Scottish Social Attitudes Survey 2021/22: Public attitudes on alcohol and tobacco use and weight

Chapter 1: Introduction

Addressing stigma is considered a policy priority for the Scottish Government as it is seen as a barrier to health improvement agendas, including around weight, alcohol use and smoking. It is recognised that stigma comes in many guises, including self-stigmatisation and workforce stigma.

This report presents findings from the 2021/22 Scottish Social Attitudes Survey (SSA) conducted between the 21^st of October 2021 and the 27^th of March 2022. The aim of the questions for this module within SSA 2021/22 was to explore population level attitudes around stigma towards people with harmful alcohol, high tobacco use and those living with overweight or obesity. The survey also provided an opportunity to compare attitudes over time, with certain similar questions asked in previous years of SSA. The following key questions are addressed:

• To what extent do people think that the responsibility lies with the individuals themselves or society?
• Who should be responsible for helping people with these issues?

Policy context

Alcohol use

In 2021, adults in Scotland self-reported consuming on average 11.3 units of alcohol per week which continues the downward trend since 2003.^[4] The latest Monitoring and Evaluating Scotland's Alcohol Strategy (MESAS) study using sales data found that in 2021, 9.4 liters of pure alcohol were sold per adult in Scotland, equivalent to 18.1 units per adult per week.^[5] Apart from 2020, this is the lowest level seen in Scotland since the time series started in 1994. However, Scotland has consistently had the highest rates of pure alcohol sold per adult compared to England and Wales. However, the gap in volume of pure alcohol sold per adult in the off-trade between Scotland and England and Wales has narrowed substantially since 2013 with sales in England and Wales at 9.0 liters per adult in 2021.^[6]

Regularly consuming alcohol over the recommended number of units increases the risk of physical and mental ill-health.^[7] In 2021, Scotland had the highest rate of alcohol-specific deaths out of all four UK nations at a rate of 22.4 deaths per 100,000 people, compared to Wales (19.3%) and England (13.9).^[8]

Alcohol-related policy in Scotland is aimed at addressing the affordability, availability and attractiveness of alcohol and has included introducing a 50p minimum price per unit of alcohol, banning multi-buy discounts and targeting prevention and early intervention.^[9] The Scottish Government has elected to take a public health approach to alcohol by diverting those with problematic alcohol use away from the justice system and into treatment and support services.^[10] Removing the stigma attached to problem drug use and harmful drinking in Scotland is a key part of the alcohol and drug strategy and in December 2021, they initiated a campaign to challenge the stigma which too often negatively impacts upon those who use alcohol and drugs. In addition, the Scottish Government has recently published a Stigma Action Plan to address the negative impact that stigma has on people accessing health services across Scotland (Drug Deaths Taskforce response: cross government approach).

Scotland's relationship with alcohol is widely perceived as harmful by the general public. An Ipsos Mori poll of adults in Great Britain in August 2022 highlighted that the public believes that the nation's drinking culture is one of its worst attributes.^[11] In 2013, 84% of respondents to a previous SSA survey stated they felt that alcohol caused 'a great deal' or 'quite a lot of harm' in Scotland and the majority of people felt that hazardous and binge drinking was problematic.^[12] In addition, around four in ten drinkers of all ages felt that others would find it odd if they were not drinking alcohol at all and over four in ten non-drinkers felt the same way.^[13] Numerous studies since have shown that there is a culture of pressuring non-drinkers to consume alcohol in the UK, influencing those who do not drink to break their abstinence to participate in social activities, among both younger and older age groups.^[14]

NHS Scotland advises that the stigma faced by people struggling with an alcohol problem may prevent them from getting treatment and support as they feel judged.^[15]

Tobacco Use

There has been a significant reduction in the proportion of adults in Scotland who smoke over time. The 2021 Scottish Health Survey (SHeS) reported that smoking prevalence among adults continued its fall, from 28% in 2003 to 11% in 2021.^[16] Scotland, in early 2020 however, was shown to have the highest proportion of smokers in the UK, with 16% of adults reporting smoking cigarettes in Scotland compared to 15.3% in Wales, 13.9% in England and 13.2% in Northern Ireland.^[17] Smoking tobacco is a well recognised risk factor for poor health.^[18]

Smoking policy in Scotland aims to have its first tobacco-free generation by 2034 through encouraging current smokers to quit, reducing the visibility of smoking around children, making indoor smoking less acceptable, raising awareness of support services to stop smoking, and preventing young people from taking up smoking.^[19] This is the latest in a series of smoking-related policies introduced over the past two decades in efforts to reduce smoking rates, which have included banning smoking in indoor public spaces in 2006, raising the minimum age of sale for tobacco to eighteen in 2007, and banning the display of cigarettes in shops in 2013.^[20] More recently, in 2016, the minimum age of sale for vape products of eighteen was introduced, alongside banning the sale of vape products from vending machines and the advertisement or promotion of vape products.^[21] In 2021, Scotland introduced a 15 meter smoking ban perimeter around NHS hospital buildings to further reduce smoking rates.^[22]

Over the past half century, smoking has become less socially acceptable and there is an increase in the intolerance of smoking, particularly in public spaces.^[23] Around the world, narratives around tobacco consumption have changed from those of glamour to ones of dependence, poor health and undesirability.^[24] In fact, studies suggest that stigma has been used as a public health tool to discourage smoking in efforts to reduce rates.^[25] Not only has this stigma led to people who smoke feeling shunned in social spaces but has also resulted in a self-imposed stigma by people who smoke, caused by feelings of disgust, shame and guilt at their inability to quit.^[26]

In Scotland, support is strong for reducing the availability and advertising of cigarettes and other tobacco products with the majority of the public agreeing that tobacco advertising should be banned, that cigarettes should not be sold near schools and cigarette sales limited in deprived areas, and that a minimum and maximum price should be set.^[27] In Britain as a whole, three in five people support the outright ban of the sale of cigarettes and two in five support this happening within the next two years.^[28]

Weight

Scotland has one of the highest rates of adults living with overweight and obesity among the OECD nations.^[29] In 2021, 67% of adults in Scotland were living with overweight and 30% with obesity.^[30] The proportion of overweight adults in Scotland has remained relatively stable since 2008 but there has been a small increase in the mean BMI of adults from 27.1kg/m² in 2003 to 28.0kg/m² in 2021.^[31]

Overweight and obesity can increase the likelihood of a person developing serious health conditions, substantially increasing the risk of diseases such as type 2 diabetes, cancer, cardiovascular disease and Alzheimers.^[32] Evidence that people who are living with overweight or obesity are highly stigmatised and face discrimination is well-documented in research.^[33] This shows that stigma towards those who are living with overweight or obesity may impact employment opportunities and promotions.^[34] For example, the British Social Attitudes Survey 2015 (BSA 2015) indicated that three quarters of Britons think that someone who is not very overweight would be more likely to be offered a manager's position than someone who was very overweight.^[35]

Weight stigma is associated with significant physiological and psychological consequences, such as depression and anxiety^[36] and can lead to 'maladaptive' practices that cause further harm, such as emotional eating and social isolation.^[37] The World Health Organisation also highlights that the stigmatisation of people who are living with overweight or obesity can lead to avoidance of medical care^[38] with potential for wide-ranging consequences for the health of those affected.

Many studies have examined the views of people towards those living with overweight or obesity and found a tendency for the public to perceive them as lacking willpower, and that their condition is the result of individual choice rather than symptomatic of wider societal structures.^[39] For example, BSA 2015 found that 53% of Britons felt that most people who are very overweight could lose weight if they tried.^[40] In SSA in 2016, 85% of adults in Scotland felt that individuals who are obese themselves should be responsible for reducing the number of people who are obese in Scotland, although reducing obesity levels in Scotland was seen largely as both an individual and a collective responsibility.^[41]

'A healthier future: Scotland's diet and health weight delivery plan'^[42] was the latest strategy published in 2018 to address obesity in Scotland. This included an action to develop consistent and accessible healthy weight information and appropriate training, including on weight bias and stigma. In 2021 Public Health Scotland launched the Challenging Weight Stigma Learning Hub^[43], aimed primarily at those who work in health and social care, public sector, third sector and community-based organisations. The hub is evidence based, aimed at raising awareness of weight stigma, its impact on individuals and what actions can be taken to address it. In addition, Public Health Scotland are working with FrameWorks UK to empower and upskill key stakeholders in Scotland to communicate confidently about health and obesity in ways which will reduce stigma, build understanding and drive action on health.

The evidence on the extent of stigma relating to harmful alcohol use, smoking and overweight / obesity to date is mixed and it is not clear to what extent people in Scotland currently hold stigmatising attitudes toward individuals experiencing these. The aim of these questions within SSA 2021/22 was to explore current public attitudes around stigma towards people with harmful alcohol use, high tobacco use and those living with overweight or obesity. This survey also provided an opportunity to compare attitudes over time, with certain questions having been asked in previous years of SSA.