Snacks, fags and booze: Scotland's triple health challenge

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Home of the deep-fried Mars Bar, the image Scotland presents to the world is not a healthy one. But it’s not just battered confectionary that is feeding Scotland’s reputation as the sick man of Europe.

Daily sugary snacks and drinks, cheap carbs, lack of exercise, smoking and alcohol misuse are all taking their toll and fuelling a raft of preventable, lifestyle-related diseases. 

Scotland has the lowest life expectancy in the UK, at 77.1 for men and 81.1 for women, and one of the lowest in the OECD. In Scotland men and women can expect to live 2.0 and 1.7 years respectively less than the UK average, with the so-called ‘Glasgow effect’ meaning that men in that city have the lowest life expectancy in the UK. 

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While life expectancy has increased considerably over the last few decades, it has now stalled in Scotland for the first time since records began in 1861 – and the gap between Scotland and England has grown since 1980. And that’s not to mention healthy life expectancy, the length of time we might enjoy in good health, which is lower still, at 59.9 for men and 62.3 for women.

Of the trio of major health time bombs – smoking, drinking, and obesity – smoking remains the biggest killer. Around a fifth of Scots smoke and tobacco is responsible for about 10,000 – one fifth of all – deaths a year in Scotland as well as 128,000 hospital admissions, costing the NHS over £300m annually. However, a number of changes brought in to reduce the appeal and the impact of tobacco over the last decade have begun to have an effect.

Smoking was banned in public places in 2006 and the legal minimum age to purchase tobacco was raised from 16 to 18 in 2007. A tobacco retailer register was introduced in 2011 and the display of tobacco in shops and tobacco vending machines were banned in 2013.

In 2013 the Scottish Government set itself the ambitious aim of Scotland becoming a tobacco-free country – with less than five per cent of the adult population smoking – by 2034 and its ‘Creating a Tobacco-Free Generation’ strategy outlined 46 actions for change. The key focus has been on discouraging the exposure to and take-up of smoking by younger people.

A target to reduce the proportion of children in Scotland exposed to second-hand smoke in the home from 12 per cent to six per cent by 2020 was achieved five years early in 2015. Smoking in cars when travelling with children became illegal in December 2016, after a member’s bill by Liberal Democrat MSP John Hume received unanimous support from MSPs.  

Scotland was the first country in the UK to call for legislation for plain cigarette packaging and rolling tobacco, a policy implemented by the UK Government that came into force in May this year.

All cigarette packs are now a standardised green colour and must have a large health warning on the front and back of the pack. After Australia banned branded cigarette packaging in 2012, it saw a 0.55 per cent drop in smoking, and it is hoped Scotland will see a similar decrease.

Public health minister Aileen Campbell said: “We want to create a tobacco-free generation in Scotland by 2034, and this is one of several measures that will help to turn that into a reality. By discouraging young people from taking up the habit in the first place, we can start to reduce the cost this product inflicts on families and communities across Scotland.”

Later this year smoking will be banned within 15 metres of a hospital building and next year smoking will be banned in Scottish prisons, one of the last indoor public spaces where smoking is still legal, with support to quit being provided for the nearly three-quarters of prisoners who smoke. 

Between 2003 and 2015 the proportion of adults who smoked decreased by 10 percentage points from 31 per cent to 21 per cent, but there is still a long way to go to hit the Scottish Government’s target of virtually zero by 2034.

Alcohol is another key health challenge in Scotland. One in four Scots drinks at harmful levels of above 14 units a week and an average of 22 people per week died of alcohol-related causes in 2015, 54 per cent more, proportionally, than in England and Wales.

There has been a ban on drinks promotions in pubs since 2009 and multi-buy offers of alcohol in shops were stopped in 2011. But according to the Scottish Government, alcohol is now 54 per cent more affordable in the UK than it was in 1980 and it is possible to exceed to guideline maximum 14 units per week for less than £3.

Minimum unit pricing is considered one of the key measures to tackle alcohol misuse by reducing the availability of cheap alcoholic drinks. Research by the University of Sheffield in April 2016 estimated that a minimum price of 50p per unit would result in 120 fewer alcohol-related deaths and 2,000 fewer hospital admissions per year by the twentieth year of the policy.

Its modelling also suggests that minimum unit pricing is a targeted way of reducing consumption, with the greatest benefit being on harmful drinkers.

However, Scottish Government legislation passed in 2012 to implement minimum pricing has been challenged by the Scotch Whisky Association and the case is currently still under consideration by the Supreme Court. In the meantime, though, last week’s programme for government contained the promise of a new framework setting out the next steps to tackle alcohol misuse.

While alcohol and smoking have long been considered public health problems, obesity has been of increasing concern in recent years. Scotland has one of the highest rates of obesity in the OECD and although obesity rates are now stable, they are still higher than they were in 1995. In 2015 almost two-thirds of adults in Scotland were overweight and 29 per cent were obese, with 28 per cent of children at risk of becoming overweight and 15 per cent at risk of obesity.

Obesity is linked to 13 types of cancer, as well as type 2 diabetes, high blood pressure, heart disease and strokes, with obesity-related illnesses costing Scotland approximately £4.6bn. The annual cost of type 2 diabetes alone to NHS Scotland is £800m.

Obesity is now the second biggest risk factor for cancer after smoking and Cancer Research UK has warned that Scotland is in the grip of an obesity epidemic, with Scots consuming 110 tonnes of sugar a day, fuelled by promotions on unhealthy foods. 

Linda Bauld, Professor of Health Policy at Stirling University, said: “Obesity is the unpalatable cost of the cheap deals routinely served up in our shops. It leaves a bad taste to know such an enormous amount of discounted sugar is lining our stomachs and weighing so heavily on the nation’s health. We need urgent action now to prevent thousands of cancers in the future.”

While lack of exercise is also a factor in obesity, and a lack of physical activity contributes to nearly 2,500 deaths in Scotland and costs the NHS around £91m per year – with 37 per cent of adults and 27 per cent of children not meeting the guidelines for regular moderate or vigorous physical activity – experts have concluded that only a change in diet can tackle Scotland’s weight problems.

The UK Government has already announced a tax on sugary soft drinks from April 2018 and as part of a commitment to expand its focus on ill-health, the Scottish Government’s programme for government promises a new strategy to tackle obesity later this year, including “bold measures” to restrict the marketing of foods high in fat, sugar and salt. Whether that will include a complete ban on promotions of unhealthy foods, such as multi-buy deals, as has already been brought in for alcohol, or simply more restrictions on advertising, remains to be seen.

However, one of the key issues outstanding is the difference between rich and poor. Smoking is more than nearly four times higher in areas of highest deprivation than the lowest and alcohol-related mortality rates are eight times as high. But levels of obesity are particularly affected by income, with many people simply not having the money to eat healthily.

In a letter to the public health minister in January following its own inquiry into obesity, the Scottish Parliament’s Health and Sport Committee called for more action to tackle Scotland’s “obesogenic environment”. It pointed out that there were two views that came across on how to tackle obesity: as a health problem involving changing behaviours, and as a social problem linked to inequality, with some people forced to prioritise “calories over nutrients as a result of poverty”. 

This latter issue has been raised repeatedly by health practitioners, including former chief medical officer Harry Burns, public health expert Michael Marmot, NHS Health Scotland and many health charities. This makes obesity a much wider issue that can only be tackled by first addressing poverty.

Nourish Scotland, in its written evidence to the committee, said: “The knowledge that obesity and poor nutrition are a social justice issue must inform policies, so that deprived communities are no longer left behind. Tackling low wages, insecure working conditions, and the poverty premium, and strengthening welfare social security nets for the most vulnerable, while not health measures, are likely to have significant benefits for improving the nutrition of all people in Scotland.”