Health and Care Bill

Written evidence submitted by Alcohol Focus Scotland (AFS) (HCB50)

WRITTEN EVIDENCE ON THE HEALTH AND CARE BILL TO THE HOUSE OF COMMONS PUBLIC BILL COMMITTEE

Alcohol Focus Scotland (AFS) is Scotland’s national charity working to prevent and reduce alcohol harm. We want to see fewer people have their health damaged or lives cut short due to alcohol, fewer children and families suffering as a result of other people’s drinking, and communities free from alcohol-related crime and violence. AFS welcomes the opportunity to provide written evidence on the Health and Care Bill to the House of Commons Public Bill Committee.

Our evidence derives from our belief that this Bill has scope to address alcohol harm in Scotland and the UK. Alcohol harm is a major risk to the health of the individual, but also to public health.

Our evidence relates to advertising restrictions for less healthy foods (clause 125) and food labelling provisions (clause 127), as these are directly applicable to Scotland. We also share our experience on the benefits of introducing minimum unit pricing. We hope that the below evidence will help the Public Bill Committee improve the legislation in its current form, so that it sufficiently addresses alcohol harm. This will enable the Bill to deliver on its aim to implement the NHS Long Term Plan and to deliver on the Government’s Obesity Strategy.

Summary

 

Our primary concern is that there is little reference to alcohol harm in a Bill that represents one of the most comprehensive pieces of health legislation in almost a decade. We highlight to the Committee the following points :

· Alcohol should be clearly and explicitly included within the definition of less healthy food and drink in the Bill ; this would mean alcohol is subject to the proposed advertising regulations due to cover ‘high in fat, sugar and salt’ (HFSS) products.

· We support Clause 127 to enable mandatory alcohol labelling to be introduced across the UK with urgency. We welcome plans to consult on potential labelling requirements but believe a more comprehensive approach to labelling is required.

· Minimum unit pricing (MUP) should be included in the Bill for its introduction in England, in line with action to tackle cheap, high-strength drinks that has been taken across the rest of the UK.

Clause 125: Alcohol should be included in the definition of ‘less healthy food and drink’

 

1. There is no denying that alcohol is an unhealthy product. Alcohol causes more than 200 health conditions, including seven types of cancer, liver disease and cardiovascular disease [1] and it is the leading risk factor for death, ill-health, and disability among 15-49-year-olds in the UK. [2] Ten people die every day [3] and someone is hospitalised every 15 minutes due to alcohol in Scotland. [4] It is estimated that 20 people die from alcohol-related cancer in Scotland every week. [5]

2. The coronavirus pandemic has further exacerbated the alcohol harm crisis, with deaths from alcohol rising by 17% in Scotland in 2020, driven by increases in alcohol-related liver disease. [6] It is critical that the increasing levels of drinking seen during the pandemic are urgently addressed.

3. The Bill’s explanatory notes make clear that the Bill aims to deliver upon the Government’s Long-Term Plan for the NHS and its Obesity Strategy. [7] The Plan itself recognises that addressing alcohol harm must be part of its effort to focus on prevention and address health inequalities, stating that it "contributes to conditions including cardiovascular disease, cancer and liver disease, harm from accidents, violence and self-harm, and puts substantial pressure on the NHS." [8]

4. Similarly, the Obesity Strategy recognises that "alcohol is highly calorific... It has been estimated that for those that drink alcohol it accounts for nearly 10% of the calories they consume. We know that each year around 3.4 million adults consume an additional day’s worth of calories each week from alcohol, that is nearly an additional 2 months of food each year." [9]

5. Despite the recognition of alcohol’s risk to health, as evidenced in the Long-Term Plan and the Obesity Strategy, alcohol is not included in the definition of ‘less healthy food and drink’. Alcohol is therefore excluded from the regulations introduced by Clause 125 and Schedule 16.

6. The Bill states that the ‘less healthy’ products within the Bill’s scope are drawn from the 2011 Nutrient Profiling Technical Guidance [10] , which does not cover ‘non-nutrient substances’ like alcohol or caffeine. [11] Schedule 16 (part 1, section 1, subsection 6) of the Bill enables the Secretary of State for Health to amend the meaning of ‘relevant guidance’ and revise what products fall under the scope of the Bill. However, it is our understanding that the Government is not planning on amending the scope to include alcohol.

7. It is therefore vital that the Bill is amended to explicitly recognise alcohol as an unhealthy product. Such an amendment would help the Government to deliver on its Obesity Strategy and NHS Long Term Plan, and enable the Government to address the many risks related with alcohol consumption.

8. One such risk is underage drinking, which negatively impacts upon the health and development of children and young people. Restricting alcohol marketing is recommended by the World Health Organization (WHO) as one of the most effective policies to reduce alcohol-related harm, particularly for young people, children and adolescents. [12]

9. There is an established evidence base that alcohol marketing causes underage drinking. [13] Exposure to alcohol marketing reduces the age at which young people start to drink, increases the likelihood that they will drink, and increases the amount of alcohol that they consume if they already drink. [14] Early age of drinking onset is associated with an increased likelihood of developing alcohol abuse or dependence in adolescence and adulthood, and also with dependence at a younger age. [15]

10. Concerningly, as with unhealthy foods, children are exposed to significant amounts of alcohol marketing. Research shows:

- Four in five 11-19-year-olds had noticed alcohol marketing in the past month, with half of those aged under 18 being exposed to 28 or more instances of marketing every month. [16]

- 10-15-year-olds in the UK are exposed to more televised alcohol marketing than adults. [17]

- Nine out of ten primary school children recognised the beer brand ‘Foster’s’, a higher recognition rate than for leading brands of crisps, biscuits and ice-cream. [18]

11. Despite alcohol being an age-restricted product and a demonstrable health risk to children, this Bill intends to prevent children from seeing an advert for a sugary soft drink, but not an alcoholic drink. Recognising that alcohol is unhealthy will enable this Bill to remedy that inconsistency. We urge the Committee to consider a consistent approach to the regulation of the marketing of unhealthy food and drink, covering both HFSS products and alcohol.

12. There is public support for ensuring the restrictions proposed in the Bill include alcohol advertising. Three quarters of Scots support controls to limit the exposure of children and young people to alcohol advertising , [19] with 68% of people support ing stopping alcohol adverts from being shown on TV before 9pm [20] and 74% supporting the introduction of controls to limit the exposure of children to alcohol advertising on social media. [21]

13. Children themselves are supportive of such restrictions. Children’s Parliament Investigators recommended that TV or online adverts should not be shown where children might see them [22]   and the Young Scot Health Panel have also recommended a TV watershed for alcohol advertising. [23]

Clause 127: Labelling

 

14. AFS welcomes clause 127 which provides for the legal framework for mandatory food labelling requirements to be introduced across UK nations . As noted in the White Paper, "This power will enable the swift introduction of key obesity strategy policies such as changes to our front-of-pack nutrition labelling scheme and mandatory alcohol calorie labelling, following consultation." [24]

15. As it stands, there are no legal requirements for alcohol products to include the low risk drinking guidelines, health warnings, or even basic information such as ingredients and nutritional content. Swift action to introduce mandatory labelling requirements for alcoholic drinks is vital, as the current voluntary approach to alcohol labelling continues to fail consumers. A review of 424 alcohol product labels in the UK by the Alcohol Health Alliance revealed: [25]

- 71% of labels did not include the low risk drinking guidelines.

- More than a quarter of labels included incorrect or misleading information that was either outdated or from other countries.

- 72% of labels did not list their ingredients.

- A majority had no nutritional information and just 7% of labels displayed full nutritional information including calories.

- 1 product displayed a health warning.

16. While we welcome the forthcoming consultation, we believe there is a need for labelling restrictions to be more far-reaching than the current focus on nutritional labelling. Mandatory labelling requirements should also include alcohol unit content, the Chief Medical Officers’ low risk drinking guidelines, health warnings, driving and age warnings, and ingredients.

17. Such requirements would help address current low levels of knowledge of alcohol harm amongst the public . For example, i n Scotland, fewer than half of people are aware that alcohol can cause cancer [26] and 77% don't know the low risk weekly drinking guideline. [27]

18. A recent review of alcohol labelling research suggests that presenting unit information alongside drinking guidelines would improve consumer understanding, and well-designed health warnings can increase awareness of the risks of drinking and even reduce consumption. [28] For example, a real-world experiment in Canada has shown that enhanced alcohol labels (which included a cancer warning, low risk drinking guidelines and the standard drinks per serving) can increase people’s knowledge of the link between alcohol and cancer [29] and drinking guidelines, [30] and prompt people to cut back on their drinking. [31] Some evidence suggests that providing nutritional information on alcohol labels could help improve alcohol health literacy. [32]

19. A recent poll from YouGov revealed that the majority of the Scottish public support more information being included on labels including. [33] This includes:

- 75% support for displaying the number of units in a product

- 59% support for displaying calorie information

- 48% support for displaying the amount of sugar

Minimum Unit Pricing: Suggested new clause in Part 5

 

20. There is no mention of Minimum Unit Pricing (MUP) in the Bill. Taking into account the positive effect of MUP in Scotland observed since the policy was implemented in 2018, we believe MUP should be included as a tool to tackle cheap high-strength alcoholic drinks in England . Implementing this live-saving policy would bring England in line with the rest of the UK.

21. Consumption is closely linked to the price of alcohol: the more affordable alcohol is, the more is consumed, and thus the more harm is caused. [34] The WHO recommends reducing the affordability of alcohol as one of the most effective policies to reduce alcohol harm. [35]

22. Evidence from Scotland shows that MUP is effective: MUP has led to a 3.5% decrease in off-trade sales in the first year following implementation, [36] and a 7.7% fall in household alcohol purchases in Scotland compared to Northern England. [37] In the first full year of data following the introduction of MUP, alcohol-specific deaths in Scotland decreased by 10%. [38] It is estimated that a 50p MUP in England would save 525 lives and prevent over 22,000 hospital admissions annually. [39]

23. One of the aims of the Health and Care Bill is to address health inequalities. The introduction of MUP would help the Bill to achieve this aim because people in our poorest communities suffer the most from the effects of cheap, high-strength alcohol. They are over four times more likely to die [40] and seven times more likely to be hospitalised due to alcohol than people in the most affluent communities. [41] Because they suffer the most harm, health gains of minimum pricing are expected to be greatest for hazardous and particularly harmful drinkers in poverty; the 2.6% of the Scottish population who are in poverty and drinking at hazardous and harmful levels were predicted to experience 46% of the lives saved by a minimum unit price. [42]

6 September 2021


[1] Shield, K. D., Parry, C., & Rehm, J. (2014). Chronic diseases and conditions related to alcohol use. Alcohol research: current reviews , 35(2), 155.

[2] Institute for Health Metrics and Evaluation (IHME). GBD Compare Visualization Tool. Seattle. WA: IHME, University of Washington. https://vizhub.healthdata.org/gbd-compare/

[3] Tod, E. et al. (2018). Hospital admissions, deaths and overall burden of disease attributable to alcohol consumption in Scotland. Edinburgh: NHS Health Scotland. http://www.scotpho.org.uk/media/1597/scotpho180201-bod-alcohol-scotland.pdf

[4] Public Health Scotland (2020). Alcohol Related Hospital Statistics Scotland 2019/2020 . https://beta.isdscotland.org/find-publications-and-data/lifestyle-and-behaviours/substance-use/alcohol-related-hospital-statistics/

[5] Tod, E. et al. (2018). Hospital admissions, deaths and overall burden of disease attributable to alcohol consumption in Scotland. Edinburgh: NHS Health Scotland. http://www.scotpho.org.uk/media/1597/scotpho180201-bod-alcohol-scotland.pdf

[6] National Records of Scotland (2021). Alcohol-specific deaths 2020. Edinburgh: NRS. https://www.nrscotland.gov.uk/files/statistics/alcohol-deaths/2020/alcohol-specific-deaths-20-report.pdf

[7] Department of Health and Social Care (2021). Health and Care Bill Explanatory Notes , p.40. https://publications.parliament.uk/pa/bills/cbill/58-02/0140/en/210140en.pdf

[8] NHS (2019). The NHS Long Term Plan. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf , p.38.

[9] Department of Health and Social Care (2020). Tackling Obesity: Empowering adults and children to live healthier lives. https://www.gov.uk/government/publications/tackling-obesity-government-strategy/tackling-obesity-empowering-adults-and-children-to-live-healthier-lives

[10] Department of Health (2011). Nutrient Profiling Technical Guidance. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216094/dh_123492.pdf

[11] Public Health England (2018). Annex A. The 2018 review of the UK Nutrient Profiling Model . https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/694145/Annex__A_the_2018_review_of_the_UK_nutrient_profiling_model.pdf

[12] World Health Organi z ation (2019). The SAFER technical package: five areas of intervention at national and subnational levels. Geneva: WHO. https://apps.who.int/iris/rest/bitstreams/1262746/retrieve

[13] Sargent, J. D., Cukier, S., & Babor, T. F. (2020). Alcohol marketing and youth drinking: is there a causal relationship, and why does it matter?.  Journal of Studies on Alcohol and Drugs, Supplement , (s19), 5-12

[14] Anderson et al. (2009). Impact of Alcohol Advertising and Media Exposure on Adolescent Alcohol Use: A Systematic Review of Longitudinal Studies. Alcohol and Alcoholism , 44(3):229-43; Smith, L. & Foxcroft, D. (2009). The Effect of Alcohol Advertising, Marketing and Portrayal of Drinking Behaviour in Young People: A Systematic Review of Prospective Cohort Studies. BMC Public Health , 9:51; Jernigan, D. et al. (2016). Alcohol Marketing and Youth Consumption: A Systematic Review of Longitudinal Studies Published Since 2008. Addiction , 112: 7–20

[15] Donaldson, L. (2009). Guidance on the Consumption of Alcohol by Children and Young People . Department of Health. http://www.cph.org.uk/wp-content/uploads/2013/09/Guidance-on-the-consumption-of-alcohol-by-children-and-young-people.pdf

[16] Critchlow, N.,  et al. (2019). Awareness of alcohol marketing, ownership of alcohol branded merchandise, and the association with alcohol consumption, higher-risk drinking, and drinking susceptibility in adolescents and young adults: A cross-sectional survey in the UK.  BMJ open ,  9 (3), e025297. https://bmjopen.bmj.com/content/9/3/e025297

[17] Winpenny, E. et al. (2012). Assessment of young people’s exposure to alcohol marketing in audiovisual and online media .

[18] Alcohol Focus Scotland, Alcohol Concern, Balance North East and Drink Wise (2015). Children’s Recognition of Alcohol Branding .

[18] https://www.alcohol-focus-scotland.org.uk/media/62890/Children_s_Recognition_of_Alcohol_Marketing_Briefing.pdf

[19] Online survey of 12,247 adults aged 18+ in Great Britain, of which 1,021 were in Scotland. Survey conducted 18 February to 18 March 2021 by YouGov on behalf of Action on Smoking and Health. The figures have been weighted and are representative of all GB adults (aged 18+).

[20] Online survey of 12,247 adults aged 18+ in Great Britain, of which 1,021 were in Scotland. Survey conducted 18 February to 18 March 2021 by YouGov on behalf of Action on Smoking and Health. The figures have been weighted and are representative of all GB adults (aged 18+).

[21] Online survey of 1,019 people aged 18+ in Scotland, conducted 12-15 November 2018 by YouGov for AFS. The figures are representative of all adults in Scotland (aged 18+).

[22] Children’s Parliament (2019). “It’s all around you, all the time.” Children’s Parliament investigates: an alcohol-free childhood . Glasgow: Alcohol Focus Scotland. https://www.childrensparliament.org.uk/wp-content/uploads/Alcohol-free-Childhood-Online.pdf

[23] Young Scot (2020). Preventing Harm - Alcohol Marketing and Young People. Edinburgh: Young Scot Enterprise. https://static1.squarespace.com/static/5cee5bd0687a1500015b5a9f/t/5fb6abac34389a62b1d9c4d8/1605807036480/YS_Preventing_Harm_Alcohol_Report_FINAL.pdf

[24] Department of Health and Social Care (202 1 ). Integration and innovation: working together to improve health and social care for all . https://www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all/integration-and-innovation-working-together-to-improve-health-and-social-care-for-all-html-version

[25] Alcohol Health Alliance UK (2020). Drinking in the Dark: How alcohol labelling fails consumers . London: AHA. https://ahauk.org/wp-content/uploads/2020/09/DRINKING-IN-THE-DARK.pdf

[26] Online survey of 1,019 people aged 18+ in Scotland, conducted 12-15 November 2018 by YouGov for AFS. The figures are representative of all adults in Scotland (aged 18+).

[27] Online survey of 12,247 adults aged 18+ in Great Britain, of which 1,021 were in Scotland. Survey conducted 18 February to 18 March 2021 by YouGov on behalf of Action on Smoking and Health. The figures have been weighted and are representative of all GB adults (aged 18+). 23% of people accurately stated that the weekly low risk drinking guideline was 14 units per week; 48% inaccurately estimated the guideline and 29% said they did not know.

[28] Dimova, E. & Mitchell, D. (2020). Rapid literature review on the impact of health messaging and product information on packaging of alcohol and other unhealthy commodities. Glasgow: Alcohol Focus Scotland

[29] Hobin, E. et al. (2020). Testing alcohol labels as a tool to communicate cancer risk to drinkers: A real-world quasi-experimental study.  Journal of Studies on Alcohol and Drugs ,  81 (2), 249-261. https://pubmed.ncbi.nlm.nih.gov/32359056/

[30] Schoueri-Mychasiw, N. et al. (2020). Examining the impact of alcohol labels on awareness and knowledge of national drinking guidelines: A real-world study in Yukon, Canada.  Journal of studies on alcohol and drugs ,  81 (2), 262-272. https://www.jsad.com/doi/full/10.15288/jsad.2020.81.262

[31] Zhao, J. et al. (2020). The effects of alcohol warning labels on population alcohol consumption: an interrupted time series analysis of alcohol sales in Yukon, Canada.  Journal of studies on alcohol and drugs ,  81 (2), 225-237. https://www.jsad.com/doi/full/10.15288/jsad.2020.81.225

[32] Walker, N. et al. (2019).  Energy labelling for alcoholic beverages in New Zealand: Impact on consumer purchase and consumption. Phase 2 report: Randomised trial.  Health Promotion Agency. https://www.hpa.org.nz/sites/default/files/documents/Energy_labelling_for_alcoholic_beverages_in_New_Zealand_Phase_2_research_report_March_2019.pdf

[33] All figures, unless otherwise stated, are from YouGov Plc. The YouGov survey was conducted on behalf of Action on Smoking and Health . Total sample size was 12247 adults, of which 1021 were in Scotland. Fieldwork was undertaken between 18/02/2021 - 18/03/2021. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+).

[34] Anderson & Baumberg (2006) cited in Österberg, E. (2012). Pricing of alcohol. Alcohol in the European Union: consumption, harm and policy approaches . Copenhagen, WHO Regional Office for Europe, 96-102.

[35] The World Health Organi z ation (2017). Tackling NCDs. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: WHO. https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf?sequence=1&isAllowed=y

[36] Giles, L., Richardson, E. & Beeston, C. (2021). Using alcohol retail sales data to estimate population alcohol consumption in Scotland: an update of previously published estimates. Edinburgh: Public Health Scotland.

[36] https://publichealthscotland.scot/media/2994/using-alcohol-retail-sales-data-to-estimate-population-alcohol-consumption-in-scotland-an-update-of-previously-published-estimates.pdf

[37] Anderson, P. et al. (2021). Impact of minimum unit pricing on alcohol purchases in Scotland and Wales: controlled interrupted time series analyses.  The Lancet Public Health . https://doi.org/10.1016/S2468-2667(21)00052-9

[38] National Records of Scotland (2020). Alcohol-specific deaths: main points . Edinburgh: National Records of Scotland. https://www.nrscotland.gov.uk/files//statistics/alcohol-deaths/2019/alcohol-specific-deaths-19-main-points.pdf

[39] Angus, C. et al. (2016). Alcohol and cancer trends: Intervention Studies. University of Sheffield and Cancer Research UK . https://www.cancerresearchuk.org/sites/default/files/alcohol_and_cancer_trends_report_final_cruk.pdf

[40] National Records of Scotland (2021). Alcohol-specific deaths 2020. Edinburgh: NRS. https://www.nrscotland.gov.uk/files/statistics/alcohol-deaths/2020/alcohol-specific-deaths-20-report.pdf .

[41] Public Health Scotland (2020). Alcohol Related Hospital Statistics Scotland 2019/2020 . Edinburgh: Public Health Scotland. https://beta.isdscotland.org/find-publications-and-data/lifestyle-and-behaviours/substance-use/alcohol-related-hospital-statistics/

[42] Angus, C. (2017). Why minimum unit pricing is not a tax on the poor . Institute for Alcohol Studies

[42] http://www.ias.org.uk/Blog/Why-minimum-unit-pricing-is-not-a-tax-on-the-poor.aspx

 

Prepared 15th September 2021