It is, in short, a perfect storm; the kind feared by governments and public health experts. The signs are that in Scotland – a nation hardly revered throughout the world for its health outcomes – the crisis is exacerbating our long-standing problem relationship with alcohol.
It is grimly ironic that the spread of the virus comes at a time when Scotland has achieved some hard-won progress through its internationally lauded strategy to prevent and reduce alcohol and drug harm.
The annual monitoring and evaluation of Scotland’s alcohol framework showed that 2019 heralded the biggest drop in alcohol consumption in a quarter of a century, with Scots purchasing 3.6 per cent less from off-sales outlets than in the previous year. The trend was no mere coincidence; in England and Wales, off-sales purchases rose by 3.2 per cent over the same period.
Those figures were widely hailed as a sign that the nation was making inroads, and that opposition to minimum unit pricing was misplaced. Beyond the headline statistics, however, the monitoring analysis also showed that there remains some way to go. Some 9.9 litres of pure alcohol were sold per adult over the course last year. That is the equivalent of 19 units per alcohol per week, five units above official recommendations.
A key question is not just how the disruption of Covid-19 threatens to make this journey even more onerous, but how it might further widen health inequalities. In May, polling commissioned by Alcohol Focus Scotland (AFS) and Alcohol Change UK suggested that a majority of Scots were changing their drinking habits during lockdown.
The polling, carried out in mid-April, found that more than a million adults (29 per cent) in Scotland were drinking more than they were before lockdown measures were introduced. However, the same proportion reported a reduction in how often they were drinking, or had stopped drinking altogether.
That divergence, according to Aidan Collins, the engagement and partnerships manager at AFS, has continued in the five months since. “It’s a very complex area and we don’t really fully understand yet what the impacts of the pandemic will be, but everything we’re hearing and seeing does seems to point to a polarisation in drinking habits,” he explained.
“One of the things we hear again and again is that where people are increasing their drinking, it’s very much linked to stress. It’s used as a coping mechanism, and it risks setting a dangerous pattern of consumption which can lead to very real harm.
“With people staying and working at home more, they don’t have to self-regulate in the same way as if they were going into the office. The social checks that used to be in place just aren’t there, and it does seem that some people are falling into really unhealthy patterns.”
Dr Peter Rice, one of Scotland’s leading experts in alcohol misuse and one of the architects of minimum unit pricing, said it is “very difficult” to identify precise consumption trends, in large part because health services have yet to return to normal.
However, he too said that the pattern which saw “heavy drinkers drinking more” and lighter drinkers cutting back or stopping altogether appeared to have been sustained since the start of the pandemic.
“We don’t yet see that pattern translating into increased demand on liver services and so forth, partly because the use of hospital services is so unusual during Covid-19. It’ll be a while before we know how that trend impacts on levels of harm,” said Rice, who is chairman of Scottish Health Action on Alcohol Problems (SHAAP) and a consultant to the World Health Organisation in Europe.
Professor Linda Bauld, the Bruce and John Usher professor of public health at the University of Edinburgh, flagged up similar problems with data on alcohol-related deaths
She said: “There’s a big issue with the reporting of drug-related deaths, but we don’t talk enough about the alcohol-attributable mortalities. It’s probably the case that we’re already seeing some effect, but we just don’t know because we don’t have the data.”
The data gap extends far beyond mortalities and hospitalisations. One of the difficulties in gauging consumption levels is that information relating to off-sales only occasionally enters the public domain, and health researchers have no access to figures spanning the pandemic to date.
A sliver of evidence, in the form of HMRC’s tax take from alcohol sales in the three months from April compared to the same period last year, indicates that there has been a 2 per cent to 3 per cent drop. But, Rice, says, that figure accounts for pubs and bars, which were closed over the period in question. “In Scotland, about three-quarters of our drinking is done at home, and there will have been an increase in off-sales and home deliveries, but we have none of that data,” he said.
It is clear, however, that off licences and retailers have moved to exploit and perpetuate that shift. Morrisons launched a service with Deliveroo which promises customers will receive their alcohol order at their door within 30 minutes. Numerous other websites also vow to make speedy deliveries. “Out of booze and got your reputation to loose?” one such firm states on its website. “Give us a call and we’ll be at yer door faster than you can say, ‘Where’s ma Bucky!?’” Oddbins it is not.
While there is an understanding of the need for flexibility, the relaxation of licensing regulations during the pandemic has raised some “red flags”, Collins said. “There’s a real risk we’ll see a regression with more relaxed approaches and changes in patterns of sales and consumption that we can’t keep up with.”
Rice pointed out that under the Licensing (Scotland) Act 2005, one of the five key objectives that must be considered by licensing boards is the need to protect and improve public health. There were difficulties in applying that principle meaningfully pre-Covid-19, and the acceleration of drinking at home has only further complicated matters.
“One of the main upcoming challenges is finding ways for the licensing system to effectively better regulate the off-trade in the interests of public health, because that’s where there’s a growth in consumption,” he said.
Bauld is of the view that the modifications to the licensing system in the past six months mean it is likely that the public health objective is being considered even less. While some countries have taken hardline approaches to alcohol sales during the pandemic – the likes of South Africa and Thailand have rolled out bans – she believes Scotland is an example of a government pursuing the opposite strategy.
“At a time of crisis like this, you have governments intervening in people’s lives in unprecedented ways, which you might think would give policymakers courage to intervene into other public health areas, whether that be increasing taxes or reducing availability,” she said.
“The alternative, which I think is happening here, is that the reverse happens, and the government gives the licensed trade and companies more freedom because of economic considerations and considerations about people’s interactions.”
The Scottish Families Affected by Alcohol and Drugs (SFAAD) charity, which offers a range of support services to those concerned about alcohol and drug use, believes the rise in home drinking throughout the pandemic has had a revelatory and negative impact on many families.
While alcohol use has long been common across Scotland’s homes, with most of it causing minimal harm or risk, the strange new reality which compels household members to spend extended periods of time together under the one roof has revealed some difficult truths.
“Somebody described the effect as, ‘We didn’t even know our families at all’,” said Justina Murray, the charity’s chief executive officer. “People have been stuck in the house together, and alcohol use that was previously outside the home has moved into the home.”
She pointed out that some alternatives people would use as coping mechanisms for stress and anxiety – such as visiting the gym or other sports facilities – are not yet possible for all. Being cooped up also makes it hard for people to openly seek out help and speak candidly. One man who contacted SFAAD for help did so from his garden shed – a desperate measure in extenuating circumstances.
SFAAD tries to help by offering the likes of webchats, which not only allow people to secure support in privacy – often while sitting on the same couch as their partner – but are free. Even so, families facing up to the problem of alcohol misuse remain under strain.
“It’s become much more visible, harder to hide, consumption is increasing, and people who were in recovery have relapsed,” Murray said. “It’s just an absolute cauldron of volatility and disappointment from some families who had been in a period of recovery.”
Indeed, the availability of treatment and support for those suffering from alcohol misuse – already a contentious issue pre-Covid-19 – has come under increasing scrutiny.
According to SHAAP, coronavirus has presented “significant challenges” for people seeking help, with the public health emergency shining a light on the “patchy” and “often disjointed” nature of alcohol treatment service provision across the country.
Despite guidance issued in April by Joe FitzPatrick, the minister for public health, sport and wellbeing, which made clear to health boards and social care partnerships that alcohol and drug services should remain open during the pandemic, the reality has been altogether more fraught.
Some staff were transferred out of alcohol services in order to help with the wider public health response demanded by Covid-19. In one case, SHAAP says, the Lothians and Edinburgh Abstinence Programme (LEAP), a life-saving residential service, was closed with no consultation, and its patients had to complete their treatment early. Several of the facility’s service users who were awaiting treatment had to be admitted to hospital in the interim.
Elsewhere, the Ritson Clinic, a 12-bed detoxification ward based in the Royal Edinburgh Hospital, was closed at short notice before reopening at reduced capacity.
Murray believes the situation faced by LEAP and the Ritson Clinic was “no doubt spread across Scotland”. The difficulty, however, is knowing exactly which services exist, let alone whether they have been downscaled or worse.
While there is a general view among alcohol misuse charities that the third sector and mutual aid support have responded thoughtfully to the pandemic with comprehensive online support, better-resourced statutory treatment services have been slower to act.
“When we’ve tried to link people calling our helpline to local services, they’re coming back to us and saying no-one is picking up the phone, or no-one is returning their messages, or they’ve been given an appointment in three months’ time,” Murray said.
A survey of Alcohol and Drug Partnerships in the summer reported that there had been no change to the accessibility or availability of services, but SFAAD and other organisations working directly with the public are sceptical at best of that analysis. “It’s just laughable if you speak to anybody on the ground,” Murray said.
“It’s just not really helping, because this is a really reachable moment for people. They are spending more time by themselves and with their families, and this is exactly the time when services should be more accessible.
“There’s very, very limited alcohol treatment to start with. There’s not a lot of options for people, and that’s something the government, ourselves and other agencies are taking forward. It’s a pretty patchy picture at the moment.”
Collins said that Alcohol Focus Scotland had “real concerns” at the start of lockdown about people being unable to access life-saving support, and the curbs which prevented those using recovery services from gathering in person.
While things have progressed, and organisations have been able to adapt to new ways of providing help, he too said one clear learning outcome was just how difficult it is to know what services are out there.
“We don’t have a clear picture of provision across the country, and it’s hard to know what’s been affected,” he said.
Taking a longer-term view, Rice points out that while services are inadequate, they have been so for the past decade, and even pre-Covid, were meeting only around 20 per cent of the need.
“What we saw with LEAP and the Ritson Clinic was a lot of decisions being made very urgently, and I think we understand that,” he said. “However, it did seem that alcohol services were particularly prone to being closed down – they were early casualties.
“It does seem things have improved somewhat since the start of April, but there’s a lot of work to be done around alcohol services. It needs attention, it has done for quite a long time.”
Bauld, meanwhile, has a less than glowing assessment of both the historic response and the current one.
“In a country which has an acute problem with this issue, there has been chronic under-investment, and that lack of support is going to store up problems for the future,” she warned.
“We’ll see more deaths, we’ll see other health consequences, such as domestic violence, and the pandemic generally has shown just how terrible we are at investing in public health.”
If an inadequate, piecemeal network of treatment and support is a historic issue that is being exacerbated by coronavirus, then so are the concerns surrounding alcohol advertising.
Alcohol Focus Scotland said the marketing blitz by drinks companies has echoed its traditional Christmas campaigns, and has sought to exploit trends and make them marketable. Collins points to adverts urging people to make cocktails at home, or – at least prior to the recent ban on household visiting – inviting friends over to have a “pub crawl” at home.
Research by Bauld and her colleagues the University of Edinburgh, published this month by the BMJ, found that drinks firms – as well as tobacco and gambling companies – were “leveraging” the coronavirus crisis to burnish their brands, build influence, and advance their strategic interests, often to the detriment of wider public health.
As well as developing product promotions that exploited the focus on social distancing and utilised face masks as advertising space, they pointed out that many breweries and distilleries shifted production to hand gels and sanitisers in the early stages of the pandemic, with some of the products branded, labelled, and packaged to resemble spirits brands.
Rice believes the long-standing need to overhaul the regulatory system around alcohol advertising has become even more pronounced.
He said: “The alcohol industry regulates itself on marketing, that’s been shown to be insufficient. Regulation needs to be revised and looked at from scratch.
“It’s not traditional print, billboard or television marketing that’s going on, it’s much more sophisticated than that, using the likes of social media, and the regulatory system just can’t keep up with the changes.”
Asked if the pandemic would hasten reform, Bauld said: “I wish I could be optimistic about that. My hunch is we’re probably going the other way and while we’ll crack down on junk food a bit more because of the obesity link [to Covid deaths], we won’t think about the marketing of other harmful commodities.”
Most experts and charities agree that as well as work to address treatment and support, issues of price, availability and marketing must form the focus of the response. Rice, who is better placed than most to assess the landscape, maintains that Scotland is a world leader in alcohol policy, highlighting minimum unit pricing, the work done on multi-buy bans and lowering the drink-drive limit.
He would like to see “close monitoring and attention” paid to minimum pricing, and emphasised that the current 50p-per-unit price remains a “test” at present, which will require regular review. Even so, the early signs are encouraging, he said. “In terms of prevention, Scotland is in a good place.”
Bauld pointed out that bold approaches are possible, if not necessarily probable. Restrictions on where alcohol is sold – such as in Sweden, where a single chain of off-sales stores is owned by the government – have never been given serious consideration in Scotland, but could theoretically form part of the mix. “We know what to do to reduce harmful alcohol consumption,” she said. “I guess the question is that once the Scottish Government can pay attention to anything else other than the current crisis, will it have an appetite to go back to these issues?”
Uncertainty among the public and policymakers will remain, however, for as long as changes and tweaks to Covid-19 regulations are made. Many, such as the imposition of a 10pm closing time for pubs, bars, and restaurants, could have mixed results. “It’s far too early to say what the impact of early closing will be,” said Murray. “In principle, anything which reduces access to alcohol is good, but what we’re not sure about is whether people will just go back to someone’s house to continue drinking.”
Beyond that, the prospect of a long, dark short-term future with continuing curbs on ordinary life perhaps poses an even greater existential challenge, sparking increased stress and anxiety, both factors which can lead people towards increased alcohol consumption.
“I think there’s a sense of impending doom among people that we’re heading into winter and being stuck in our houses again,” Murray added. “There’s no doubt it’s going to be challenging, but amidst all of this, what’s vital is ensuring services and support is available and accessible.”