There has been much said about how to deal with the challenges facing the NHS in Scotland. An oft-repeated mantra is that we need to focus more on prevention, as argued in a previous NHS2048 blog by Paul Johnston of Public Health Scotland. In many respects this is a ‘no-brainer’. Of course preventing illness will reduce the disease burden and reduce the pressure on our beleaguered healthcare services. The argument is even more compelling when you appreciate just how much of that disease burden is preventable. Non-communicable diseases (NCDs) – including heart disease, cancer, diabetes, Alzheimer’s, lung disease and liver disease – account for 83% of all deaths in Scotland, and an estimated 20% of NCDs are preventable. The key drivers are tobacco, alcohol and unhealthy foods. In this blog I will focus on alcohol, for 3 reasons: (1) Scotland has a particularly unhealthy relationship with alcohol; (2) the steps which can be taken to improve the situation are well-known and compelling; and last but not least, that being the case, (3) why have we not already taken these steps?
Alcohol kills over 1200 Scots per year. That is 3 times as many as when I entered the NHS in 1979! These are alcohol-specific deaths, i.e. those deaths which are due to alcohol alone, mostly liver disease. But that is not the whole story. When you also take account of the many diseases in which alcohol plays a part, such as heart disease, stroke and cancer (alcohol is proven to cause 7 types of cancer, including breast and bowel cancer) then the death toll rises 3-4 fold, i.e. around 4000 deaths in Scotland per year. Hospital admissions directly due to alcohol are running at around 30,000 per year, and that does not include the many thousands of alcohol-related attendances at our overcrowded A&E departments. So no-one should be in any doubt that alcohol harm is a major component of the current crisis facing our NHS.
We have known for decades what public health measures work to reduce alcohol harm. What the WHO describe as the 3 ‘best buys’ can be thought as the 3As: reduce affordability, reduce the attractiveness and reduce availability. The single most important is affordability. The principal reason for that 3-fold increase in alcohol deaths is that alcohol is much cheaper in real terms than it used to be. That is why Scotland is to be applauded as the first country in the world to introduce a minimum unit price for alcohol (MUP), i.e. a floor price below which alcohol cannot be sold. The attractiveness of this measure is that it specifically targets the cheapest alcohol which is favoured by the heaviest drinkers who are at most risk of harm. And it is working: MUP is estimated to be saving around 150 lives per year, nearly all of these from deprived communities, making MUP a progressive measure which is reducing health inequalities. Of course the level at which MUP is set is crucial to its effectiveness. The level of 50p at its introduction in 2018 was actually the level proposed 6 years earlier, in 2012. You may remember that the policy was delayed by repeated unsuccessful legal challenges from the Scotch Whisky Association (SWA) – of which more later. So 50p in 2018, which equates to 65p in 2024 when it was uprated, is perhaps less effective than it might have been. The point is that regular uprating to keep pace with inflation is crucial to its continuing success.
And yet, despite MUP, the total number of alcohol deaths has been rising. This is the result of the Covid-19 pandemic which has had a major detrimental effect on our drinking behaviours: those already drinking more than they should have greatly increased their consumption.
So MUP alone is not the answer. We should be introducing regulation to restrict alcohol marketing and advertising to protect particularly the young – including a ban on advertising in public places and a ban on sports sponsorship; to separate the point of sale of alcohol in supermarkets; to enforce alcohol licensing regulations supposed to take account of health harm. We should be encouraging the UK government to increase alcohol duty at or above the rate of inflation; to ban alcohol advertising on all media outlets before the 9pm watershed and to introduce mandatory health warnings on all alcohol products akin to those for cigarettes. All of these measures in combination will reduce the toll of death and illness from alcohol.
That being so, why have such measures not been introduced long ago? The problem is not uncertainty regarding their effectiveness, nor is it a lack of support from the public. No, the reluctance of successive governments in Holyrood and Westminster to implement measures to reduce alcohol consumption and therefore alcohol harm is due principally to the power and influence of the alcohol industry. The track record of the alcohol industry is just like that of the tobacco industry and the unhealthy foods industry. They attempt to move responsibility for the harm their products cause away from the manufacturers and on to a minority of ‘problematic’ consumers. They intensely lobby policy makers with misinformation intended to deny the evidence for public health interventions, delay their implementation (as with the SWA and MUP), overstate the economic importance of alcohol and the supposed economic damage from public health measures, and instead argue for ineffective alternatives such as self-regulation and supposed consumer education.
Paul Johnston has argued, Scotland’s health problems are growing and without preventative action to address unhealthy lifestyle and behavioural factors, our NHS, even with reform to improve the delivery of healthcare, will be unable to cope. In contrast, if the Scottish Government – which has previously been seen internationally as a beacon of hope for progressive alcohol policy – rediscover the political will to introduce evidence-based, effective public health measures, there is no reason why we cannot get the levels of alcohol harm in Scotland back down to those of a generation ago. Such progress could make a major contribution to the NHS successfully delivering healthcare in 2048.
PS How much is too much?
This blog makes the case for population level measures to reduce our alcohol healthcare burden to help our beleaguered NHS. Readers may also be interested in what they as individuals should do with regard to alcohol. Well, we should follow the Chief Medical Officers’ guidance to drink not more than 14 units per week. That works out as a bottle and a half of wine, 6 pints of beer or half a 70cl bottle of spirits. These limits were chosen because that is the point at which the risk of alcohol being responsible for your death reaches 1% and rises rapidly with higher consumption. We are not talking here about that small minority of drinkers who unfortunately develop alcohol dependence, important as they are in terms of the major impact on their lives, their health and their families. They will be drinking far more than 14 units. Most patients who develop liver disease are also drinking at substantially higher levels. But it is the more subtle, hidden risks such as heart disease, and particularly cancer which explain that 14 unit limit. Current evidence suggests the old story that a little alcohol is good for your heart is not, in fact, true. Alcohol is a class A carcinogen (something the public are unaware of, hence the need for mandatory health warnings) and the cancer risk rises with any alcohol at all. So from a health perspective, less is better and none is fine. For me, I am comfortable that the risk of continuing to drink but at less than 14 units per week is acceptably low, but that should be a personal, informed decision for each individual.
Dr Alastair MacGilchrist is a hepatologist (liver specialist) who worked from 1992 to 2022 at the Royal Infirmary of Edinburgh which houses the Scottish Liver Transplant Unit. He has been the hepatology specialty advisor to the Scottish Government, a non-executive director of UK Transplant, a council member of the Royal College of Physicians of Edinburgh and the president of the Scottish Society of Gastroenterology. Since 2021 he has chaired Scottish Health Action on Alcohol Problems (SHAAP). SHAAP, a partnership of the Medical Royal Colleges and Faculties in Scotland, provides the authoritative clinical voice on how to tackle Scotland’s alcohol problem.