19. People with co-occurring physical health conditions
Healthcare assessments, treatment and recovery planning and referral pathways for primary or secondary healthcare for people with alcohol related physical health conditions including liver disease, cardiovascular disease, specific cancers, and smoking and lung health issues.
Alcohol increases the risk of many health conditions including some cancers, liver disease, cardiovascular disease, and diseases of the central nervous system.
Smoking and drinking in combination increases the risk of some alcohol-related diseases.
Everyone starting alcohol treatment should receive an initial assessment of their health as part of comprehensive assessment. The assessor can then refer the person (with their consent) to their GP or a clinician (a doctor or nurse) in the alcohol treatment service for a further assessment of any symptoms or unmet healthcare needs.
If a physical health assessment suggests concerns, the person should be quickly referred for further investigation and supported to access and complete any necessary treatment.
Commissioners and strategic managers of local alcohol treatment services and primary and secondary healthcare services should develop and support care pathways for people with alcohol-related illnesses, such as liver disease.
There should be ongoing communication between clinicians or keyworkers in alcohol treatment services and clinicians in primary and secondary care about the person’s physical healthcare needs.
When developing a treatment and recovery plan with the person, alcohol treatment practitioners should include goals and actions related to the person’s physical health where relevant.
Alcohol treatment services should ensure their teams are aware of the latest guidance on supporting people to stop smoking and provide opportunities for them to support smokers to quit.
Alcohol treatment services should make sure there are clear local referral and care pathways to stop smoking support.
People who drink alcohol, especially people who drink at harmful or dependent levels, have an increased risk of a range of health problems, including:
- some cancers
- liver disease
- cardiovascular disease
- diseases of the central nervous system, such as alcohol-related brain damage
Alcohol-related health risks vary according to the volume and frequency of alcohol consumed, as well as several other factors including:
- age
- sex
- body mass index (BMI)
- length of time someone has been using alcohol
In general, the more that someone drinks, the greater their risk of alcohol-related health harms.
Alcohol treatment services and other health professionals should provide people with simple, accessible information on alcohol-related health risks, and personalise advice on reducing health harms.
Everyone starting alcohol treatment should receive an initial assessment of their health as part of comprehensive assessment. The assessor, who might not be a clinician, can then refer the person (with their consent) to their GP or a clinician (a doctor or nurse) in the alcohol treatment service for further assessment of any symptoms or unmet healthcare needs.
The clinician prescribing in the alcohol treatment service needs to be satisfied that an adequate health assessment is being provided for each person they prescribe to, or whether further assessment is needed from primary care or secondary care specialist services.
It is good practice for the clinician assessing a person for alcohol treatment to complete a general health assessment that they are competent to carry out. Following this, they can decide whether the person needs a further assessment (or other intervention), and whether it is urgent or not. It is important for services to achieve a balance that focuses on the needs of the person, while not attempting to replace the role of primary care.
Clinicians should assess for health conditions that are alcohol-related and conditions that are unrelated. You should read guidance on providing a physical health assessment in alcohol treatment services in section 4.9.11 of chapter 4 on assessment and treatment and recovery planning.
If a physical health assessment suggests concerns, people should be quickly referred for further investigation and supported to access and complete any necessary treatment.
The alcohol treatment clinician or the person’s keyworker should work with the person’s GP and relevant secondary care clinicians to make sure that the person’s healthcare needs are addressed.
When developing a treatment and recovery plan with the person, alcohol treatment practitioners should include goals and actions related to the person’s physical health where relevant.
For example, a treatment and recovery plan might include:
- personal goals and actions in relation to physical health such as stopping smoking
- actions around attending healthcare appointments and reviewing outcomes
- attendance at health and wellbeing activities such as support groups for people with long term conditions and appropriate physical activities
- discussion of harm reduction and health information
You can find guidance on treatment and recovery planning in chapter 4 on assessment and treatment and recovery planning.
An evidence review on the public health burden of alcohol found that risks for the following diseases were increased by drinking.
19.5.1 Cancers
There is strong evidence for an association between alcohol use and cancer, including cancers of the:
- lip, oral cavity and pharynx
- oesophagus
- larynx
- colon
- rectum
- liver and intrahepatic bile ducts
- breast
Smoking and drinking alcohol increases several health risks.
There is evidence that for men who have never smoked, the risk of alcohol-related cancers is not much higher than for those drinking less than 3.75 units per day (Cao and others, 2015). However, for women who have never smoked, the risk of alcohol-related cancers, mainly breast cancer, increases even within the range of up to around 2 units per day.
A large scale longitudinal study found that compared to men who have never smoked and do not drink, men who smoke and drink more than 15 units a week have the highest mortality from smoking-related cancers (Hart and others, 2010a). Either drinking alcohol or smoking increases the risk of getting cancer but doing both increases the risk to a greater extent than either behaviour alone.
Healthcare professionals treating people with these cancers should ask about their alcohol use and, where possible, use a screening tool such as the alcohol use disorders identification test (AUDIT or AUDIT-C) to do this.
You can find screening tools at Alcohol use screening tests and guidance on identification of alcohol use disorders in chapter 3 on alcohol brief interventions.
19.5.2 Alcohol-related liver disease
Overview
Alcohol-related liver disease is a type of damage or disease to the liver caused by heavy alcohol use, including fatty liver disease, alcoholic hepatitis and cirrhosis.
In 2023, 76% of alcohol-specific deaths in the UK were from alcohol-related liver disease (Office for National Statistics, 2025).
There is evidence that obesity-induced fatty liver can progress to cirrhosis and liver failure, but obesity can also increase the harm to the liver caused by alcohol use (Hart and others, 2010b). In simple terms, for a person with a BMI of over 35, the liver risk doubles at any given volume of alcohol use.
Hepatitis C (or B) can increase the harm to the liver caused by alcohol-related liver disease.
There is evidence (Williams and others, 2014) that people with alcohol-related liver disease experience stigma, including from healthcare professionals. Stigma can deter people from seeking help and can lead to poor healthcare experiences. A non-judgemental, non-stigmatising approach is vital to help people engage with treatment as early as possible in the development of the disease. Alcohol treatment staff may need to advocate for people with alcohol-related liver disease with other healthcare services, so they can access the care they need.
You can find guidance on delivering pharmacological interventions for medically assisted withdrawal and relapse prevention for people with liver disease in section 10.6.6 in chapter 10 on pharmacological interventions.
Detecting liver disease early
Signs and symptoms of alcohol-related liver disease (ARLD) develop late in the progression of the disease and a high proportion of people with ARLD will have no clinical symptoms nor significant blood test abnormalities.
Eventually, their liver may fail to function sufficiently and will decompensate. This is the stage at which ARLD becomes clinically apparent. The risk of developing liver disease and subsequent decompensation decreases with abstinence (or reduced alcohol consumption). So, it’s important to detect liver disease early and begin interventions.
Screening for liver disease
National Institute for Health and Care Excellence guideline Cirrhosis in over 16s: assessment and management (NG50) recommends that women drinking more than 35 units per week, or men drinking more than 50 units per week, for 3 months or more should have their liver stiffness measured by transient elastography (TE, also known as Fibroscan) to determine the stage of progression of liver disease.
There are other non-invasive screening methods for liver fibrosis in development, which include the following.
Ultrasound based screening includes:
- acoustic radiation force impulse
- shear-wave
Serum fibrosis markers include:
- enhanced liver fibrosis (ELF)
- liver traffic light test
- intelligent liver function test (iLFT)
However, research shows that these tests are currently less well validated for ARLD than TE is (Moreno and others, 2019).
Healthcare professionals who perform and interpret non-invasive fibrosis tests should be trained to do so.
Any screening test should be part of a specified pathway, to make sure the tests are reviewed and acted on.
Care for people with liver disease
People diagnosed with significant fibrosis or cirrhosis should be followed up by a specialist in liver disease.
Alcohol abstinence is a vital goal for people with ARLD, since abstinence improves outcomes in all stages of ARLD. However, the patient should not be excluded from treatment if they do not accept this goal initially. Guidance on developing pathways for alcohol treatment is clear that it is better to engage the person, rather than alienate them if they fail to agree to or achieve abstinence.
Commissioners and system leaders should develop and support effective care pathways between specialist liver services and alcohol treatment services in the hospital and in the community.
You can find guidance on treating cirrhosis in chapter 16 on acute hospital settings.
Scottish Health Action on Alcohol Problems published Alcohol-related liver disease: guidance for good practice for healthcare staff in primary and secondary health services and in alcohol treatment services. The content may also be useful for healthcare staff in other UK nations.
19.5.3 Cardiovascular disease
Hypertension
There is a close relationship between drinking alcohol and hypertension (high blood pressure). Risk of high blood pressure starts at lower levels of alcohol use for women (from about 2 units per day) than for men. High blood pressure accounts for most alcohol-related hospital admissions for cardiovascular disease.
Alcohol treatment services and other health professionals should screen people with alcohol dependence or harmful patterns of drinking for high blood pressure. Healthcare professionals treating people with high blood pressure should ask people about their alcohol use and where possible should use a screening tool such as AUDIT or AUDIT-C to do this.
Stroke
There is evidence (Ronksley and others, 2011) that people who drink more than 7.5 units a day are at increased risk of incident stroke (bleeding in or around the brain or blocked artery to the brain) compared with people who do not drink at all.
Either drinking alcohol or smoking increase the risk of stroke, but smoking and drinking together increases the risk to a greater extent than either behaviour alone.
There is evidence (Hart and others, 2010a) that men who smoke and drink more than 15 units per week have the highest risk of death from stroke.
Heart disease
Heavy drinking and episodic (binge) drinking increases the risk of heart disease (angina, heart attack, heart failure) and death from heart disease.
Men who smoke and drink more than 15 units per week have the highest risk of death from heart disease.
Atrial fibrillation
Binge drinking is a risk factor for atrial fibrillation (severe irregular heartbeat). However, the risk of atrial fibrillation increases with the amount the person drinks from 1.5 units per day upwards.
19.5.4 Central nervous system
Brain damage
Alcohol-related brain damage describes various psychoneurological or cognitive conditions that are associated with long-term, heavy alcohol use and related vitamin deficiencies (particularly thiamine deficiency).
Wernicke’s encephalopathy is an acute medical emergency where alcohol withdrawal and lack of vitamin B1 causes inflammation of the brain. It has a high risk of death and if untreated, may lead to Wernicke-Korsakoff syndrome which involves irreversible memory loss. However, if caught early enough and treated with thiamine supplementation, long term brain damage is preventable.
You can find guidance on prescribing thiamine for prevention of Wernicke’s encephalopathy in section 10.4.3 of chapter 10 on pharmacological interventions.
You should read guidance on alcohol-related brain damage in chapter 20.
Peripheral neuropathy
Peripheral neuropathy is damage to the nerves that results from excessive drinking. It causes symptoms that include numbness in the arms and legs and abnormal sensations such as pins and needles.
Epilepsy
There is a relationship between heavier levels of drinking and the risk of epilepsy. People with alcohol dependence can also experience withdrawal seizures.
You can find guidance on seizures in withdrawal in section 10.4.1 in chapter 10 on pharmacological interventions.
19.5.5 Acute health risks
In addition to the disease risks associated with alcohol use, there are acute (short term) health risks including injuries.
The risk of unintentional and intentional injuries resulting from drinking alcohol increases with the amount of alcohol people drink. Health risks associated with intoxication and alcohol dependence include risks arising from:
- road traffic accidents
- alcohol poisoning
- overdose or increased harms when alcohol and other substances (illicit, prescribed or over the counter) are taken together
- falls
- fires
- drowning and water transport incidents
- air or transport incidents
- work or machine incidents
- firearms incidents
- inhalation and ingestion of gastric contents
- exposure to excessive cold (from passing out while outside)
- intentional self-harm or suicide
- increased risk of sexual diseases and unplanned pregnancies resulting from unprotected sex
- increased risk of being a victim or perpetrator of violence
Alcohol treatment services should provide harm reduction information and advice on the risks associated with intoxication and alcohol dependence. You can read guidance on harm reduction information and advice for several of those risks in section 8.14 of chapter 8 on harm reduction.
Alcohol, both intoxication and dependence, increase the risk of self-harm and suicide.
You can find guidance on self-harm and suicide in section 4.9.9 of chapter 4 on assessment and treatment and recovery planning. and section 18.6 of chapter 18 on co-occurring mental health conditions.
19.5.6 Complications of alcohol withdrawal
For people with alcohol dependence, unplanned withdrawal and in some cases, medically assisted withdrawal can be associated with complications that have health consequences. In some people, these can be severe and can even lead to death.
You should read guidance on preventing and managing complications in withdrawal in section 10.4 in chapter 10 on pharmacological interventions.
Smoking harms every organ in the body and causes several diseases including lung cancer. Smoking and drinking combined increases the risk of several alcohol-related conditions.
Alcohol treatment staff are in an ideal position to help reduce smoking-related harm in people in treatment.
19.6.1 Asking a person about their smoking and related problems
Alcohol treatment services need to:
- identify a person’s history of smoking tobacco and other drugs
- provide information on the stop smoking support available locally
- help the person engage with local smoking cessation interventions or provide smoking cessation support directly
- support the person to engage with services to treat respiratory problems, including their GP or specialist respiratory health services
Clinicians should ask questions to explore potential respiratory disease, including asking about:
- current or recent history of cough, shortness of breath and symptoms of asthma, and any impairment caused by activities like walking
- previous respiratory diagnoses and any treatment for existing lung disease
Clinicians should also ask questions to explore the person’s smoking history and intentions to quit, including their:
- recent and previous levels of smoking and current quit status (for tobacco and other smoked drugs)
- desire, now or in the future, to quit tobacco smoking
- experience of previous quit attempts
- willingness to consider smoking cessation (including pharmacotherapy)
- use of e-cigarettes
19.6.2 Physical examinations and exploring respiratory disease
Physical examination and investigations for smoking and exploring respiratory disease are normally undertaken by the GP or respiratory team, but they can be carried out by in some alcohol or drug treatment services where clinical staff have the appropriate competencies.
Examinations and investigations include:
- checking for signs of breathlessness, cough, wheeze, and other signs of respiratory (or cardiovascular) disease
- pulse oximetry, a simple test that can show unrecognised impaired lung function (this may be useful if the person is using opioids and other respiratory depressants or has had a recent opioid overdose)
- spirometry (including handheld spirometry, which may be more easily used in non-specialist clinics) can quantify impairment that could have been caused by tobacco or other drug use
19.6.3 Accessing interventions for respiratory problems
Clinicians can support people to access appropriate interventions for respiratory problems by:
- clearly documenting smoking and respiratory health in the patient record
- noting any observed deterioration in apparent respiratory health over time
- referring the person to their GP for investigation and treatment, if necessary (which may include full lung function tests and chest X-ray)
- supporting referral (usually by the GP) to the local specialist respiratory service or chest clinic, which may be required for people with established respiratory disease if there are health concerns (such as evidence of low oxygen levels)
- making an urgent referral to the GP or local rapid access chest clinic for any person with respiratory disease who has ‘red flag’ symptoms of chest malignancy (such as patients who report haemoptysis and weight loss)
- making an urgent referral to an emergency department for people presenting with imminently dangerous conditions such as unstable or deteriorating asthma
19.6.4 Providing or supporting smoking cessation interventions
Staff in alcohol treatment settings also need to be competent to provide or support smoking cessation interventions.
Alcohol treatment services should:
- provide feedback to commissioners about where local stop smoking services are working well and where there are problems for people accessing support
- ensure their teams are aware of the latest guidance and interventions to help people to stop smoking
- provide learning and development opportunities for team members on how to support smokers to quit and to provide very brief advice
- make sure there are clear local referral and care pathways to stop smoking support
19.6.5 Very brief advice
Very brief advice has 3 components: ask, advise and act.
Ask and record smoking status: is the patient a smoker, ex-smoker or non-smoker?
Advise on the best way of quitting: a combination of stop smoking aids and specialist support.
Act on the patient response: build confidence, give information, refer and prescribe.
Staff can access free online training from the National Centre for Smoking Cessation and Training. They can also make the most of existing opportunities like the NHS Health Check to include smoking cessation support in routine clinical care.
19.6.6 Providing different options to stop smoking
Different approaches suit different people, so if the first thing a smoker tries does not help, they should try another way to quit. Clinicians should be confident to talk to people about the different options available for stopping smoking and how effective they are. There is guidance to support conversations between clinicians and people who want to quit smoking, which will help them with what method to choose.
19.6.7 Vaccinations
Alcohol dependence by itself is not an indication for either influenza (flu) or pneumococcal vaccination. However, if there are other underlying health issues, for example chronic liver disease or respiratory disease, this would place the person in a clinical risk group and the Green Book recommends vaccination. The Green Book provides guidance on which vaccines should be administered to people with at-risk comorbidities including comorbidities that may be attributable to alcohol. For flu and pneumococcal disease, see 19.4 Influenza: the green book, chapter 19 and table 25.3 Pneumococcal: the green book, chapter 25.
Cao Y, Willett WC, Rimm EB, Stampfer MJ and Giovannucci EL. Light to moderate intake of alcohol, drinking patterns, and risk of cancer: results from two prospective US cohort studies. British Medical Journal 2015: issue 351, article h4238.
Hart CL, Davey Smith G, Gruer L and Watt GC. The combined effect of smoking tobacco and drinking alcohol on cause-specific mortality: a 30 year cohort study. BMC Public Health 2010a: issue 10, article 789.
Hart CL, Morrison DS, Batty GD, Mitchell RJ and Davey Smith G. Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies. British Medical Journal 2010b: issue 340, article c1240.
Moreno C, Mueller S and Szabo G. Non-invasive diagnosis and biomarkers in alcohol-related liver disease. Journal of Hepatology 2019: volume 70, issue 2, pages 273 to 283.
Office for National Statistics. Alcohol-specific deaths in the UK: registered in 2023, 2025.
Ronksley PE, Brien SE, Turner BJ, Mukamal KJ and Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. British Medical Journal 2011: issue 342, article d671.
Williams R, Aspinall R, Bellis M, Camps-Walsh G, Cramp M, Dhawan A, Ferguson J, Forton D, Foster G, Gilmore I, Hickman M, Hudson M, Kelly D, Langford A, Lombard M, Longworth L, Martin N, Moriarty K, Newsome P, O’Grady J, Pryke R, Rutter H, Ryder S, Sheron N and Smith T. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. The Lancet 2014: volume 384, pages 1,953 to 1,997.