Explaining trends in alcohol-related harms in Scotland 1991–2011 (II): policy, social norms, the alcohol market, clinical changes and a synthesis

Objective: To provide a basis for evaluating post-2007 alcohol policy in Scotland, this paper tests the extent to which pre-2007 policy, the alcohol market, culture or clinical changes might explain differences in the magnitude and trends in alcohol-related mortality outcomes in Scotland compared to England & Wales (E&W). Study design: Rapid literature reviews, descriptive analysis of routine data and narrative synthesis. Methods: We assessed the impact of pre-2007 Scottish policy and policy in the comparison areas in relation to the literature on effective alcohol policy. Rapid literature reviews were conducted to assess cultural changes and the potential role of substitution effects between alcohol and illicit drugs. The availability of alcohol was assessed by examining the trends in the number of alcohol outlets over time. The impact of clinical changes was assessed in consultation with key informants. The impact of all the identified factors were then summarised and synthesised narratively. Results: The companion paper showed that part of the rise and fall in alcohol-related mortality in Scotland, and part of the differing trend to E&W, were predicted by a model linking income trends and alcohol-related mortality. Lagged effects from historical deindustrialisation and socio-economic changes exposures also remain plausible from the available data. This paper shows that policy differences or changes prior to 2007 are unlikely to have been important in explaining the trends. There is some evidence that aspects of alcohol culture in Scotland may be different (more concentrated and home drinking) but it seems unlikely that this has been an important driver of the trends or the differences with E&W other than through interaction with changing incomes and lagged socio-economic effects. Substitution effects with illicit drugs and clinical changes are unlikely to have substantially changed alcohol-related harms: however, the increase in alcohol availability across the UK is likely to partly explain the rise in alcohol-related mortality during the 1990s. Conclusions: Future policy should ensure that alcohol affordability and availability, as well as socio-economic inequality, are reduced, in order to maintain downward trends in alcohol-related mortality in Scotland

Estimating the changing nature of Scotland's health inequalities using a multivariate spatiotemporal model

Health inequalities are the unfair and avoidable differences in people's health between different social groups. These inequalities have a huge influence on people's lives, particularly those who live at the poorer end of the socio‐economic spectrum, as they result in prolonged ill health and shorter lives. Most studies estimate health inequalities for a single disease, but this will give an incomplete picture of the overall inequality in population health. Here we propose a novel multivariate spatiotemporal model for quantifying health inequalities in Scotland across multiple diseases, which will enable us to understand better how these inequalities vary across disease and have changed over time. In developing this model we are interested in estimating health inequalities between Scotland's 14 regional health boards, who are responsible for the protection and improvement of their population's health. The methodology is applied to hospital admissions data for cerebrovascular disease, coronary heart disease and respiratory disease, which are three of the leading causes of death, from 2003 to 2012 across Scotland

Informing investment to reduce inequalities: a modelling approach

Background: Reducing health inequalities is an important policy objective but there is limited quantitative information about the impact of specific interventions. Objectives: To provide estimates of the impact of a range of interventions on health and health inequalities. Materials and methods: Literature reviews were conducted to identify the best evidence linking interventions to mortality and hospital admissions. We examined interventions across the determinants of health: a ‘living wage’; changes to benefits, taxation and employment; active travel; tobacco taxation; smoking cessation, alcohol brief interventions, and weight management services. A model was developed to estimate mortality and years of life lost (YLL) in intervention and comparison populations over a 20-year time period following interventions delivered only in the first year. We estimated changes in inequalities using the relative index of inequality (RII). Results: Introduction of a ‘living wage’ generated the largest beneficial health impact, with modest reductions in health inequalities. Benefits increases had modest positive impacts on health and health inequalities. Income tax increases had negative impacts on population health but reduced inequalities, while council tax increases worsened both health and health inequalities. Active travel increases had minimally positive effects on population health but widened health inequalities. Increases in employment reduced inequalities only when targeted to the most deprived groups. Tobacco taxation had modestly positive impacts on health but little impact on health inequalities. Alcohol brief interventions had modestly positive impacts on health and health inequalities only when strongly socially targeted, while smoking cessation and weight-reduction programmes had minimal impacts on health and health inequalities even when socially targeted. Conclusions: Interventions have markedly different effects on mortality, hospitalisations and inequalities. The most effective (and likely cost-effective) interventions for reducing inequalities were regulatory and tax options. Interventions focused on individual agency were much less likely to impact on inequalities, even when targeted at the most deprived communities

Impact of smoking and smoking cessation on overweight and obesity: Scotland-wide, cross-sectional study on 40,036 participants

<p>Background: Weight control is cited by some people, especially adolescent girls, as a reason for commencing smoking or not quitting. The aim of this study was to explore the relationship between smoking behaviour and being overweight or obese, overall and by age and sex sub-groups.</p> <p>Methods: We used data from the six Scottish Health Surveys conducted to date (1995--2010) to undertake a population-based, cross-sectional study on 40,036 participants representative of the adult (>=16 years) Scottish population. Height and weight were measured by a trained interviewer, not self-reported.</p> <p>Results: 24,459 (63.3%) participants were overweight (BMI >=25 kg/m2) and 9,818 (25.4%) were obese (BMI >=30 kg/m2). Overall, current smokers were less likely to be overweight than never smokers. However, those who had smoked for more than 20 years (adjusted OR 1.54, 95% CI 1.41-1.69, p < 0.001) and ex-smokers (adjusted OR 1.18, 95% CI 1.11-1.25, p < 0.001) were more likely to be overweight. There were significant interactions with age. Participants 16--24 years of age, were no more likely to be overweight if they were current (adjusted OR 1.01, 95% CI 0.84-1.20, p = 0.944) or ex (adjusted OR 0.88, 95% CI 0.67-1.14, p = 0.319) smokers. The same patterns pertained to obesity.</p> <p>Conclusions: Whilst active smoking may be associated with reduced risk of being overweight among some older adults, there was no evidence to support the belief among young people that smoking protects them from weight gain. Making this point in educational campaigns targeted at young people may help to discourage them from starting to smoke.</p&gt

Explaining trends in alcohol-related harms in Scotland, 1991–2011 (I):The role of incomes, effects of socio-economic and political adversity and demographic change

Abstract Objective: This paper tests the extent to which differing trends in income, demographic change and the consequences of an earlier period of social, economic and political change might explain differences in the magnitude and trends in alcohol-related mortality between 1991 and 2011 in Scotland compared to England & Wales (E&W). Study design: Comparative time trend analyses and arithmetic modelling. Methods Three approaches were utilised to compare Scotland with E&W: 1. We modelled the impact of changes in income on alcohol-related deaths between 1991–2001 and 2001–2011 by applying plausible assumptions of the effect size through an arithmetic model. 2. We used contour plots, graphical exploration of age-period-cohort interactions and calculation of Intrinsic Estimator coefficients to investigate the effect of earlier exposure to social, economic and political adversity on alcohol-related mortality. 3. We recalculated the trends in alcohol-related deaths using the white population only to make a crude approximation of the maximal impact of changes in ethnic diversity. Results: Real incomes increased during the 1990s but declined from around 2004 in the poorest 30% of the population of Great Britain. The decline in incomes for the poorest decile, the proportion of the population in the most deprived decile, and the inequality in alcohol-related deaths, were all greater in Scotland than in E&W. The model predicted less of the observed rise in Scotland (18% of the rise in men and 29% of the rise in women) than that in E&W (where 60% and 68% of the rise in men and women respectively was explained). One-third of the decline observed in alcohol-related mortality in Scottish men between 2001 and 2011 was predicted by the model, and the model was broadly consistent with the observed trends in E&W and amongst women in Scotland. An age-period interaction in alcohol-related mortality was evident for men and women during the 1990s and 2000s who were aged 40–70 years and who experienced rapidly increasing alcohol-related mortality rates. Ethnicity is unlikely to be important in explaining the trends or differences between Scotland and E&W. Conclusions: The decline in alcohol-related mortality in Scotland since the early 2000s and the differing trend to E&W were partly described by a model predicting the impact of declining incomes. Lagged effects from historical social, economic and political change remain plausible from the available data

A cross-sectional analysis of the relationship between tobacco and alcohol outlet density and neighbourhood deprivation

Background There is a strong socio-economic gradient in both tobacco-and alcohol-related harm. One possible factor contributing to this social gradient may be greater availability of tobacco and alcohol in more socially-deprived areas. A higher density of tobacco and alcohol outlets is not only likely to increase supply but also to raise awareness of tobacco/alcohol brands, create a competitive local market that reduces product costs, and influence local social norms relating to tobacco and alcohol consumption. This paper examines the association between the density of alcohol and tobacco outlets and neighbourhood-level income deprivation. Methods Using a national tobacco retailer register and alcohol licensing data this paper calculates the density of alcohol and tobacco retail outlets per 10,000 population for small neighbourhoods across the whole of Scotland. Average outlet density was calculated for neighbourhoods grouped by their level of income deprivation. Associations between outlet density and deprivation were analysed using one way analysis of variance. Results There was a positive linear relationship between neighbourhood deprivation and outlets for both tobacco (p <0.001) and off-sales alcohol (p <0.001); the most deprived quintile of neighbourhoods had the highest densities of both. In contrast, the least deprived quintile had the lowest density of tobacco and both off-sales and on-sales alcohol outlets. Conclusions The social gradient evident in alcohol and tobacco supply may be a contributing factor to the social gradient in alcohol- and tobacco-related disease. Policymakers should consider such gradients when creating tobacco and alcohol control policies. The potential contribution to public health, and health inequalities, of reducing the physical availability of both alcohol and tobacco products should be examined in developing broader supply-side interventions

The aftershock of deindustrialization - trends in mortality in Scotland and other parts of post-industrial Europe

<p><b>Background:</b> Post-industrial decline is frequently cited as one of the major underlying reasons behind the poor health profile of Scotland and, especially, West Central Scotland (WCS). This begs the question: to what extent is poor health a common outcome in other post-industrial regions and how does Scotland's experience compare to these other comparable regions?</p> <p><b>Methods:</b> Regions were identified by means of an expert-based consultation, backed up by analysis of regional industrial employment loss over the past 30 years. Mortality rates and related statistics were calculated from data obtained from national and regional statistical agencies.</p> <p><b>Results:</b> Twenty candidate regions (in: Belgium; France; Germany; Netherlands; UK; Poland; Czech Republic) were identified, of which ten were selected for in-depth analyses. WCS mortality rates are generally higher and—crucially—appear to be improving at a slower rate than in the other post-industrial regions. This relatively poor rate of improvement is largely driven by mortality among the younger working age (especially male) and middle-aged female populations.</p> <p><b>Conclusion:</b> WCS mortality trends compare badly with other, similar, post-industrial regions of Europe, including regions in Eastern Europe which tend to be characterized by higher levels of poverty. This finding challenges any simplistic explanation of WCS's poor health being caused by post-industrial decline alone, and begs the question as to what other factors may be at work.</p&gt

Excess mortality and urban change: Investigating similarities and differences in the extent of urban change in Glasgow, Liverpool and Manchester and their surrounding regions from 1945, and the extent to which this might be part of the excess mortality explanation

No abstract available

What would it take to eradicate health inequalities? Testing the fundamental causes theory of health inequalities in Scotland

This report warns that efforts to reduce Scotland's health inequalities gap will fail unless they tackle the fundamental causes of poor health.<p></p> The study looked at 30 years of health inequality trends in Scotland and the rise and fall of particular causes of death. Decreasing periods of health inequality have previously been observed in the UK suggesting that this situation is not inevitable and that there is urgent need for action to address inequalities in income, resources and power across society.<p></p> The report shows that the gap in deaths across different social groups for specific causes decreased, while others emerged. It reveals that there is little difference in death rates from non-preventable diseases like brain and ovarian cancer, but large differences in more preventable causes like alcohol-related deaths and heart disease.<p></p> Research has shown that causes of death responsible for inequalities have changed over time from heart disease and tuberculosis in the 1970s and 1980s to drugs and alcohol-related deaths more recently. The common factor in the persistence of health inequalities is social inequalities.<p></p> The results have important policy implications for continued efforts to reduce health inequalities in Scotland.<p></p&gt

What can ecological data tell us about reasons for divergence in health status between west central Scotland and other regions of post-industrial Europe

<p>Background: The link between the effects of de-industrialization (unemployment, poverty) and population health is well understood. Post-industrial decline has, therefore, been cited as an underlying cause of high mortality in Scotland's most de-industrialized region. However, previous research showed other comparably de-industrialized regions in Europe to have better and faster improving health (with, in many cases, a widening gap evident from the early to mid-1980s).</p> <p>Objectives: To explore whether ecological data can provide insights into reasons behind the poorer, and more slowly improving, health status of West Central Scotland (WCS) compared with other European regions that have experienced similar histories of post-industrial decline. Specifically, this study asked: (1) could WCS's poorer health status be explained purely in terms of socio-economic factors (poverty, deprivation etc.)? and (2) could comparisons with other health determinant information identify important differences between WCS and other regions? These aims were explored alongside other research examining the historical, economic and political context in WCS compared with other de-industrialized regions.</p> <p>Study design and methods: A range of ecological data, derived from surveys and routine administrative sources, were collected and analysed for WCS and 11 other post-industrial regions. Analyses were underpinned by the collection and analysis of more detailed data for four particular regions of interest. In addition, the project drew on accompanying literature-based research, analysing important contextual factors in de-industrialized regions, including histories of economic and welfare policies, and national and regional responses to de-industrialization.</p> <p>Results: The poorer health status of WCS cannot be explained in terms of absolute measures of poverty and deprivation. However, compared with other post-industrial regions in Mainland Europe, the region is distinguished by having wider income inequalities and associated social characteristics (e.g. more single adults, lone parent households, higher rates of teenage pregnancy). Some of these distinguishing features are shared by other UK post-industrial regions which experienced the same economic history as WCS.</p> Conclusion From the collection of data and supporting analyses of important contextual factors, one can argue that poor health in WCS can be attributed to three layers of causation: the effects of de-industrialization (which have impacted on health in all post-industrial regions); the impact of ‘neoliberal’ UK economic policies, resulting in wider inequalities in WCS and the other UK regions; and an as-yet-unexplained (but under investigation) set of factors that cause WCS to experience worse health outcomes than similar regions within the UK