Dr Alastair MacGilchrist, liver specialist and Chair of Scottish Health Action on Alcohol Problems (SHAAP) considers the possible explanations for, and implications of the latest statistics on alcohol deaths in Scotland.

On 29^th August, the National Records for Scotland  released figures for alcohol-specific deaths in Scotland for 2022¹. There were 1276 deaths, a rise of  31, or 2%, from 2021. Deaths have now risen in each of the last 3 years by a total of 25%, following a 10% fall in 2019. The latest figures are the highest number of alcohol-specific deaths since 2008.

It is important to consider what might be causing this rising number of deaths, each of which is a personal and avoidable tragedy for the individuals and their families.

The sharp rise in deaths in 2020 and 2021 coincided with the Covid-19 pandemic and associated lockdowns. In the early months of the pandemic reduced access to health services may have been a contributing factor, but the main cause is likely to have been a change in drinking patterns which was seen not just in Scotland but in the rest of UK and in Europe and North America. Moderate drinkers drank the same or less, but heavy drinkers drank significantly more, resulting in a sharp increase in deaths, mainly from alcohol-related liver disease². A possible explanation for the further increase in deaths in 2022 is that our drinking behaviour has not returned to what it was pre-pandemic.  2 modelling reports in England, one by the Sheffield Alcohol Research Group³ and the other by the Institute of Alcohol Studies and Health Lumen⁴ predicted thousands more hospital admissions and deaths over the coming years if a return to pre-pandemic drinking patterns is delayed or fails to occur.

Work by Public Health Scotland (PHS), published in the Lancet in March this year, looked at the impact of Minimum Unit Pricing, introduced in Scotland in May 2018 at a level of 50 pence per unit, on alcohol health harm⁵. They looked at hospital admissions and deaths due to alcohol before and for 30 months after MUP implementation (i.e. to December 2020) in Scotland compared to England where there is no MUP. They found that alcohol-specific deaths were 13.4% lower in Scotland than in England, indicating that MUP was having a beneficial effect. England suffered a higher increase in alcohol deaths than Scotland during the pandemic years 2020 and 2021. Thus MUP may be having a mitigating effect on the adverse consequences of the Covid-19 pandemic, particularly in those living in more deprived areas.

However the level of MUP at 50p has not changed since its introduction in 2018, indeed that 50p level was first proposed over a decade ago in 2012. Since then, particularly in recent years, high levels of inflation are diluting the effectiveness of that 50p floor price. Therefore another factor to consider in the rise in deaths in 2022 is that MUP is now less effective at reducing health harms than when initially introduced.

All the increase in deaths in 2022 were in women. The age standardised mortality rate, a better indication of underlying trends than absolute numbers, showed no significant change in female deaths, so we should not over-interpret this finding. Indeed it is important to point out that twice as many men as women die from alcohol, a ratio which has remained remarkably consistent over the years. However the gender-specific age standardised mortality figures reveal that the reduction in deaths in 2019 – which followed the introduction of MUP - applied only to men; there was no reduction in female deaths. Sheffield Alcohol Research Group have modelled the possible effects of MUP at different levels on men and women⁶. Their results, published in 2021, predicted that MUP at 50p would not reduce female deaths – whereas a higher level (the price modelled was 70p) would do so. This is plausible given the different drinking patterns for men and women. The former favour beer, the latter wine, and we know from PHS data that MUP at 50p has not reduced wine sales in Scotland⁷. So the 50p level of MUP may be too low to prevent the rising number of deaths in women in 2022.

Another consideration, should the pattern of rising deaths in women continue, is the role of alcohol marketing. We know that alcohol companies attempt to grow their markets by  targeting women in numerous advertising strategies⁸,  as recognised in the #DontPinkMyDrink campaign⁹.

So a ‘Covid hangover’ of unhealthy drinking behaviour and reducing efficacy of MUP at the 50p level, particularly in women, are possible contributors to the rising deaths. There may of course other factors at play. Alcohol consumption and harm are closely linked to its affordability. Alcohol duty was frozen, rather than raised in line with inflation, every year from 2018 to 2022, making it relatively more affordable every year. The 10.1% rise in duty in line with inflation in August 2023 is very welcome, but will have had no effect on the 2022 death figures. An economic downturn might reduce alcohol affordability if inflation outstripped wages, but in fact alcohol price inflation has been running significantly lower than overall or food inflation. Alcohol harm is more prevalent in deprived communities than affluent ones, and in Scotland and the UK inequalities in income¹⁰ and health¹¹ have widened in recent years.

To reverse this trend and reduce alcohol deaths in Scotland, we must optimise existing policies, which for MUP means both increasing the level of MUP as soon as possible to compensate for its erosion by inflation since 2018  - SHAAP are calling for an immediate increase to at least 65p - and linking the level to some measure of inflation or affordability to prevent future loss of its effectiveness. We must also introduce other public health measures proven to reduce alcohol harm, such as restrictions on marketing and advertising. Thirdly, we must improve alcohol treatment services for those already suffering from alcohol dependency, both in terms of capacity and access, to counter the alarming 40% reduction in numbers entering treatment over the last decade¹².

The rising death toll from alcohol is not a reason to wring our hands in despair, it is a call to action.

A MacGilchrist

September 2023

SHAAP Blogposts are published with the permission of the authors. The views expressed are solely the authors' own and do not necessarily represent the views of Scottish Health Action on Alcohol Problems (SHAAP).

References

1. Alcohol Specific Deaths 2022. Published by National Records for Scotland, 29^th August 2023. https://www.nrscotland.gov.uk/files//statistics/alcohol-deaths/2022/alcohol-specific-deaths-22-report.pdf

2. Burton R, Sharpe C, Amasiatu C, et al. Monitoring alcohol consumption and harm during the Covid-10 pandemic. Public Health England, 2021. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1002627/Alcohol_and_COVID_report.pdf

3. Angus C, Henney M, Price R. Modelling the impact of changes in alcohol consumption during the COVID-19 pandemic on future alcohol-related harm in England. Published by University of Sheffield April 2022. https://figshare.shef.ac.uk/articles/report/Modelling_the_impact_of_changes_in_alcohol_consumption_during_the_COVID-19_pandemic_on_future_alcohol-related_harm_in_England/19597249/1

4. Boniface S, Gard-Gowers J, Martin A et al. The COVID hangover: addressing long-term health impacts of changes in alcohol consumption during the pandemic. Report, Institute

of Alcohol Studies, July 2022. https://www.ias.org.uk/wp-content/uploads/2022/07/The-COVID-Hangover-report-July-2022.pdf

5. Wyper G, Mackay D, Fraser C, et al. Evaluating the impact of alcohol minimum unit pricing on deaths and hospitalisations in Scotland: a controlled interrupted time series study. Lancet 2023; 401:1361-70.

 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00497-X/fulltext

6. Meier P, Holmes J, Brennan A, Angus C. Alcohol policy and gender: a modelling study estimating gender-specific effects of alcohol pricing policies. Addiction 2021; 116: 2372-84. https://pubmed.ncbi.nlm.nih.gov/33651444/

7. Evaluating the impact of minimum unit pricing for alcohol in Scotland: Final report. Published by Public Health Scotland 27 June 2023. https://publichealthscotland.scot/media/20366/evaluating-the-impact-of-minimum-unit-pricing-for-alcohol-in-scotland-final-report.pdf

8. Atkinson A, Meadows B, Emslie C, et al. 'Pretty in Pink’ and ‘Girl Power’: an analysis of the targeting and representation of women in alcohol brand marketing on Facebook and Instagram. International Journal of Drug Policy 2022; 101: 1-12. https://www.sciencedirect.com/science/article/abs/pii/S0955395921004655?via%3Dihub

9. The feminisation of alcohol Marketing. BBC Worklife website (accessed 7 Sep 2023). https://www.bbc.com/worklife/article/20200924-the-feminisation-of-alcohol-marketing

10. Office for National Statistics. Household income inequality, UK: financial year ending 2022, published January 2023. https://www.ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/incomeandwealth/bulletins/householdincomeinequalityfinancial/financialyearending2022

11. The Impact of Covid-19 on health inequalities in Scotland. The Scottish Government, 2020. https://www.gov.scot/binaries/content/documents/govscot/publications/research-and-analysis/2020/09/the-impacts-of-covid-19-on-equality-in-scotland/documents/full-report/full-report/govscot%3Adocument/Covid%2Band%2BInequalities%2BFinal%2BReport%2BFor%2BPublication%2B-%2BPDF.pdf

12. Scottish Parliament. Question reference S6W-19111. 22^nd June 2023. https://www.parliament.scot/chamber-and-committees/questions-and-answers/question?ref=S6W-19111