2.1 The purpose of the literature review

The purpose of the literature review was to:

Review the available literature on the trend of alcohol consumption in Scotland;

Review literature on accessibility, drinking patterns and the socio-economic impact of alcohol misuse among young persons below the legal drinking age;

Evaluate literature on the effectiveness of minimum age policy on reducing underage alcohol misuse; and

Review literature on interventions that have been put in place in Scotland to reduce underage alcohol use.

The literature review starts with the review on alcohol consumption in Scotland using the General Household Survey (ONS, 2009) and Scottish Health Survey (Scottish Government, 2008) reports, alcohol sales data from Scotland from 2005 to 2009 (Robinson et al, 2010) and alcohol sales data from the UK from 1970 to 2003 (ScotPHO, 2007). In terms of alcohol consumption among underage persons in Scotland, the literature reviewed include the 2006 and 2008 SALSUS (ISD Scotland, 2007 and 2009) and the 2006 Health Behaviour of School-aged Children ( HBSC) survey (Roberts et. al, 2007). Literature on the relationship between alcohol price and consumption are also reviewed using studies from Switzerland (Heeb et al, 2003), and Finland (Koski et al, 2007).

2.2 Alcohol consumption in Scotland

The literature on alcohol consumption patterns in Scotland comes from two sources: self reported consumption data largely from the General Household and the Scottish Health Surveys; and alcohol sales data for Scotland, England and Wales from 2005 to 2009 and also sales data from Her Majesty’s Revenue and Customs (HMRC) showing sales of pure alcohol in litres per capita from 1970 to 2003 for the whole of UK. Alcohol consumption in relation to price will also be reviewed. It should however be pointed out that looking at alcohol consumption in Scotland by sales data and self reported consumption is not likely to present the true picture of what really pertains because not all alcohol purchased will be consumed and not all consumptions will be reported in surveys.

2.2.1 Alcohol sales

Data from alcohol sales in Scotland indicates that the total amount of pure alcohol sold in Scotland increased from 49.5 million litres in 2005 (with population of 4,165,800) to 50.5 million litres in 2009 (with population of 4,278,700), this compared to pure alcohol sales data from England and Wales which sold 436.5 million litres in 2005 (with population of 43,145,900) and 419.5 million litres in 2009 (with population of 44,566,000), translates into 11.9 and 11.8 litres per capita for 2005 and 2009 respectively for Scotland and 10.1 and 9.4 litres of per capita for 2005 and 2009 respectively for England and Wales (Robinson et al, 2010). This implies that the volume of pure alcohol sold per person aged 16years and above in Scotland has remained relatively stable from 2005 to 2009 (11.9 litres per person in 2005 and 11.8 litres per person in 2009) whereas in England and Wales alcohol sold per person has decreased from 10.1 litres in 2005 to 9.4 litres in 2009 (Robinson et al, 2010). In terms of units of alcohol, the per capita alcohol sale in Scotland translates into 1,219 units of alcohol a year for every adult. This is equivalent to 23.4 units per week which is above the recommended weekly UK alcohol allowance of 14 units for women and 21 units for men. Similarly, available sales data from HMRC indicate that the recorded alcohol consumption in the UK has been increasing since the 1970s as shown in figure 1. The pattern shown indicates that pure alcohol consumption followed a steady increase since the early 1970s (consumption was 6.4 litres per capita in 1970) and reached about 9.4 litre per capita in 2003; this rise took place against a background of falling per capita consumption at an European level which peaked at around 11.8 litres in 1980 and has been falling afterwards (ScotPHO, 2007). In other words the amount of alcohol consumed per person in the UK has increased from 6.4 litres in 1970 to 9.4 litres in 2003 (assuming that all the alcohol that have been recorded by HMRC as having been taxed in the UK are going to be consumed in the UK). This literature is weak in the sense that it cannot be disaggregated to Scotland level.

2.2.2 Alcohol surveys

In terms of alcohol consumption patterns in Scotland, the key surveys considered for adults were the General Household Survey 2007 (ONS, 2009) and the revised 2003 Scottish Health Survey (Scottish Government, 2008b) and for children; the Scottish Schools Adolescent Lifestyle and Substance Use Survey, SALSUS (ISD Scotland, 2009) and the 2006 Health Behaviour of School-aged Children, HBSC survey (Roberts et. al, 2007). With exception of the General Household Survey, the remaining surveys were selected based on the fact that, they were routinely conducted by agencies within Scotland and they provided information on Scottish behaviour at a national level.

The General Household Survey 2007 (ONS, 2009) found the following in relation to patterns of consumption:

Of those who drank alcohol in the last week, 41% of men and 34% of women drank more than the recommended daily amount of units (established as not more that 3-4 units for men and not more than 2-3 units for women) on their heaviest drinking day.

On the heaviest drinking day in the past week 24% of men and 15% of women reported drinking more than two-times the recommended daily amount of units.

In the case of the revised 2003 Scottish Health Survey (Scottish Government, 2008), the key findings were:

On average, men drank 20.3 units of alcohol and women 9.1 per week; these two figures fall below the recommended weekly safe limits of 21 units per week for men and 14 units per week for women.

The percentage of all men whose reported weekly consumption exceeded the recommended 21 units has increased from 33% in 1988 to 34% in the revised 2003 survey. The percentage of all women whose reported weekly consumption was more than 14 units has also seen an increase from 15% in 1988 to 23% in the revised 2003 survey. This suggests that more women are drinking in excess of the recommended weekly allowance compared to men. The reason behind this trend is not known.

On the heaviest drinking day in the past week, 63% of men and 64% of women drank more than the recommended daily amount of units.

Young people’s alcohol consumption in Scotland is evaluated using the surveys from the 2006, 2008 and the 2006 HBSC.

According to the 2006 and 2008 SALSUS (ISD Scotland, 2007 and ISD Scotland 2009), the key findings are as follows:

On average, the 2008 SALSUS report showed that 52% of 13-year-olds and 82% of 15-year-olds have ever had an alcoholic drink. These figures compared to the 2006 SALSUS report showed a downward trend in both cases (from 57% in 2006 to 52% in 13-year-olds, and 84% to 82% in 15-year-olds).

The proportion of pupils who reported having had a drink in the past week also saw a decrease from 14% in 2006 to 11% in 2008 among 13-year-olds; and a decrease from 36% in 2006 to 31% in 2008 among 15-year-olds.

On the issue of drinking to excess, about 50% of 13-year-olds who had ever had an alcoholic drink reported having been ‘really drunk’ at least once compared to 72% of 15-year-olds in the 2008 SALSUS report. Among the 15-year-olds, girls were more likely to report having been ‘really drunk’ (74% of girls compared to 71% boys).

Findings from the 2006 Scottish HBSC (Roberts et. al, 2007), survey showed that:

One in five 13-year-olds and two in five 15-year-olds drink alcohol at least once a week.

Forty eight percent of 15-year-old girls and 43% of 15-year-old boys have been drunk on at least two occasions.

It is likely that these survey figures underestimated the current level of drinking in Scotland, given the self-reported nature of the data.

2.3 Price and consumption

A range of studies have found that price of alcohol influences its availability and consumption. The influence of alcohol pricing on consumption was seen in Switzerland in 1999, when taxes on foreign spirits were reduced by 30-50% in fulfilment of World Trade Organisation’s (WTO) requirement to reduce discrimination against imported products; spirit consumption increased by 28.6% within six months after the tax reduction (Heeb et al, 2003). Another illustration of the link between price and consumption is provided by Finland where a 33% reduction in alcohol excise duty by the government in 2004 led to a 10% rise in alcohol consumption and a 30% rise in liver cirrhosis deaths within one year (Koski et al 2007). In line with this evidence the British Medical Association (BMA) in Scotland has suggested the introduction of minimum price levels for the sale of alcoholic beverages based on alcohol contents (BMA Scotland, 2009). In a similar vein the Chief Medical Officer for England in his annual report on the state of public health in 2008, suggested the introduction of a minimum price of 50 pence per UK unit of alcohol (Department of Health, 2009). Indeed, the Scottish Governments’ recent alcohol policy clearly proposes the setting of “A minimum price per unit of alcohol to raise the cost of the cheapest ciders, lagers and low-grade spirits favoured by problem drinkers” (Scottish Government, 2009).

Cook (2007) asserts that a policy that increases the price of alcohol, delay the start of drinking and slows young people’s progression towards heavy drinking. This assertion though true to an extent, should be accepted with caution, in that, the factors that determine the time at which a young person starts drinking does not depend on only price policies but on several other factors including the age of the person and the settings in which the drink is consumed (Templeton, 2009). Competition in the alcohol market also drives down the price thereby making alcohol cheap and encouraging consumption (Academy of Medical Sciences, 2004). . Aside the usual extended promotions like ‘buy-one-get-one-free’ and deep discounting, some top UK supermarkets including Asda, Morrisons, Sainsbury’s, Sommerfields and Tesco have also adopted a strategy called ‘loss-leading’ where they intentionally price alcoholic products at less than the recommended retail price in order to attract customers into their stores and thereby help sell their other products (Competition Commission, 2007). This practice has been found to be a contributory factor in increased alcohol consumption in the UK (Academy of Medical Sciences, 2004).

In summary, sales data for alcohol sales in Scotland from 2005 to 2009 show that alcohol consumption has been increasing (Robinson et al, 2010). Sales data from the UK for the past 50 years also indicate that alcohol consumption has been increasing (ScotPHO, 2007). The lack of disaggregation of the 50 years sales data for the UK to Scotland level makes it weak in the estimation of alcohol consumption for Scotland.

Alcohol consumption surveys on the other hand showed an increase in trend in the number of adults exceeding the recommended weekly allowance but children’s surveys done in Scotland indicated that the number of under aged persons drinking alcohol in the previous week has reduced between 2006 and 2008. This survey data on alcohol consumption in und