Scotland and alcohol: bigger drinkers than on the Mediterranean?

Included in a Lancet paper published in 2007, the graph tracks mortality rates for liver cirrhosis among men and women aged 45 to 64 in Scotland, England and Wales, and Europe.

It seems incomprehensible to us now, but back in the mid-1970s middle-aged men in Europe were dying from the disease at more than three times the rate of Scots. For women, rates were more than twice as high.

Almost all of these deaths were driven by southern Europe - countries that we stereotypically associate with moderate consumption. This was not always the case.

Throughout the 1950s, 60s, and 70s, Scotland's mortality rates from liver cirrhosis were well below the European average for both men and women(The Lancet, 2007) (Image: Lancet)

According to the World Health Organisation, per capita weekly consumption in France was an astonishing 50 units in 1961, while Italy peaked at 38 units in 1973 and Spain at 36 units in 1975.

To put this into context, when Scotland hit "Peak Booze" in the mid-Noughties the average intake was 22.5 units.

The 1970s marked a turning point, however.

Since then, consumption has fallen dramatically in all three nations and in the mid-1990s Scotland overtook Europe on liver cirrhosis mortality as our death rates rocketed.

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"Every country tends to think 'this is our drinking' culture - that it's fixed and unchanging," said Dr Peter Rice, a Scotland-based addiction psychiatrist and vice-chair of the European Alcohol Policy Alliance.

"It's a romantic explanation for our drinking patterns, but it's simply not true. Our drinking patterns, and patterns of harm, change considerably.

"They did in Scotland, as the graph shows, and they do in other countries. What seems to be a national characteristic is open to change."

Italy was one of the few countries where alcohol became comparatively more expensive in the final decades of the 20th Century, while France banned alcohol from sports sponsorship and television advertising.

In Scotland - and the UK - the past 70 years have been characterised by rapidly rising alcohol consumption and deaths hand-in-hand with increases in availability, affordability, and changing social norms, particularly around female drinking.

In real terms, alcohol was 78% more affordable by 2021 than it was in 1987.

If that seems surprising, it is probably because popular imagination - and successive UK Budgets - tend to focus on the price of a pint in the pub. This is misleading.

By 2021, 85% of all the alcohol consumed in Scotland was purchased "off-trade", from supermarkets and shops, compared to just under 50% in 1994.

While the cost of alcohol nearly doubled between 2000 and 2015 in pubs and bars - which have to cover staff costs and other overheads - in the off-trade it rose by around 35%.

The past 30 years has seen a huge decline in alcohol consumption in pubs, bars and restaurants in favour of drinking at home, with the trend accelerated during the pandemic (Image: Mesas/PHS)The cost of alcohol 'on-trade' has risen much more sharply compared to the off-trade sector, with the difference in the price per unit now wider than ever (Image: Fraser of Allander)

By 2021, the average price per unit of alcohol sold in Scotland was 64 pence in the off-trade versus £2.04 in the on-trade.

"It used to be that people only really drank in pubs - 40, 50, 60 years ago - now far more people drink at home because it's so much cheaper," said Jem Roberts, from the Institute of Alcohol Studies.

In addition, average disposable incomes have grown much faster than the price of alcohol in recent decades and the 2023 UK Budget also heralded only the second increase in alcohol duty since 2012.

Mr Roberts said: "Most of us aren't necessarily very good at recognising the difference [between price and affordability] when it comes to alcohol.

"The nominal increase over a decade or so might seem high, but when you compare it to wages it's not.

"And one of the other reasons why alcohol has become so much more affordable, in Scotland and across the UK, is the Westminster Government freezing or cutting duty basically at every budget for the last 12 years."

By 2022, Scotland recorded 1,276 alcohol-specific deaths - the highest number since 2008.

Unlike the all-time high of 1,417 deaths in 2006, which followed 20 years of steadily increasing consumption and mostly affected middle-aged adults, the latest peak has occurred after a decade which saw drinking habits polarised, first by austerity and then by lockdown.

Low to moderate drinkers cut back, and heavier drinkers consumed more.

Overall, Scots are consuming 20% less alcohol on average than we were in the mid-2000s, but this is mainly skewed by younger generations drinking much less than they used to.

Compared to 2006, alcohol death rates are lower now in every age group from 20 to 64, but rising among the over-70s.

Among 75-84-year-olds, the mortality rate from alcohol has never been higher: 110 people in this age group died in 2022 as a result of illnesses wholly attributable to alcohol misuse, up from 33 in 2006.

Mortality rates from alcohol are currently highest in the 65-74 age group, and have risen significantly for the over-75s (Image: NRS)

It is a trend that Dr Alastair MacGilchrist, a retired consultant liver specialist and the chair of Scottish Health Action on Alcohol Problems (SHAAP) recognises.

He said: "If you lump together everyone 45 to 65, that still constitutes the majority [of deaths], but we are now seeing pensioners with alcoholic liver disease.

"That has started to increase in the last 10 years, but it's something we never used to see.

"Partly it's the fact that we're living longer so there's more over-70s around and maybe older people with alcoholic liver disease are surviving until then where they didn't in the past.

"But there is concern that drinking habits may have changed in the young but might be getting worse in the older population."

Graeme Callander, policy lead at drug and alcohol charity, We Are With You - formerly Addaction - previously carried out research which identified bereavement, 'empty nesting', and retirement as contributors to problem drinking in older adults.

He said: "Some people are able to retire quite young so that opens up a world where you have more time on your hands and if you experience any sort of adversity or mental health challenge, alcohol can be one way that people choose to cope.

"But it tends to be hidden because people are drinking at home on their own."

Since the year 2000, beer and wine sold off-trade has become 110% and more than 60% 'more affordable' after adjusting for changes in the price and levels of disposable income (above). Meanwhile, pubs and bars have been closing (below) (Image: PHS/Mesas)

The statistics for 2022 also revealed that deaths among women had reached a record high of 440.

In fact, of the extra 31 deaths in 2022 compared to 2021, the increase was driven solely by deaths in female drinkers.

"Men are still drinking more than women and dying at a higher rate, but the gender gap is reducing and the increase in deaths among women is something to be concerned about," said Professor Carol Emslie, who leads the Substance Use Research Group at Glasgow Caledonian University.

She added that the uprating of minimum unit pricing to 65 pence was "something to watch" as it would affect wine more than the previous MUP threshold of 50p, potentially reducing levels of harmful drinking to a larger extent among women.

The current rise in alcohol deaths dates from 2012, and is generally seen as beginning with the Credit Crunch.

"What happened during the recession and austerity was very similar to what happened in the Covid pandemic," said Jem Roberts.

"During the pandemic, there was this real polarisation of drinking where people who were already drinking heavily tended to drink a bit more and people drinking at low to moderate levels tended to drink a bit less.

"After 2008, overall consumption fell slightly, but some high-risk groups consumed more.

"People might respond to losing their job by cutting back on things and trying to save, others will drink more as a coping mechanism.

"But it's not simply about the polarisation of drinking - it's also about the social determinants of health, and whether public services and the NHS are being properly funded."

When lockdown came along in 2020, forcing pubs to close, it also accelerated the shift towards home drinking.

Alcohol, including spirits, remained available in supermarkets throughout the pandemic, while other countries banned its sale or imposed restrictions on standalone 'liquor stores' (Image: Getty)

While some countries, including South Africa and Turkey, banned the sale of alcohol during lockdown, wine, beer and spirits remained freely available in supermarkets across Scotland and the rest of the UK.

Dr Rice said: "I remember being in Tesco at the start of the pandemic when there was a guy in front of me with four packets of muesli and the checkout operator took two bags off him.

"The guy behind me had eight bottles of vodka but there was no restriction at all. I guess they were less concerned about supply shortages."

Deaths have increased throughout the UK, but analysis suggests that the picture in Scotland would have been even worse had minimum unit pricing not been implemented in 2018.

Between 2018 and 2022, the death rate increased by 10% in Scotland compared to 36% in England as a whole, 38% in north-east England, and 40% in London.

Alcohol deaths in Scotland have risen more slowly than other parts of the UK in recent years (Image: IAS)

"If you compare the rise in deaths in England and Scotland, it is quite shockingly different," said Mr Roberts.

"The mitigating factor has been minimum unit pricing. Basically, deaths have increased everywhere, but not as fast in Scotland as they would have done if MUP hadn't been in place."

So what is the outlook from here?

Could Scotland - like those European nations of the mid-1970s - be on the cusp of a downturn driven by the younger generation?

John Holmes, a professor of alcohol policy and director of the Sheffield Alcohol Research Group, hopes so.

He said: "The trend in deaths was always going to get worse before it got better, because we knew we had those heavy drinking generations coming through.

"Younger people started drinking less around the mid-2000s, so people who were 15 in 2005, by the time those people are 40 - which is when people start dying of alcohol problems - I'd expect to see some of those benefits from that decline in drinking.

"Somewhere between 2030 and 2040.

"But it's difficult to make predictions. The pandemic has thrown things up in the air a bit.

"We're still waiting to see whether this increase in deaths is temporary."