5.2% (N=106) of harms were experienced daily or almost daily.

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Figure 2

Frequency of all reported harms to others, weighted data, weighted n=2052 (represents the total number of harms across all individuals).

The frequency of harm varied by harm type (online supplementary table 4). The harm types reported to reoccur most often were those for which the description implies that the harm occurred over a prolonged period of time with someone whom the respondent was in regular contact. These included ‘had to spend my personal time caring for a person with a long-term health condition or disability that resulted from their current or previous drinking’ (19.4% of people [10/53] who reported experiencing this harm did so  daily or almost daily, 95% CI 10.2% to 33.8%) and ‘had to stop seeing or being in contact with someone because of their drinking’ (19.3% of people [21/107] who reported experiencing this harm did so daily or almost daily, 95% CI 11.9% to 29.6%). It was less common for other harms to be experienced at a daily or almost daily frequency. Nevertheless, all harm types had at least one respondent reporting daily or almost daily frequency of harm.

Discussion

In this exploratory study, one in five respondents experienced AHTO in the previous 12 months. The most commonly reported AHTO were being kept awake due to noise or disruption and feeling uncomfortable or anxious at a social occasion which have been identified as the most prevalent harms in other studies.4 5 More concerning, 4.6% reported experiencing an aggressive harm. Experiencing AHTO was associated with a number of demographic and socioeconomic variables. Friends and strangers were the dominant perpetrators of AHTO.Most harms occurred less than monthly but some harms were experienced daily or almost daily.

The main strength of this study is its large sample size; this is the largest survey on AHTO conducted in the UK and the first to provide data for England. The sampling and weighting strategy employed ensured the sample was representative of the English population and thus the generalisability of the findings. There are a number of limitations to note. Recall is always a problem with surveys; harms that occurred a year ago or had little impact on the respondent may be more difficult to recall. Attributing causality is not possible using a cross-sectional design. There are also some social groups that are systematically missing from surveys such as homeless people, those in hospital or care homes and those in prison; populations whose alcohol use is likely to be different.17 Previous studies on AHTO have also largely relied on cross-sectional surveys and are affected by the same limitations. A response rate could not be calculated because Ipsos MORI did not collect the necessary data. While the total amount of missing data is small, any missing data can potentially introduce bias. There were some significant differences in the characteristics of those that answered the AHTO questions and those that did not. The internal validity of the AHTO questions used here has not been measured; in the initial search of the literature the authors failed to identify a validated survey. Consequently, it is possible that discrepancies exist between the responses provided by participants and their actual experience of alcohol-related harm. Finally, ecological fallacy, where the inferences about individuals are made based on data for a group, is also a consideration in this type of study. It is likely that systematic differences exist in harm by population subgroups (eg, by sex and ethnicity) and future work on AHTO in the UK should explore this. It is possible that the findings on factors associated with harm represent those that are associated with the most common but ‘low impact’ harms and cannot be generalised to more severe harms. However, the fact that we specifically examine factors associated with aggressive harms (which are the most serious harms considered) mitigates this. That said, further research to identify the factors associated with individual harms would be advantageous.

In this study, the prevalence of harm was 20.1%. The closest comparison is from a cross-sectional survey conducted in Wales in 2015 which used identical AHTO questions and reported the prevalence of any harm in the previous 12 months to be 59.7%.10 There is some evidence from routine data to support a lower prevalence of harm in England than Wales. For example, the percentage of violent incidents where the victim believed the offender(s) to be under the influence of alcohol tends to be higher in Wales than England18 although not conclusively so. However, the magnitude of the difference in the reported prevalence of harm between England and Wales seems questionable, given the similarities between the two nations. This difference could be due, in part, to differences in methodology and caution needs to be applied in drawing direct comparisons. In Wales, a free text box was included that gave participants the option to report ‘other alcohol-related harm’, and these were included in the ‘any harm’ figures for Wales which would likely increase the prevalence compared with England. This approach was not undertaken in England because not all harms reported in the free text box appeared to be alcohol- related,  while others appeared to repeat harms already included within the 18 specific AHTO questions. In England, the harm questions were asked after the ATS questions; this may have affected how people perceived harm, and therefore how they responded to the harm questions. It is also possible that respondents were experiencing fatigue by the end of the survey and this may have affected how fully they reported their experiences of harm. The English survey was administered face-to-face while the survey in Wales was administered via the telephone using landline numbers. Using data from the USA, researchers comparing face-to-face and telephone interviews reported that telephone surveys may miss certain sections of the population if they solely rely on landlines, including those with lower incomes.19 However, the Welsh survey was weighted so the data were representative of the deprivation of the general population.10 Other surveys of AHTO conducted in the UK have reported the prevalence of harm in adults to be 28% in Ireland,11 51% in Scotland,9 79% in the North West of England,13 however these studies used very different AHTO questions so the results are not comparable. Despite the difference in prevalence between the Welsh survey and the current study, the relative prevalence of the types of harm were similar; being kept awake at night, feeling uncomfortable or anxious at a social occasion and having a serious argument were the most prevalent harms in both surveys.

Being a hazardous/harmful drinker increased the odds of experiencing AHTO. This is perhaps unsurprising given that drinking with other drinkers and in places where alcohol is consumed increases one’s exposure to drinkers. However, the association with drinking and experiencing alcohol-harm is not conclusive. A cross-sectional comparison of harm from ‘heavy drinking’ friends and family across five Nordic countries and Scotland reported that drinking frequency was not significantly related to experiencing harm from others but binge drinking frequency was. A higher frequency of binge drinking increased the risk of experiencing AHTO in Sweden and Norway, and there was some evidence for this relationship in Finland also, but not in the other countries.7 A paper using the same Norwegian data showed that the association between experiencing harm, and one’s own drinking was not evident for all types of harm.6 Other cross-sectional surveys show an association between one’s own drinking and experience of any harm,20 21 including two which report a dose response relationship, with dependent/frequent risky drinkers having the greatest risk.4 22

Here, age was also associated with experiencing any harm and aggressive harm. A number of studies from a range of countries have reported that being of younger age increases the risk of being harmed from another’s drinking.4–7 23 However, ‘younger age’ in this context does not always mean ‘young’; one study, for example, concluded that those aged 59 or less had a higher risk of being negatively affected by a known drinker than those aged 60 and over.7 A global survey of 63 725 respondents aged 18–34 years reported that those aged 18–24 years were significantly more likely to experience an aggressive AHTO than those aged 30–34 or 25–294; similar to results reported here.

The respondent’s sex was not significantly associated with experiencing harm. The literature is mixed regarding sex as a risk factor. Women were reported to be significantly more likely to experience harm than men in Finland and Sweden but not in Denmark, Iceland, Norway or Scotland.5 6 Being a woman was found to be a significant risk factor for all harms and aggressive harms using data from the Global Drug Survey.4 The association of sex and experiencing harm is different for different types of harm. For example, women are significantly more likely than men to experience unwanted sexual attention/sexual harassment or assault,4 6 whereas men are more likely to have clothing, property or other belongings damaged.4 6 Survey data from the USA examined family/marriage, financial and assault harms due to drinking of a partner/spouse/family member and reported that women were more likely to report financial and family/martial harms while a higher proportion of men experienced assaults.24 While examining differences in harm by sex was not the focus of this study, online supplementary table 2 shows that such differences may exist. For example, there is a clear difference between the proportion of men (2.1%, 95% CI 1.6% to 2.9%) and women (4.8%, 95% CI 3.9% to 5.8%) who reported experiencing alcohol-related emotional hurt or neglect. Such differences should be considered in future work on this topic in the UK.

Few studies have considered whether ethnic background is a risk factor for experiencing harm. Data from the USA demonstrate that the link between ethnicity and experience of harm is not conclusive (two studies show no association and one a weak association).20 23 24 Here, being white British was significantly associated with experiencing harm and also aggressive harm. Most minority ethnic groups in the UK have higher rates of abstinence from alcohol and lower levels of drinking than people of white ethnicity.25 However, the results of the multivariate modelling presented in this study show that white British ethnicity is associated with experiencing harm and aggressive harm independently of AUDIT score.

Having a disability was also significantly associated with experiencing any harm and an aggressive harm. No previous studies on the association between having a disability and experiencing alcohol-related harm were identified. However, there is good evidence to show that those with a disability are the victims of harm more generally including physical, sexual and intimate partner violence,26 27 and financial hardship.28

Being in the family stage of life also lowered the odds of experiencing harm compared with being single. This is perhaps surprising given that the survey included questions which specifically asked about harms most likely caused by a family member. Evidence on the effect of relationships and household types is mixed and largely dependent on the way these are categorised and so cannot be directly compared.

Educational attainment, type of accommodation, social grade and employment status are proxy measures for socioeconomic status. Literature on the effect of socioeconomic status is mixed, and comparisons are hindered by the multitude of different measures used in different studies. In this study, social grade was not significantly associated with harm or aggressive harm in the bivariate analyses. A study in Scotland also reported no significant difference in experience of any harm according to social class.9

Here, findings show that experiencing harm was significantly associated with having qualifications (compared with having none) with the greatest odds being for those with a degree or higher degree. The association between education and experience of harm in the literature is mixed. Data from two national surveys (Denmark29 and the USA20) showed no clear association between experiencing harm and education level. Data from the Global Drug Survey showed no association between education and experience of harm or aggressive harm but there was an association between education and experiencing particular types of harm.4 However, a comparison of northern European countries reported that a significantly higher proportion of respondents with high school/university education experienced harm than those with elementary education in four of the six countries considered.5 Those with higher educational attainment were more likely to experience any harm in a Canadian study.30

The current study shows that being retired lowers the odds of experiencing harm and aggressive harm compared with all other employment statuses. This association was independent of age. The odds of being harmed did not differ significantly between those who were employed and not employed. A cross-sectional survey in Canada also reported that those who were retired were least likely to experience harm.30 Data from two surveys conducted in the USA show that those who were unemployed were significantly more likely to experience AHTO than those who were employed.23 24 Data from Denmark show that employment might be significantly associated with experiencing harm but no conclusive results were provided, and the wide CIs show that estimates lacked precision.29 Conversely, data from the USA reported no association between experiencing any harm and employment status.20

Here, compared with those that owned their home outright, those who rented from a private landlord had significantly greater odds of experiencing harm and those who rented from the local authority or rented from a private landlord had significantly greater odds of experiencing an aggressive harm. No previous studies on the association between type of accommodation tenure and experiencing alcohol-related harm were identified. It is possible that those who rent represent a more transitory, poor and vulnerable population which increases their risk of harm. Research not specifically related to alcohol shows that those living in unstable housing (eg, living on the streets, in temporary sheltered accommodation or with relatives or friends) experience relatively high rates of victimisation,31 32 while data from national surveys in Great Britain show that being the victim of domestic property crimes is higher among those who rent (including those in the private-rented sector) than those who own their own homes.33

How exactly socioeconomic status influences the experience of harm is not clear from our findings. Neither social grade nor employment status (excepting retirement) were associated with AHTO in our study. Education, as a proxy of earning potential, was associated with AHTO, but there was no significant variation between the groups GCSE/O-level/CSE, A-level/vocational and degree/higher degree. No clear picture of the association between experience of harm and socioeconomic status emerges from the literature either. A comparable study of AHTO in Wales reported no association between experience of any harm and area-level deprivation.10 It is possible that more sensitive methods are needed to fully explore the relationship between socioeconomic status and AHTO, and any patterns in relation to particular types of harm.

In the UK, there are cultural differences in drinking behaviour, and some of these are reflected in our AHTO findings (such as differences between ethnic groups).34 However, other sociocultural variations are not easily identified in our findings. For example, while national survey data show that people have different drinking habits across income levels (people on higher incomes tend to drink more34), this pattern is not reflected in our findings on socioeconomic status.

This study identified friends and strangers as the dominant perpetrators making up around 46% of all reports, though the perpetrator varied depending on type of harm. For example, family members made up a larger proportion of perpetrators of harms such as stopping seeing someone or having to care for someone because of their drinking. While three-quarters of harms were experienced less than monthly, 5.2% were experienced daily or almost daily indicating a considerable burden of alcohol-related harm for a section of the population. The frequency of experiencing harm was largely dependent on the type of harm. Harms with the highest frequency of daily/almost daily reports were those which occurred over a prolonged period of time and/or implied frequent contact with the perpetrator such as caring for someone with a long-term health condition or disability that results from them drinking. Data from two surveys suggest that exposure to heavy drinkers is associated with poorer health, well-being and quality of life.37 38

To conclude, this is the largest ever survey of AHTO conducted within the UK and the first national study in England. It is clear that AHTO is relatively prevalent and that some individuals experience harm frequently. The most prevalent harms could be considered trivial but even apparently minor harms such as sleep disruption can have an impact on health and quality of life,39 particularly if experienced persistently. It is difficult to compare results with the literature because of the diversity of methods being employed. In order to support temporal and geographical comparisons, it would be advantageous for studies to use a consistent methodology including the sampling and data collection methods, in addition to the harm questions. The WHO ThaiHealth project has designed a survey to measure AHTO in order to facilitate international comparisons40 41 but unfortunately authors were not aware of this when they began the current study. While lengthy, using this would be a good way to develop a comprehensive and consistent evidence base. However, it is clear that there are differences across harm types and more detailed analysis of specific harms would be valuable for supporting remedial action from policy-makers. Here, we consider ‘aggressive harms’ as a distinctive group of harms; future research could consider other harm groupings in order to provide a more detailed assessment of specific harm types. Research on the types of alcohol consumption patterns that increase the likelihood of experiencing AHTO in the UK would be valuable. Understanding what puts younger adults at increased risk could be a useful focus for future research as it might identify the contextual factors which make experiencing harm more likely. Further focus on the differences in harm by sex would also be advantageous as there is little data on this in relation to the UK. Policy to address AHTO is less well developed than policy that seeks to address harms to the drinker; exceptions include crime and violence and harm to the unborn fetus which have been included in previous Government’s Alcohol Strategy.42 Given that AHTO research is in its early stages, it is too early to advocate a detailed policy response but results presented here will be of interest to policy-makers to help understand the wider impact of other people’s drinking.