2.1 The purpose of the literature review
The purpose of the literature review was to:
Review the available literature on the trend of alcohol consumption in Scotland;
Review literature on accessibility, drinking patterns and the socio-economic impact of alcohol misuse among young persons below the legal drinking age;
Evaluate literature on the effectiveness of minimum age policy on reducing underage alcohol misuse; and
Review literature on interventions that have been put in place in Scotland to reduce underage alcohol use.
The literature review starts with the review on alcohol consumption in Scotland using the General Household Survey (ONS, 2009) and Scottish Health Survey (Scottish Government, 2008) reports, alcohol sales data from Scotland from 2005 to 2009 (Robinson et al, 2010) and alcohol sales data from the UK from 1970 to 2003 (ScotPHO, 2007). In terms of alcohol consumption among underage persons in Scotland, the literature reviewed include the 2006 and 2008 SALSUS (ISD Scotland, 2007 and 2009) and the 2006 Health Behaviour of School-aged Children ( HBSC) survey (Roberts et. al, 2007). Literature on the relationship between alcohol price and consumption are also reviewed using studies from Switzerland (Heeb et al, 2003), and Finland (Koski et al, 2007).
2.2 Alcohol consumption in Scotland
The literature on alcohol consumption patterns in Scotland comes from two sources: self reported consumption data largely from the General Household and the Scottish Health Surveys; and alcohol sales data for Scotland, England and Wales from 2005 to 2009 and also sales data from Her Majesty’s Revenue and Customs (HMRC) showing sales of pure alcohol in litres per capita from 1970 to 2003 for the whole of UK. Alcohol consumption in relation to price will also be reviewed. It should however be pointed out that looking at alcohol consumption in Scotland by sales data and self reported consumption is not likely to present the true picture of what really pertains because not all alcohol purchased will be consumed and not all consumptions will be reported in surveys.
2.2.1 Alcohol sales
Data from alcohol sales in Scotland indicates that the total amount of pure alcohol sold in Scotland increased from 49.5 million litres in 2005 (with population of 4,165,800) to 50.5 million litres in 2009 (with population of 4,278,700), this compared to pure alcohol sales data from England and Wales which sold 436.5 million litres in 2005 (with population of 43,145,900) and 419.5 million litres in 2009 (with population of 44,566,000), translates into 11.9 and 11.8 litres per capita for 2005 and 2009 respectively for Scotland and 10.1 and 9.4 litres of per capita for 2005 and 2009 respectively for England and Wales (Robinson et al, 2010). This implies that the volume of pure alcohol sold per person aged 16years and above in Scotland has remained relatively stable from 2005 to 2009 (11.9 litres per person in 2005 and 11.8 litres per person in 2009) whereas in England and Wales alcohol sold per person has decreased from 10.1 litres in 2005 to 9.4 litres in 2009 (Robinson et al, 2010). In terms of units of alcohol, the per capita alcohol sale in Scotland translates into 1,219 units of alcohol a year for every adult. This is equivalent to 23.4 units per week which is above the recommended weekly UK alcohol allowance of 14 units for women and 21 units for men. Similarly, available sales data from HMRC indicate that the recorded alcohol consumption in the UK has been increasing since the 1970s as shown in figure 1. The pattern shown indicates that pure alcohol consumption followed a steady increase since the early 1970s (consumption was 6.4 litres per capita in 1970) and reached about 9.4 litre per capita in 2003; this rise took place against a background of falling per capita consumption at an European level which peaked at around 11.8 litres in 1980 and has been falling afterwards (ScotPHO, 2007). In other words the amount of alcohol consumed per person in the UK has increased from 6.4 litres in 1970 to 9.4 litres in 2003 (assuming that all the alcohol that have been recorded by HMRC as having been taxed in the UK are going to be consumed in the UK). This literature is weak in the sense that it cannot be disaggregated to Scotland level.
2.2.2 Alcohol surveys
In terms of alcohol consumption patterns in Scotland, the key surveys considered for adults were the General Household Survey 2007 (ONS, 2009) and the revised 2003 Scottish Health Survey (Scottish Government, 2008b) and for children; the Scottish Schools Adolescent Lifestyle and Substance Use Survey, SALSUS (ISD Scotland, 2009) and the 2006 Health Behaviour of School-aged Children, HBSC survey (Roberts et. al, 2007). With exception of the General Household Survey, the remaining surveys were selected based on the fact that, they were routinely conducted by agencies within Scotland and they provided information on Scottish behaviour at a national level.
The General Household Survey 2007 (ONS, 2009) found the following in relation to patterns of consumption:
Of those who drank alcohol in the last week, 41% of men and 34% of women drank more than the recommended daily amount of units (established as not more that 3-4 units for men and not more than 2-3 units for women) on their heaviest drinking day.
On the heaviest drinking day in the past week 24% of men and 15% of women reported drinking more than two-times the recommended daily amount of units.
In the case of the revised 2003 Scottish Health Survey (Scottish Government, 2008), the key findings were:
On average, men drank 20.3 units of alcohol and women 9.1 per week; these two figures fall below the recommended weekly safe limits of 21 units per week for men and 14 units per week for women.
The percentage of all men whose reported weekly consumption exceeded the recommended 21 units has increased from 33% in 1988 to 34% in the revised 2003 survey. The percentage of all women whose reported weekly consumption was more than 14 units has also seen an increase from 15% in 1988 to 23% in the revised 2003 survey. This suggests that more women are drinking in excess of the recommended weekly allowance compared to men. The reason behind this trend is not known.
On the heaviest drinking day in the past week, 63% of men and 64% of women drank more than the recommended daily amount of units.
Young people’s alcohol consumption in Scotland is evaluated using the surveys from the 2006, 2008 and the 2006 HBSC.
According to the 2006 and 2008 SALSUS (ISD Scotland, 2007 and ISD Scotland 2009), the key findings are as follows:
On average, the 2008 SALSUS report showed that 52% of 13-year-olds and 82% of 15-year-olds have ever had an alcoholic drink. These figures compared to the 2006 SALSUS report showed a downward trend in both cases (from 57% in 2006 to 52% in 13-year-olds, and 84% to 82% in 15-year-olds).
The proportion of pupils who reported having had a drink in the past week also saw a decrease from 14% in 2006 to 11% in 2008 among 13-year-olds; and a decrease from 36% in 2006 to 31% in 2008 among 15-year-olds.
On the issue of drinking to excess, about 50% of 13-year-olds who had ever had an alcoholic drink reported having been ‘really drunk’ at least once compared to 72% of 15-year-olds in the 2008 SALSUS report. Among the 15-year-olds, girls were more likely to report having been ‘really drunk’ (74% of girls compared to 71% boys).
Findings from the 2006 Scottish HBSC (Roberts et. al, 2007), survey showed that:
One in five 13-year-olds and two in five 15-year-olds drink alcohol at least once a week.
Forty eight percent of 15-year-old girls and 43% of 15-year-old boys have been drunk on at least two occasions.
It is likely that these survey figures underestimated the current level of drinking in Scotland, given the self-reported nature of the data.
2.3 Price and consumption
A range of studies have found that price of alcohol influences its availability and consumption. The influence of alcohol pricing on consumption was seen in Switzerland in 1999, when taxes on foreign spirits were reduced by 30-50% in fulfilment of World Trade Organisation’s (WTO) requirement to reduce discrimination against imported products; spirit consumption increased by 28.6% within six months after the tax reduction (Heeb et al, 2003). Another illustration of the link between price and consumption is provided by Finland where a 33% reduction in alcohol excise duty by the government in 2004 led to a 10% rise in alcohol consumption and a 30% rise in liver cirrhosis deaths within one year (Koski et al 2007). In line with this evidence the British Medical Association (BMA) in Scotland has suggested the introduction of minimum price levels for the sale of alcoholic beverages based on alcohol contents (BMA Scotland, 2009). In a similar vein the Chief Medical Officer for England in his annual report on the state of public health in 2008, suggested the introduction of a minimum price of 50 pence per UK unit of alcohol (Department of Health, 2009). Indeed, the Scottish Governments’ recent alcohol policy clearly proposes the setting of “A minimum price per unit of alcohol to raise the cost of the cheapest ciders, lagers and low-grade spirits favoured by problem drinkers” (Scottish Government, 2009).
Cook (2007) asserts that a policy that increases the price of alcohol, delay the start of drinking and slows young people’s progression towards heavy drinking. This assertion though true to an extent, should be accepted with caution, in that, the factors that determine the time at which a young person starts drinking does not depend on only price policies but on several other factors including the age of the person and the settings in which the drink is consumed (Templeton, 2009). Competition in the alcohol market also drives down the price thereby making alcohol cheap and encouraging consumption (Academy of Medical Sciences, 2004). . Aside the usual extended promotions like ‘buy-one-get-one-free’ and deep discounting, some top UK supermarkets including Asda, Morrisons, Sainsbury’s, Sommerfields and Tesco have also adopted a strategy called ‘loss-leading’ where they intentionally price alcoholic products at less than the recommended retail price in order to attract customers into their stores and thereby help sell their other products (Competition Commission, 2007). This practice has been found to be a contributory factor in increased alcohol consumption in the UK (Academy of Medical Sciences, 2004).
In summary, sales data for alcohol sales in Scotland from 2005 to 2009 show that alcohol consumption has been increasing (Robinson et al, 2010). Sales data from the UK for the past 50 years also indicate that alcohol consumption has been increasing (ScotPHO, 2007). The lack of disaggregation of the 50 years sales data for the UK to Scotland level makes it weak in the estimation of alcohol consumption for Scotland.
Alcohol consumption surveys on the other hand showed an increase in trend in the number of adults exceeding the recommended weekly allowance but children’s surveys done in Scotland indicated that the number of under aged persons drinking alcohol in the previous week has reduced between 2006 and 2008. This survey data on alcohol consumption in underage persons is weak in the sense that it fails to capture the alcohol consumption among young people who are in non formal institutions like apprenticeship programs or are in rehabilitation projects. It is therefore suggested that future surveys that intend to capture alcohol consumption that is representative of young people should consider the other categories that are enrolled in other programs outside the formal educational institutions. Evidence showing the link between alcohol price and consumption has been use to support proposals to increase the minimum price per unit of alcohol.
Accessibility, drinking patterns and the socio-economic impact of alcohol misuse among young people below the legal drinking age
This section will look at how underage persons get access to alcohol in spite of the existence of the minimum legal age law and will examine the factors that enable them to get alcohol using papers from (Freisthler et al, 2003), (Rossow et.al, 2008) (Toomey et al, 2008) (Wechsler et al, 2002) (Boreham and McManus, 2003) (Wagenaar and Toomey, 2002). The pattern in which alcohol is consumed is also reviewed using the literature form Coleman and Carter (2005); Talbot and Crabbe, (2008); Bellis et al (2007); Forley et al (2004) and Templeton (2009). The socioeconomic impact of alcohol use is also reviewed using papers from the WHO (WHO, 2007); Swahn and Donovan (2004); Scottish Government (2008); Scottish Health Action (2008) and data from the General Register Office for Scotland (2009).
Access to alcohol
Access to alcohol by young persons is not a straight forward issue but a mix of several factors that are partly determined by the individual involved and the context in which it occurs. A study investigating the ability of underage persons attempting to purchase alcohol in Sacramento, California, in which boys and girls aged above 21 years but appeared or looked 17 to 20 years (pseudo underage buyers), were made to buy alcohol from on and off-sale alcohol outlets without identification found that youth successfully purchase alcohol in 26% to 39% of attempts, depending on location (Freisthler et al, 2003). This illustrates the fact that checking of identification before selling alcohol to young persons is not being practised in about 30% of shops in Chicago. In contrast to this, a study done in Finland and Norway in which pseudo-underage buyers were made to attempt to buy alcohol from government monopolised alcohol outlets showed that they were asked to present their identifications in more than 50% of the purchase attempts (Rossow et.al, 2008). This goes to suggest that government monopolised alcohol outlets are relatively effective in controlling illegal alcohol access among underage persons compared to privately controlled ones. The question one may ask at this point is should governments take control of alcohol sales points? The monopolisation of alcohol sales outlets by government agencies should be piloted in several countries to evaluate their effectiveness in reducing alcohol sales to under aged persons.
Another factor that has been found to play a role in access to alcohol by underage persons is the local alcohol outlet density (Meng-Jinn et al, 2008). The higher the number of alcohol outlets within a community the likely it is for young people to access alcohol. Also the likelihood that a purchase attempt without identification succeeds at one outlet is increased if several outlets are aggregated in the same vicinity (Toomey et al, 2008). Aggregation of several alcohol sales outlets in one area tend to encourage competition and the likelihood of a shop overlooking the issue of identification to sell to an underage person in order to make their profit is likely to be high. Aggregation of drinking outlets around colleges has also been found to aid excessive drinking that lead to negative secondary effects such as vandalism, noise making and drunkenness (Wechsler et al, 2002). This goes to suggest that citing of alcohol outlets outside college vicinities has the likelihood of reducing alcohol access young people because of the distance they will have to travel.
Although community based strategies like public education and enforcement of minimum age for alcohol sales has been ongoing in several countries including the UK and the US for some time, the problem of illegal access to alcohol by young people continues to exist and minors continually obtain alcohol with ease (Wagenaar and Toomey 2002). This goes to suggest that the either the strategies for controlling illegal alcohol access are not working and/or the targeted group have found ingenious ways of beating the law.
A study in England in which 3000 students were interviewed about their use of cigarette, alcohol and other drugs showed that 29% of 11-year-olds, 37% of 12-year-olds, 41% of 13-year-olds, 55% of 14-year-olds and 67% of 15-year-olds had bought alcohol on their own from grocery outlets (Boreham and McManus, 2003). Similarly, in Scotland, evidence from a survey by the Scottish Executive in 2002 showed that minors continued to have access to alcohol after the implementation of the Scottish National Plan for Action on alcohol problems the previous year (Scottish Executive, 2002). Available evidence suggests that young people are now sourcing alcohol from relatives and friends rather than from pubs and off-licences (ISD Scotland, 2009). A recent survey in Scotland shows that the top three avenues through which young people source their alcohol are pubs, friends/relatives and off-licences (ISD Scotland, 2009). Of the three, according to the Scottish survey, sourcing alcohol from off-licences have seen a decrease from 33% in 1996 to 15% in 2008 (ISD Scotland, 2009), but getting alcohol from friends and relatives has seen an increase from 15% in 1996 to 32% in 2008 (ISD Scotland, 2009). These survey figures suggest that, alcohol is still being accessed by minors somehow, despite efforts by the government to reduce it. It is therefore recommended that further research be done to identify the other avenues aside the traditionally known ones, through which alcohol is obtained by underage persons.
In the United States of America the minimum legal drinking age (MLDA) policy has been in place since 1988, but the illegal access to alcohol by young persons below 21 years still exists. A systematic review of literature on MLDA policy from 1960 to 1999 showed that the implementation of the policy has led to reductions in alcohol consumption and drink driving among young people below the age of 21 years but has not been able to prevent underage persons from obtaining alcohol (Wagenaar and Toomey, 2002).
The Scottish Government in its previous policy proposal to raise the minimum age from 18 to 21 years argued that accessing alcohol from off-licences and drinking them in unsupervised settings were likely to encourage high levels of drunkenness and increased risk of antisocial behaviour and harm to the drinkers and the community, however, their argument for the maintenance of the 18-years minimum age for unsupervised drinking in premises like pubs and night clubs is that these on-sale premises offered a more controlled environment where excessive drinking and antisocial behaviour can be regulated by the operators of the premises (Scottish Government, 2008a). As to whether this argument is true or not, needs to be confirmed through future research to determine which of the two drinking avenues (on-sale and off-sale) is most likely to be associated with drunkenness and increased risk of antisocial behaviour.
2.4.2 Drinking patterns
Reasons given by young people for drinking alcohol includes, to ‘fit in’, ‘get a buzz’, and to ‘get drunk’ (Coleman and Carter, 2005; Talbot and Crabbe, 2008).
According to a survey done in North West England involving 10,271 young persons aged between 11-16 years, to examine the behavioural, economic and demographic predictors of risky drinking behaviour; risky drinking was found to be associated with alcohol obtained from friends, older siblings and from adults outside shops, however, alcohol provided by parents to children in a family environment was found to be associated with improved in child-parent dialogues on alcohol and reduced youth consumption (Bellis et al, 2007). Similarly, Forley et al, (2004) in evaluating the impact of parental approval on recent alcohol consumption among young people concluded that drinking with a parent offers some kind of protection against excessive drinking for young people. This suggests that parental supervision is significant in determining the amount of alcohol consumed by young persons.
Coleman and Carter (2005), in investigating the factors that motivate young people to drink, found that young people drank to increase enjoyment and comfort in social situations, they also used drinking to increase confidence in securing a sexual interaction. Similarly, Templeton (2009) in investigating the meanings, practices and contexts in which underage alcohol was used in England, found that the pattern of drinking is determined by several factors including, the age of the person, the settings in which the drink is consumed, the social meanings which alcohol carries, and with whom the drinking takes place.
It is quite clear that the pattern of drinking among underage alcohol users is determined by several factors including the age, the environment in which it occurs, and the social meanings of alcohol and thus all these factors need to be considered to fully understand the reasons behind why a particular underage person consumes alcohol the way they do. Understanding these meanings has the potential of helping develop effective control measures.
In spite of the negative health and social consequences associated with underage alcohol misuse, alcohol drinking among minors still persists. Perhaps, in the near future, research should also be initiated to explore the possibility of setting up a guide for alcohol consumption among young people below 18 years.
2.4.3 Socio-economic impact
This section looks at the economic, health and social impact of alcohol misuse on individuals and the wider community.
There exist numerous costs and consequences as a result of underage alcohol use. Underage alcohol use has been linked with negative behaviours such as violence, high risk sex and the likelihood for abuse and dependence through research findings (Swahn and Donovan, 2004).
The Scottish government endures immense economic burden as a result of alcohol misuse. The estimated cost of alcohol misuse to the Scottish Government in 2006/2007 was £2.25 billion (Scottish Government, 2008). This was made up of £820 million from productivity and economic loss; £405 million from NHS Scotland as cost of treatments; £170 million from Social work services; £385 million from Criminal justice and Emergency services and £470 million from human cost. Clearly, this huge amount of money could have been channelled into other developmental projects to improve the well-being of the people rather than on alcohol related issues which can be prevented by adopting the appropriate strategies suitable for the Scottish situation. This calls for a continuous evaluation and review of existing strategies until they get it right.
On the health front, Scotland has a high alcohol related death rate compared to the rest of the UK, and also the highest rates in liver cirrhosis in Western Europe and the highest record of deaths due to liver disease in the world (Scottish Health Action, 2008).
According to the General Register Office for Scotland (2009) the trend in alcohol related deaths for all ages has been increasing since the early 1990s and continues to do so in the last decade (figure 3 ). Figure three shows that, for those under 30 years, the total number of people who died each year for the period between 1979 and 1992 were on average, 600 per year. The number of deaths in this group assumed an upward trend and rose to about 1500 in 2002 and then eventually dropped to 1400 in 2008. The explanation for this pattern is not known. The trend in the all age group ranged between 800 and 300 deaths per year between 1979 and 1996 and then showed a step rise to 1600 deaths per year in 1999 before eventually falling to around 900 in 2008 (GROS, 2009). The reasons for these changes are not known. It is however, worth noting that alcohol plays a role in the development of a wide range of diseases albeit that alcohol may not be recorded as the underlying cause of death for all of these diseases, cancers being an example. Hence, it is likely that the number of alcohol related deaths is underestimated in using GROS data for alcohol as underlying cause of death.
Figure 3: Alcohol related deaths for all age and under 30s from 1979 to 2008.
Source: GROS SCOTLAND
Alcohol misuse among young people has been linked with several negative consequences including smoking, risky sexual behaviour, illegal drug use, disruptive behaviour and injuries (Newbury-Birch et al, 2009). The impact of alcohol misuse among young people is also highlighted from figures from A&E departments. Nearly 650 children ranging from 8-15 years were treated for alcohol related problems in Scottish A&E department over a 5-week period in 2006 (NHS, 2006). These figures reflect a worrying consequence as a result of alcohol misuse and clearly demonstrate Scotland’s alcohol problem. The reason underlying these trends require further research, but it is also important that measures like the intensification of community based alcohol education programs, provision of more recreational facilities at community centres to keep young people occupied in their spare times, are put in place to help change social attitudes towards alcohol in Scotland.
The Chief Medical Officer’s (2009) report states that in England in 2006/07 nearly 8000 young people aged below 18 years were admitted to hospital as a result of conditions that are directly attributable to alcohol use. Underage alcohol use has also been associated with negative behaviours. The 2008 SALSUS survey reported that, 39% of 13-year-olds and 55% of 15-year-olds in Scotland who drunk alcohol recently, had an argument or fight, tried an illegal substance or engaged in unprotected sex while under the influence of alcohol. Also the most recent ESPAD survey showed that 12% of 15 to 16 – year-old girls who responded from the UK indicated that they had had unprotected sex after drinking alcohol (Hibell et al. 2009).
2.5 Effectiveness of the minimum age laws in reducing underage alcohol misuse
This section looks at how the minimum age law has been effective in minimising the harm associated with underage alcohol use using literature from the WHO (2004); the ICAP (2002); the NHS Quality Improvement Scotland (2006) and the National Highway Traffic Safety Administration survey (2003) from the United States.
In many countries there exists a minimum age at which it becomes legally allowable to purchase or drink alcohol (WHO, 2004). Although there is no universally agreed age at which alcohol consumption is considered suitable, legislations passed by countries on minimum drinking age tend to reflect on the prevailing cultural attitudes towards alcohol and drinking by young persons (International Centre for Alcohol Policies, 2002). Minimum age laws are thus, used to set formal thresholds at which the consumption of alcohol is considered suitable in a particular society.
In Scotland, although there is a minimum age law, the short term negative impact associated with alcohol misuse affects the younger age groups compared to older age groups, as evidenced by the number of alcohol related emergency attendances; alcohol related assaults and alcohol related road accidents that involves young persons who are under the influence of alcohol (NHS Quality Improvement Scotland, 2006).
Evidence from research done in the United States suggest that raising the minimum legal drinking age reduces alcohol sales as well as the associated problems in underage drinkers. A systematic review of 132 published papers from 1960 to 1999 by Toomey and Wagenaar (2002) concluded that increasing the minimum age from 18 to 21 years has led to the reductions in youth drinking and alcohol-related harm, particularly road traffic accidents. Other researches have also established the importance and the relative advantages of delaying the onset of drinking. A study by Grant and Dawson (1997) showed that young people who began drinking before age 15 were four times more likely to develop alcohol dependence than those who begin to drink after 21 years. In addition those who begin drinking in their teenage years are also more likely to experience alcohol-related injuries than those who begin drinking at a later age (Hingson et al, 2000). Again a National Highway Traffic Safety Administration (NHTSA) survey in 2003 showed that the Minimum Legal Drinking Age policy saves about 700-1000 lives every year in the United States. Further to this, the reduction of the legal age for purchasing alcohol in New Zealand from 20 to 18 years in 1999 led to a 12% increase in alcohol related car crashes among 18-19 year-olds and 17% among 15-17 year-olds (Kypri et al, 2006). This suggests that increasing the minimum legal drinking age to above 21 years can at least help reduce alcohol related road traffic accidents among under 21- year-olds. Although increasing the minimum legal drinking age cannot entirely eliminate the problem of underage alcohol use and its associated problems, the above evidence suggests that it can, together with other measures can be effective in minimising some of the negative impact of alcohol misuse among underage persons.
In summary, it can be said that the implementation of the minimum legal drinking age has been shown to be effective in reducing alcohol related road traffic accidents in the United States. It is therefore suggested that countries that have legislation on minimum legal drinking age but are not enforcing the law should takes steps to enforce it because it can be effective when properly implemented.
Interventions that have been put in place to combat underage alcohol misuse in Scotland.
This section looks at interventions at both the adult and underage level. The interventions would be looked at from the point of view of policy and legislation, enforcement of existing alcohol drinking laws and prevention through mass education. Papers considered here include Publications from the Scottish Executive (1999 and 2002); O’Donnell (2006) and Berridge’s (2005) publication on Temperance.
The first target in terms of alcohol policy set by the Scottish Executive following devolution were those set out in the policy document ‘Towards a Healthier Scotland’ (Scottish Executive, 1999). Following a series of consultations and debates a final Plan of Action on Alcohol Problems was launched in 2002 (Scottish Executive, 2002) and was updated in 2007, with the broad objective of reducing alcohol related harm in Scotland. The Plan of action made recommendations including reviews of licensing laws, supply of alcohol on on-sale environments, enforcement of the minimum legal purchase age, server training and other promotions including “happy hours” and “buy-one-get-one-free” (O’Donnell, 2006). The passage of the Licensing (Scotland) Act 2005, the publication of the consultation paper “Changing Scotland’s Relationship with Alcohol” and the subsequent plan of action are some of the consequences of the recommendations that have been carried out.
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