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Beeston C., Geddes R., Craig N. et al.
NHS Health Scotland, 2014.
Report evaluating Scotland’s national alcohol strategy concludes that changes to alcohol licensing laws are unlikely to have affected alcohol-related harm, but that the ban on quantity discounts in the off-trade and increased delivery of brief interventions may have contributed to recent declines in alcohol consumption and harms.
Summary The Scottish Government has tasked NHS Health Scotland with evaluating Scotland’s alcohol strategy through the Monitoring and Evaluating Scotland’s Alcohol Strategy (MESAS) programme of work. Key evaluation questions are:
• How and to what extent has implementing the measures (taken together and/or individually) in the Scottish alcohol strategy contributed to reducing alcohol-related harms?
• Are some people or businesses affected more than others?
• How might the strategy be implemented differently to improve effectiveness?
This fourth annual report from the programme includes the main findings from two studies published in 2014, one to assess the impact of increased investment in alcohol treatment and care services, the other to assess changes in knowledge and attitudes related to alcohol. It also provides an overview of results from studies detailed in previous annual reports which assessed the implementation of alcohol brief interventions in health service settings and the feasibility of their extension to youth work and social work settings, the implementation and impact of the Licensing Act, and the potential contribution of the external economic context.
Scotland’s alcohol-related death rates have fallen by 35% since 2003 but remain 1.4 times higher than in 1981. Similarly, the alcohol-related new patient (hospitalisation) rate fell by 25% since 2007/08, but was still 1.3 times higher in 2013/14 than in 1991/92. Alcoholic liver disease hospitalisations followed a similar pattern to all alcohol-related hospitalisations: an upward trend in new patients presenting to hospital up to 2005/06, and then a decline until last year. By contrast, the new patient rate for alcohol psychosis, accounting for 17% of alcohol admissions (driven by alcohol ‘withdrawal’), continued to rise until 2007/08, and has plateaued but not declined since then.
Declines in alcohol-related harms are expected to follow a decline in the average quantity of alcohol consumed in the population. Per adult alcohol sales have continued to fall recently in Scotland, declining by 9% since the peak in 2009. Increases in alcohol service provision are also expected to contribute to a reduction in harms. In 2012, an estimated one in four adults with possible alcohol dependence actually accessed alcohol services, and providers and users of those services felt that increased investment in specialist treatment and care services had improved their quality and accessibility. Better understanding of the problems alcohol causes in Scotland are also expected to contribute to a decrease in harms, but except for increased awareness of the harm caused by alcohol, between 2004 and 2013 there was little notable change in population knowledge and attitudes related to alcohol.
Alcohol-related mortality rates in Scotland are almost twice those in England and Wales, but the rate peaked five years earlier in Scotland and declined more sharply. Changes to alcohol licensing laws are unlikely to have affected alcohol-related harm, but the ban on quantity discounts in the off-trade and increased delivery of brief interventions may have contributed to the declines in alcohol consumption and harms respectively. In addition, the decline in alcohol-related mortality in Scotland from the peak in 2003 may at least partly be explained by declines in disposable income in the lowest income groups. Some more detailed findings are presented below.
The Licensing Act was, in the main, perceived to have been implemented as intended and to have reduced irresponsible promotions in the on-trade. However, licensing boards found it difficult to address the public health objective of the Licensing Act and to apply assessments of the overprovision of licensed premises, and licensing forums struggled to function effectively.
The Alcohol Act implemented in Scotland on 1 October 2011 included a ban on quantity-based discounts and restrictions on the display and promotion of alcohol in Scotland’s off-trade. In its first year the Act was associated with a 2.6% decrease in per adult off-trade alcohol sales not evident in England and Wales, due mainly to reduced sales of wine. A statistically significant 1.7% reduction was estimated for Scotland after trends in England and Wales had been adjusted for in the analysis.
An earlier MESAS annual report included the results of a simulation model of the health impacts of the national alcohol brief interventions programme, concluding that it had made a small contribution to the decline in alcohol-related harm in Scotland, even under the most conservative assumptions.
The study of alcohol treatment and care services found 149 specialist alcohol treatment services in Scotland in 2012 which had treated 31,796 individuals, about one in four of all adults with possible alcohol dependence as indicated by their scores on the AUDIT questionnaire. In-depth consultation with service commissioners, providers and service users in three areas revealed that the additional resources for these specialist services and reform of local delivery arrangements were considered to have had a positive impact. The consultation also identified ongoing issues relating to service gaps, service planning, staffing, demand and missed appointments. Direct service user contact accounted for approximately one third of the time spent by staff on alcohol-related activities in services in the two areas which participated in this strand of the study.
Findings from the 2013 Scottish Social Attitudes Survey suggest adults in Scotland have a complex and sometimes contradictory relationship with alcohol. Many recognise its potential for harm, yet attitudes to getting drunk have not changed greatly since 2004. Alcohol is recognised as a ‘social lubricant’, but heavy drinking is seen as problematic and most recognise its long-term negative consequences. Slightly more support setting a minimum price per unit of alcohol than are against it, yet knowledge of the unit content of drinks has not improved over time. In 2013, around half of adults did not know the correct number of units in measures of alcoholic drinks. Just over 40% of both men and women correctly identified the recommended daily alcohol limits for their sex. Since 2004 the proportion of 18–29-year-olds who say getting drunk at weekends is acceptable has fallen from 53% to 40%, and the proportion of adults seeing alcohol as the drug causing most problems in Scotland rose from 46% to 60%. There has, however, been a small but significant increase in the proportion of people who think it easier to enjoy a social event if you’ve had a drink, from 35% in 2004 to 39% in 2013, and more people think others would see them as odd if they did not drink at all, up from 31% in 2007 to 41% in 2013.
Alcohol-related mortality and morbidity, and inequalities in these harms, are continuing to decline in Scotland, and on some measures are improving more quickly than in England and Wales. Alcohol sales are falling in both Scotland and England and Wales. It is likely that declining affordability of alcohol due to the economic downturn and the associated policy context across Great Britain in recent years is responsible for a substantial proportion of these improvements. However, the ban on quantity discounting of alcohol and the increased number of brief interventions delivered are likely to be contributing to the improvements seen in Scotland. Changing knowledge and attitudes around alcohol are unlikely to have had much impact.
commentary Other MESAS reports analysed for the Effectiveness Bank deal in greater detail with alcohol treatment and care services, the implementation of alcohol brief interventions in health service settings, and the impact of the Licensing Act.
Last revised 09 January 2015. First uploaded 09 January 2015
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