Alcohol harm - From the front line of health challenges 1

Alcohol - PA

Much progress has been made in tackling Scotland’s biggest killers: heart and lung disease and cancer. Meanwhile, other leading causes of mortality have been more stubborn to shift. 

Holyrood approached leading clinicians from the front line to examine why, and what policy makers could do to help.

The first of our Q&A with clinicians facing Scotland's persistent health challenges is with Tayside doctor Peter Rice, chair of Scottish Health Action on Alcohol Problems (SHAAP).

Is there a typical patient that you see, and if so, what are they like?

The range of alcohol problems is very broad and in adult services, patients will be aged from 18-80 and beyond. Drinking behaviours are changeable throughout life in response to family, work and relationship circumstances and all of this happens against the background of the influences of marketing and retail practices.

Alcohol problems affect all income groups, although lower income groups seem to have less of a “buffer zone” and develop problems more readily. One of the heartening things about the progress made in Scotland where alcohol deaths have fallen by a third over the past 10 years or so, is that most of that fall has been among the communities on lowest incomes, so it seems that effective policy particularly benefits those in poverty and can narrow health inequalities. However, our recent progress follows a very bad period from the early 1990s and alcohol deaths remain considerably higher than a generation ago, and the falls have levelled off over the past three years.

Despite this, alcohol consumption continues to rise in Scotland, with 20 per cent more sales than England and Wales. Why does alcohol harm remain a persistent problem? 

There has been substantial improvement in Scotland’s rates of alcohol harm in recent years, and the gap between Scotland and England has narrowed. 

Improved access to industry sales data has shown that much of Scotland’s higher rates of consumption is due to more off-sales purchase of low cost spirits, specifically vodka. The trend from whisky to vodka has been a marked trend in Scotland over the past decade or so, as has been the trend away from pub towards home drinking.    

I suspect these changes have been driven by cost. This analysis that affordability is crucial is supported by the improvements we have seen post-economic crash as incomes fell and prices rose. These are topics which the big producers and retailers don’t seem to like talking about much, but if they were more open about what they know about their business, that would help in further developing our understanding. 

The big spirits producers make a range of products, with vodka being easier and quicker to manufacture and get onto the shelves. It seems to me that they use whisky as the acceptable, prestigious face of their business, but they are really protecting low-cost vodka which has become very important to them.

Despite court judgements/international allies, what has held back Minimum Unit Pricing?

The MUP legislation was passed in April 2012 and the measure was planned to come into force in April 2013. The delay has been due to the legal challenge led by the Scotch Whisky Association. It seems that all that is needed to delay the introduction of legislation is the motivation and deep enough pockets to fund a series of challenges in Scottish and European courts, and we may have the UK Supreme court to come yet. The SWA said they would do this as soon as MUP began to be seriously discussed almost 10 years ago, and they have kept to their word, mirroring the tactics adopted by the tobacco industry over many years. 

The term “regulatory freeze” has been used to describe the impact of these challenges and I think that effectively captures the effect of both delaying implementation and trying to put a chill through governments taking on global operators. From my perspective, in Scotland we are fortunate that the Government and most of the Parliament understand the importance of MUP and are determined to see it through.

It’s interesting that the opposition to MUP comes from the international scale producers and the trade associations which they dominate. Smaller firms, such as local brewers and independent stores and pubs often support MUP and I think part of the reason is that they are closer to their communities and the harm which alcohol can cause.

The encouraging thing for me is the harder academics and policymakers look at MUP, the more they support it. The same is true for the public and I think we will see it come into force once the legal challenges are exhausted. 

How could people be supported better to live healthier and take more preventative measures?

Prevention is crucial. For instance, we have good services for liver disease in Scotland, but every front-line liver physician would say that prevention is better than cure for liver disease, the majority of which is alcohol-related. 

Effective prevention needs a mix of information and regulation. People often talk of underlying cultural factors and, of course, countries have different histories with alcohol, food, tobacco and other things. But behaviours change, and if we look at examples like the wearing of seat belts, domestic violence, treatment of children, tackling discrimination, change has come about from a range of complementary actions, both awareness campaigns and legislation, and the same is true of alcohol.

What could policymakers do to better support your work? 

There has been a lot of international recognition for the work done in Scotland on alcohol over the past 10 years. The policy mix of early identification and advice, improved access to specialist treatment, restrictions on discounts for bulk buys, tighter age checks, training of bar staff has shown broadly good results, though there’s a lot still to do.

If you look historically, patterns of alcohol harm are often cyclical. Things get bad, people notice, there’s a flurry of activity, things improve, and then the prevention activity gets scaled back.  

We saw this argument used to support the sale of alcohol in football grounds last year. “We’ve all matured from the bad old days of the 1980s and can enjoy a relaxing beverage as we politely cheer on our team.” All this despite alcohol mortality being 50 per cent higher than in 1981. I think what we need is an approach which is maintained long term and it’s part of our job as advocates to achieve that.

What is the landscape likely to look like in 10 or 20 years’ time, even if the fight for MUP is won?

I hope it looks like Sweden and Norway! A common answer in Scottish politics these days, I know, so I’ll throw in New Zealand, parts of Canada and the USA as well. These countries have their problems, but they have much better records than Scotland and didn’t experience the big increase in harm we saw with deregulation in the 80s and 90s. 

This is achieved by systems of controls on outlets able to sell alcohol, effective price controls especially at the cheap end of the market and restrictions on marketing. We have moved towards these approaches in Scotland and we need to keep up that momentum.