Beating cancer: ambition and action

3. Prevention

Our Ambitions

To encourage and support people to reduce their risk of cancer by living healthier lives, focusing on reducing health inequalities.

To create a generation of young people who do not want to smoke, with aim of reducing smoking prevalence to 5% or less by 2034.

To reduce alcohol-related harm by helping to prevent problems arising in the first place.

To make it easier for people to be more active, to eat less, and to eat better.

To help more people be more active more often.

To help people make healthier choices to reduce their exposure to UV radiation.

There is strong evidence that smoking, alcohol consumption, physical inactivity, diet and obesity are risk factors for many health conditions, including cancer.^[13] By encouraging and supporting people to live healthier lives, be more active and improve their diet we can reduce the risk of many individuals not only for cancer but a range of other conditions such as heart disease and stroke.

Our positive health promotion activity on tobacco, alcohol, diet and physical exercise is already working to improve the health of Scotland's population as a whole and we expect that this will have a consequent long-term positive effect on reducing the risk of cancer. We need to better understand whether and how to focus activity to reduce health inequalities.

Evidence suggests that concern about single diseases may be greater, and more motivating, than of collective diseases in general. In particular, it is clear that despite widespread public awareness of the health risks associated with unhealthy lifestyles, the population does not appear to explicitly link this with cancer causation.^[14]

Through the implementation and development of our public health initiatives, we will work to change this perception and shift cultural attitudes towards cancer risk factors including smoking, poor diet, physical inactivity and alcohol consumption. Through this strategy we will explore how the 'Act Well' programme can be further piloted on a larger scale.

The rising incidence of melanoma in Scotland indicates the need for continued efforts to raise awareness of the risks associated with unsafe tanning. This increase also poses challenges for dermatology services who will need to adapt to meet this increasing demand.

Tobacco Control

Smoking is the primary preventable cause of ill-health and premature death. Each year, tobacco use is associated with 128,000 smoking attributable hospital admissions and 10,000 smoking attributable deaths per year in Scotland - a fifth of all deaths.

Smoking remains one of the principal causes of illness and premature death in Scotland and is strongly associated with a range of cancers.

Cancer of the trachea, bronchus and lung is significantly more prevalent in the most deprived areas, mirroring the socially patterned smoking rates. Scotland has amongst the highest incidence rates and lowest survival rates from lung cancer in Europe and there are clear links with historic smoking rates.^[15,16,17]

The 2014 Scottish Household Survey showed that 20% of adults smoke - a drop of 3 percentage points on the previous 3 years and the sharpest year-to-year decline in smoking rates since the survey began in 1999. Encouragingly, the sharpest decline in smoking rates is in the most deprived areas which dropped from 39% in 2013 to 34% in 2014.

Alcohol

We know that, as well as many other harms, alcohol has a significant causal role in cancers such as breast, liver, bowel, mouth and throat, and so we have taken bold action to tackle and reduce the damage it causes through our alcohol strategy, Changing Scotland's Relationship with Alcohol: A Framework for Action.^[18] We have placed a whole population approach at the heart of our Alcohol Framework which includes a package of over 40 measures to reduce alcohol-related harm by helping to prevent problems arising in the first place, and includes improving support and treatment for those who are already experiencing problems.

We know that drinkers living in the most deprived areas suffer greater harms than drinkers living in the least deprived areas. Tackling alcohol-related harm through minimum unit pricing of alcohol has the potential to significantly reduce health inequalities.

Considerable progress has been made on implementing key aspects of the Framework including:

• a record investment in tackling alcohol misuse of over £319 million since 2008;
• delivery of over 569,000 alcohol brief interventions by NHSScotland;
• establishment of 30 Alcohol and Drug Partnerships;
• introduction of the quantity discount ban;
• improved substance misuse education;
• passing of minimum unit pricing legislation; and
• introduction of lower drink-drive limit.

We have seen some improvements in harm levels in recent years and the Framework has been shown to have a positive impact. However, harm levels are still higher than they have been in previous decades. New lower-risk drinking guidelines were issued by the Chief Medical Officers in January 2016^[19] following a review of the scientific evidence on the short and-long term impact on health from alcohol.

The evidence which has emerged since the previous guidelines were issued in 1995 suggests that there are adverse effects on a range of cancers from drinking alcohol and these risks start from any level of regular drinking and then rise with the amounts of alcohol being consumed. This is consistent with the International Agency for Research on Cancer's World Cancer Report 2014^[20] and the Canadian Cancer Society which state that there is no "safe limit" of alcohol consumption when it comes to cancer prevention.

Diet and Obesity

We can lower our risk of developing certain cancers by eating a healthy balanced diet that is low in fat (especially saturated fat), salt and sugar, with plenty of fruit and vegetables and starchy foods, choosing wholegrain versions when we can.

In addition to those nutrients associated with increased risks of overweight and obesity, Cancer Research UK estimate that more than 30,000 cancer deaths could be prevented by adopting a healthy diet, in particular, through an increase in fruit, vegetable and fibre consumption, limiting red and processed meat and reducing sugar and salt.^[21]

To improve diet we have invested over £10 million in the four years to 2016 in projects to encourage healthy eating. With the assistance of Food Standards Scotland, we are also engaging with the food and drink industry through our Supporting Healthy Choices Voluntary Framework,^[22] to support consumers to make healthier choices and press for action to reduce sugar intake. Key areas for action are around labelling, rebalancing promotions, responsible marketing of food and drink and reformulation of products, including a focus to reduce calories, salt, fats and added sugar in foods.

Poor diet is often associated with people on lower incomes, the most deprived consume less fibre and fruit and vegetables, and more sugar than the most affluent. We continue therefore to support Community Food and Health (Scotland)^{[23, 24]} to help build capacity in the community food sector at a national level. In addition, we provide core support to established community food networks to help them give healthy eating assistance to those most vulnerable groups in society.

Food Standards Scotland (FSS) have made recommendations to Scottish Ministers on further action to support healthier diets in Scotland. We will consider these recommendations, which support a whole government approach, the food and drink industry, and the public sector, with a view to building on our current programmes of work to accelerate progress.

We have recently accepted FSS recommendations to revise the Scottish Dietary Goals for sugar and fibre as well as agree a new goal for total carbohydrates.^[25] The scale of the health inequalities problem is strongly influenced by the magnitude of the underlying inequalities in power, money and resources within a society. Action on the worsening trends in health inequalities needs to be rebalanced to address the fundamental drivers of social inequality which determine income, employment, education and daily living conditions.

Physical Activity

Taking part in physical activity is recognised to lead to a wide range of benefits, not least to individual health. UK Chief Medical Officers have issued joint guidelines to explain these benefits.^[26]

The Active Scotland Outcomes Framework^[27] describes Scotland's ambitions for sport and physical activity over the next 10 years. Success will rely on the collective efforts of communities, individuals and a wide range of partners. Key evidence informing progress towards the outcomes is available at the link above. The headline measure of progress is the proportion of the population who meet the recommended level of physical activity. This is a National Indicator.

The Active Scotland Outcomes Framework is underpinned by a commitment to equality. An analysis of equality data across the indicators has been carried out and to provide a baseline from which progress can be monitored.^[28]

To achieve the vision, a transformational change programme of actions is ongoing. The work is overseen by the National Strategic Group for Sport and Physical Activity (NSG), chaired by the Cabinet Secretary for Health, Wellbeing and Sport.

It includes:

• Implementation of the National Walking Strategy^[29] and the Cycling Action Plan.^[30] This work is supported by £58 million committed to walking and cycling projects.
• Investing £500,000 annually to support Active Girls^[31] which aims to increase the number of teenage girls participating in PE, physical activity and sport in and around schools.
• Working towards the establishment of 150 Community Sport Hubs across all local authorities by 2016, with 50% based in schools.
• Awards to a total of 188 projects across all 32 local authorities from the £10 million Legacy 2014 Active Places Fund^[32] to help enable communities to build, upgrade and improve facilities to drive participation in sport and physical activity.
• Continuing to invest £1.6 million of legacy funding to maintain momentum and continue to capitalise on the inspiration that the Commonwealth Games have provided. £800,000 of this is being used for the Legacy 2014 Physical Activity Fund,^[33] aimed at building on current good practice at local level and scaling this up to impact on many more people, with a particular focus on inactive groups.

UV Exposure

There are a number of simple actions that people can take to reduce their exposure to UV radiation, but there is also a continuing need to support people in making healthier choices in relation to sunbeds.

Education and awareness of lifestyle choices and behaviours should begin in childhood. Through our Detect Cancer Early programme we have supported the development of Teenage Cancer Trust's schools-based education programme. The education programme provides young people with the information on lifestyle choices, common signs and symptoms to be aware of and encourages them to discuss cancer prevention and awareness with older family members.

Breaking down barriers and getting people to talk about cancer is an important part of the Detect Cancer Early programme and the longer-term opportunities are exciting as young people become more at ease discussing cancer and take with them an increased awareness, knowledge and understanding of cancer into their adult lives, resulting in a change in presentation behaviour, earlier diagnosis and improved survival chances.

Ultraviolet radiation (UV) exposure is the primary recognised risk factor linked to malignant melanoma of the skin. It is now the sixth most common cancer in men and the fifth most common in women. The increase in the number of people being diagnosed with malignant melanoma may in part be due to better public awareness and improved diagnosis, however, continued action is important to ensure that malignant melanoma is prevented where possible.

Scotland was the first part of the UK to introduce legislation to address the health risks associated with sunbed use. The Public Health etc. (Scotland) Act 2008 Sunbed Regulations (Scotland) 2009^[34] prohibits the use of sunbeds by under 18s; requires operators to supervise the use of sunbeds; places a duty upon the operator of sunbed premises to display a public information notice; and requires operators to provide customers with health information on the health risks associated with sunbed use.

Occupational Exposure

Some people may have an increased risk of cancer because they used to work with cancer-causing substances before more recent regulations came into force. It is estimated that occupational exposure to cancer-causing chemicals is responsible for nearly 4% of cancer cases in the UK.^[35]

These exposures are now less of a problem as the most dangerous chemicals have been banned for several decades, and employers are now legally required to prevent and control exposure to chemicals that may cause cancer.

Occupational health and safety is a reserved matter; with responsibility for enforcement of occupational hygiene standards and control of occupational hazards residing with the Health and Safety Executive who enforce standards across the UK.

In Scotland, HSE works within the health policy delivery model and with different, uniquely Scottish delivery organisations along with the support of the Partnership on Health and Safety in Scotland (PHASS). We will continue to do this with relevant stakeholders to consider evidence of links between work and cancers. We will work with a wide range of partners including the HSE, local government, trades unions and employers' bodies through the Partnership on Health and Safety in Scotland (PHASS) to support safe and healthy workplaces, and to understand the evidence on links between work and cancers.

HPV Vaccination

Immunisation has a role to play in preventing a number of cancers. The Scottish Government takes its advice on immunisation from the Joint Committee on Vaccination and Immunisation (JCVI).

In 2008 we introduced an HPV vaccination programme to protect girls against cervical cancer. Uptake of this programme has been extremely high, and investigations are underway to determine the feasibility of testing women for the presence of HPV in the first instance which will mean that many women may not have to undergo a cervical 'smear' test.

The JCVI recently recommended the expansion of the HPV vaccination programme to Men who have sex with Men (MSM); to the HIV positive population and to a number of other groups to protect against a range of cancers. We are currently investigating how this can be taken forward in Scotland.

The JCVI is also investigating a gender neutral programme for the HPV vaccine, to establish whether it would be advisable for boys to be vaccinated as well as girls.^[36]

Health Promoting Health Service (HPHS)

Evidence shows that people from deprived communities are more likely to have poorer health outcomes and they also use acute services more than the population as a whole. The HPHS ethos provides an opportunity to address inequalities and we are supporting NHS Boards to ensure that routine enquiry for vulnerability is built into person-centred care and, therefore, those at risk of poverty and inequality attain the best possible health outcomes.

The vision for a Health Promoting Health Service (HPHS) is a cultural transformation, one which ensures that every healthcare contact is maximised and a health improvement opportunity. Although this ethos applies to individuals and visitors, the promotion of staff health and wellbeing is equally central to the HPHS vision.

NHSScotland has a key responsibility for promoting health and wellbeing within the population it serves. It has a leading role as a public service, as a healthcare organisation, as a major employer and as a partner to other organisations that have a mutual interest in population health.

This requires that all hospital settings embed specific actions that promote health improvement. This need has been communicated over the last few years through a series of letters from the Scottish Government to Board Chief Executives. The latest letter, CMO (2015) 19,^[37] Health Promoting Health Service: Action in Secondary Care Settings, was issued on 9 October 2015, from the Chief Medical Officer (CMO) for Scotland.

Clinical buy-in and leadership is paramount to ensure that health improvement is prioritised. To this end we will encourage and support clinical staff in screening services to maximise opportunities to deliver health improvement messages with the proviso that appropriate onward referral pathways are available for staff to refer individuals.

Actions - Prevention

• We will ensure all the actions in our Tobacco Control Strategy, Creating a Tobacco Free Generation^[38] are implemented in full. This focusses on reducing the health inequalities inherent in smoking; creating an environment that supports young people to choose not to take up smoking; continuing to protect people from second-hand smoke; and supporting smokers to quit.
• We will continue to task health boards to deliver a higher proportion of successful smoking quits from the most deprived areas, and to increase that proportion in future years.
• We will explore how initiatives like the 'Act Well' programme, (a personalised breast cancer risk reduction programme offered to women attending routine breast screening clinics) can be fully tested for effectiveness and roll out. If proven effective we will invest up to £1m over four years to offer similar opportunities in a wider range of NHS Boards.
• Through the next phase of the Alcohol Framework we will highlight the potential causal links between excessive alcohol consumption and the risk of cancer.
• We will undertake a review of the Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight^[39] to ensure that it is reflecting the best available advice, including on cancer risks, and practice into the future.
• Through our Detect Cancer Early programme we will continue to work in partnership with Teenage Cancer Trust to roll out their schools based education and awareness programmes. This will help ensure young people across Scotland have access to cancer prevention and early detection messages. We will highlight in particular the links between unsafe tanning and cancer to help protect those who are most vulnerable - the young and impressionable.