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Occupational Medicine Advance Access originally published online on December 12, 2008
Occupational Medicine 2009 59(1):25-31; doi:10.1093/occmed/kqn152
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Alcohol misuse in the Royal Navy

Arthur Henderson, Victoria Langston and Neil Greenberg

King's Centre for Military Health Research, Academic Centre for Defence Mental Health, King's College London, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK

Correspondence to: N.Greenberg, Academic Centre for Defence Mental Health, King's College London, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK. Tel: +44 20 7848 54351; fax: +44 20 7848 5408; e-mail: sososanta{at}aol.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Funding
 Conflicts of interest
 References
 
Background Evidence suggests that military personnel consume considerable amounts of alcohol which may have both medical and occupational implications.

Aim To compare alcohol consumption and misuse within the Royal Navy (RN) to that in the civilian population.

Methods The Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) questionnaire is a short measure of alcohol use disorders. It was administered to 1333 male RN personnel from operational naval units. ‘Heavy’ drinking was defined as consuming >21 units/week, ‘very heavy’ as >42 units/week, binge drinking as >8 units in one session and ‘problem’ drinkers as those advised to cut down in the last year. The study also measured psychological health using the General Health Questionnaire (GHQ)-12 and post-traumatic stress disorder checklist for civilians (PCL-C).

Results The response rate was 70%. The majority (92%) scored as hazardous drinkers on the AUDIT-C, 40% met the criteria for heavy drinking, 27% for very heavy drinking, 48% reported binge drinking at least once a week and 15% were classed as problem drinkers. Heavy drinking was associated with younger age, lower rank and higher scores for both PCL and GHQ. All results were substantially higher than in age-matched civilian samples.

Conclusions Excessive alcohol consumption, especially binge drinking, is significantly more prevalent in the RN than in the general population. Such high levels of drinking are likely to impact upon occupational efficiency and have both short-term and long-term health effects. We suggest that more needs to be done to deter excessive levels of consumption in order to avoid long-term health consequences.

Keywords      Alcohol; alcohol use disorders; AUDIT-C; military; Royal Navy


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Funding
 Conflicts of interest
 References
 
The consumption of alcohol is a feature of western society never far from the public eye [1,2]. Evidence suggests that although there may be benefits from moderate alcohol consumption, excessive consumption leads to detrimental health effects [3]. It is estimated that alcohol and alcohol-related incidents cost the UK National Health Service ~£1.6 billion/year [4] with the detrimental physical [5], psychological [6] and social [7] effects of alcohol, and binge drinking in particular [8], being well documented. The UK Office of National Statistics General Household Survey (ONS GHS) in 2002 [9] suggested that in the region of 30–35% of adult males aged 16–44 consume in excess of the recommended maximum of 21 units/week [9]. A similar percentage regularly binged upon alcohol (drank in excess of 8 units on one occasion). The ONS GHS estimated that 38% of men suffer from an alcohol use disorder (AUD), with 12% being alcohol dependent [10].

Excessive alcohol use is not just harmful for health. Alcohol misuse, and especially binge drinking, contributes to reduced work performance and decreased attendance [11]; as well as being implicated in thousands of criminal offences annually [12], including violent offences. Furthermore, the impact upon the nation’s mental health may be seen as multiplicative; those who come into regular contact with those who misuse alcohol may also suffer as a result [13].

Military culture has often been blamed for fostering excessive alcohol use [14] and research in the USA over the past 20 years points to higher levels of heavy drinking in the military in comparison with civilian populations [15]. Indeed, recent literature on the British Army appears to mirror this [16]. It may be argued that the military culture makes service personnel especially vulnerable to the consequences of heavy drinking; in effect, alcohol misuse may perhaps be viewed as an occupational hazard of military life.

Although there is some data on the UK military as a whole [14], there is a relative paucity of publications concerning the drinking habits of the Royal Navy (RN). This may be of particular importance as other maritime occupations, including the Merchant Navy, share the RN’s propensity to alternate between restraint while at sea and the opportunity for excess while ashore. Whether or not the RN shares similar risks to those of Army is unclear [17].

This paper reports the response of a sample of RN personnel to a questionnaire on alcohol consumption with a view to assessing the extent and patterns of alcohol misuse and comparing them with the general population. It is of relevance to a particular occupational group as the data concerns only RN personnel serving in operational warships as opposed to those engaged on land operations or based within shore bases.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion
 Funding
 Conflicts of interest
 References
 
The study gained ethical approval from the Ministry of Defence (Navy) Research Ethics Committee. The sample data are taken from a baseline survey used to evaluate the effectiveness of a novel system of traumatic stress management within the RN [18]. The data collection and response rate are reported elsewhere [19]; however, in brief, 12 RN ships were surveyed prior to the introduction of a novel system of traumatic stress management. Questionnaires were issued by researchers (V.L. and N.G.) to all members of the ships’ companies (n = 2236), by visiting and distributing by hand. The questionnaire enquired about demographic details including rank, age, sex, marital status and time in service, as well as personal experiences of stress, the General Health Questionnaire (GHQ) [20], the post-traumatic stress disorder checklist (PCL) [21] and the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) [22]. In addition, individuals were asked Question 10 from the full AUDIT questionnaire [23] (Table 1).


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  		Table 1. AUDIT-C (with adjusted Q3) and Q10 from the main AUDIT questionnaire, as used in the questionnaire issued for the study

 
The AUDIT-C is a brief three-item tool used to screen for AUDs [24]. It comprises the first three questions of the full AUDIT and has proved an effective quick screen for AUDs where time does not allow the use of the full AUDIT questionnaire [25]. Scored out of 12, ≥4 is taken as ‘positive’, being 89% sensitive and 83% specific for AUDs. Although a very sensitive tool for detecting hazardous drinking, it assesses alcohol consumption and not the effects of alcohol (as in the full AUDIT questionnaire) and as such has been shown to be less specific for identifying active alcohol abuse and dependence [25]. This is of particular relevance in military populations where elevated alcohol consumption is more widespread and the direct relationship between elevated consumption and dependence is not entirely clear. It has been suggested that increasing the cut-off scores for positive on the AUDIT-C may be appropriate to more accurately represent the prevalence of AUDs in military populations [14].

In view of this and in order to increase specificity in identifying those with AUDs in this study group four measures were taken: (i) Cut-off scores of both 4 and 8 out of 12 were used on the AUDIT-C; four to compare with civilian populations and as a sensitive marker of hazardous drinking and eight as a more specific measure for a military population; (ii) as suggested by the Alcohol Needs Assessment Research Project (ANARP) 2005 [26], we categorized those who consumed in excess of 50 units/week as being at considerable risk of being alcohol dependent; (iii) Question 2 asks about units consumed in a typical drinking day with the highest category being 10+ units, we added three further categories (10–20, 20–30 and 30+ units) and (iv) in order to increase specificity still further, we altered the question concerning the drinking daily limit from 6–9 units. ‘Binge drinking’ was thus classified as drinking ≥9 units in a drinking session, and regular binge drinking as binging on at least a weekly basis, in common with levels used by the ONS [9].

Weekly alcohol consumption (in standard units of ethanol) was calculated by multiplying the number of days per week an alcoholic beverage was consumed by the number of units consumed on an average drinking day. One unit of ethanol was defined in the questionnaire as half a pint of standard strength beer/lager, a 25 ml shot of spirits or a 125 ml glass of wine. Where the number of units consumed per typical drinking day was reported as a range (e.g. 7–9 units), the median figure was used (e.g. 8 units). Those who reported drinking ≥30 units per typical drinking day were scored as consuming 30 units. We defined ‘safe drinkers’ as consuming ≤21 units/week, ‘heavy drinkers’ 22–42 units and ‘very heavy drinkers’ >42 units/week.

As well as the AUDIT-C questions, we also included the final question from the full AUDIT which enquired about whether someone had suggested that the respondent should cut down on their alcohol consumption; a response ‘yes, in the past year’ was taken as an indicator of ‘problem drinking’.

As in our previous studies [27,28], we defined caseness on the GHQ-12 [20] as a score of ≥4, PCL-C caseness was set at 50 [29]. Statistical analysis was performed using SPSS V.12.0.1. Pearson chi-squared tests were used to determine the significance of categorical data (with significance defined as P = <0.05); continuous variables were assessed using two-tailed independent t-tests. The ONS GHS (2002) provided the data on alcohol use in the civilian population that was used to compare to the study sample.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 Funding
 Conflicts of interest
 References
 
A total of 2236 questionnaires were issued, 1559 were returned (response rate 70%). Given the small number of female respondents (n = 159), our analyses were restricted to males. Of the 1400 male responses, 1333 provided answers to the questions on alcohol use. The demographics of the sample and, for comparison, the RN as a whole, are shown in Table 2. The data set can be seen to be broadly representative of the RN in general in relation to rank and age [30].


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  		Table 2. Comparison of study sample and RN demographics

 
Alcohol consumption is reported in Table 3. Weekly consumption ranged from being abstinent (n = 18, 1%) to cases consuming in excess of 180 units/week (n = 29, 2%); mean consumption was 29 units/week. Over half of those under 20 years of age were categorized as heavy drinkers (averaging 41 units) and 20% (n = 261) of the study population drank ≥50 units/week.


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  		Table 3. Alcohol consumption in the study population

 
Only a small number of male respondents, 57 (4%), reported not binge drinking at all, with 646 (48%) binge drinking, but less than weekly, and a further 639 (48%) binge drinking at least weekly.

In terms of problem drinking, 196 (15%) had been recommended to cut down by a relative, friend or health worker in the last year alone. Problem drinkers were younger (mean age 25 years) than non-problem drinkers (29 years) (t = 6.7, P < 0.001) and more likely to be a heavy drinker ({chi}2 = 101.5, P < 0.001) or binge drinker ({chi}2 = 85.423, P < 0.001) than those who were not.

Risk factors for heavy drinking, binge drinking and problem drinking were broadly the same: youth, lower rank, living without a partner and being PCL-C or GHQ-12 positive; these results are shown in Table 4.


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  		Table 4. Risk factors for heavy, binge and problem drinking in the study population

 
A total of 1396 respondents (92%) scored ≥4 on the adjusted AUDIT-C which was suggestive of AUD by civilian standards and 866 (57%) scored ≥8.

Alcohol consumption in the study group was higher than the age-matched civilian population in all areas (Table 5) [31].


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  		Table 5. Comparison of heavy and binge drinking prevalence between RN personnel and the UK age-matched civilian population

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Funding
 Conflicts of interest
 References
 
Our results demonstrate that alcohol misuse is common within the RN: over one-third of naval personnel reported drinking in excess of the recommended weekly alcohol intake and 20% drank in excess of 50 units/week. Furthermore, nearly half of the sample binge drank at least once a week and ~15% had been recommended to cut down on their alcohol consumption in the last year. We also found that >90% scored positively on the adjusted AUDIT-C test which is a recognized marker of hazardous drinking in civilian populations and ~60% scored ≥8 putting them in a very high-risk group for AUD. Those most at risk of heavy drinking were the young, single, low-ranked personnel and those with subjectively poorer mental health scores. Lastly, our data suggest that the RN personnel drink more than the aged-matched civilian population.

We recognize that our study had some limitations. Firstly, although the sample is broadly representative of the RN, it is taken solely from service personnel serving on warships and as Micklewright [32] suggested alcohol abuse might be more common in this section of the service than in the RN as a whole. Thus, although our results may be an overestimate of the scale of alcohol misuse in the RN as a whole, they do represent those who are performing the RN’s major operational role in manning vessels deployed at sea. In addition, our method of estimating weekly alcohol consumption used, multiplying frequency of drinking by consumption on a regular drinking day, may not have provided an accurate estimate of true consumption. However, it could be argued that this method more accurately represents the amount of alcohol consumed, by reducing the self-conscious act of under- or over-reporting units per week.

The AUDIT-C questionnaire has only been validated in the civilian population [22] and its use in military populations may be less reliable. Certainly, the proportions of naval personnel who appear to meet criteria for harmful and dependent drinking in this study are high and this may suggest that the AUDIT-C may need to be revalidated before being further used in military samples. Lastly, the volume of alcohol consumed alone is not a definitive marker of long-term physical harm or dependence, although there is evidence that high volumes of consumption are linked to harmful and dependent drinking [26].

Matching our sample to the general British public [9] revealed a substantially higher percentage of heavy drinkers and binge drinkers in the RN across all compared age groups. This finding is in keeping with other studies which find that military personnel consumed more than civilians [14,15,33,34]. Fear et al. [14], using the full AUDIT questionnaire, recently reported similarly high levels of hazardous (88%) and harmful drinking (67%) in the UK Armed Forces, with dependency at ~7%. If the ANARP indicator of possible dependent drinking (≥50 units/week) was applied to this RN study sample, it would equate to 20% of the study population. In our view, such high levels of dependency would make carrying out operational duties difficult. We believe our results therefore indicate that the volume of alcohol consumed alone is a poor indicator of dependency in this sample. It is likely that most of the alcohol consumed was done so whilst ashore rather than in a dependent fashion whilst at sea. However, dependency aside, it seems unlikely that the longer term health effects of consuming such considerable amounts of alcohol will be negligible.

Our findings reflect the same high-risk and high-user groups as shown previously in both civilian and military populations: young single men of lower rank [14,15,33–35]. We also found that poor mental health was associated with higher levels of alcohol misuse, which again has been found in other studies of military populations [16,35]. Co-morbid alcohol use may represent a maladaptive coping strategy or it may be that the misuse of alcohol leads to poorer mental health. It is noteworthy that post-traumatic stress disorder has been linked with alcohol misuse in past studies [36].

It is probable that there are a number of factors contributing to the high levels of alcohol misuse in the study population and by inference in the RN in general. Firstly, it can be argued that the study population and RN personnel in general are not directly comparable with a purely age-matched sample of the general population [37]. Recruitment for the armed forces is weighted towards high-risk groups in the general population [36]. Not only are the majority of recruits young single males but also there is a weighting towards recruits from relatively deprived socio-economic backgrounds and the link between alcohol consumption and lower socio-economic status has been well documented [9]. Furthermore, those who enter the military could be argued to be less risk averse, and thus less inclined to observe the recommended alcohol limits.

Secondly, argument points towards the environment of the military itself as a contributor to increased alcohol consumption [15]. Traditional ideas about group camaraderie and bonding may be seen as causative factors, as well as close-knit social interaction and peer pressure. Higher levels of alcohol consumption have also been shown in police and fire services [38,39], suggesting perhaps that a sense of communal risk taking and bonding may be reflected in alcohol use and that this problem is not unique to the RN or even the military. In addition, the military fosters an environment in which access to and availability of alcohol are high and, significantly, one in which its cost is low [40].

By extrapolating the statistics above to active manpower numbers, not only would 90% of the RN be at high risk of alcohol abuse but also that ~17 500 RN service-men (50–60%) are likely to be abusing alcohol to hazardous levels. By civilian measurement standards, ~6400 (20%) exhibit risk factors for alcohol dependence; however, we consider this likely to represent the inaccuracy of civilian alcohol measurement tools, such as the AUDIT-C, in military populations. In addition, 4800 (15%) exhibited drinking behaviours which had caused their peers or family to suggest that they cut down. Although very little clear evidence exists to quantify the impact of this, research into the mortality of submariners from the 1980s showed particularly high rates of liver cirrhosis [41], which may be indicative of the increased levels of dangerous drinking among these service personnel.

The direct impact of alcohol misuse upon operational effectiveness in the RN is not yet known. However, our results suggest that it is unlikely, with the high levels of consumption revealed in this study, that the use of alcohol by military personnel would not have a detrimental operational effect. In addition, the high degree of association between subjective ill-health and alcohol misuse warrants further investigation.

Since new entrants to the services are likely to exhibit many of the risk factors for heavy drinking, we suggest that the services need to consider how to offset these risk factors rather than to further encourage excessive alcohol use. While effecting a change in social drinking habits countrywide is not the task of the RN, it does have a duty of care to its personnel and a need to ensure high standards of operational fitness in those who operate warships at sea. Furthermore, those who leave the services may well take with them a culture of drinking they acquired during their service career and therefore our results also bring into question the RN’s duty of care to its veterans.

The RN is not complacent; it conducts alcohol awareness days and video sessions for recruits [42] and regular updates for active duty personnel. In addition, it provides a clear structure for commanding officers at all levels on policy regarding alcohol use and appropriate action following offences against the Naval Discipline Act that are associated with alcohol [43] (these include warnings for discharge and referral to basic alcohol education courses). Despite this, our results suggest more needs to be done. While some have argued that limiting access to alcohol, either through cost or monitoring, at sea may be desirable, doing so might not engender a safe drinking culture when personnel have easy access to local pubs and bars when they are ashore. It may be that in order to foster an environment that does not condone excess, there should be an emphasis on vigorous detection of problem drinkers and a clear message imparted by leaders that drinking behaviour which causes occupational inefficiency will not be tolerated.


Key points
  • Alcohol misuse, particularly binge drinking, is higher in the RN than in the civilian population from which it recruits. Although the same high-user groups exist in the RN as in the general population, higher consumption is seen throughout the whole service.
  • The cause of this may lie in the environment fostered by the military and other similar organizations and in a culture of communal risk taking.
  • Given the high levels of alcohol misuse reported, we believe that more needs to be done both punitively and supportively to effect a change in the perception of alcohol misuse within the service and to provide intervention for those in need.

 


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
Conflicts of interest
 References
 
Ministry of Defence.


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Conflicts of interest
References
 
A.H. and N.G. are full-time employees of the Ministry of Defence who funded this study. However, the authors’ work was independent of the funders and the findings of the paper were only disclosed to the Ministry of Defence at the time of submission to this journal.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Conflicts of interest
 References
 

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