PHIAC took account of a number of factors and issues in making the recommendations.
3.1 Under UK law, children and young people can consume different types of alcohol in different contexts, depending on their age. For instance, young people aged 16 or 17 may consume beer, cider or wine with a meal when under adult supervision on licensed premises. In all other circumstances, it is illegal for anyone under 18 to 'knowingly' consume alcohol on licensed premises, or to buy or attempt to buy alcohol. It is important that schools take this legal framework into account when planning and delivering alcohol education and when developing partnerships to tackle alcohol issues (within and outside schools).
3.2 Different countries favour different approaches to alcohol education. For example, alcohol use is considered normal for a large proportion of the population in the UK where a 'harm reduction' approach is favoured for young people. By contrast in the US, where most of the research on school-based interventions comes from, abstinence is encouraged among children and young people.
3.3 The renewed national alcohol strategy suggests that, 'more needs to be done to promote sensible drinking'. Sensible drinking for adults is described as 'drinking in a way that is unlikely to cause yourself or others significant risk of harm' (HM Government 2007).
3.4 There is no consensus about what constitutes safe and sensible levels of drinking for children and young people. In 2008, the government plans to provide guidance about 'what is and what is not safe and sensible in the light of the latest available evidence from the UK and abroad' (HM Government 2007). PHIAC did not, therefore, consider it part of its remit to define these levels.
3.5 In the absence of guidance on safe and sensible levels of alcohol consumption, PHIAC focused on encouraging children not to drink, delaying the age at which young people start drinking and reducing the harm it can cause among those who do drink. The second recommendation acknowledges that some young people may already be drinking harmful amounts of alcohol.
3.6 A number of social, cultural and economic factors have an influence on alcohol consumption among children, young people and parents. These include peer pressure, the alcohol industry, the media, and the availability and cost of alcohol.
3.7 While schools have an important role to play in combating harmful drinking, PHIAC acknowledged that they are limited in terms of what they can achieve (see 3.6 above).
3.8 The recommendations for schools are in line with existing guidance from the DCSF (Department for Education and Skills 2004). They support the National Healthy Schools Programme's 'whole school' approach (Department for Education and Skills 2005). They also support standards one, four, five (DH 2004b) and nine of the 'National service framework for children, young people and maternity services' (DH 2004c).
3.9 The recommendations support implementation of 'Every child matters: change for children' (HM Government 2004b). This outlines a common assessment framework (CAF) or process to help professionals identify children and young people with specific needs (including those who are misusing alcohol). When a child or young person requires support, 'Every chiId matters: change for children' recommends that these services should be coordinated by a lead professional.
3.10 The new PSHE and PSHE education curricula, which are being introduced from September 2008, move away from an emphasis on content and instead promote concepts such as 'healthy lifestyles'. They should be tailored to meet individual needs. Alcohol education involves promoting a healthy lifestyle as excessive alcohol use is linked to a range of health and social problems (see section 2).
3.11 PHIAC acknowledged that alcohol use is the cultural norm among most adults in the UK. Some people believe it is normal and acceptable for young people under 18 to drink. Some individuals and groups find alcohol use among any age group unacceptable. It is important to take individual, social, cultural, economic and religious factors into account when delivering alcohol education programmes.
3.12 While some individuals may be more vulnerable than others (see section 2), it is inappropriate only to focus on those individuals. Children and young people from all backgrounds – and in all types of school – may drink harmful amounts of alcohol.
3.13 Those delivering alcohol education programmes need to have the trust and respect of the children and young people involved. They should have received validated training and be able to provide accurate information using appropriate techniques.
3.14 Work with children and young people who use alcohol may lead to confidentiality issues. Where a child or young person requires individual guidance and support, best practice guidelines on consent and confidentiality should be followed (DH 2001). Children and young people should be encouraged to involve their parents or carers and the best interests of the child or young person should be the primary concern. This is in line with the duty to safeguard and promote the welfare of pupils, imposed on all schools and colleges of further education under the Education Act 2002 and Children Act 1989 (HM Government 2006).
3.15 The evidence on school-based interventions was not extensive and, as most of it was US-based, it has to be applied with caution. Common shortcomings include:
non-validated surrogate outcome measures that are not relevant to English policy
uncertainty whether studies were large enough to detect differences between groups
inappropriate analyses for the study design used
analyses which did not take baseline imbalances into account
high attrition rates.
Nevertheless, PHIAC considered that some evidence was of sufficient quality and sufficiently applicable to England to inform the recommendations.
3.16 Due to the limitations of the evidence, it was not possible to determine the differential effectiveness of the interventions in relation to disadvantaged and minority groups. In addition, it was not possible to determine what impact the recommendations may have on health inequalities.
3.17 As alcohol use is a sensitive issue associated with social values, self-reported data may be biased.
3.18 The economic analysis carried out to determine whether or not an intervention was cost effective in the long term was subject to uncertainties.
3.19 A number of studies evaluated the input of external contributors to school alcohol education programmes. However, there was a lack of evidence about which type of contribution worked best. The literature focused mainly on 'stand-alone' interventions (rather than those contributing to teacher-led programmes, or giving advice and support to schools). In addition, these studies had limited cultural relevance for England. As a result, PHIAC was unable to make any recommendations about the use of external contributors in schools.
3.20 The recommended interventions were not compared with other types of intervention because it was beyond the remit of this guidance to make such a comparison. (Examples of other types of intervention aimed at preventing or reducing alcohol use include targeted and indicated activities and those taking place outside educational establishments.)
3.21 Forthcoming NICE guidance on PSHE and PSHE education, with reference to sexual health behaviour and alcohol (due September 2009) may lead to additional recommendations on this topic.