Public health: Eyes back on the ball

It’s almost five years to the day since Boris Johnson addressed the nation as Covid infections surged across most of the world. The then prime minister described the virus as “the biggest threat this country has faced for decades” and announced a nationwide lockdown, restricting people’s movement to essential travel for the first time. 

Scotland spent more than 200 days in lockdown and further days under partial restrictions were much higher, particularly in the most populated local authorities. It was unchartered territory, and the restrictions were deemed necessary as the NHS dealt with the most severe pressure on its services for generations. As hospital admissions grew and thousands tragically died, non-urgent care was suspended to free-up hospital capacity, while cancer treatments and emergency procedures continued but faced delays due to staff shortages and increased demand. 

The mark left by the pandemic remains in all kinds of ways for Scots, and this is also the case for the state of the nation’s public health. As health officials battled against the heavily transmissible disease, the Scottish Government’s approach to tackling non-communicable diseases (NCDs) took a back seat. By December 2023, 10 per cent of Scots were on an NHS waiting list – 73 per cent higher than at the beginning of the pandemic. 

While the immediate strain of Covid is no longer at the top of the agenda, the burden on the service caused by NCDs such as cancer, heart disease, diabetes, Alzheimer’s, and respiratory conditions has greatly intensified.  

A shocking report published in October last year by NCD Alliance Scotland, a coalition of 24 health organisations, found that NCDs were responsible for more than 52,000 deaths in 2023 – around 80 per cent of the total that year. It is estimated that a fifth of those NCD-related deaths, over 10,000, are linked to the consumption of alcohol, tobacco and unhealthy diets, areas which the Scottish Government had before the pandemic been working to reduce.

The future looks bleak. New data published by Public Health Scotland last week suggests the number of people in Scotland living with chronic liver disease will increase by 54 per cent by 2044. It expects cases, which are currently 43,200, to rise to 66,300 in the next 20 years.

Reacting to the report, Dr Alastair MacGilchrist, chair of Scottish Health Action on Alcohol Problems, said “over 70 per cent of this liver disease burden is due to alcohol”, and the figures “underline the severity of the public health emergency from alcohol that Scotland is facing”. He added that legislative moves like minimum unit pricing are “already reducing the level of harm”, but the Scottish Government should “restrict alcohol marketing”.  

A reduction in that marketing is key to NCD Alliance Scotland’s 10-year strategy for the nation. It has outlined a comprehensive plan aimed at reducing the prevalence of NCDs which heavily emphasises the need for restrictions on the advertising, sponsorship and packaging of alcohol, tobacco and unhealthy food and drink, in particular for children and young people, to create healthier environments and reduce health inequalities. 

Public health minister Jenni Minto welcomed the report and said the government was continuing to engage closely with NCD Alliance Scotland. She added: “Increasing healthy life expectancy and reducing health inequalities across Scotland remains a clear ambition for this government.” 

However, the Alliance believes the Scottish Government “has lost its way” in tackling public health harms. David McColgan, chair of NCD Alliance and head of British Heart Foundation Scotland, says the Scottish Government has “entirely lost its way over the last few years”, and argues it has “rested on its laurels for too long about being a public health champion”. 

“Never take anything away from the Scottish Government and the parliament with what they did around smoking in public places and standardised plain packaging for tobacco,” he says.

“Minimum unit pricing on alcohol should be a moment in time that should be celebrated too.

“But there has definitely been a pause on that innovation and bravery, and I think much of that has been caused by the court case that the government had to fight around minimum unit pricing.” 

He’s referring to the legal challenge by the Scotch Whisky Association, along with other groups, which argued that the policy violated EU trade laws and claimed that minimum unit pricing unfairly discriminated against imported goods and undermined the free movement of goods within the EU. The policy was upheld by the Supreme Court in 2017, which ruled that it was a necessary public health measure to reduce alcohol-related harm. 

McColgan tells Holyrood that the “industry shouldn’t be anywhere near” Scotland’s health policy. “The lesson that needs to be learned from the court case [on minimum unit pricing] is the government can implement good policy in the face of industry opposition. Looking back at that time, it shows you can operate politically, not siding with business. Look at the New Deal for Business that the government launched recently. One of its tenets is to test health policy with industry – industry shouldn’t be anywhere near health.” 

He adds: “I think the threshold around public health evidence is so much higher than it ever has been, while at the same time, the threshold for evidence from industry has dropped.” 

The Scottish Government has a history of innovative public health measures; along with the smoking ban and minimum unit pricing, it made prescriptions free in 2011 and expanded free school meals to children from primary one to five.  

The Environmental Protection (Single-use Vapes) (Scotland) Regulations 2024, which bans the sale and supply of single-use vapes in Scotland, was introduced by the Scottish Government and will take effect in the summer. It is seen by many as the next piece of legislation that will help to improve public health outcomes over the next decades. 

According to the Scottish Health Survey 2023, the number of adult smokers has fallen to 15 per cent – a dramatic decrease from 28 per cent in 2003.  

However, the introduction of vapes, in particular single-use flavoured products, has supercharged the market in recent years. In 2023, 12 per cent of adults reported using e-cigarettes or vapes – an increase from 10 per cent in 2022. But worryingly, it is more popular with younger people. As many as 22 per cent of Scots aged 16-24 reported usage, which is a steep increase from 15 per cent in 2022.  

The Scottish Government’s Growing Up in Scotland survey in 2022 reported that 21.5 per cent of children aged 14 had tried a vape, while ASH Scotland, an anti-smoking charity and member of NCD Alliance Scotland, says almost 15 per cent of 15-year-olds are current users.  

While the long-term full health effects of vaping are not yet known, Sheila Duffy, chief executive of ASH Scotland, says it’s telling that China, where most of the single-use vapes are made, banned them from being sold because of concerns over “youth uptake and adverse health impacts”, yet still allows them to be exported. 

“They [single-use vapes] have evaded the existing tobacco regulatory structure because they have been sold in places like hairdressers and gift shops that weren’t used to selling tobacco products and therefore didn’t necessarily have their heads around the regulations. They were cheap, colourful, sweet flavoured, and so caught on with young people. 

“They have been promoted by industry through influencers and targeted social media, and they are easy to conceal in school. So, while we have seen a welcome downward trend in youth smoking for decades, the picture has changed for recreational nicotine products and children.” 

She points to growing evidence that youth vaping is becoming a gateway to smoking in later life, while some vapes have been found to produce highly toxic compounds when brought to vapour point, and research by the International Agency for Research on Cancer has found that some of the products they have tested contain formaldehyde.  

“The problem is there is a lag time between exposure and most serious diseases – with tobacco it takes 30 to 60 years to see the full health impacts manifest, similarly for asbestos it’s 40 to 60 years from exposure to serious lung and circulatory disease. So, I think the precautionary approach by Scotland is the only appropriate response to take,” Duffy says. 

The Scottish Health Survey also shows that the prevalence of smoking is significantly higher in the country’s most deprived areas compared to the least deprived areas. It stands at 26 and six per cent respectively. Duffy says a year on from the survey the gulf has increased by a further point. 

NCD Alliance Scotland says it’s not just smoking that disproportionately affects people living in areas of multiple deprivation contributing to higher levels of NCDs, alcohol use is higher, as is exposure to foods high in salt, sugar and fat. Research by the British Medical Journal indicates that individuals in Scotland’s most deprived areas experience significantly higher disease burdens. It says the overall burden in these areas is more than double that of less deprived regions, with substantial disparities in premature mortality. 

Dr Andrew Fraser, chair of Obesity Action Scotland, told Holyrood in November that there is a “very big issue” between ease of access to shops that offer a good balance of healthy food for people living in deprived areas. “Many of the outlets that people in deprived areas rely on in their neighbourhoods have very poor offerings. We need to look at some of these outlets in the areas of greater deprivation to tackle this problem.     

“We also have to look at what it means to families so that they don’t have to worry so much about paying the bills. There is definitely a poverty element to this problem as well.” 

McColgan says it is “crucial” over the next 10 years that the Scottish Government focuses on tackling the usage of tobacco, alcohol and foods high in sugar, salt and fat. “There needs to be a conscious decision within government, a political will, to move forward with population health prevention. We have heard the public health minister say the age of personal responsibility is over. I agree with that, the evidence shows educating people doesn’t work.

“We need to not victimise the consumer, but we need to accept that our environment is broken.

If you’re in alcohol recovery and you want to buy crisps, cereal, or soft drinks generally you’re going to have to walk by the alcohol aisle. You can still purchase tobacco on nearly every street corner in the country. In what world is that a normal environment? What other deadly substances do we sell that are so readily available? 

“We are bombarded walking down the street, on our phones, on TV, with fast food adverts and alcohol companies. In the next 10 years, we need to see that environment change.”