Scottish Health Survey - topic report: UK comparisons

2 ALCOHOL CONSUMPTION AND SMOKING

2.1 INTRODUCTION

Smoking and drinking are major modifiable risk factors for increased risk of mortality and chronic disease. As set out below, both behaviours have recently been the subject of major pieces of legislation in all parts of the UK and continue to be areas of major public health concern. This chapter discusses alcohol consumption in Scotland and England, and smoking prevalence in Scotland, England, Wales and Northern Ireland.

2.2 ALCOHOL CONSUMPTION

2.2.1 Policy context

Most adults in Britain drink alcohol, at least occasionally. However, in recent years, concern has been growing about the damage caused by excessive drinking to individuals, communities and society as a whole. Misuse of alcohol contributes to a wide range of health problems, including high blood pressure, chronic liver disease and cirrhosis, pancreatitis, some cancers, mental ill-health, and accidents, as well as social problems such as antisocial behaviour including violent crime. Some of the alcohol-related adverse health outcomes, such as alcoholic liver disease, are associated most with sustained heavy drinking, ¹ whereas some, such as injuries and cardiovascular events, may also be linked with excessive drinking on one or more occasion. ²

Public health advice about alcohol consumption is based on sensible drinking guidelines. ³ The UK-wide recommended sensible drinking guideline is that women should not regularly drink more than 2-3 units per day and men should not regularly drink more than 3-4 units per day. In addition, people are advised to aim to have at least two alcohol free days per week. Men who regularly drink more than eight units a day (or 50 units a week) and women who regularly drink more than six units a day (or 35 units a week) are considered to be at particular risk of harm. ⁴ Pregnant women are advised to avoid alcohol altogether. ⁵ There is no standard definition of 'binge drinking' in the UK; however the Scottish, English and Welsh surveys use the binge drinking definitions which are also employed in the General Lifestyle Survey. These are: more than 6 units for women and more than 8 units for men ( i.e. more than twice the daily maximum units). ⁶

In the 1980s and 1990s, the sensible drinking message was coupled with the advice that one unit was equivalent to a half pint of ordinary beer or lager, a small (125ml) glass of wine or a single measure of spirits. Following concern that increases in both the typical strengths and serving size of alcohol products were resulting in systematic underreporting of unit consumption in all surveys, new conversion factors were published by the Office for National Statistics in 2007. ⁷ These new conversion factors were used in the Scottish, English and Welsh surveys in 2008. ⁸

Estimates of alcohol consumption can be based on sales data or on personal reports. Neither measure is perfect, for example not all alcohol that is purchased is consumed, some will be consumed abroad, and not all consumption is reported. However, there is increasing recognition that data from multiple sources are essential to help build up as complete a picture as possible of alcohol consumption. Figures based on sales data from the alcohol industry in Scotland in 2009 estimated that 11.9 litres of pure alcohol were sold per person over the age of 16 in Scotland. ⁹ The estimate for England and Wales was considerably lower (9.6 litres per person). In unit terms the figures for Scotland equate to 1,190 units a year for every adult aged 16 and over, equivalent to an average weekly consumption of 22.9 units a week for all adults (the equivalent amount in England and Wales was 18.4 units). Consumption at this level exceeds the recommended weekly intake for men, which is particularly concerning given that not all adults drink alcohol and some do so only occasionally. It is therefore unsurprising that Scotland's death rates from chronic liver disease and cirrhosis are around twice as high as those in England and Wales, and (until very recently) were increasing at a time when the rates in many countries were declining. ¹⁰, ¹¹ In addition, the alcohol related death rate for women in Scotland exceeds the comparable rate for men in England. ¹²

The cost of alcohol misuse to Scottish society in 2007 was estimated at around £3.56 billion. ¹³ This figure includes costs to NHS Scotland of £268 million. Concerns about excessive drinking in Scotland were outlined in the Scottish Executive's 2002 "Plan for Action on Alcohol", ¹⁴ its update in 2007, ¹⁵ and the Scottish Government's 2009 Framework for Action. ¹¹ One of the Scottish Government's National Performance Framework national indicators, ¹⁶ relates directly to alcohol:

Reduce alcohol related hospital admissions by 2011

The Framework for Action includes around 40 initiatives designed to tackle Scotland's damaging relationship with alcohol. As well as a national programme of alcohol brief interventions and increased support for alcohol treatment services, the Framework includes a range of measures aimed at changing attitudes to alcohol. New regulatory measures, including limiting alcohol promotions in licensed premises, were introduced through the Licensing (Scotland) Act 2005, which came into force in September 2009. The Alcohol Etc. (Scotland) Bill, currently being considered by the Scottish Parliament, outlines a number of provisions aimed at reducing alcohol-related harm. These include further restrictions on off-sale promotions, a requirement for licensees to operate age verification policies, an enabling power for the introduction of a social responsibility levy and, of most controversy to date, minimum pricing for alcohol.

The annual cost to the NHS in England of alcohol misuse has been estimated as £2.7 billion in 2006/7 prices. ¹⁷ Hospital admissions for conditions specifically related to alcohol, and deaths attributed to alcohol, increased substantially between 1991 and 2007. ¹⁸ Following a wide ranging review of the current extent and nature of alcohol-related harms, the then government published its "Alcohol Harm Reduction Strategy for England" in 2004, with a further report, "Safe. Sensible. Social. The next steps in the national alcohol strategy" in 2007. ¹⁹, ²⁰, ²¹ The 2004 strategy included a number of actions, such as making the sensible drinking message easier for people to understand and apply, targeting messages at those most at risk, providing better information for consumers, and improving alcohol education in schools. The 2007 strategy update claimed some success for the actions identified in 2004, but acknowledged that more needed to be done. Among new initiatives proposed were the development of informal sources of support for people who wanted to drink less, the provision of authoritative guidance about what is safe for young people to drink, local alcohol strategies and a public consultation on alcohol pricing and promotion. ²², ²³

Minimum pricing for units of alcohol became the focus of public debate in England when the Chief Medical Officer's 2008 annual report highlighted the impact of what he called 'passive drinking' - how one person's drinking affects others. ²⁴ The CMO recommended a minimum price of 50 pence per unit, based on research suggesting this would have relatively little impact on moderate drinkers but would significantly reduce social harms caused by heavy drinking. ²³, ²⁴ The coalition government formed in May 2010 has not yet developed formal policy on alcohol pricing.

2.2.2 Data collection issues

The known weaknesses typically associated with surveys such as social desirability biases and recall errors on the part of respondents may be especially problematic for alcohol consumption. As described in the Introduction to this report, the health surveys in Scotland and England use a face to face questionnaire with only minor differences between questions ²⁵ (see Appendix 1 for full details). In contrast, the Welsh Health Survey is a paper self-completion. As the reporting of alcohol consumption has been found to be influenced by the mode of questionnaire, ²⁶ comparisons have therefore been restricted to Scotland and England.

2.2.3 Consumption in Scotland and England

The proportion of men in Scotland (31%) and England (29%) who had not had an alcoholic drink in the last week was very similar.

A significantly lower proportion of men in Scotland (25%) drank alcohol within sensible drinking guidelines - i.e. up to 4 units - on their heaviest drinking day in the last week than in England (30%). In addition, there were marginally significant differences between the proportion of men in Scotland and England who had drunk more than 4 units of alcohol on their heaviest drinking day (44% versus 41%). Though it should be noted that the confidence interval around the difference between daily unit consumption in Scotland and England indicates that this difference could be very small indeed.

Mean daily unit consumption on the heaviest drinking day was also higher among men in Scotland (6.2 units) than men in England (4.3 units), and considerably exceeded the recommended daily maximum for men (3 to 4 units), while the consumption level in England only did so slightly. Table 2.1, Table A1

As with men, the proportion of women in Scotland and England who had not had an alcoholic drink in the last week was similar (42% and 43%, respectively).

Scotland had a significantly lower proportion of women (21%) drinking alcohol within sensible drinking guidelines - i.e. up to 3 units - on their heaviest drinking day in the last week than England (26%). The higher proportion of women in Scotland than England consuming more than 3 units was also statistically significant (36% versus 32%), and the difference for more than 6 units (18% versus 15%) was marginally significant.

Women in Scotland drank a significantly higher number of units of alcohol on their heaviest drinking day (3.5) than women in England (2.2 units per day). Unlike the equivalent finding for men, mean daily consumption for women in Scotland exceeded the recommended daily maximum units (2 to 3 units on heaviest day for women), but did not in England. Table 2.1

The major changes introduced in 2008 to the methods of calculating unit consumption levels discussed above mean that the overall rates of drinking prior to that are not directly comparable over time. However, the nature of the patterns between the countries should not be affected by this. The findings in 2003 and 1998 both showed similar consumption levels for men in Scotland and England while in 1995 men in Scotland drank more. In contrast, while the 2003 findings for women confirm those presented above (with women in Scotland drinking more), in both 1998 and 1995 women's drinking was lower in Scotland than England.

2.3 Smoking

2.3.1 Policy context

Smoking is acknowledged as the greatest contributor to inequalities in health and mortality in the UK. ²⁷ The World Health Organisation ( WHO) Tobacco Atlas estimates that in developed countries, smoking cigarettes kills between one third to one half of lifetime users. ²⁸ In the United Kingdom, smoking is recognised to be the greatest single cause of preventable illness and premature death. Many of these smoking-related deaths are avoidable deaths, with the average years of life gained by smokers who quit ranging from 10 years for those stopping at 30 to three years for those stopping at 60. ²⁹ It is estimated that eradication of smoking would eliminate one-third of cancer deaths and one-sixth of deaths from other causes, including cardiovascular and chronic respiratory diseases. ³⁰

Action to reduce the prevalence of smoking has not been implemented uniformly across the UK, though it is mainly the timing rather than the specific policy that has varied. For example, the minimum age for the purchase of tobacco was raised from 16 to 18 in Scotland, England and Wales on 1 October 2007, and one year later in Northern Ireland. In contrast, health warnings with stark images (rather than just wording) were added to cigarette packets across the UK in October 2008. More recently, a ban on the sale of cigarettes though vending machines, and new restrictions on the promotion of cigarettes within shops, have followed similar legislative and implementation timetables throughout the UK³¹, ³² (though these measures are currently the subject of legal challenges in the English and Scottish courts).

The most notable variation in recent policy implementation was the smoke-free legislation introduced in Scotland in March 2006, Wales and Northern Ireland in April 2007, and England in July 2007. The impetus to introduce the ban in Scotland first came in part from the realisation that smoking posed a greater threat to public health in Scotland than elsewhere in the UK. Approximately 13,500 people are estimated to die every year from smoking-related illness in Scotland. ³³ In addition, the financial burden of smoking on Scotland's economy as a whole has been estimated at £837 million per year, including the costs associated with treating ill-health, lost employee productivity and reduced consumer spending as a consequence of early death. ³⁴ Smoking levels and related mortality are strongly socially patterned, and are highest among more socially disadvantaged groups. ³⁵ Consequently, reducing smoking-related harm is a major component of the Scottish Government's agenda for improving health and reducing inequalities.

In 2008 the Scottish Government published its Action Plan Scotland's Future is Smoke-Free. ³⁶ This document included a number of actions that would be undertaken in the coming years, and reported that an additional £9m over the 3 years 2008/09 to 2010/11 would support the actions outlined in the Plan, bringing the total dedicated resources for tobacco control to £42m over the same period. These various actions are intended to support the National Performance Framework national indicator ¹⁶ on smoking:

Reduce the percentage of the adult population who smoke to 22% by 2010

Figures from the report Statistics on Smoking: England 2009³⁷ showed that in England in 2008 around 83,900 deaths among adults aged 35 and over were estimated to be caused by smoking, accounting for 23% of deaths in men and 14% of deaths in women in this age group. These included around 37,700 deaths from cancer, 23,200 from respiratory diseases, 21,600 from circulatory diseases and 1,400 from diseases of the digestive system. This report also estimates that around 5% (440,900) of all hospital admissions among adults aged 35 and over in England were attributable to smoking.

The previous UK government set a target to reduce the rate of smoking among adults in England to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less. This commitment to reduce smoking prevalence was emphasised in the revised PSA targets published in 2007. ³⁸ The General Household Survey (now the General Lifestyle Survey), which monitors progress towards these PSA targets, showed that smoking prevalence in England had already fallen to 21% by 2007.

Furthermore, as in Scotland, it is widely recognised that levels of smoking vary between different socioeconomic groups in England. The 1998 white paper, "Smoking Kills", stated that reductions in levels of smoking in England should occur equitably among manual and non-manual groups. ³⁹ In 2004, the then government set out its strategy for England to tackle smoking and its effects on other people in the white paper "Choosing Health: Making healthy choices easier". ⁴⁰ Since then a number of proposed initiatives have been implemented, including the introduction of smoke-free legislation and the UK-wide measures mentioned above.

It is estimated that there are some 6,000 smoking-related deaths in Wales each year. Since 1999, the Welsh Assembly Government has implemented a comprehensive tobacco control programme with three main aims: discouraging children and young people from starting to smoke; encouraging adolescents and adults to quit; and reducing exposure to environmental tobacco smoke. ⁴¹

Estimates in 2002 suggested that were about 350,000 smokers aged 16 and over in Northern Ireland. ⁴² The same report noted that although smoking prevalence declined between 1983 and 2001, this was confined to men (a reduction from 39% to 26% compared with a stable rate in women of 29% and 28% in both years). Furthermore, smoking among women aged 16-19 increased in this period from 19% to 27%. Tobacco is responsible for about 18-20% of all deaths, claiming between 2,700 and 3,000 lives in Northern Ireland each year. The overall cost to the economy (in 2002) was estimated to be £3.1 billion.

2.3.2 Smoking prevalence

Some minor differences in the wording of the questions about smoking are outlined in Appendix 1. The key point to mention is that the figures for Scotland, England, and Northern Ireland relate specifically to cigarette smoking whereas those in Wales cover all smoking so include cigar and pipe smokers as well. Also note that the HSE reports combine people who have never smoked at all with those who only smoked occasionally; the data in this chapter combines ex-regular and ex-occasional smokers and reports the prevalence of never smoking on its own.

All self-reported estimates of smoking can be subject to mis-reporting but these can be validated using objective measures of tobacco consumption. The validation carried out in Scotland and England has shown a small tendency for younger smokers to conceal their behaviour. ⁴³ Although the evidence outlined in the Introduction suggested that self-reported alcohol consumption levels are affected by questionnaire mode, reports of current smoking behaviour were not. We have therefore concluded that the smoking data collected in Wales is sufficiently comparable to be included in this discussion.

The prevalence of current smoking was significantly higher among men in Scotland (27%) than in England (24%). It was also higher than among men in Wales and Northern Ireland (25% in both countries), but this difference was not statistically significant.

The proportion of men who had never smoked was similar in Scotland (45%), Wales (45%) and England (44%). In contrast, it was significantly lower in Northern Ireland (38%).

The difference between the prevalence of current smoking among women in Scotland (25%) and England (20%) was statistically significant, and was marginally significant between Scotland and Wales (22%). In contrast, the rate in Northern Ireland (26%) was very similar to Scotland. The rates of never having smoked followed the same pattern: 48% of women in both Scotland and Northern Ireland had never smoked, compared with significantly higher rates in England (53%) and Wales (52%). Table 2.2, Table A1

Smoking rates have been found to be consistently higher in Scotland than England, for both men and women, on each occasion that comparisons have been drawn (in 1995, 1998 and 2003). The confidence interval of the difference found in 2008 between men in Scotland and England suggests that the difference could be very small, however the finding for women was more conclusive. This is also consistent with the trend over time data that suggest the difference between Scotland and England's smoking rates is more pronounced among women. Action to further reduce the rate of smoking among women in Scotland would therefore go some way to close the gap between the countries.