Associate Feature: New First Minister must put public health first

If you want to understand how much damage alcohol, smoking and obesity is doing to health in Scotland, speak to GP Dr David Blane. He’s spent 13 years working in the southside of Glasgow at a “Deep End” practice serving one of Scotland’s 100 most deprived populations.

“Basically every day that we’re in practice, a significant proportion of our patients have health problems related to smoking, alcohol and obesity, and often all three,” he explains.

“The health harms start 10-15 years earlier than in better off areas. That’s multiple long-term conditions starting when people are in their forties or sometimes thirties. 

“It’s not so unusual for us to see alcohol dependence in people in their thirties, obesity for sure in their twenties and thirties, and smoking related lung damage in their thirties and forties.”

There is nothing out of the ordinary, he adds, in people who are still in their thirties coming to the surgery complaining of having trouble breathing because of smoking. 

It’s no exaggeration to say millions of lives in Scotland are blighted by avoidable ill-health, much of it connected to smoking, alcohol and high fat, salt and sugar (HFSS) foods. The statistics hide endless individual stories of misery and distress, from parents too ill to play football with their children, to middle-aged people having regular admissions in hospital because of long-term conditions. 

The cost to the NHS, and by extension the taxpayer, is immense. 

NCD Alliance Scotland is an organisation of health organisations working together in Scotland to reduce the burden of non-communicable diseases like cardiovascular disease, cancer and diabetes through action on alcohol, tobacco and vaping, and HFSS foods.  It states that alcohol use, tobacco use and obesity have been estimated to cost the Scottish NHS more than £1.5bn a year. 

Ill-health and disability caused by tobacco, alcohol and being overweight or obese is also hammering the economy. That cost has been estimated at between £5.6bn and £9.3bn every year. 

Scotland has been a leader on public health measures, but in recent years things have been getting worse, not better. Life expectancy, particularly in the poorest communities, is dropping.

Five years ago, the Scottish Government committed to halving childhood obesity by 2030, but there has been no clear pattern of improvement since.

In 2021, there was a five per cent year-on-year increase in the number of people dying from illnesses caused by alcohol, according to National Records of Scotland – returning to rates last seen in 2008.

The Scottish Government could act and has promised to do so. Education and public health campaigns, while they have their place, are not enough to make the significant inroads needed into this massive problem, but a mountain of evidence shows that acting on the three As – availability, affordability and acceptability – can start driving down poor health. 

The Scottish Government under Nicola Sturgeon committed last year to legislate to restrict promotions of HFSS foods. The Scottish Government also committed to restricting alcohol marketing as other near neighbours such as Ireland have done and implement the next tobacco action plan. Now it will be up to the new First Minister, when elected, to drive these initiatives forward.

But candidates in the SNP leadership contest have sounded equivocal about these measures.

NCD Alliance Scotland is deeply concerned by this. 

Industry can no longer be allowed to hold the nation hostage
-David McColgan, chair of NCD Alliance Scotland

 

The food and alcohol industries in Scotland are resisting restrictions on companies’ ability to promote HFSS foods and advertise alcohol products, but NCD Alliance Scotland stresses that public health must come first.

David McColgan, chair of the alliance, says: “Public health interventions can’t be seen as ‘nice to do’. 

“We’ve been bitterly disappointed to hear the views of some of the candidates, siding with industry on areas of public health and alcohol marketing. 

“Industry can no longer be allowed to hold the nation hostage.

“We know there are endemic challenges around alcohol and tobacco consumption, particularly in poorer communities, so interventions are absolutely needed.

“More than 10,000 deaths a year from NCDs are preventable.  

“If we can reduce the number of people who are obese or have alcohol or tobacco-related problems, we will reduce the number of people turning up at GP surgeries and hospitals. 

“It could save the NHS many millions of pounds and massively boost the economy.

“There was a 17 per cent reduction in heart attacks in one year after the 2006 ban on smoking in public spaces. 

“This is about ending the phenomenon of people who are still relatively young drifting into a world of non-communicable disease, hospital appointments and admissions.

“We know there has been a decline in life expectancy in Scotland that has been matched by a decline in quitting smoking. We know that the rate of obesity is increasing, there’s more heart disease, more cardiovascular illness, more cancer. And we know one of the leading causes of the decline in life expectancy has been an increase in alcohol-related deaths.

“Industry has a lot of money and a lot of power. We need to put citizens first, not industry.

“There’s a wealth of evidence around the impact that alcohol marketing has on people’s consumption of alcohol. There’s a wealth of evidence around the impact of tobacco control and restrictions on high fat foods in reducing smoking and obesity.”

In 2021, 53,000 people in Scotland died of non-communicable diseases like cancer and cardiovascular disease, 83 per cent of all deaths. NCD Alliance Scotland calculates that more than 10,000 of those could be saved every year.

They have eight “asks” of the Scottish Government, which include: restricting price and location promotions of HFSS foods; restricting the advertising of alcohol, HFSS foods and vaping and tobacco products; restricting the display and promotion of alcohol; and restricting the promotion of vaping products.

Prof Steve Turner, consultant paediatrician at NHS Grampian, explains why the marketing of vaping products must be curtailed.

He says: “We don’t know about the long-term effects of vaping but we do know about the long-term effects of nicotine, and that’s the main drug in vaping devices. We have a huge amount of evidence on that.

“If you look at the umbilical arteries of unborn children, they will go into spasm when the mum smokes, because of nicotine. It’s not too dissimilar to being briefly strangled. To the unborn baby, exposure to nicotine is extremely harmful.

“People aged 15 to 20 are extremely susceptible to becoming addicted to nicotine and this age group is targeted [by the vaping companies]. That’s why devices are sweet and brightly coloured. Anyone who’s addicted to it will face a lifelong burden.”

Scottish Government figures suggest that regular e-cigarette use by 15-year-olds has tripled and more than doubled for 13-year-olds in the last five years. 

Prof Turner adds that just as vaping can be an aid to smoking cessation, it stands to reason that it can work the other way round too, by introducing nicotine to non-smokers who could later take up smoking.

“There are rules if you are selling cigarettes that they are behind a screen. Buyers have to show ID. None of that applies to vaping. There is much less governance and control of vaping.

“The industry wants to carry on the smoking culture when we are trying to snub it out. They realise that in more affluent countries we are moving away from smoking and so they are buying up vaping companies. 

“The industry makes money out of people’s ability to become addicted.”

Dr David Blane adds that when people drink unhealthy amounts of alcohol, smoke or eat unhealthy foods, it’s not because they lack knowledge about the harms they could do, but that “the odds are stacked against them”. 

“The environmental drivers of unhealthy behaviour are at times overwhelming, in the context of lives which are difficult due to poverty, family stress, unemployment, poor housing: all of these things are extremely stressful and often people use smoking or alcohol or unhealthy food as a coping strategy.

“Our mantra is to make the healthy choices the easy choices.”

Advertising messages have an impact on people’s perceptions of products, he adds, for instance by associating sports and athleticism with drinking through sports sponsorship. “The campaigning and marketing is very clever.”

As well as restricting advertising and promotion of health-harming products, he’d like to see more effort to increase the availability, affordability and acceptability of healthy choices, like fruit and vegetables.

Although the case for action is powerful, Dr Blane says that public health professionals face a daunting challenge. 

“We have hardly any budget and it’s just health professionals saying it as it is. You’re up against a massive marketing arm of vested interests. 

“My income doesn’t go up if people are prevented from being ill so I have no vested interest other than the shameful statistics for Scottish health. I want to see those improve.”

NCD Alliance Scotland believes this is a pivotal moment. “The Scottish Government has been a world-leader on public health,” says David McColgan. “It has put tackling diseases caused by alcohol, tobacco and obesity front and centre. 

“It would be a sorry legacy if the new First Minister abandoned this vital public health mission.” 

 

This article is sponsored by NCD Alliance Scotland.