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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).

Cultural aceptance

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.”

Changing cultures

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 common goal.

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 capita consumption.

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 alcohol use.


key points

In Lothian, as in the rest of Scotland, action to increase sensible alcohol use can be summarised in five simple points:

  1. We need to encourage a great many more people to simply drink less and drink less often.
  2. Our health promotion messages need to be updated and consistent with those of others.
  3. Addressing problematic alcohol use is everyone’s business within the NHS.
  4. Culture change needs to be driven nationally and supported locally with regulation and enforcement.
  5. Staff training in alcohol brief intervention is a priority.