Drinking is an everyday part of Scottish
life. Yet it can be a social problem
and a cause of personal ill-treatment
and of risky behaviour. A change
culture is needed.
It is estimated that, in Lothian, 81,000 men and
56,000 women drink more than the recommended
levels each week, while 17,000 men and 6,000
women are drinking at very hazardous levels (1).
Deaths in Scotland reported as due directly to
excessive alcohol use more than doubled between
1990 and 2000, from 13.4 to 31.2 per 100,000
population, with a sevenfold higher rate in deprived
areas compared with affluent neighbourhoods.
Attention is rightly given to binge drinking
and its health and social consequences.
However, this can overshadow the role that
consistent over-consumption – exceeding
maximum advised daily units over a long period
– is having on the health of both Lothian and
Scotland. Sensible drinking in Scotland requires
a great many more people to simply drink less
and drink less often. Unfortunately this conflicts
with Scottish culture and the reputation of
Scottish people. In the 2004 Scottish Social
Attitudes Survey, two-thirds of respondents
agreed that alcohol is part of a “Scottish way
of life”. Furthermore, over a third (rising to 47%
amongst Scottish men) agreed that it is easier to
enjoy a social event if you have had a drink (1).
In Scotland, where drinking alcohol is so culturally
and socially acceptable, the main challenge
remains clarification of what is sensible drinking
and what is problematic. Would it be a problem to:
- Drink a bottle of wine throughout a four-course meal at dinner party?
- Have four or five pints of beer watching a football match with friends in a pub?
- Drink nine pub measures of vodkas by yourself at home one evening watching the TV?
Each situation involves drinking approximately
nine units of alcohol, just over twice the upper limit
for men and three times the upper limit for women.
However, many would see the first two scenarios
as acceptable, being in social circumstances.
The third, however, is more likely to be seen as a
problem, drinking alone. Drinking is often seen as
a problem only when people get into a fight, are
violent towards a partner or when they are caught
drunk driving. Excess alcohol use is associated
with violence, crime, relationship problems,
unprotected sex and other general anti-social
behaviour yet it is difficult to see alcohol misuse as
anything other than someone else’s problem.
At times it seems that the attitude in Scotland
really is: “I drink, you binge, he has a problem
and they are anti-social.”
There is compelling evidence, from many
populations, that overall level of alcohol
consumption is linked to the prevalence of
heavy drinking and that changes in per capita
consumption are associated with changes in
the level of alcohol related harm (2). As an
immediate measure, the Academy of Medical
Sciences in its report Calling Time recommended
that the Government’s aim should be to prevent
any further rise in alcohol consumption, and
strategies should then aim to bring consumption
back to the 1970 level.
If we are to reduce per capita consumption, this
cannot be achieved solely at local level. Government
has the key role in taxation of alcohol impacting on
affordability. The price of alcoholic drinks in the UK
has increased more than general price increases
since 1980 as measured by the Alcohol Price
Index. Between 1980 and 2005 the price of alcohol
increased by 22% more than prices generally.
However, because households’ disposable income
has increased by 97% in real terms (1980-2005),
alcohol is 62% more affordable in 2005 than in 1980.
There is also a need for: restrictions on where
and when alchohol may be purchased; further
restrictions on advertising; law enforcement
(e.g. on underage purchasing of alcohol); and campaigns to provide awareness of
recommended drinking levels and of the
harms associated with alcohol misuse. What is
important is that legislation, enforcement, health
promotion and treatment services are consistent
in their approach and work together to achieve a
Marketing for culture change
Getting effective messages regarding alcohol use
across to the general public is notoriously difficult.
Even with good social marketing approaches,
many health-related campaigns concerning alcohol
use are competing with multi-national alcohol
companies promoting the benefits of drinking
their products. Companies spend millions of
pounds relating alcohol to partying, fun, laughter,
naughtiness, excitement, and acceptance. Sensible
alcohol use campaigns use thousands of pounds
focusing on drinking a maximum number of units,
being sensible, not making a fool of yourself, not
getting sick and dealing with the consequences
of drinking too much. The drinks industry wants
people to spend more on their products and in
their facilities. We want people to drink less. It is
not difficult to see why there is an uphill struggle in
preventing alcohol misuse.
In December 2006, the Joseph Rowntree
Foundation published ‘Alcohol strategy and the
drinks industry: a partnership for prevention?’ (3)
The report considered how policy has developed
as a result of the Government identifying the drinks
industry as a key partner in preventing alcohol
problems. If we truly wish to change the culture
regarding alcohol use then there needs to be a
platform for all messages to be agreed by different
organisations, public sector and private, so that
consistent, clear, realistic and relevant messages
are provided to the target population. We have a
lot to learn from the drinks industry and can benefit
from their expertise and experience. We need to
convince them of the benefits to society of people
drinking smaller amounts of alcohol that is less
strong, less often. The Scottish people can only
benefit from us all working together.
The NHS and changing the culture
Health professionals have a key role in the
prevention of alcohol misuse. Considering
137,000 people in Lothian are drinking more than
the recommended levels each week, there is a
significant need for staff throughout the NHS to
engage with patients about their alcohol use and
provide brief interventions. This is not just the
responsibility of specialist services or general
practitioners but includes health visitors, midwives,
A&E staff and community and hospital nurses. We
all have a role to play in helping people to drink
less and we all have a part to play in reducing per
At a national level, the Scottish Government has
identified alcohol misuse as a priority and is investing
a further £85.3 million over the coming three years.
While this provides a significant opportunity to
improve services, sustainability of such services
can only be maintained if staff throughout the NHS
are working with all patients rather than waiting until
they are drinking at harmful or dependent levels.
Further training will be required, so that all staff feel
equipped to raise issues with patients. An important
part of the training will be looking at staff attitudes
and their perceptions of acceptable / sensible
In Lothian, as in the rest of Scotland, action
to increase sensible alcohol use can be
summarised in five simple points:
- We need to encourage a great many more people to simply drink less and drink less often.
- Our health promotion messages need to be updated and consistent with those of others.
- Addressing problematic alcohol use is everyone’s business within the NHS.
- Culture change needs to be driven nationally and supported locally with regulation and enforcement.
- Staff training in alcohol brief
intervention is a priority.