Alcohol problems are a major public health issue in the UK. The consequences affect individuals, their families, the health and emergency services and wider society. The strong association between alcohol consumption and an individual's risk of being either a perpetrator or victim of violent crime has been identified internationally . The extent of alcohol problems in UK and Scottish offender populations is also being increasingly recognised [2–4].
In Scotland, alcohol is known to be closely associated with domestic abuse  and is a risk factor in both the social patterning of assault  and facial injury . The Scottish Crime and Justice Survey 2009/10  reports that in 62% of violent crime the victims perceived offenders to be under the influence of alcohol (the equivalent figure for drugs was 26%). Where known, alcohol is also a factor in 69% of homicide cases , while 70% of assaults in Scottish Accident and Emergency departments are likely to be alcohol-related , the majority of these involving young men. In addition, alcohol treatment was a condition of 10% of probation orders (community sentences) in 2008/09 . Overall costs of alcohol misuse in Scotland are estimated to be £3.6 billion (based on mid-point estimates) with alcohol-related crime accounting for over £700 million .
The prevalence of alcohol problems is markedly higher in the Scottish prison population compared to the general population, at all ages and for both women and men, as shown in comparative analysis conducted as a separate part of this study . Among male and female prisoners, 44% and 48% respectively responded positively to two or more questions from CAGE, a four question screening tool where two or more positive responses indicate problematic alcohol use. This compares with 13% and 9% males and females in the general population in response to equivalent questions. Among 16-24 year-olds, the prevalence was more than two-and-a-half times greater among men in prison, and three-and-a-half times greater among women. Among women in prison aged 45-54 years, 54% were likely to have an alcohol problem, more than five times the equivalent general female population figure .
It is important to put alcohol-related offending into a broader social and economic context. Prisoners in Scotland are predominantly young men from disadvantaged backgrounds, many of whom have substance misuse problems . The Scottish Health Survey 2009  showed that young men were the group most likely to drink to excess and that men living in the most deprived areas of the country are likely to drink the most. According to Richardson and Budd , binge drinkers are those most likely to offend. Alcohol-related problems in offenders also co-exist with drug-related and mental health problems, as well as a range of other health and social problems, resulting in a complex picture of individual need [2, 14, 17–19]. A health care needs assessment carried out in the Scottish Prison Service (SPS) in 2007 identified key areas for service development in SPS healthcare to address some of these complex and interconnecting problems . These key areas included more health-related services for those on short term sentences and on remand (i.e. in custody, pending trial) and the strengthening of links with community services and agencies, both on the way into prison and on liberation. More specifically the assessment recommended formal screening for alcohol problems on admission and the piloting and evaluation of brief interventions for those with mild to moderate alcohol problems staying for short periods. It also identified the need for better integration between healthcare and substance misuse specialist services, both within the prison estate and on the way into and out of prison.
Identifying individuals with alcohol problems is fundamental to providing high quality interventions tailored to individual needs in prison settings. It is also a necessary step to address the links between alcohol and offending described above by aiming to intervene in the often cyclical process of prison admissions where alcohol plays a major part. Effective identification is needed to signpost individuals to appropriate intervention, treatment and support options.
Currently, there are prescribed screening points on admission to all Scottish prisons at which alcohol problems could be identified: reception screening (nurse), medical check (general practitioner) and Core Screen (prison officers). Additionally, prisoners can be referred or self-refer to medical and addiction services at any point during their incarceration. However, questioning on entry for alcohol does not extend much beyond a 'yes/no' response to the question 'Do you have an alcohol problem?' This was recalled by prisoners themselves as an "aye or no" question in the course of qualitative interviews conducted as a separate part of this study . Any further enquiry following a closed question such as this depends on the individual prisoner's response and the professional's interpretation. Furthermore, the question on alcohol is part of a much wider assessment of a range of health and social needs carried out at a stressful and busy time when entering prison. Drinking problems are therefore unlikely to be an immediate concern for individuals at this time, apart from the possible presence of withdrawal symptoms, and so more extensive and validated identification/screening is required for all.
Effective assessment of prisoners is also essential to establish the range of needs relating to alcohol problems, in order to provide adequate, high quality health and social supports to address these needs. Research in England has suggested that only a limited proportion of those with alcohol problems are identified on entry to the prison system . In the Scottish prison system, Graham  found disparities between self-reported rates of alcohol problems and recording of clinical diagnosis that "suggest that alcohol problems are under-detected, under-recorded and under-treated in SPS" [:p18]. In England, Newbury-Birch and colleagues  also found discrepancy between prevalence of alcohol use disorders (AUDs) detected through screening using AUDIT  (score 8+) and prevalence identified by the current OASys (Offender Assessment System) process (part of the National Offender Management System (NOMS)). Research relying on current routine, administrative data sources in UK prisons is therefore likely to underestimate prevalence of alcohol problems.
In a rapid review conducted as part of this study, 13 studies which evaluated the reliability and/or validity of a range of alcohol screening tools with prison populations were identified . The Alcohol Use Disorders Identification Test (AUDIT) was one of three screening tools which emerged as having good reliability with adult prisoners. AUDIT is a 10 question screening tool addressing key areas of alcohol experience as described further below. The AUDIT screening tool is currently being used in the UK for several schemes relating to offenders, for example, to screen offenders for inclusion in Alcohol Arrest Referral Schemes (AARS). It is also the screening tool of choice in a current Scottish pilot study exploring the feasibility and potential effectiveness of alcohol brief interventions (ABI) in the community justice setting (an overview of the Alcohol and Offenders CJS Research Programme is available ). In England, AUDIT is recommended as a screening tool for probation officers  and in the piloting of a training intervention for Offender Health Trainers (OHTs).
This paper reports on data collected using the AUDIT screening tool with entrants to a Scottish prison. It assesses the extent of alcohol problems in this particular setting and provides additional analysis by key socio-demographic and crime-related factors. The paper also assesses the value and feasibility of using the AUDIT screening tool in prison settings. This work formed part of a larger national study  designed to directly inform Scottish policy and practice developments to address the links between alcohol and offenders and to provide high quality healthcare to prisoners in Scotland.