A sobering thought if you’re expecting a baby. Of course, you’d never swap your baby’s bottle for a gin bottle. But if you drink during pregnancy, that’s exactly what you’re doing. From spirits to alcopops, whatever you drink, your child drinks. So when you’re tipsy, your baby’s drunk. And when you’re hung over, your baby could have brain damage. These problems are known as Foetal Alcohol Syndrome. At present 1 in every 1000 babies suffers. The problem is that so few mothers and fathers know this because of the lack of information that’s available.

If you drink when you’re pregnant, so does your baby.

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Fetal Alcohol Syndrome (FAS), is the name given to a group of physical and mental birth defects which are the direct result of maternal alcohol consumption during pregnancy. FAS is now known to be the world's leading cause of mental retardation. Symptoms can include growth deficiencies before and/or after birth, major organ damage, skeletal deformities, damage to the Central Nervous System resulting in learning disabilities, behavioural problems, lower IQ, and facial characteristics common to all children diagnosed with FAS.

Fetal Alcohol Effects (FAE), is the name given when all the characteristics required for a diagnosis of FAS is not present. This does not mean FAE is a lesser problem. Children who have FAE can still display the same learning disabilities and behavioural problems as a child with FAS, and it is largely under diagnosed. Research has shown that as many as 1/3 of learning disabled children (not otherwise diagnosed) may have been affected by alcohol before birth. Figures show that between1 and 3 per 1000 live births in the UK are born with FAS, and many times that number are affected by FAE.

THERE IS NO KNOWN SAFE LIMIT FOR ALCOHOL CONSUMPTION DURING PREGNANCY!

The National Alcohol Harm Reduction Strategy:

A Submission by FASawareUK

1. Why should the Government get involved in the managing the harmful effects of alcohol misuse? At what point does the Government intervention become justified?

• The Government is already responsible for all NHS guidelines, include those covering the safe consumption of alcohol.
   

• The Government should review, extend and develop existing guidelines to take account of Foetal Alcohol Syndrome. (Hereinafter referred to as FAS).
   

• Education and Awareness training regarding FAS should not be left to volunteer groups. The Government should be responsible for the accuracy and the uniformity of information regarding FAS. Small, scattered volunteer groups can often have conflicting information. Uniformity and accuracy are of the utmost importance.

2. How far is alcohol misuse a matter of individual responsibility and when does Government have a responsibility to intervene, whether through services, legislation or persuasion?

• Government intervention is justified now.
   

• Through our groups contacts with various academics and professionals in the alcohol field, as well as the feedback we received at 2 recent conferences, one of which we hosted, FASawareUK is aware that there is a demand from professionals for information, advice and solutions to the problems posed by FAS.

3. How can we strike a balance between individual and community rights and choices?

• Informed choice is a democratic right. To be fully and correctly informed of the damage caused by drinking before, during and after pregnancy is vital. Only then can a woman and her family make an informed decision whether to continue drinking or not.
   

• The community also has a responsibility to provide care and support for it’s less fortunate members who had no say as to whether or not they were affected by alcohol.

• Honest information about Alcohol and its wide effects leading to informed choices.
   

• Help and advice.
   

• Support for the children that inherit the effects of Alcohol abuse.

4. What are the respective roles and responsibilities of consumers, voluntary groups, commercial interests and others?

• Consumers need to be correctly informed so that they can make their own decisions.
   

• Voluntary groups need to be sure their information is correct and up to date.
   

• Commercial interests have a responsibility to educate the public about the proper use of their products and services.
   

• All agents are equally responsible for honest information about all aspects of their roles/products and should work together for the common good.

5. What principles should underpin a national alcohol harm reduction strategy?

• That alcohol related problems could affect anyone, at any time without prior warning regardless of age, race, class etc.
   

• Education must therefore be a vital principle of the strategy and must be delivered by means of all available channels to ensure that it reaches everyone.
   

• There should be warnings on all alcohol containers (including Alco pops) about the dangers of alcohol to health and the unborn child.
   

• That FAS should be considered across all area’s of the strategy.

6. How do you define alcohol misuse? What factors do you take into account?

• Alcohol Misuse forms part of a continuum starting with alcohol use, through alcohol misuse then Alcohol Abuse and finally Alcohol Dependency.
   

• Alcohol Abuse and Alcohol Dependency are both medically diagnosable conditions using internationally accepted criteria such as DSM IV and ICD10.
   

• Alcohol Misuse therefore could best be defined, for the purposes of the National Alcohol Harm Reduction Strategy, as any episode of drinking which has the potential to lead to harm to self, others or to society and which does not fit the diagnostic criteria for alcohol abuse or alcohol dependency.
   

• It is important that any strategy recognise the above distinctions.
   

•  In considering the meaning of what constitutes a definition of an episode of drinking which has the potential to lead to harm to others the following factors should be considered:
   

  • Alcohol has contributed to the “Ladette” culture of binge drinking, where women are drinking regularly in larger quantities well over and above the 2 units. This can lead to drunken, unprotected sex and consequently pregnancy.
     

  • In Governments pregnancy leaflet “Drinking for two” the advice given is that 1-2 units of alcohol once or twice a week is acceptable. This is questionable in the light of recent research that suggests there is no known safe level of alcohol consumption whilst pregnant.
     

  • It states in the Government Indices, that the UK has the highest teen pregnancies and underage drinking in Europe. Research is needed to explore the relationship between these two facts – especially so as if there is a linkage then these children will be at a higher risk of prenatal alcohol related harm.
     

  • The foetus’s brain is developing all through the pregnancy.
     

  • The brain is still developing into the early twenties.

7. What drinking patterns should an alcohol harm reduction strategy seek to effect? How susceptible are patterns to change? Where should Government concentrate its efforts in prevention?

• Drinking forms a large part of our social culture. Some people even plan major life events around alcohol. We therefore need to appreciate that we are talking about cultural change.
   

• Binge drinking has become a major problem, especially for women, who may consume the government’s recommended safe weekly quota of 14 units of alcohol in a single sitting.
   

• The Government should concentrate its efforts in prevention by developing an education programme, which should be integrated with smoking and drugs education programs in schools.
   

• The programme should ideally commence at age 7 bearing in mind that statistics show that children as young as 9 are experimenting with alcohol.
   

• Alcohol education programmes should be ongoing, continuing throughout school life.
   

• The United States also utilises public service announcements, brief interventions by medical personal and signage laws at points of sale.
   

• US Studies have shown that just one form of education in not as effective as several forms of education combined.
   

• This is especially true of education that is done at an early age.
   

• The evidence shows that when these forms of education are combined with other initiatives aimed at adult consumers a significant reduction in risky drinking behaviours can result.

8. Is there a relationship between trends in drinking and wider social changes e.g. the spread of higher education, changes in workplace culture, later marriage and/or family formation? Where does this suggest we need to focus attention-influencing behaviour?

• Attention needs to be focused particularly on women; Education and Awareness campaigns are needed to prevent the lasting damage that alcohol can cause to the Foetus.
   

• Government Indices show that the North West has the highest teen pregnancies in Europe and underage drinking. There is also a problem in the area of bootleg alcohol coming in from Europe making it economical to drink. The links between the cost of alcohol and alcohol related damage to health, as shown by statistics for liver disease has been well documented. In this area over the last 12 months there has been an increase in babies born with physical and mental disabilities.
   

• The 1990 US Census report show that the women most likely to drink is white with two year associate’s degree or a baccalaureate degree and earns an income over $20,000.
   

• A Swedish study demonstrated that the stresses of the workplace, in combination with after hour’s homework escalate for women and probably contributes to the increased drinking among modern women.
   

• Very early marriage, very late marriage, no marriage (living together), marriage under duress, a significant other who drinks financial and personal problems and a family history of alcohol abuse can all lead to risky drinking behaviours.

9. One group we need to focus on specifically is young people, where the evidence suggests a rise in consumption, particularly by young women. Are there other groups we should be focusing on? For example are there specific issues around minority ethnic attitudes to, and use of alcohol, which we should bring into our analysis?

• The need to belong to a social group brings peer pressure to all parts of the community, including ethnic groups (i.e. secret drinking/drug taking particularly with third generation immigrants) and starts during the primary school years.
   

• The media influences social habits of a wide nature including appearance, entertainment, what to eat and drink as well as behaviour by giving a voice to the wrong type of role models. People are taking greater risks because others are appearing to get away with it.

10. It is easy to focus on the negative aspects of alcohol use and misuse. But what are the positive cultural and behavioural (as opposed to economic) aspects?  What parts of culture would change for the worse if we did not have alcohol?

• Alcohol has been part of our religious and ceremonial society since the beginning of time.  When used sparingly (it used to be expensive for a society to brew alcohol) and for special occasions, it is beneficial and bonding. However the blatant use of alcohol in our society has degraded it to psychological “oil” that lubricates the way for conversation and superficial bonding. It has taken the place of honest, open relationships and prevents people and governments from openly facing the problems of education, employment and other economic quandaries.

11. Is there such a thing as recognisably English drinking culture and if so what does it look like? What are the factors, which influence it, for example are there sharp regional differences? Does it look different for different ages groups?

• The so-called “Ladette” culture is making the headlines more and more. This involves young women who binge drink. Often this is linked with the pub-crawl cum nightclub trawl. Some areas are more noted for it and they should be identified as causing concern.
   

• Young women often start their drinking habits on the streets at a very early age and in family homes. It is a known fact that a large number of young people are under age drinkers. They look older than their true age and are putting themselves at risk. Identity/Proof of Age card schemes could be encouraged as part of the answer here.
   

• Pubs now offer two for the price of one and happy hours to encourage drinkers into their premises knowing full well that once a customer is in the, they are reluctant to leave. This also encourages binge drinking.
   

• Broad regional differences occur between rural and urban areas (WHO Global Status Report on Alcohol).
   

• Women tend to start drinking at a later age than men but then tend to consume more and develop serious medical problems at an earlier age.
   

• Women’s drinking can cause Foetal Alcohol Syndrome, Foetal Alcohol Effect and or other alcohol related birth defects/disorders.
   

• Men’s drinking can produce offspring who are hyperactive and unable to solve test problems and have gross motor skill problems.

12. What factors influence behaviour-fashion and marketing, family background, education and information, financial, legal and regulatory, scientific, environmental? Which are the most influential in your view? How easy is it to exert influence through those factors?

• Fashion and marketing within the pop/media influences a wide range of social habits including appearance, entertainment, what to eat and drink and behaviour by giving a voice to the wrong type of behaviour.
   

• People are taking greater risks because others are appearing to do so and to get away with it. The wrong role models are always in the “news”. Positives role models/heroes should be highlighted.
   

• Alcohol dependency and alcohol abuse tend to run in families, there is evidence that some individuals are genetically predisposed to develop alcohol related problems.
   

• The alcohol industry must learn to diversify the nature of their product lines in order to ease their way out of their way out of their dependence on alcohol as a primary source of income.
   

• The Government must decide whether it wishes to protect its youngest and unborn citizens above the rights of companies to make money and of adults to determine the life outcome of children before they are even born.  It is not easy to change the mind of businesses that seek to make a profit but the alternative in the long term could be a general population with lower IQ’s.

13. How do attitudes to risk affect use of alcohol?

• Young people have a tendency to think, “It won’t happen to me”. This causes a great deal of complacency that in turn increases the risk factor applying to all that they do. Greater access to information and education at all ages is vital. See also replies to questions 11 and 12.
   

• Many people have the impression that “moderate” drinking is not harmful and carries no risks. The risk of alcohol related harm does not suddenly appear after a given number of units of alcohol.
   

• The use of “moderate” must be carefully defined as it means different things to different people, including the different genders. The US National Institute of Alcohol Abuse and Alcoholism have stated that 1 drink a day is moderate for a woman and 2 drinks a day is moderate for a man. More than “moderate” means a greater risk to organ failure, brain damage as well as a possible inclination towards alcohol dependency. For women there is an increased risk of breast cancer.
   

• These figures are substantially different from the UK government’s suggested safe drinking limits. Is it possible that the UK is willing to accept a higher level of risk?

14. How do you define harmful drinking? What factors do you take into account in deciding whether heavy drinking has become problematic drinking?

• Please see reply to Question 6.
   

• It is a fallacy to believe that drinking has to be heavy to be problematic. How many road traffic accident deaths occur each year in which a driver has been drinking, but not heavily? How many workplace accidents? There are many settings where the consumption of any alcohol whatsoever increases risks – and surely this should be included in any definition of problematic?
   

• There are additional risks, and therefore problems, when alcohol is combined with other factors such as legal or illegal drugs.
   

• Foetal Alcohol Syndrome (FAS) can be caused before a woman knows she is pregnant. It therefore requires an intense pre-warning and information system long before the woman even considers getting pregnant or even wants to.
   

• The unborn child is at risk of being born with physical and neurological disabilities of varying degrees. In addition to this there is evidence that the child is likely to have a higher risk of predisposition to alcohol related problems in later life, depression and mental illness.
   

• According to recent findings by Dr Mary Connor of UCLA published in the American Journal of Drug and Alcohol Abuse psychiatric disorders, in particular mood disorders, are common in children exposed to alcohol in the womb.
   

• Dr Mary O'Connor and colleagues from the University of California, Los Angeles (UCLA) studied 23 children between the ages of five and 13 years who were referred to UCLA's Foetal Alcohol and Related Disorders Clinic because of heavy exposure to alcohol in the womb. After assessing the children's intellectual and psychological functioning, researchers concluded that 87 per cent of the children met criteria for a psychiatric disorder. Twenty-six per cent were diagnosed with major depressive disorder or adjustment disorder with depressed mood and 35 per cent met criteria for bipolar disorder.
   

• Although the mechanisms underlying risk for mood disorders are unclear at present, the team point to recent findings showing structural damage to specific areas of the brain in children parentally exposed to alcohol.
   

• We therefore have to conclude that alcohol use by pregnant women should be a special cause for concern and must be taken into account when formulating any definition of harmful drinking.

15. How clear is the evidence both for the health costs and the health benefits of alcohol? Are there key pieces of research of which we should be aware? Where are the gaps in evidence?

• There may be some benefits to health in drinking alcohol in moderation but there is a fine line between this and drinking to excess. On balance the benefits are heavily outweighed by the risks.
   

• Estimates of the health costs of alcohol have been made, i.e. by Alcohol Concern in their 2002 report “Your very good Health” who came up with a figure of £3 billion per annum. Unless research is done however it will be difficult to ascertain the true cost to the NHS of alcohol related illnesses and effects.
   

• Apart from the direct health related costs of drinking there are many others but one that is not so well known is the effect on the unborn child. In the light of the statistics given in 14 above the ongoing costs of lifetime support for FAS children must be substantial and further research would appear to be warranted.
   

• Because medical practitioners often fail to identify alcohol as a causal factor many physical and mental problems remain undiagnosed or are misdiagnosed. There is evolving research that indicates that alcohol may be a contributing factor in conditions such as autism, cerebral palsy, epilepsy and may even effect the genetic development of cells.
   

• Death certificates normally only require the primary cause of death. It might be more accurate to also list contributing factors. We might then find that alcohol abuse plays a major role in many illnesses and causes of death.
   

• The statistics for child abuse, domestic abuse, suicide, learning disabilities, depression and teen pregnancy also need to be examined if we are to arrive at a true picture of the health related costs of alcohol misuse.

16. What are the costs for the NHS both directly and indirectly due to alcohol? We will be examining evidence on this but would welcome your views and any evidence you think we should be aware of.

• Refer to question 15.

17. What, in your experience, are the most appropriate means of prevention of alcohol dependence and serous alcohol misuse? What forms of training are most appropriate for professionals in health and social care, as well as other fields? Who plays a role in prevention?

• The most effective means is education in the primary grades of school.
   

• This must be in conjunction with the banning of advertisements on television, magazines and billboards; especially those bill boards shown during sporting events.
   

• Warning signs at points of sale, liquor stores, restaurants and pubs are also effective in conjunction with other forms of warnings and information.
   

• Professionals (medical personnel and educators) should be trained to know and recognise the symptoms of Foetal Alcohol damage so that the parents can work effectively with educators to be properly informed and can take remedial steps for the child.
   

• Studies have shown that it is essential to have organised support groups in a variety of settings for convenience and availability.

18. “Brief interventions” can be offered to patients who have been identified as a risk from alcohol misuse. They may consist of a short session with a doctor or nurse to discuss a patient’s drinking and to offer help and support to cut down on alcohol intake, if the patient wishes to do this. How effectively do you think those at risk are identified? How well have you found brief interventions to work and how might they work better?

• There is evidence that “brief interventions” can be effective when offered to those patients at risk from alcohol misuse. However the evidence also suggests that they will not be effective for those patients who are alcohol dependent or heavy alcohol abusers.
   

• It is therefore essential that medical practitioners delivering brief interventions should have the necessary assessment skills to be able to differentiate.
   

• It is also essential that the facilities exist to refer on to appropriate services without delay. Timing is an important factor – often the circumstances that lead to the patient seeking medical help at that time mean that there is a window of opportunity to intervene. This window will not necessarily remain open for long when the immediate medical crisis has past.
   

• Posters and brochures containing information about alcohol and support groups might be placed in medical and dental offices, at the chemist, other allied medial and health facilities. Consistent reminders of the dangers of alcohol misuse and sources of help may be more effective than brief interventions.

19. Do current treatment for alcohol dependence and hazardous drinking work? Are they sufficiently tailored to meet differing and individual needs? Are there other forms of treatment we should be aware of? Is there a need for guidance for the commissioners of local treatment services? How should individuals best access treatment services?

• Current research such as Project Match clearly shows that treatment works.
   

• Research has shown that alcohol dependent women do better in a single sex treatment setting.
   

• One of the major obstacles blocking women coming forward for treatment is the fear of loosing their children – although there can obviously be child protection issues when parents are drinking problematically policies need to be framed in such a way as to ensure that they do not become another obstacle to seeking help.
   

• Residential treatment facilities which accept mothers together with their young children can have certain advantages – the mother can learn parenting skills and begin to repair the mother/child bond during the course of treatment, the child can be assessed for FAS, FAE or other problems related to the mothers use of alcohol and a structured care plan can be worked out for the child which can be fully integrated with the mothers own care plan.
   

• Such mother and baby facilities here in the UK have a high failure rate because of economic factors associated with the funding system. There is a good case for suggesting that they could be provided as a National Resource.
   

• Alcoholism and alcohol related problems are normally quite complex and often require more than just physicians or psychologists working together. A program in Washington State (U.S.A.) for alcoholic mothers combines physicians with therapists, social workers, family counsellors to not only deal with addiction but to help with seeking services for the children.

20. What can we learn from drugs prevention and treatment?

• That you are even asking this question highlights a problem. Alcohol is a drug, albeit a legal one. A comparison of the numbers of alcohol related deaths and drug related deaths in the UK reveals that the number 1 drug problem in the UK today is not heroin, crack cocaine or ecstasy – it is alcohol.
   

• Within the drugs treatment field it is accepted that patterns of poly drug use are exceedingly common. Alcohol forms part of this pattern and is often not possible to draw any clear distinction between alcohol and drug abusers.
   

• The symptoms, progression and consequences of alcohol and other drug dependencies are similar, so much so that they can best be regarded as varieties of the same condition. The tendency of alcohol services to disregard drug use and of drug services to ignore alcohol use is artificially created and is counter productive in terms of treatment. It has come about as a result of historical accident.
   

• Alcohol and other Drugs Services should be integrated, however it is important that the additional workload that this will create should be properly resourced.
   

• Alcohol Services should come under the auspices of the National Treatment Agency for Substance Misuse. If Alcohol remains separate there will be duplication and two parallel systems would complicate matters to the detriment of the quality of service delivery.
   

• There is evidence that children are experimenting with alcohol, smoking, and drugs as early as 9 years old. These factors are predictive of problems with substance abuse later on in life. Children who are identified as being at greater risk should be supported with behaviour modifying classes.

21. How, in your experience, can we minimise and prevent the injuries that are presented to A&E departments as a result of alcohol related assaults (often with glasses and bottles) or home and workplace alcohol-related accidents?

• If a person is caught driving while drunk, arrested or warned before or during an assault, the last drinking place visited should be warned about serving alcohol or selling to this person.
   

• Companies should make it public policy that alcohol beverages will not be served or allowed on the premises during business hours. In addition companies should be given strong incentives to implement comprehensive alcohol and drugs in the workplace policies.
   

• The Health and Safety Executive should take a more proactive stance on workplace alcohol and drug policies than it does at present – allowing an employee to work whilst under the influence of alcohol should be an offence and employers should be required to demonstrate that they have “safe systems of work” in place to ensure that their employees and the general public are not exposed to risk.
   

• All local and central government contractors should be required to have workplace alcohol and drugs policies in place as a condition of the contract.
   

• Again, the dangers of alcohol should be taught to children primary school. Early education is the most effective method.

22. What are the links between alcohol misuse and mental health problem, including depression and suicide? How are services-both those aimed at prevention and treatment best co-ordinated?

• Studies have indicated that women are usually undergoing some type of depression before they start drinking on a regular basis. Severe depression can lead to suicide.
   

• Care co-ordination is the key here – there are several services in existence specialising in working with dual disorder clients and the beginnings of a substantial knowledge base.
   

• In the long term a similar system to the “Models of Care” being implemented through the National Treatment Agency for Substance Misuse will be called for – another reason to integrate alcohol with other drugs services.

23. What evidence is there about the links between alcohol and crime and the links between alcohol and anti-social behaviour? Are there key studies or pieces of evidence you think we should be aware of? Where are there gaps in the evidence?

• The behaviour patterns of many FAS/FAE, children/adults bring them into conflict with the law. The problems of poor judgement and gullibility that became apparent in childhood are not outgrown.
   

• The criminal justice system needs to find a more appropriate response to individuals with these disabilities. Recent research studies have revealed that our prison system is filled with adults with Foetal Alcohol Syndrome.
   

• This opportunity that presents itself to members of the judicial system is directly related to the concept of early identification and intervention.
   

• Commonly, it is the police officer on a street beat that encounters an intoxicated pregnant woman. Knowledge of community referral resources for pregnant women in crisis provides an alternative to incarceration and places the woman in a system designed to support the pregnant woman in her efforts not to drink alcohol.
   

• The best method of dealing with FAS related crime is to prevent it. Across the world several innovative projects have been developed that take the weaknesses commonly associated with FAS teens and adults and turn them into strengths. This gives self-esteem a valuable boost that thereby facilitates further rehabilitation.

24. In your experience, is alcohol a factor in habitual re-offending? Does it lead to particular types of crime? How far does it lead to one-off offences?

• Dr Ann Streissguth of the University of Washington Foetal alcohol (FAS) and Drug unit has said that one of the most distinctive characteristics of a person with FAS is the inability to learn from their mistakes. It is self evident that this type of inability could contribute to recidivism.
   

• FAS affect men and women of all ages and they commit a wide variety of crimes. One of their characteristics is their tendency to copy what others do. Thus, a person with FAS might be incarcerated for a minor crime and then follow a fellow inmate into a more serious crime, often without recognising the inherent wrong of the other person. Dr Streissguth has indicated that she feels the most outstanding characteristic of a person with FAS is the inability to connect an action with its consequences. Because brain cell damage is permanent, it is unlikely that any modern day punishment will deter the person with FAS from committing more and more serious crimes once they are led in that direction.

25. To what extent can alcohol convincingly be demonstrated to be a factor in criminal and disorderly behaviour? How much is perception and how much is reality? What fuels the perceptions and are they accurate?

• A study by Dr Julianne Conry on the University of British Columbia has concluded that nearly 60% of the men he studied in the Canadian penal system may be prenatally alcohol affected. Further studies need to be conducted. However, Dr William Healy has previously explored the connection between prenatal alcohol exposure and criminal activity as far back as 1918. Further research of older literature may reveal more studies of the connection between prenatal alcohol exposure and crime.

26. Alcohol is far from being the only factor in crime and disorder. Other factors are involved - for example, town centre disorder can be influenced by lack of availability of transport or design of environment. What other factors might be involved? How easy are these factors to influence? Who is responsible for them?

• If there is an excessive drop out rate in the schools and an increase in juvenile delinquency, the Government will be blamed. If the country has growing rates of mental health problems, violence, domestic abuse and increased use of health and mental facilities, the responsibility of improving these statistics with fall on the Government. All these things can and will happen if the Government allows problems like Foetal Alcohol Syndrome and alcohol abuse to go unchecked in the country.
  

• Starting an early education program will go a long way in preventing other problems. The important thing is to start now and not allow these problems to proliferate.

27. How does the impact of alcohol on urban environments differ from its impact on rural environments? What are the differences between urban and rural drinking patterns and how do they affect those communities and surroundings.

• The World Health Organisation’s Global Status Report on Alcohol indicates that alcoholism might be even more of a problem in rural area. The hard work and lack of close neighbours encourages the use of alcohol.
  

• Individuals affected by FAS usually difficult to employ, they might feel that an urban area could offer better opportunities and travel there to seek a job, thus taking a rural problem to the city. There is a general tendency for young people to seek the excitement of city life.
  

• The problem with urban life is the anonymity and psychological distress that is encountered may tend to exacerbate rather than diminish personal problems and addictions issues.

28. To what extent can impacts on the environment (including crime, disorder, noise and waste) be designed out, for example by use of plastic drinking glasses? Are there examples of good practice it would be helpful for us to be aware of?

• While we do not oppose attempts to reduce the impact on the environment and we are aware of the approaches being tried such as part the various communities against drugs and crime and disorder initiatives we feel that we must point out that these initiatives only address the symptoms, rather than the causes of problems.
  

• There are also issues involved here concerning personal responsibility. To what extent are we likely to perpetuate problems in the long term if we start to take responsibility for the actions of individuals?
  

• Manipulation of the environment is a treatment after the fact and is always less effective than prevention. Several after-the-fact suggestions were offered in Question 20. However, early education of children about the dangers of alcohol is the best and most complete method of dealing with the current problems of alcohol.

In respect of individuals who are affected by FAS:

39. How can the services provided by the state and others to vulnerable groups with complex problems be joined-up most effectively? Are there examples of joined-up delivery it would be helpful for us to be aware of? What gets in the way of joining up services?