The document summarizes the results of focus groups conducted with alcohol service users to understand their perspectives on a proposed voluntary restriction of high-strength, low-cost alcohol in one London borough. The main themes that emerged were: 1) The scheme was seen as a good start but unlikely to succeed as proposed due to alcoholics finding ways to obtain alcohol and retailers not following voluntary restrictions. 2) Drinkers would not switch to lower alcohol options but rather find alternatives like spirits or a black market. 3) For the scheme to have a chance of success, it would need to be mandatory across a larger area and accompanied by improved treatment services.

1. Original research
Restricting the availability of cheap, ‘super-strength’
alcohol: does it improve health? The perspective of
alcohol service users in one London Borough
J Burke*, M Phelan†, J Hacker‡,
At Public Health Croydon, London Borough of Croydon
ABSTRACT
Objectives: The main purpose of this research was to establish whether and how
local plans to restrict the availability of cheap, ‘super-strength’ lager and cider would
affect the drinking behaviour of those affected, and whether the scheme was likely to
have an impact on the health of those most affected.
Study design: Qualitative research study utilising focus group discussions with
alcohol service users.
Methods: Four focus groups were held with: a user group for recovered and
recovering alcoholics, a drop-in breakfast club and outreach project for people with
substance misuse issues in the criminal justice system, a hostel for homeless people
with substance misuse or mental health problems, and a service user group for
recovered or recovering female alcoholics.
Three of the four focus groups were recorded and transcribed with permission from
participants. Thematic analysis was undertaken using a grounded theory approach.
Emergent themes were grouped around two key issues, likelihood of success of the
scheme, and recommendations to improve the scheme.
Results: The main theme to emerge was the expectation that the scheme as it stood
would fail. This was for two main reasons: that neither the drinkers at whom the
scheme was targeted nor the retailers involved in the voluntary ban were likely to
change their behavior. None of the focus group participants said they would switch to
low strength alcohol as a result of this scheme, and many said that alcoholics would
‘do what it takes’ to obtain the ‘buzz’ associated with high strength drinks. Some
participants, particularly in the female only group, felt that the voluntary ban was a
good start, but needed to go further. Many advocated a ban across the whole of the
Borough, London as a whole, or nationally, as with the smoking legislation.
Participants felt the scheme could be improved by ensuring it was accompanied by
improved treatment services, and improving prevention measures, including tackling
the social causes of alcoholism such as homelessness and unemployment.
* Senior Public Health Principal/health improvement Commissioner
† Public Health Principal - alcohol lead
‡ Consultant in public health

2. Conclusions: The feasibility and viability of such voluntary ban schemes should be
thoroughly investigated and established prior to their implementation. In this case,
the proposal and its purported benefits had no firm foundation in evidence and
consequently the voluntary ban can be considered to have been unsuccessful,
though a proper evaluation has not taken place to date.
No impact on drinking
Lost opportunities for health promotion
Key words: alcohol, substance misuse, health improvement, high strength, beer,
lager, cider, alcohol service users

3. Introduction
Although alcohol forms an important part of the social, cultural and economic life of
many communities, it is associated with much morbidity and mortality. Alcohol
contributes to around 60 health conditions, principally heart disease, stroke, liver
disease and cancer. More than 21,000 deaths are attributable to alcohol each year in
England.§
Alcohol misuse comes at a huge cost to both health and society. The annual costs to
the NHS of treating alcohol related disease at around £3.5 billion.** Those who are
alcohol dependent cost the health system twice as much as lower risk drinkers. The
costs of alcohol go beyond the health services. Alcohol has a close association with
crime and disorder: nearly half of violent offences are believed to be committed
under the influence of alcohol.†† When crime and productivity are included, the
annual costs of alcohol to society increase to around £21 billion.‡‡
The 2012 national strategy for alcohol§§ highlights the need for local areas to work in
partnership to address both the health and the crime implications of problem
drinking. Its ‘next steps’*** includes a challenge to industry to reduce the availability
of cheap high strength alcohol products such as beer and cider. These offer very
high ABV (alcohol by volume) at a very low price, enabling dependent drinkers to
consume a high number of units on a minimal budget.
Several London Boroughs have explored and implemented initiatives to locally
restrict access to cheap ‘super-strength’ alcohol schemes. Schemes have
predominantly been based around voluntarily restricting access, and have generally
seen good engagement from small independent off-licences and varied engagement
with larger chain retailers. Through the London Safer-Street Forums, early
conversation have taken place as to the impact of a Londonwide scheme.
Our research centred on one of these London Boroughs, a designated Local Alcohol
Action Area (LAAA)†††, where good partnership arrangements are in place and the
local authority has entered into a voluntary agreement with license holders in one
ward to remove cheap high strength alcohol products from sale. The main aim is to
reduce crime and disorder in the town centre in a ward where alcohol-related violent
crime was high.
Public Health were interested in assessing the likely impact of the voluntary bans on
those most affected: drinkers of cheap, high strength alcohol products. Would they
simply adapt their drinking habits and switch to lower strength products? Or move to
other areas of the Borough or beyond? What were the likely impacts on both health
and crime? Would the scheme work?
§ Public Health England Local Alcohol Profiles
**
Statistics are from the period 2011/12,Crime Survey for England and Wales,Office for National Statistics
††
Crime Survey for England and Wales (CSEW); 2011/12,Office for National Statistics
‡‡
Alcohol Treatmentin England 2013-14,Oct 2014 Public Health England.2014458
§§
The Government’s Alcohol Stategy; March 2012. CM 8336
***
Next steps following the consultation on delivering the Government’s alcohol strategy,July 2013.Home Office
††† Local Alcohol Action Areas, of which there are20 in England, are areas which have been set up to tackle
the harmful effects of irresponsibledrinking,particularly alcohol-related crimeand disorder,and health harms.

4. In order to inform our assessment, we chose to access the unique perspective of
those most affected by the proposals at street level.
Methods
The research took the form of four focus group discussions with people using local
services aimed at alcoholics or former alcoholics. The research was inspired by an
initial meeting between Public Health and the local Peer Led User Group (PLUG)
which offers informal support and advice for recovered and recovering alcoholics.
This produced a wealth of rich and unique insight, from a marginalised and under
researched group, into the potential limitations of the scheme as well as proposals
for how the scheme could be improved.
The decision was taken to undertake a formal research exercise, led by local public
health staff with expertise in qualitative research, in order to elicit the views of a
wider range of local service users and establish whether the views expressed in this
group were representative and generalisable. Discussions with staff coordinating the
first group effectively identified two other local groups for alcohol service users with
mechanisms already in place for service user involvement. A further, female only
group was also identified from discussions with staff and was seen as a priority,
given the domination of males over females in the group that had previously taken
place.
Research governance approval was sought and received from the local authority. All
three groups were approached and each agreed to take part (see Box 1 for details of
each group).
Box 1: Details of focus groups
Group 1 Peer Led User Group
Users of local alcohol and/or drug treatment services, now recovered or in
recovery; evening meeting, attended by approximately 30 service users.
Overwhelmingly male group, only two were female.
Group 2 Outreach project for people with substance misuse issues in
the criminal justice system
Focus group carried out during a regular drop in breakfast club for dependent
drinkers. Between six and nine participants took part at any time and all were
male.
Group 3 Hostel for homeless with substance misuse or mental health
issues
Focus group held during breakfast, with between five and eight residents
(mainly male) drifting in and out of the discussions at any one time. Staff were
present but did not contribute. This was a difficult session, as service users
seemed distrustful of the public health visitors, and some appeared to be
intoxicated. One was removed from the group by a member of staff for this
reason. The discussion was shorter than other groups and took approximately
20 minutes.

5. Group 4 A support group for recovering or recovered alcoholics
The focus group took place during one of the regular meetings of a female
only group, and was attended by eleven women who use the group, which is
managed by service users.
Participants were assured of their individual anonymity at the start of the project. A
small number of participants, particularly from group 3, drifted in and out of the
discussions, most remained throughout. Group 3 was particularly difficult to facilitate
since a small number of participants appeared to be intoxicated, and one was
removed by staff. Each of the four focus groups took place in a setting familiar to the
participants, and members of the groups were generally known to each other. At
each of the four groups, staff were present in the background, sometimes preparing
food whilst the discussions were taking place.
The same semi-structured framework was used to structure each of the four
discussions (see Box 2). Each discussion was hosted by two members of the three
members of the research team. For groups two to four, discussions were recorded
and transcribed with written consent from participants. Each of the team read the full
transcripts to immerse themselves in the themes emerging from the groups. One‡‡‡
subsequently took the lead in identifying a thematic framework from this data, using
a grounded theory approach to identify the most common themes, and another
assisting with highlighting key quotes to demonstrate the frequency with which
themes had occurred.
The key themes that have been identified are those which occurred in at least three
of the four groups and were shared by several people within each group. Where
themes were specific to one or two of the groups, this has been indicated. Views
which were not common to more than one group or shared by more than one person
have not been developed as themes. Themes were grouped into those relating to
the likely impact of the scheme, and those relating to suggested improvements.
Feedback was given to each of the service user groups.
Box 2: Focus group framework
Question 1: The council is concerned that cheap, so-called ‘super-strength’ alcohol
products, mainly beer and cider, may pose an especial harm to health and may be
implicated in public order and public nuisance issues. The council proposes to
promote a scheme requesting that license holders in the town centre ward of X
voluntarily agree to cease the sale of these products.
What are your views on the proposal?
Question 2: What, if any, problems could this proposal cause?
Question 3: What, if any, benefits could it bring?
Question 4: Would drinkers do anything differently if the scheme was introduced?
‡‡‡ Jenny Hacker

6. Question 5: Is there anything else that could be put in place to ensure there are
benefits?
Results
Part A: Likely impact of the scheme
1. Good start that does not go far enough
There was some support for the scheme as a positive step. Participants in groups 1
and 4 in particular welcomed the scheme:
‘It could be a step in the right direction.’ Group 1
‘What you’re doing, I think it’s a start, it is a start.’ Group 4
‘I think it’s a good idea. I think anything is better than nothing… Anything you
can do to help it I think will be brilliant.’ Group 4
‘I know that they harp on and I’m guilty a couple of times, about alcohol users
using their beds (at the local hospital), but if it reduces the amount of people
who are going in for drinking ….’ Group 4
Some were cynical about the reasons for the actions, stating that the Council were
simply concerned with the profile of the borough given upcoming commercial
developments:
‘The real agenda here is trying to clear undesirables out of the town centre to
make the place look more upmarket for the X development.’ Group 1
Participants in Group 3 were less likely to see the scheme as a good start. A small
number of vocal, and possibly intoxicated, participants from Group 3 thought the
scheme should be scrapped.
‘Leave our beer alone!’ Group 3
‘Just keep it as it is.’ Group 3
‘No, no, no, no, no, no, no, no, no. That’ll never happen. I like my super-
strength lager.’ Group 3
Others in this group felt that there was unfair stigmatisation of street-drinkers
compared to ‘club goers’ who were felt to also ‘cause grief’ in the town centre.
However, across each of the four groups, there were individuals who had empathy
for those whom street-drinking might affect:
‘I can understand that people don’t want a town centre full of drunks – I
sympathise with that.’ Group 1

7. ‘There are people who hang around in the churchyard right next to the off-
licence, so that can cause grief and you don’t need that if you’re mourning
someone… If you’re attending a funeral or anything like that, you don’t want a
load of pissheads around you, do you?’ Group 3
‘We’re as discreet as we possibly can [be], the majority of us. We try and hide
our alcohol or transfer it to a different bottle.’ Group 3
‘I don’t think it will work, but I understand that, for families entering the town, it
will get drunks off the street.’ Group 2
2. The voluntary restrictions will not work
A more common theme to emerge, indeed the key theme to emerge overall, was that
the scheme as it stood would not work. This was for two key reasons: that alcoholics
were dependent on alcohol and would find a way to buy what they needed, and that
retailers were unlikely to comply with a voluntary ban. Participants were split
between those who thought drinkers would move on to other areas, and those who
felt that they would buy the drink elsewhere and continue to come into the town
centre.
a) ‘We are alcoholics – we will find a way’
The most common subtheme was that those affected by the proposals were
dependent drinkers and would not reduce their consumption of alcohol.
‘When I was dependent nothing would ever stop me from getting the drink I
needed.’ Group 1
‘We’ll just go further to get the strong lager.’ Group 3
‘If I went in an off-license and they refused to serve me I would just keep
walking until I found one that would.’ Group 1
Participants in the groups were keen to remind the research staff that they were
alcoholics and could not simply stop or reduce their units:
‘I want a quick hit. That’s why problem drinkers don’t want to drink low alcohol
lagers.’ Group 4
‘If that man on the top of George Street, if he agrees to voluntarily stop, and
the man down the bottom doesn’t, they’ll all go to the man down the bottom
because they [the street-drinker] have a problem.’ Group 4
One pointed out the danger of restricting alcohol to drinkers:
‘It is dangerous! An alcoholic will need the alcohol in his system to survive,
what will they do if they can’t get access?’ Group 2

8. None of the participants in any of the four groups said they would switch to lower
strength products. If no high strength lagers or ciders were to be found, participants
said they would switch to high strength alternatives:
‘You will just push me on to spirits – I can get cheap spirits from Lidl’ Group 2
‘They’d go on to spirits.’ Group 3
‘I will just turn to spirits, turpentine or even paraffin if I need alcohol.’ Group 1
b) High strength alcohol will still be available
Another reason why the scheme was felt likely to fail was an expectation that
retailers would not take part in a voluntary ban. This was particularly strong in group
4, the female only group:
‘The retailers are there to earn money and do they have a conscience?’
Group 4
‘They’re just here for the money! … people will shoplift for toiletries and
exchange it for alcohol. Quite a few shops will do that.’ Group 4
‘Are they [the council] going to check on it so they’re [the licensees] not
sneaking selling? Regular drinkers coming into the shop, they’re getting it
from under the counter and they’re walking out with it.’ Group 4
‘You’ll always get super-strength lager. I don’t care where you are. They’ll
never stop it.’ Group 3
‘If you want a drink in the town centre, every newsagent you go in will sell you
drink. If they need it, they will get it.’ Group 4
Slightly less common was the expectation that the ‘black market’ would provide:
‘There could be a black market, like drugs. A man sitting there in (X) gets a
man from (Y) to bring it to him because the shops in (X) aren’t selling it any
more. Makes a mockery of it really, doesn’t it.’ Group 4
‘It will increase the bootlegging of alcohol and gangsters with carloads of drink
will get involved.’ Group 1
‘You’d get it underground.’ Group 3
c) Alcohol will continue to be brought into the town centre from outside
Some also explained that restricting sales in town centres was avoiding the issue:
people tended to buy the alcohol elsewhere and bring it into the town centre:

9. ‘When I was a street-drinker I never bought these products in the town centre
anyway. It was £1.70 for a can of super-strength in (town centre) and only £1
for the same can in [an adjacent ward]. I brought it into the town centre with
me.’ Group 1
‘You’ll take it in [to the town centre].’ Group 3
‘It will mean an increase in people bringing drink into the town centre – we
don’t need to buy it here!’ Group 2
d) The problem will be displaced to other areas
Others felt that it would affect drinking in the town centre but would simply displace
the problem to other areas:
‘I will move to (names other areas nearby) - you are just moving the problem.’
Group 2
‘I will just walk further down to where I can drink.’ Group 2
‘If they’re not going to make it mandatory…I don’t think there’s much that one
council can actually do about this.’ Group 3
3. Crime will increase
In terms of crime, some felt that the action would lead to more crime:
‘It will increase hostility and violent crime towards police if they remove
alcohol.’ Group 2
‘There will be more shoplifting.’ Group 1
‘More shoplifting. You can go into a shop and nick a bottle of wine.’ Group 3
‘It will mean more crime. When I was drinking I would steal enough to fund
the number of alcohol units I needed. If cheap high-strength alcohol was not
available I would steal more to be able to buy enough alcohol to get the units I
needed.’ Group 1
‘… taking away strong lager and strong cider, there’s more aggravation
because they need that drink, there’s going to be more violence, there’s going
to be more thieving.’ Group 3
Part B: Recommendations
The groups were prompted into thinking about how the scheme could be improved
by the question: “Is there anything else that could be put in place to ensure there are
benefits?” Participants made a number of suggestions that they thought would
improve the scheme, principally around strengthening and broadening it, making
sure it was accompanied by improved treatment services, and improving prevention

10. of alcohol, including tackling the social causes of alcoholism such as homelessness
and unemployment.
1. Strengthen and broaden the scheme
Many reached the conclusion that the only way to make the scheme work was to
make it a compulsory ban and/or broaden it to the whole area, to London, or even
nationally, ‘like the smoking ban’:
‘It’d probably be better if it could be mandatory.’ Group 4
‘It could work but you would have to restrict the products throughout (the
Borough) and, even better, the whole of London.’ Group 1
‘These products should be banned nationally. The alcohol producers have
deliberately targeted these products at vulnerable dependent drinkers.’ Group
1
‘Do it but don’t just stick to one place.’ Group 3
2. Improve treatment services
Participants felt there was a need locally to provide better information and
signposting to treatment services. One suggested that
…If shop owners decide to stop selling high strength ciders and beers, maybe
can they signpost either information on where to get alcohol or offer support to
service users?’ (Group 2).
They also felt there was a need for more rehabilitation services, and more funding:
‘Not enough money is spent on alcohol treatment – most of it goes on drugs.’
Group 1
‘The taxes on alcohol should be increased and the money used to fund
services.’ Group 1
‘… the public health money should go towards the problem drinkers kicking it.’
Group 4
Some felt there was a need to provide ‘wet centres’:
‘Why not consider a wet centre to actually support service users within the
town centre instead of just moving them on to somewhere else.’ Group 2
‘Develop a safe place for drinkers to go so we don’t have to drink on the
street.’ Group 2
3. Invest in more preventative work:

11. Participants also had a number of suggestions relating to strengthening prevention
work. Group 4 (the female only group) was particularly vocal regarding the need to
restrict the availability of alcohol locally:
‘I’m amazed that the licensing department continues to issue licences to four
or five shops in the same road, on the same side… if you’ve got all these
public offences, why are they still granting them licences?’ Group 4
‘You know next to Waitrose there’s a paper shop … even in there they’ve got
a huge stand of wine. That shouldn’t be allowed, should it, it’s a paper shop.’
Group 4
‘Every single paper shop, next to the tram stop and the station, it’s literally
from floor to ceiling and I’ve mentioned it when we’ve been to meetings
before. It really bugs me…It’s not a good area and a lot of these shopkeepers
I’m sure are non-drinkers and it’s bursting with booze.’ Group 4
Some also felt that many drank ‘to avoid having to face very difficult problems’ such
as homelessness and unemployment and that the social causes of street-drinking
should be addressed.
‘It’s not the alcohol, it’s what’s going on in their lives’ Group 4
‘More opportunities for training with prospects of a job at the end of it.’ Group
1
Discussion
This research has provided rich information and valuable insights into the views of
an under researched and marginalised group. Participants across the four groups
had markedly similar, strong views as to what would and would not work locally
based on their own unique insight into the issues arising from the scheme. This
should be seen as a valuable addition to the debates on this topic in particular and to
alcohol strategies in general.
Participants felt strongly that the scheme as it stood would not work – this was the
strongest single theme to emerge from the research. Many, particularly from the
female only group, welcomed the scheme as a good start, however most felt it
simply did not go far enough. Participants gave valuable insight into the reasons for
this from their own perspective, including the lengths they would go to feed their
addictions. None of them would switch to lower strength alcohol, and many
challenged the view that there would be any impact on crime reduction locally, given
that they brought their alcohol into the town centre from neighbouring wards, hiding it
where necessary. Some did say they would change their behaviour, but not to stop
drinking, simply to move elsewhere. They correctly identified that not all retailers
would comply with the voluntary ban, and argued for better local prevention and
treatment, particularly if (as many felt was necessary to make the scheme work) a
regional or national ban was introduced.

12. The impact of the voluntary ban it has been difficult to evaluate due to the fact that
only a handful of licensed premises have begun displaying the voluntary scheme
posters. Further, uptake has not been systematically monitored, nor has any proper
evaluation taken place. It is perhaps because the implementation of the voluntary
ban, though easy in theory, is fraught with problems in practice. During the
development of the scheme, its many difficulties became apparent and, significantly,
the councillor that introduced a proposal lost his seat in local elections, and this has
meant that the voluntary ban has been imposed somewhat half-heartedly and with
little concern the continuity of the scheme. Lessons could be learned here for the
future. For instance, in this case it seemed the decision to push ahead with a
voluntary ban scheme was made before any proper investigation of feasibility took
place. Clearly, in future it would make sense to establish the risks, benefits and
overall viability of such a proposal before commencing its implementation.
Corresponding author
Jimmy.Burke@croydon.gov.uk

13. Author statements
To be added…
Ethical approval
Research Governance approval was sought and received from Croydon Borough Council
Funding
Not applicable
Competing interests
JB is the Health Improvement Commissioner for Addictive Behaviours, including the broader
lifestyle issues of alcohol as well as tobacco, substance misuse and gambling. chairs the
Croydon Healthy Behaviour Change Alliance