INTRODUCTION

The 2001 UK census was the first to ask a specific question of ethnic origin and religion. This allowed for the derivation of estimates of the size of Black and Minority Ethnic (BME) population of Britain¹. BME groups make up 7.9% (one in twelve) of the UK population, some 4.6 million people.

 When confined to the population of England, the proportion of minority ethnic origin rises to 9.1% (one in eleven), of whom just over half (4.6% of the population) are of South Asian (Indian, Pakistani, Bangladeshi) origin. The census also recorded religious differentials of ethnic minority populations in England as 3.1% Muslim, 1.1% Hindu and 0.7% Sikh. The majority of people of BME origin live in the Greater London area or the West Midlands, with smaller numbers in other metropolitan centres¹. As a general rule, it is the case that most people of BME communities are living in areas of relative deprivation with high rates of long-term unemployment, lower paid occupations, poor working conditions and poor housing².

South Asians are classified into Indians, Pakistanis and Bangladeshis. Indians are distinct from Bangladeshi, Pakistani and Gowanese groups and are currently classified according to religious preference and practice into Hindus, Muslims and Sikhs. Britain had an Asian community long before the Second World War³. Unfortunately settling in Britain was emotionally taxing⁴. Stress, as a consequence of a multitude of factors fuelled the desire to smoke and drink, most alarmingly in binges⁵.

Table 1: Population of Asians in the UK, April 2001

Indians form part of the Asian community and are classified as part of the BME which represents 22.7% of the total British population of 58,789,194 people (April 2001 Office for National Statistics, UK) (Table 1). Of the ethnic groups Asian or Asian British constituted 50% of the non-White population in 2001.

There is a tendency for a strong drive in education amongst low-income Indian immigrants whose children tend to stay in full-time education after 16 in contrast to their White counterparts, and are, therefore, increasingly well-qualified in comparison⁶. However, with increasing trends in birth rates amongst mothers resident in Britain but born abroad, especially in London boroughs, children of Indian origin are more likely to attend school with less opportunity to speak English and limited access to British culture⁷. Due to concentrations of ethnic groups in certain areas, immigrant society in UK is becoming more segregated and divided by race and religion. In some communities, particularly of Bangladeshi and Pakistani origin, this situation is exacerbated by high incidences of arranged marriages with partners from overseas. These communities are constantly being refreshed by new arrivals from the sub-Continent; thus, most Pakistani and Bangladeshi children will have a mother born abroad⁷. Furthermore, the process of integration for these communities is constantly being shifted back by a generation⁷. This is, however, much less the case for communities of Indian and other origins⁷. Other research indicates that Asian immigrants to the UK on average have a higher level of education that their UK counterparts, although this is usually followed by considerable downgrades to jobs that are less skilled and pay lower wages⁸.

We suggest that South Asian migrants residing in the UK show an increased prevalence to drink and smoke more because they are socially and economically disadvantaged. Drinking and smoking is a direct response to the consequent stress of inequality faced by this ethnic group. It should be noted that this occurrence is more evident in adult Indians particularly first-time immigrants, and not in teenagers, the vast majority of whom abstain. The aim of the current review was to identify alcohol use and cigarette smoking as a consequence of inequalities due to lower income, health economics and social issues amongst Asian Indians resident in India vs. Britain.

MATERIAL AND METHODS

The criteria used in the current review for selecting articles to be included were both theoretically and practically motivated and adopted from proposed criteria in The International Classification of Functioning, Disability and Health- ICF (2001)⁹. These criteria were as follows:

• We classified articles with internationally recognised impact factors as follows: > 5 (Class A), 5-1 (Class B) and <1 (Class C).
• Articles were rated (1 – excellent, 5- poor) concerning relevance therein of impact of lifestyle, stress and/or environmental factor/s predisposing Indians to consume alcohol and/or smoke.
• Criteria for selection of literature used included yes-no responses to: the appropriateness of methodology; adequacy of subject numbers; specificity of sex and/or age of subjects; and statistically significant response rates to survey questionnaires.
• The time frame used was limited to 1990-2007 inclusive.
• A multi-factorial overview of the factors eschewed concerning alcohol and cigarette use were elucidated. We presumed that collective articles detailing known factors of usage were not necessarily correlated with functionality and health.
• Compilation of materials for the review started with published literature or easily accessible academic research.
• The articles were accessible from on line sources including PubMed and Medline. The research strategy was refined using particular search terms including: alcohol/tobacco and Indian and India OR alcohol/tobacco and Indian and Britain.

Articles will be categorised into four groups using the ICF criteria proposed above: India and alcohol use; British Indian alcohol use; India and tobacco use; and British Indian tobacco use.

RESULTS

The criteria for rejection of an article included a rating of 4 or 5 (point 2, ICF criteria) and/or two or more no responses to selection criteria (point 3, ICF criteria). Results are summarised in Table 2.

Table 2:  Selection results for articles of alcohol and tobacco usage by South Asian Indians in India and those resident in Britain

South Asian immigration to UK – sowing the seed for substance use

There was a concerted wave of immigration from India from the 1930s. Migration to the UK reached a peak for South Asians in 1966¹⁰. Indians before 1947 who settled in Britain did not have to be naturalised, as they were British subjects³. The 1962 Commonwealth Immigrants Act marked a serious shift in the immigration of Indians, Pakistanis and Bangladeshis to England¹¹. Reasons for making the journey to England varied enormously, from political expulsion in the case of Ugandan Asians by the notorious racist dictator Idi Dada Amin in August 1972¹², to career development or even marriage¹¹. However, broadly speaking, South Asian migrants in the later half of the twentieth century were motivated by improved economic prospects, even if they anticipated a short stay. Despite attempts to control the number, and type of South Asians entering Britain, by 1961 over 100, 000 Indian and Pakistani nationals had taken up residence¹¹. Early post-war South Asian migrants faced prejudice in finding private rented accommodation and council housing¹¹.

Ethnic health inequalities

The importance of socio-economic status as a determinant of health has been vastly documented^13,14. Large-scale surveys like the Health Survey for England show that BME groups as a whole are more likely to report ill-health, and that ill-health among BME people starts at a younger age than in the White British. Rates of long-term unemployment are higher within ethnic minorities; they are also more likely to have low-paid occupations, poor working conditions and poor housing^15,16. The extent of poverty amongst South Asians includes four out of five households falling below the British average household income¹⁷. Such inequalities across all social sectors for ethnic minorities have profound consequences and bearings on their health.

A more in-depth analysis of Asian Indians¹⁸ shows how proportions of this ethnic group varied across different levels of deprivation in certain selected regions of England. The study made clear that their was an increased proportion of Asian Indians living in more deprived areas and that regionally there were differences with some regions (West Midlands and London) having higher proportions living in deprives areas than others (East Yorkshire) (Figure 1).

Figure 1: Ethnic incidences amongst South Asian Indians in various study catchment areas of Britain¹⁸

Country of origin and incidence of alcohol and tobacco smoking

Alcohol use by South Asian Indians

Alcohol use is a symbol of economic status, caste, a person’s karma, a period of turmoil and gender privilege¹⁹. Drinking is a common habit in India and in subjects consuming alcoholic beverages alone, the prevalence of leukoplakia is high²⁰. Studies have shown a greater percentage of makes smoking particularly amongst respondents with no formal education, school dropouts and illiterate parents²¹. In this study the number of respondents was high (650, 15-24 yr. old) and initiated from 8 randomly selected tea plantations. In a similar study, Medhi et al.²² determined alcohol consumption in 2,264 people aged 15 yr. and over, being 32.2% in 15-24 yr. olds. The authors concluded that users of alcohol were mostly illiterate, manual workers and widows/widowers. Alcohol consumption increased with age, in excess of 25% males above 54 yr. old. Alcohol consumption in the elderly was also noted in Swami et al.²³. In a study of 3,148 people in rural India regular alcohol intake was observed in 19% males (n=377) and in 2% females (n=26)²⁴. Among males there were 43% light drinkers (≤28 g ETOH/d), 32% moderate drinkers (28-56 g ETOH/d), and 5% heavy drinkers (>56 g ETOH/d). The alcohol intake-smoker group had a significantly higher prevalence of hypertension.

In India, socioeconomic status differentials substantially account for the health inequalities between indigenous and non-indigenous groups, the former drinking more alcohol²⁵. Drinks brewed in villages of West Bengal included rice beer (handia), palm wine (tadi), distilled country liquor (chullu) and Indian-made foreign liquor (IMFL)²⁶. Effects of problem drinking included social disturbances, family discord and domestic violence.  In another study of 1806 subjects, alcohol consumption prevalence was 10.4%, with moderate (6.6%) alcohol intake significantly higher by comparison with mild (1.2%) and heavy (2.5%) alcohol drinking²⁷. The relative risk of alcohol is highest among people smoking cigarettes or beedis, and among those using mishri with betel quid and tobacco²⁸. The risk of alcohol use increased with the frequency of tobacco use, and with higher volumes of alcohol consumed, peaking at 100-150 mL of absolute alcohol use. Another study demonstrated that Indian alcohol drinking was associated with lung cancer risk under limited power [Odds ratio (OR) = 2.67; 95% CI = 1.02-7.02]²⁹. The OR of oral cancers for alcohol drinking in never smokers and never chewers was 2.56 (95% CI 1.42-4.64) and oesophageal cancers 3.41 (95% CI 1.46-7.99)³⁰. Another study determined the adjusted OR for ever-alcohol-drinkers was 3.0 (95% CI, 1.6-5.7) after controlling for age, sex, education, body mass index, chewing tobacco and smoking³¹. Chewing of fermented betel nut may potentiate cancer³². Pal et al.³³ used the WHO Alcohol Use Disorders Identification Test (AUDIT) and the Short Michigan Alcoholism Screening Test (SMAST) effectively to evaluate alcohol use disorders in urban community outreach and de-addiction centres in north India.  Limitations included reluctance of alcohol users to seek treatment for their addiction whereby 26.5% (n=21) were “ashamed to admit problems” and 22.8% (n=18) believed “treatment does not help”³⁴.  Studies have shown that there are always a certain percentage of subjects that relapse (28.5%), engage in social drinking (8.5%) or default and die (3%)³⁵.

Alcohol use by South Asian Indians resident in Britain

Alcohol is a socially acceptable and legal drug within the UK and plays a focal role in people’s socialising³⁶. However, drinking in the South Asian communities has not been equated with ‘being sociable’ as is the case in many Western societies. Comparisons of the incidences of alcohol use in Indians versus the general British population is shown in Figure 2. Although certain minority ethnic communities place restrictions on the (mis)use of alcohol (for religious or cultural reasons) there already exist complex patterns of alcohol use within these communities³⁶. Patterns of alcohol and tobacco usage in ethnic minority groups show substantial differences from White people of European origin¹.

Figure 2:                Incidences of alcohol use amongst Indians in Britain compared to the general population⁸⁵

 I

All the three main religions of South Asians condemn the use of alcohol; in practice it is only amongst Muslims that this precept is followed widely rather than limited to the most devout³⁷. Sikhs, notably, are prohibited by religion from smoking and Muslims from drinking alcohol. Often it is socially unacceptable for women from several ethnic groups to smoke and/or drink³⁸. Additionally, men born in India but living in Britain have a higher than expected prevalence rate of alcohol-related disorders³⁹. In a study in India, respondents belonging to scheduled castes and tribes (recognised disadvantaged groups) were significantly more likely to report regular use of alcohol and smoking or chewing tobacco⁴⁰. The study showed that the regular use of both tobacco and alcohol increased significantly with each diminishing income quintile. In this study, questionnaire surveys revealed that Sikhs were more likely to be regular drinkers followed by Whites and Hindus⁴⁰. The small proportion of Muslim men who drank consumed the largest volume of alcohol. Heavier levels of consumption were reported by Sikhs and Hindus born in India than respective groups born in Britain³⁹. Regular drinkers included a higher proportion of Sikhs. There was a clear association of no (Muslim men) or little (Sikh, Hindu and White men) alcohol consumption with religious observance³⁹.

The impact of Western culture, however, has seen an increasing proportion of heterogeneous Indian teenagers and young adults of both sexes, or descendants of Asian immigrant parents, smoking and drinking³⁹. Although a study in an isolated Asian community in Glasgow showed that 13-16 year olds were less likely to smoke or drink⁴¹, surveys are lacking in other cities in Britain. Another study in Glasgow showed that at age 14-15 abstinence of substance use was high in the largely British-born generations of Asians mainly for cultural reasons, although there has been an erosion of constraints on smoking with time⁴². In South Asians aged 15-16 years old less favourable attitudes were held towards drinking alcohol than their White counterparts⁴³. In a survey of 7,009 teenagers in Scotland (1990), drinking was most likely heavy and less frequent than in English teenagers⁴³.

It must also be highlighted at this point that there is a noticeable shift or cultural drive in the more affluent South Asians and drinking. Many young people are now drinking with the same attitudes as their white counterparts. Young South Asian people feel that their culture is not as permissive. When juggling the different value systems their identity, beliefs and faith come into question. Crisis identity can lead to misuse of alcohol.

Tobacco use by South Asian Indians

In a study of 432 tobacco users in rural/urban areas of Lucknow, smoking occupied 59.3%, women preferring smokeless tobacco⁴⁴. The majority of subjects (54.3%) used tobacco 7-24 times/day, 60% of whom started consuming tobacco before 21 yr. old and 22% before 15 yr. Aggressive marketing campaigns by cigarette companies targeting men, women and children in different socioeconomic groups in India have successfully circumvented the Indian tobacco advertising ban⁴⁵. Indian-made bidi cigarettes may have added flavours and study has shown that concentrations of eugenol and trans-anethole are 70,000 and 7,500 times greater than in US cigarette brands, respectively⁴⁶. It is interesting that smoking ≥10 cigarettes or beedies/d in India increases the risk of developing acute myocardial infarction four-fold⁴⁷.  Exposure to tobacco smoke from various Indian smoking products, showed relatively higher levels of nicotine and minor alkaloids from bidi (37.7 mg/g) and chutta (34.5 mg/g), by comparison with Indian and US cigarettes (14-16 mg/g)⁴⁸. High levels of tobacco-specific N-nitrosamines in tobacco and mainstream smoke of Indian cigarettes⁴⁹. Excessive bidi smoking reduced T4/T3 thyroid hormones and thyroid stimulating hormone (TSH) and T4 levels in cigarette smokers⁵⁰.

Tobacco use by South Asian Indians resident in Britain

There may be a genetic association between the risk of developing coronary heart disease in Indians as indeed modulation of DNA damage and mutation caused by polymorphisms in detoxification enzymes during tobacco-related carcinogenesis⁵¹. Heart disease in first-generation Indian immigrants in the US⁵² and resident Indians in the UK⁵³ may not necessarily be associated with cigarette smoking. Cigarette smoking has a lesser carcinogenic effect that bidi smoking with lung cancer risks of OR 4.54 (95% CI = 2.96-6.95) and 6.45 (95% CI = 4.38-9.50), respectively²⁹.

Changes in alcohol usage in South Asian Indian immigrants and their siblings

The World Health Organisation states that poverty is the number-one cause of ill health⁵⁴. Usually, a variety of factors contribute to the development of a problem with alcohol. Social factors such as the influence of family, peers, and society, and the availability of alcohol, and psychological factors such as elevated levels of stress and anxiety, inadequate coping mechanisms, depression, and reinforcement of alcohol use from other drinkers can contribute to alcoholism⁵⁴.

Studies suggest a number of trigger factors for problematic drinking that are specific for such South Asian groups.  The association between social inequality and substance misuse is widely acknowledged. Unemployment, poor housing, poor access to descent education and health services all contribute to social inequality⁵⁵. Unemployed people had slightly higher levels of drinking above sensible levels and binge drinking than the working population⁵⁵.

The commonest reasons for drinking by members of ethnic minority group are that alcohol assists in providing self confidence, improving social relationships, relaxation and improving health or wellbeing⁵⁶. Interestingly, Cochrane and Howell in a survey in the West midlands found that regular attendance at a temple was a clear indicator of the frequency and level of drinking among Sikh men⁵⁶. Those attending on a weekly basis drank less frequently and had lower levels of consumption. This was confirmed by the findings of Miller⁵⁷ and Orford et al.⁵⁸ who identified that individuals with stronger religious beliefs usually drink less than those with weaker religious beliefs.

A survey showed 66 % of Indian men and 35 % of women who consumed alcohol currently, included drinks brewed or made at home⁵⁹. Amongst South Asians alcohol-related morbidity rates for some communities are higher than for the general population⁶⁰. Trends show an increased consumption in Sikhs than in Hindus or Muslims, and heavy spirit drinking occurs amongst Sikh men, associated with a rise in psychiatric admissions since 1971 in the latter^60.

Alcohol consumption may be a cause of death in the UK⁶¹. Some important data include alcohol-related mortality accounting for 2 % of all deaths in young adults during the early 1980s, rising to 7 and 6 % of all deaths in young adult men and women, respectively, in 2001⁶¹. Previous analysis showed that most of these deaths were the result of chronic liver disease and cirrhosis, which accounted for 80 % of all alcohol-related mortality in young adults in 2001⁶². Age-specific mortality rates for young adults by sex for alcohol-related deaths from 1979 to 2000 showed that mortality rates in men were higher than those in women in all age groups, and increased with age in both sexes⁶². There was a steep increase in death rates in both men and women aged between 35 and 44 from the mid-1980s with rates in both sexes for those aged 40-44 doubling during this time⁶¹. The 2001-2003 trends of alcohol-related deaths per 100, 000 population in the UK by local authority were: men [Blackpool (43.9) – Sandwell (26.6)] and women [Corby (20.3) – West Lancashire (13.7)] ⁶¹.

South Asian men who abuse alcohol may be more susceptible to alcohol-related liver damage and acetaldehyde-mediated haemoglobin modification than European men who abuse alcohol to a similar extent for a considerably longer period⁶³. This trend was also identified in a long term study within a West Midland Gastroenterolgy hospital unit⁶⁴. The study determined, over a 14 year period (1987-2000), the ethnic proportion of cirrhotic patients with the ethnic make-up of the local catchment area. South Asians were over-represented with 29.3% cirrhotic patients compared with the local South Asian population being only 18.5%.

Several other studies have highlighted these increased diagnoses of alcohol related disease amongst South Asians. The overall incidence of alcohol related diagnoses was higher in Indian than White males presenting to a London Psychiatric Hospital⁶⁵. Further studies identified that alcoholic cirrhosis was more common in Asian Indians than the general British population and a contributing factor could have been that Sikhs were more likely to consume spirits, and to drink more frequently on a daily basis^39,60. Most South Asian males with alcohol cirrhosis were non-Muslims and were younger at diagnosis than their White counterparts⁶⁴. Genetic factors may explain the ethnic differences in the frequency of alcoholic cirrhosis as the observation that only 15% of alcoholics develop liver cirrhosis has led to the suggestion that genetic factors may be responsible for the individual susceptibility to develop this disease⁶⁶.

Changes in tobacco usage in South Asian Indian immigrants and their siblings

Higher social disadvantage in ethnic groups has promulgated cigarette smoking and obesity⁶⁷. The effect of passive smoking can have damaging consequences for children, often associated with wheeze and asthma attacks and impairing lung function⁶⁸. Bola and Walpole⁶⁹ and Patel et al.⁷⁰ point out that some religious faiths have a clear position against the use of tobacco (and alcohol), but if religious leaders do not recognise illicit drug use in their community and/or do not discuss it, it is difficult and confusing for that community to relate drug use to their cultural background.

In their review Bhopal et al.³⁸ showed a greater gender difference with more Asian Indian men smoking than female. Additionally, the Health Survey for England 1999 showed 23 % of male and 6 % of female Indian respondents smoke cigarettes, and 28% male and 8% female reported smoking any tobacco products⁵⁹.

Negative barriers exist amongst smokers in the South Asian communities in UK in that motivation, although the most important factor, often resulted in failure even during Ramadan⁷¹. Other factors include temptations from others, daily stresses and withdrawal symptoms. Interestingly, few participants seek advice from health services or take cessation aids like nicotine replacement therapy of buproprion⁷¹. Additionally, GPs were not regarded as accessible sources of advice on quitting. Common barriers included language, religion and culture; negative attitudes to services; and lack of time and resources for professionals to develop necessary skills⁷¹.

Comparison of South Asian Indian immigrant and descendents’ use of alcohol vs. British Whites

In 1999, the incidence of drinking more than 21 and 14 units of alcohol per week amongst Indians in Britain was 14% in men and 2% in women, respectively⁷². This was considerably less that equivalent consumption in the general population of 30% and 18%, respectively. Comparisons of Indian men with Britons showed that obesity, salt and alcohol intake, being sedentary, smoking and dietary fat intake do not explain the cause of higher prevalence of hypertension among South Indian men⁷³. In another study on diabetes prevalence in the UK, Asian patients mostly abstained from alcohol consumption⁷⁴. If there is a significant quantity of alcohol consumed, however, especially on an empty stomach, the health consequences are likely to be more profound. In a study in Coventry, South Asians ate fewer meals per day and 2-3 h later at night than in Whites⁷⁵. In their study they also found that Muslims were less likely to drink alcohol.

Comparison of South Asian Indian immigrant and descendents’ use of tobacco vs. British Whites

In 1999, the incidence of cigarette smoking and the use of tobacco products amongst Indians included 23% of men smoking cigarettes and 5% using tobacco products, and 6% of women smoking cigarettes and 2% tobacco products⁷². The overall prevalence of tobacco use was 32% amongst men and 27% amongst women in the general population, respectively. There is an association of tobacco smoking (and alcohol) use amongst Asian men (Hindu, Sikh & Muslim), e.g. in Leicester⁷⁶. Muslim males were found to use tobacco more than other groups, but avoided alcohol. Sikh men drank more, in particular spirits; however, tobacco smoking was low. First and second generation Hindu men (10 %) combined all three habits of alcohol and tobacco smoking, and were considered to be at the highest risk of developing oral cancer⁷⁶.

Lung cancer, as a consequence of smoking, displays a strong positive association with deprivation⁷⁷. Incidence rates in the most deprived men and women in the West Midlands were double those in the least deprived in 2003⁷⁷. This gap has been widening steadily since the early 1980s, especially amongst women. Indeed, the incidence in men has dropped from 4.64 (1981-1983) to 2.29 times greater than that in women (1999-2001)⁷⁷. The harmful consequences of tobacco smoking on renal function have been reviewed⁷⁸.

Interventions to address smoking and alcohol use amongst South Asian Indians in Britain

There are few studies designed to determine interventions used amongst Indians resident in Britain to combat alcohol and/or tobacco use. Currently there is only reference to smoking. Indeed, data concerning ethnic differences in all-cause and cardiovascular mortality following smoking for South-Asians is limited and affected by fewer South-Asian men traceable by the Office for National Statistics⁷⁹. As a consequence, the survival status of Indian men is undetermined and there is a complete lack of data on South-Asian women⁷⁹. Findings do not support the hypothesis that the relatively high cardiovascular disease burden in British South-Asians is related to exposure to risk factors like smoking⁸⁰. Further populations from lower social groups with larger numbers of samples of Asian subjects resident in Britain should help to confirm associations between health and alcohol and/or tobacco use.

DISCUSSION

It is clear from the literature currently available that more research needs to be conducted to identify the exact causal factors amongst South Asians in particular Indians that result in the increase (mis)use of alcohol and increased tobacco smoking.  Although small-scale research has been undertaken over the last two decades, there is limited data available with regards more in-depth studies in the UK. Therefore, it was unreliably difficult to determine the consistency of results across investigations, differentiate Indian study populations or analyse time differences in findings. There is also a dearth of comparative studies of alcohol and tobacco smoking use amongst the various races resident in Britain.

To prevent the spread and use of alcohol and cigarettes, and contributing factors such as poor lifestyles and diet, efforts are required at the grass root level to educate children about the importance of their health. There is also a need to adapt and to test effective drinking and smoking cessation interventions in order to make them more appealing to ethnic minority communities. Such interventions need to be sensitive to the target group and made more focal in community setups and indeed places of worship. There is an urgent need to improve the cross-cultural validity of survey methods, particularly in multilingual, multi-ethnic societies³⁸. There is often an association between factors that increase the average consumption of alcohol and an increased prevalence of heavy drinking. Health promotion programmes to limit alcohol use and abuse should not only target the general population, but specific groups of health professionals in training and clinical practice to raise the like’s awareness of the consequences of at-risk drinking⁸¹. Health professionals need to take note of trends in all population groups in order to gain an accurate correlation of incidences of substance use and deal effectively with health issues. The finding that alcohol consumption was influenced by having friends outside one’s community and friends who drink alcohol⁸², suggests that social networks and peer behaviour impact on drinking behaviour amongst ethnic groups. This suggests that projects dealing with BME alcohol-related problems would benefit from an accompanying focus on peer groups within and outside the respective communities. It is also clear that there is a lack of awareness amongst young Indian people regarding specialist alcohol service providers. Highlighting alternatives to Alcoholics Anonymous⁸³ should therefore be considered an important goal of alcohol awareness and intervention programmes catering for ethnic minorities.

We prescribe that Britain should adopt and implement policies in published Government White Papers that specifically expound upon the “Smoking Kills” theme introduced in 1998⁸⁴, to include a broader focus on population and ethnic groups in order to reduce both smoking and alcohol consumption. Additionally, it is suggested that there needs to be reduced foreign immigration and tighter rules to discourage intercontinental marriages, if there is to be a reasonable prospect of achieving the degree of integration needed to maintain social harmony in Britain⁷.

Conflict of interest

None.

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