Scotland pays dearly for its troubled relationship with alcohol. In economic terms, alcohol harm currently costs the Scottish economy £3.5bn each year. We pay with our health too, as deaths from alcohol-related conditions have doubled in the past 15 years and there are 100 alcohol-related hospital admissions every day in Scotland. Socially, it is also a destructive feature in the lives of ordinary Scots, with alcohol cited as a contributory factor in one in three divorces and around 65,000 children in Scotland are thought to be living with a dependent drinker. While many can and do enjoy a drink in moderation, it is clear we pay a high price for its presence in our lives.
Whether it crosses our lips in large quantities or not, alcohol is a problem that affects all Scots. Indeed, a formal recognition that alcohol misuse is no longer a marginal issue is one of the most important things to come out of the alcohol discussions that dominated much of the debate in the last Parliament, argues Dr Evelyn Gill, chief executive, Alcohol Focus Scotland.
“That is quite critical because people in the past have always been keen to say, ‘It is the youth binge drinkers, or the chronic alcoholics. It is not you, it is not me, it’s not us, it is not the majority.’ And I think what the statistics have been telling us is that we sell enough alcohol in Scotland for each person over the age of 16 to exceed the recommended daily limits.
“So one of the most important things that happened is we now have a policy, and we are unique in the UK in this, we have a policy memorandum that states very clearly that this is not a marginal issue and we require whole population responses,” says Gillan.
Scotland faces a “real apocalypse” if we don’t address this acceleration in the consumption of alcohol, Scotland’s most recent Lord Advocate Elish Angiolini warned last month. The rapidity of our increasing consumption of alcohol is startling, with consumption rates doubling from just over five litres of pure alcohol per person in 1960 to almost 12 litres today. Then, we had one of the lowest levels of liver cirrhosis in Western Europe, whereas we now find ourselves at the wrong end of the scale contending with a 450 per cent increase in liver cirrhosis mortality over the past 30 years.
It is no coincidence that consumption has grown as alcohol has become more affordable, more available and more heavily marketed than at any time during these past three decades, Gillan asserts. She welcomes the fact that Scotland now has a policy objective to reduce overall alcohol consumption, and says some of the policy solutions designed to achieve that, such as banning quantity discounts in off-sales and also happy hours, are to be commended. However, she says it remains a regret that the Scottish Government’s flagship minimum pricing policy, which she argues would have made “a huge difference”, was unsuccessful.
“Without a doubt, minimum pricing was a missed opportunity but it will come back. It is not going to go away,” she says.
Indeed, the SNP have committed itself, if re-elected, to reintroducing legislation on minimum pricing, with Health Secretary Nicola Sturgeon promising to “campaign vigorously to persuade the chamber”.
However, Scotland may find itself piped to the post. The Northern Ireland Assembly recently announced that it is to consult on introducing minimum pricing and support for the policy has also been expressed by Welsh politicians; while Labour’s shadow public health minister at Westminster, Diane Abbott, has also called for the UK Government to explore minimum pricing.
“So we have got ourselves into this rather odd situation in Scotland where having initially advocated for a policy that has got very broad-base support – if you look at the Chief Medical Officers, the WHO, etc. – so having been at the forefront of advocating such an innovative response, we may find ourselves having to run to catch up if other parts of the UK introduce it before us,” says Gillan.
While alcohol misuse is not unique to Scotland, it is felt particularly acutely north of the border, she argues, and so it is appropriate that we try new and innovative approaches.
“Harm levels are much higher than the rest of the UK so it would be absolutely right for us to trial this. To be fair, the Cabinet Secretary for Health and Wellbeing at the time said, ‘We will try it for a couple of years; if it shows it is not working, we’ll stop’ and I think that is where the opposition politicians lost some credibility because they were seen to not be thinking in the public interest.”
And yet, opposition politicians have all recognised the link between consumption and harm and acknowledged the important role price can play in reducing that during the many debates on alcohol in the last Parliament, and so Gillan said it would be “fantastic” if the other parties had an alternative pricing mechanism to put on the table in the next session. However, while the unionist parties have all expressed a preference for working with the UK Government on this issue in order to pursue pricing mechanisms that are reserved to Westminster and avoid cross-border trade complications, Gillan warns that the alternative currently under discussion south of the border will be “virtually ineffective”.
“Banning alcohol below the sale of duty VAT, a measure that was not advocated by public health bodies but by the alcohol industry, it was Diageo and the Scotch Whisky Association that advocated that particular measure, and we said at the time that it would not raise the floor price of hardly any products. In fact subsequently, the Guardian did an investigation and found that only one out of 3,600 alcohol products would actually increase in price if that measure was introduced tomorrow.
“So we have got a situation where the opposition politicians have said this has to be handled at UK level, and then at UK level, we have six leading health organisations walking away from the table saying we are not signing up to this because it is basically going to be ineffective, it is not evidence based. So that presents a problem for the current opposition politicians.”
However, there are other issues under consideration where two parliaments may prove better than one. Prospective MSPs and the public health lobby in Scotland are currently paying close attention to the progress of a Private Member’s Bill that has been brought forward by Conservative MP Sarah Wollaston, which seeks to protect children from alcohol advertising. The Bill has been modelled on the French ‘loi evin’, which allows alcohol advertising in adult media only and ensures promotional messages are factual and verifiable.
The French, who introduced the measure in 1991, have “led the way” in their efforts to protect children from alcohol advertising, Dr Nick Sheron, a liver disease specialist from the University of Southampton, argues, calling ‘loi evin’, “a really impressive piece of legislation.”
“What that legislation does is rather than trying to second guess the bright young people of the marketing industry and come up with a list of things they can’t do or say, it says you can only say certain things about your product and these are the things you can say, and it says you can only use certain channels to contact consumers and it lists those.”
You only have to look at the tobacco industry to see why it is important to be unambiguous about marketing, he argues.
“Just look at Silk Cut, what more do I need to say? The purple curtain with the slash in it. How on earth could you draw up legislation that would prevent you from using that image unless you went down the ‘loi evin’ route? We know that trying to do it the way they are at the moment just doesn’t work, it is a challenge to the marketers and they are bright young people and they will always find a way around those challenges. And actually, when they do that, the impact of the adverts is even more impressive, particularly on young people who are impressed by imagination and innovation.”
Sheron, along with Professor Gerard Hastings, Director of the Institute for Social Marketing at the University of Stirling, recently penned an article in which they set out their support for the Bill and argued that removing this “profoundly unhealthy influence” should be a key public health priority.
Alcohol, and its impact on young people in particular, is a significant issue, Sheron says.
“There are around about 600 alcohol-related deaths every year in England and Wales in people aged between 15-24 years. 2,500 deaths in total, so alcohol-related deaths are 23 per cent of the total. So alcohol kills more children than cancer, respiratory disease and heart disease combined and I think that is a significant issue.”
However, the public remain unaware of just how dangerous a produce alcohol can be, he says.
“I’m a trustee of the Drinkaware trust and they have done a lot of market research on this. On the whole, the public are aware that alcohol is linked to liver disease. The majority of the public are aware of the link to liver disease but they know nothing more about it. They are not aware of the link between alcohol and cancer and when surveyed, nobody talked about alcohol and alcohol dependency. So although everybody knows about George Best and alcoholics, I think they assume it is something that could never happen to them.”
And yet, it so easily could. Of the world’s top ten risk factors for ill-health and premature death alcohol is third, after childhood underweight and unsafe sex. For the middle-aged, working population it becomes the number one most important risk factor. Similarly, a study published in the BMJ last week found that one in ten cancers in men, and one in 33 cancers in women in Western Europe are caused by former and current alcohol consumption. Forewarned is forearmed and so Sheron, who is also the Royal College of Physicians’ representative to the EU Alcohol Forum, expresses his disappointment that MEPs didn’t seize the opportunity last summer to introduce nutritional information and health warnings on the labels of alcohol products, instead, voting to exclude alcoholic beverages from the mandatory nutritional declaration requirement on the provision on food information to consumers.
“I’m completely gob smacked, to be frank,” says Sheron.
“I am astonished. I just simply can’t understand how a democratic body could have come to that conclusion. It seems completely counterintuitive. I really can’t understand it other than the fact that the alcohol industry did a colossal amount of lobbying.”
Mariann Skar, Secretary General of the European Alcohol Policy Alliance, Eurocare, shares his bewilderment at the decision.
“The MEPs’ position on exempting alcohol is astonishing and it is a bitter reminder of the influence of the alcohol industry over politicians. It is a consumer’s right to know what is in their drinks, then it is up to them to decide whether they drink or not. But why are we not given information on how many calories a glass of wine has but we are given this information for a bottle of water?”
Labelling of alcoholic beverages at an EU level would be one of the “easiest” measures to implement to support national efforts, she argues.
“Doing this at the EU level would also make it more cost effective for the industry as they could produce same labels for the whole of the EU and it would correspond with the EU single market principles.”
In the balancing act between protecting the health of European citizens while still recognising the contribution the alcohol industry makes to national economies, there are a lot of good intentions but not enough action, she declares.
“The alcohol industry has been really good in almost blackmailing the politicians, by using the economic downturn as an argument not to do anything about the problem of excessive drinking. But if you look at their annual reports, they seem to tell a different story of a year on year profits. For example, only last year Carlsberg predicted profit growth of 40 per cent.”
However, Mark Baird, head of Corporate Social Responsibility, Diageo Great Britain, says the industry has already made voluntary commitments to increase information for consumers.
“We are signed up to the responsibility deal, which included putting a responsible drinking message, the Chief Medical Officer’s advice on the recommended daily drinking guidelines, and a pregnancy symbol. So we will have all of those on our products within the next year or two – we’ve actually started with some of our major products this year. So we do believe in giving factual information that helps the consumer make choices,” he says.
“We also, from a Diageo perspective, we put our own website address where people can go in and find all the nutritional information allied to our drinks. So we do believe in giving information that helps consumers to make choices.”
However, he argues that putting information such as calorie content directly onto labels, rather than directing people to a website, would be a step too far.
“I think you can go too far with information on labels and it is really important that we almost have a hierarchy. We believe it is important that consumers understand how many units are in the bottle. We do provide a link to go and view calorie information so it is there if people want to see it. But it gets to the point where if you have too many warnings on a bottle then people are not going to read any of it.”
He also disputes that picture warning messages, similar to those that are mandatory on tobacco products, would make the messages clearer.
“I think that has the chance to confuse people even more unless you give the information of what that picture means, and I would suggest to you that scare tactics in terms of giving people messages is not the way forward.”
There is a need for an inclusive debate about the role alcohol plays in society, argues Baird, when asked if he agrees that Scotland’s relationship with alcohol needs to be rebalanced.
“It depends what you mean by rebalanced,” he replies. “We would never say that Scotland didn’t have issues with alcohol and we didn’t need to have a debate. Obviously, like many other areas around the world, there is a minority of Scots who misuse alcohol – and I think we do need to remember it is a minority of Scots, it is not the majority. We have seen some levelling off of alcohol-related admissions and alcohol deaths over the last few years, which is very encouraging. So we would never say that there isn’t a problem in Scotland with alcohol, but we believe that we need to have a balanced debate about how we can take that forward and we believe that the industry should be involved in that debate.”
However, the enthusiasm of the alcohol industry to participate in such discussions is treated with suspicion by the public health lobby, who maintain it is not in the interests of the alcohol industry, or their shareholders, to see consumption rates fall.
Baird denies the charge, however. “Responsible drinking is in all our interests and is in our commercial interests as well,” he says.
“We have been promoting responsible drinking for quite some time and it doesn’t do the industry any good at all if people are seen to be misusing alcohol – it brings the wrong kind of publicity for the industry on the whole.
“So it makes commercial sense and it makes sense from a social responsibility angle for the industry to be promoting responsible drinking – it is not the wrong thing to do, it is the right thing to do.”
Gillan, however, remains sceptical of their motives, and bemoans how comfortable the alcohol industry has been made to feel at the negotiating table.
“We have to bear in mind that one of the main conclusions of the Westminster Health Select Committee Inquiry into alcohol in 2009 was that the reason that UK alcohol policy was so ineffective was because the Government is too close to the alcohol industry – that was a cross-party Health Select Committee that came to that conclusion – and we have very good scientific evidence that says when the alcohol industry is so heavily involved in dictating policy that what you get is policies that focus on education and the least effective measures.”
Unsurprisingly, the alcohol industry favours self-regulation, whereas Gillan would argue that regulation is what the system is missing.
“They don’t want legislation, they don’t want regulation, they want to be able to police themselves – even doctors are not allowed to police themselves these days, so I think we have to have an honest discussion.”
There is a clear conflict of interest in the alcohol industry seeking to influence matters of public health policy related to alcohol misuse and alcohol harm, she asserts. While she agrees there are areas directly related to the industry’s role where they can work together; she adds, “but to say they should be at every table, very comfortably, and telling government what they should be writing in a public health policy is not what we should be aiming for.”
There is a striking similarity in the way the promotional tactics of the alcohol industry, and the arguments deployed in return by the public health lobby, mirror those related to tobacco. Is it inevitable that we will one day talk of alcohol in the same stark terms as we speak of tobacco now?
“I think we have to,” says Sheron. “I think we have to recognise the similarity between alcohol and tobacco is that they are both pushed by massive corporate industries who are making billions and billions of pounds and dollars selling these products.
“Now, you can say there is a difference in that you can say there is no such thing as a safe cigarette and many people drink alcohol quite happily and they are not going to suffer any harm with it, and that is absolutely true. So I guess what you’ve got is a spectrum, with tobacco at one end, alcohol in the middle, and cream cakes and the food industry at the other end. But nevertheless, they are all industries of unhealthy behaviours and corporate profitability, and until that aspect of the corporate profitability and the lobbying that then goes into it is recognised as a significant health issue then it is going to be very difficult to move forward.”
There is also much that those with an interest in alcohol can learn from tobacco control. Against all odds, a massive cultural shift has been brought around tobacco, helped largely, Gillan points out, by a foundation of bold public health legislation. However, outside of the walls of Holyrood and Westminster, there is also a need for ordinary Scots to reflect on the type of relationship we want to have with alcohol going forward, and the price we are willing to pay.
It is incongruous, yet sadly the case, that it is more socially acceptable to be a drunk in Scotland than it is to be a non drinker, she argues.
“I think the industry has been very successful in normalising alcohol and its positive associations as they see it, and I think the reality is there are now more negative consequences to our alcohol use than positive and we actually have to start being honest about that and reflecting that and showing that the way that we need to show it. Because it is not the case that alcohol is this harmless substance that most people enjoy responsibly, that is just not where we are at when you have 50 per cent of men and 39 per cent of Scottish women drinking more than the recommended limits in a typical week.
“If you go into any A&E of any weekend, if you go into any street on a Saturday night, into any prison, you will find half the prisoners were drunk at the time of the offence; that is where alcohol is taking us. That is what alcohol is doing in Scotland at the moment and we need to start being honest about that and reflect on that.”