Last call at any British pub can be like a contact sport, with a crush of drunken customers suddenly heaving toward the bar in quest of one last round.
It's a hallowed tradition, and doctors say an increasingly dangerous one.
Britain's propensity toward binge drinking, driven by a pub culture in which a good night out means packing in as many pints as possible before the traditional 11 p.m. closing time, could lead to a liver disease epidemic within two decades unless Britons learn to drink more responsibly, experts warn.
"There's been a frightening increase in alcoholic liver disease in recent years," said Dr. Ian Gilmore, president of the Royal College of Physicians.
According to government statistics, deaths from cirrhosis in Britain have risen dramatically in the past two decades, while they have fallen steadily everywhere else in the Western developed world.
In England and Wales, 17.5 deaths of every 100,000 men were due to cirrhosis in 2002, up from 8.3 in 1987. And in Scotland, the increase was even more dramatic: cirrhosis deaths among men went from 16.9 per every 100,000 in 1987 to 45.2 per 100,000 in 2002.
By comparison, every nine per 100,000 U.S. deaths in 2004 was attributable to cirrhosis. Else
"Deaths from cirrhosis (in Britain) are increasing out of proportion with anywhere else in the world," said Dr. Rajiv Jalan, a consultant hepatologist at London's University College Hospital.
Cheaper alcohol and easy availability in Britain are partly to blame. While other European countries also consume large amounts of alcohol, there are cultural differences that might explain why the British are paying such a high toll.
"We need to understand what drives our particular drinking culture," said Gilmore. "Here, it tends to be more binge drinking, which can be very dangerous."
According to a 2003 European-wide alcohol survey, nearly one-third of 15 to 16-year-old British students reported having gone binge drinking at least three times during the last month. The legal drinking age in Britain is 18.
The British custom of buying rounds creates lots of social pressure to drink: With everyone taking a turn at buying, being out with a dozen friends can mean downing at least a dozen pints.
And unlike other European countries such as France, Spain or Italy — where alcohol is the accompaniment to a meal — many Britons are unlikely to eat anything more substantial than a few packets of chips alongside their lagers.
While other major causes of death like cancer and heart disease are dropping, liver disease — the fifth leading cause of death in Britain — is rising steadily.
"What is happening in Britain is clearly an anomaly in Europe," said Gilmore.
Attempts to curb binge drinking, including 2005 legislation allowing round the clock alcohol sales, may have made the situation worse. At one London hospital, doctors noticed that since the alcohol licensing law changed, the number of overnight patients in emergency rooms linked to alcohol has tripled. In any event, the effect of the law has been limited because most pubs have chosen not to apply for a license to stay open all night.
In the past decade, hospital admissions across Britain related to excessive drinking have doubled. In 1995-1996, 89,000 people were admitted for alcohol-related conditions; by 2005-2006, the figure was 187,000 people.
And unlike the most of the rest of Europe, Britons are drinking more every year.
Total alcohol consumption in Britain doubled between 1960 and 2004, from about 5.6 liters (1.5 gallons) per person over 14 years old to 11.6 liters (3 gallons) per person. In contrast, other European countries, particularly in the south, recorded drops in consumption.
Cirrhosis used to be a disease that mostly affected men in their 60s. Now, doctors are treating patients of both genders in their 20s and 30s. Because symptoms can be non-specific, including fatigue and sexual problems, many people may not realize they have liver problems until damage is irreversible.
Chronic alcoholism and the hepatitis C virus are the main causes of cirrhosis but it can also be triggered by other hepatitis types, genetic diseases, other infections, auto-immune disorders, or a bad reactions to drugs.
Excessive alcohol intake kills healthy liver cells, leaving scar tissue that cannot regenerate itself. Once the liver starts to fail, a domino-like chain reaction in the body is set off, often leading to kidney, heart and circulatory failure.
"If the disease goes undiagnosed, you can go from being entirely well to being in the intensive care unit with multiple organ failure in six to eight weeks," Jalan said.
At a June meeting of the British Medical Association, doctors called for several measures to address the growing drinking problem in the country, including a ban on public drinking in the streets, higher alcohol taxes, and a lower threshold for drunk-driving.