Paper 2 Appendix 2 Alcohol Licensing Consultation Response Midlothian November 2023
Midlothian Council · 12 December 2023
Back to Midlothian Licensing Board — 12 December 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 Midlothian Alcohol Licensing Policy Consultation NHS Lothian & Midlothian HSCP Response November 2023
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2 Contents Introduction ............................................................................................................................................ 3 What works well ..................................................................................................................................... 3 What could be improved ........................................................................................................................ 3 Link to Strategy and Best Practice .......................................................................................................... 3 Taking a Population Approach ............................................................................................................ 4 Alcohol licenses in Midlothian ................................................................................................................ 4 The Association between Alcohol Outlet Density and Alcohol-Related Harm in Midlothian ................ 5 The burden of disease in Midlothian attributable to alcohol consumption ........................................... 5 Alcohol-related A&E attendances ....................................................................................................... 6 Alcohol related hospital admissions ....................................................................................................... 7 Alcohol related mortality ...................................................................................................................... 12 The impact on children and young people ........................................................................................... 15 Summary …………………………………………………………………………………………………………………………………………15
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3 Introduction The below response to Midlothian’s Alcohol License Policy Review has been produced by the Public Health and Health Policy Directorate of NHS Lothian. Further information or clarification on any points can be sought by contacting Jim Sherval, Public Health Consultant jim.sherval@nhslothian.scot.nhs.uk, Ruth Flynn, Public Health Practitioner ruth.flynn2@nhslothian.scot.nhs.uk or Amie Willson, Population Health Project Manager amie.willson2@nhslothian.scot.nhs.uk. As a statutory partner in the licensing forum, NHS Lothian contributes staff capacity to the licensing agenda, with the aim of supporting the licensing objectives of protecting and improving public health and protecting children and young people from harm. The impact of our contribution seems very limited as reflected in the number of alcohol licenses granted and refused. A study conducted by the University of Stirling explored the impact of public health teams on the licensing system1. Key messages from the study were: • No clear evidence that allocating public health resources to engagement in licensing activity resulted in downstream reduction in alcohol related harm. • Benefits are constrained as the system cannot currently reduce alcohol availability or contain online sales. However, NHS Lothian will continue to support the licensing forum and board, such as with health-related data and advice, as is necessary and helpful. What works well NHS Lothian recognise and support the five licensing objectives that the license board are required to contribute to. The five objectives referred to being: preventing crime and disorder; securing public safety; preventing public nuisance; protecting and improving public health; and protecting children and young persons from harm. We will continue to support the licensing board and licensing forum particularly in relation to the objectives of protecting and improving public health and protecting children and young persons from harm. We continue to value receiving new premises licenses, or variation, applications, and the opportunity to comment, including stating objections. What could be improved To strengthen the board’s licensing policy, we feel further links and association with local and national strategy, best practice, and use of local data in relation to alcohol consumption and harm would be beneficial. Link to Strategy and Best Practice Further links with national strategy and best practice in the areas of alcohol consumption and harm would be beneficial. This would strengthen the board’s support of the licensing objective around protecting and improving public health, identifying how the board considers these strategies during decision making.
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4 Other related national policies such as the Scottish Government’s tobacco control action plan2 should also be considered alongside any implications from the refreshed tobacco action plan which is due to be published soon. It would also further highlight this area to license applicants, which they should consider and respond to more robustly in their application, resulting in a comprehensive discussion about protecting harm in the licensing application review process. Key policy and best practice guidance that could strengthen the board’s license policy could be: • The World Health Organisation’s best buys to reducing the harmful use of alcohol3 • The Scottish Government’s Alcohol Framework4 • The Scottish Government’s Public Health Priorities – (PHP4 – A Scotland where we reduce the use and harm from alcohol, tobacco, and other drugs)5 Taking a Population Approach We feel the board’s licensing policy could be further strengthened by taking a population health approach, which considers the implication for each license application across the spectrum of the population, with a focus on children and young people. This approach could be embedded in the license application process or the outcome discussions. Each life stage of the population would be considered in terms of risk and exposure, such as women during preconception and pregnancy, children and young people, families, older people, and people recovering from alcohol dependency. Alcohol licenses in Midlothian No alcohol sales licenses in Midlothian were refused in the 5 years between 01 April 2017 and 31 March 2022. Over the same period, 2 applications were approved. As of 31 March 2022, Midlothian has 223 alcohol outlets6 (132 on trade and 91 off trade), which means there is approximately one outlet for every 334 residents aged 18 and over (and roughly one outlet for every 84 ‘harmful’ drinkers in the region (consuming over 14 units a week). The Centre for Research on Environment, Society and Health (CRESH) published data for alcohol availability (2020 data)7. This data shows an average of 2.2 alcohol retailers (both on and off sales) in Midlothian, which is considered low. However, there are pockets of higher density within Midlothian coupled with higher rates of alcohol-related hospital admissions and crime. The areas highlighted by NHS Lothian analysis include Straiton and Dalkeith. These 2 intermediate zones are in the top 20% of intermediate zones for alcohol outlets and are above the Scottish average for alcohol related admissions or crime rate. This data should be interpreted with caution as there is no current definition of overprovision and the availability of alcohol across Midlothian is influenced by deliveries of alcohol and purchase of alcohol from shops further from people’s homes.8
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5 The Association between Alcohol Outlet Density and Alcohol-Related Harm in Midlothian There has been good evidence for over a decade that increased alcohol outlet density is associated with harms to health9. Specifically, within Scotland, researchers at the University of Edinburgh have found that alcohol outlet density is higher in more deprived areas10 and is a contributing factor to health inequalities. A study conducted pre-pandemic helped to further understand how social and spatial factors influence alcohol issues. Alcohol related mortality and morbidity are more prevalent in neighbourhoods with more alcohol outlets, most significantly the off- sales outlets. Different types of outlets are likely to encourage distinct types of drinking behaviours and may influence health in varying ways11. It is vital to consider the public health impacts of the changes in consumption since the pandemic began and drinking in unregulated spaces such as the home together with the risks for individuals and those who live with them. Overprovision of alcohol creates harm by directly increasing opportunities for purchases, influences the perceived normality of alcohol consumption, and presents multiple challenges for people trying to recover from alcohol dependence12. Reducing the availability of alcohol is considered by WHO to be one of the ‘best buys’ for the prevention of non-communicable diseases and is a key activity in Scotland’s Alcohol prevention framework (2018). Inequalities are a particularly important consideration in relation to overprovision. There is a stark inequalities gradient to alcohol harm, and a growing awareness that the impact of harmful drinking and alcohol dependence is much greater for those experiencing the highest levels of deprivation. The burden of disease in Midlothian attributable to alcohol consumption Data related to some of the burden of disease attributable to alcohol consumption is summarised below. Alcohol-Related Morbidity in Midlothian The Scottish Burden of Disease study13 estimates the total impact of alcohol use on years of healthy life lost. In addition to alcohol-specific deaths from causes such as alcoholic liver disease and alcohol poisoning, it also contributes to years of healthy life lost due to a much wider range of physical illnesses such as cancer, stroke, pneumonia, and accidental injuries in addition to mental ill health and behavioural disorders. Figure 1 below shows the leading causes of ill health (years of healthy life lost to illness) in Midlothian for 2019. For males in particular, alcohol use is the fifth leading cause of years of healthy life lost, and in 2019 was estimated to be directly associated with 206 years of healthy life lost (corresponding to a rate of 477 years per 100,000 population). Meanwhile for females, alcohol use was the twenty-fourth leading cause of years of healthy life lost and was
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6 estimated to be directly associated with 76 years of healthy life lost (corresponding to a rate of 159 years per 100,000 population). Figure 1. Leading causes of ill health in Midlothian (2019) During the pandemic drinking behaviour were polarised, this was associated with drinking behaviour before the pandemic: those who increased their alcohol consumption tended to drink more before the pandemic, and those who decreased consumption tended to drink less14. Alcohol specific deaths in Scotland increased by 17% in 2020 and a further 5% in 202115. It will take longer, possibly up to 20 years to see the full effects of changes in alcohol consumption such as cancers but like the pandemic and economic crisis, it will widen existing and create new inequalities in relation to alcohol related harm16. Alcohol-related A&E attendances Relatively small numbers are recorded for alcohol related attendance at A&E by Midlothian residents for 2022. Approximately 140 attended over the year and were coded with any of the following ICD 10 diagnosis codes, Alcohol intoxication, Alcohol dependence syndrome; Alcohol Withdrawal syndrome; Alcohol withdrawal seizure. Data excludes the Western General Hospital as ICD diagnosis codes for A&E attendances are recorded only at Royal Infirmary of Edinburgh and St Johns Hospital.17 This does not include attendance for issues where alcohol may be an underpinning factor, for example, domestic abuse, violence, or mental health concerns.
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7 The burden of alcohol significantly affects all emergency services and such demand limits or delays emergency service provision to other incidents.18 A recent study by the Institute of Alcohol Studies found that in Scotland, around 16% of ambulance callouts were alcohol-related (2019), rising to 28% across a Friday and Saturday night 18. Based on the average ambulance call out cost it is estimated that alcohol related call outs cost the Scottish Ambulance Service over £30million a year, during a time where demands are exceptionally high 18. Audit Scotland19 reported a lack of evidence of the impact that services were having on their local communities and stigma remained a significant barrier to treatment and support. Alcohol related hospital admissions Alcohol related hospital stays are the number of general acute inpatient and day case stays with a diagnosis of alcohol misuse in any position: 488 patients in Midlothian had alcohol related hospital admissions (2020/2021).20 Alcohol-related hospital admissions are heavily patterned by deprivation, with those living in the most deprived neighbourhoods in Midlothian being approximately three times as likely to be admitted for an alcohol-related illness than those in the least deprived areas 20 The most deprived areas have 79% more hospital admissions than the overall average 20. Alcohol-related hospital admissions would be 43% lower if the levels of the least deprived area were experienced across the whole population 20. Eleven of Midlothian’s intermediate zones sit above the Midlothian average for alcohol related hospital stays including (rate of admissions per 100,000 population) 20: • North Gorebridge (1,240) • Dalkeith (1,180) • Bonnyrigg North (908) • Newtongrange (778) • Penicuik East (686) • Penicuik Southeast (680) • Loanhead (584) • Easthouses (564) • Thornybank (563) • Gorebridge & Middleton (549) • Mayfield (519)
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8 Figure 2. Alcohol related hospital admissions between deprivation groups Data collected related to alcohol related hospital stays, as shown below 20, indicate the huge burden on hospitals in terms of patient numbers and overnights stays, which is increasing in length. This preventable burden is very concerning and puts additional pressure on the health and social care system which is extremely strained.
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9 Figure 3. General acute inpatient and day case stays with an alcohol-related diagnosis in any position from 2009/10 to 2020/21 Figure 4: Number of stays per 100,000 population (EASR), main conditions in general acute hospital.
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10 Figure 4. Average number of stays per patient for all alcohol conditions in general acute Figure 5 below shows the admissions to general acute hospitals for Midlothian patients. Over half (55%) of these patients in 2020/ 21 were admitted for the first time for alcohol- related conditions. Figure 5. European Age-Sex Standardised Rates (EASR) per 100,000 population for all alcohol conditions in general acute
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11 Figure 6. European Age-Sex Standardised Rates (EASR) per 100,000 population for all alcohol conditions in psychiatric Excessive drinking over a period of years may lead to a condition known as alcohol-related brain damage (ARBD). This can cause problems with memory, learning and other cognitive skills. National data on ARBD for individuals with one night in an acute bed with a diagnosis of ARBD shows a rising trend in people with ARBD requiring a hospital stay. It is understood that this client group can be regular attenders of acute services through repeat admissions and / or visits to A&E. Generally, these clients are mid- 50s to early 60s in age. If given the appropriate support to address their alcohol consumption and cognitive impairment people with ARBD can make some form of recovery and go onto live longer and healthier lives. Although current numbers of individuals with ARBD are likely to be low in Midlothian, the impact of increasing rates of alcohol consumption at harmful levels can increase the risk to individuals. Nationally and locally, there are people currently undiagnosed and therefore not known to services or being counted. Figure 7. The number of people treated for Alcohol Related Brain Damage since 2015/16 in NHS Lothian compared to Scotland level. 0 100 200 300 400 500 600 700 800 15/16 16/17 17/18 18/19 19/20 20/21 No. people treated for ARBD NHS Lothian Scotland
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12 Alcohol related mortality In 2021, 1,245 people died in Scotland due to a cause wholly attributable to alcohol, an average of nearly 24 people per week 20. Alcohol-specific death rates increased between 2019 and 2021, an increase that was largely driven by deaths among males aged 45 years and over. People living in the most deprived areas are 5.6 times more likely to die from alcohol related issues that those in the least deprived areas. Alcohol-specific death rates are consistently higher in Scotland than in England and Wales21 and nationally higher than numbers reported for drug related deaths. Alcohol-Specific Mortality in Midlothian The figures reported below are based on a narrow range of causes of death where alcohol is 100% contributory. It has been calculated that at a Scottish level this figure can be doubled22 to include the total number of deaths where alcohol was a contributory factor (e.g., certain cancers, CHD, stroke, hypertension etc). Nevertheless, this definition is useful for monitoring trends.
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13 Figure 8. Deaths from alcohol conditions 2007-2011 to 2016-2020 (rolling 5-year average) Data source: Scottish Public Health Observatory. [Accessed Feb 2022]. The rates indicate that alcohol specific deaths are decreasing generally in Scotland23. The rate for Midlothian is slightly less than the Scottish average at 19.3 deaths per 100,000 (20.8 deaths p/100,000 Scotland). As a comparison, the rate of alcohol specific deaths (19.3 p/100,000) is slightly less than the Midlothian (age-standardised) drug misuse deaths (21.9 p/100,000)24 which are far more publicised than the alcohol related deaths. It is important not to lose sight of the harm that accessibility to alcohol presents. Alcohol specific deaths in Midlothian are generally increasing in number and a significant variation exists, with alcohol specific death rates in the most deprived communities (SIMD 1) compared to the least deprived communities (SIMD 5), as illustrated by figure 9. Therefore, inequalities in health should be considered in this review in terms of high levels of harm and death that individuals in our most deprived communities experience.
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14 Figure 9. Differences in alcohol specific deaths between deprivation groups in Midlothian The Scottish Burden of Disease study25 has reported on estimating ill health. As per Figure 10, Midlothian’s age-sex standardised rates of Years Lived with Disability (YLDs) for alcohol use disorders in 2019 were slightly lower than Scotland’s rates, although they were roughly the same for the 15-24 and 85 and over age groups. YLD are estimated using disease and injury prevalence estimates, levels of severity and disability weights, basically the years lost to ill-health by different age groups.
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15 Figure 10. Alcohol related age standardised rate of years lived with disability (YLD) The impact on children and young people The United Nations Convention on the Rights of the Child (UNCRC)26 contains 54 articles and sets out the civil, political, economic, social and cultural rights that all children are entitled to. The UNCRC (Incorporation) (Scotland) Bill is a bill to respect, protect and fulfil children’s rights and will make it unlawful for public authorities to act incompatibly with the incorporated UNCRC requirements. Key UNCRC articles include: • Article 2 (non-discrimination) – the convention applies to every child without discrimination. • Article 3 (best interests of the child) – the best interests of the child must be a top priority in all decisions and actions that affect children. • Article 6 (life, survival and development) – every child has the right to life. Governments must do all they can to ensure that children survive and develop to their full potential. • Article 12 (respect for the views of the child) – every child has the right to express their views, feelings and wishes in all matters affecting them, and to have their views considered and taken seriously. Children and young people have a right to protection from alcohol related harms. Early familiarity and onset exposure to alcohol encourages earlier use of alcohol, drinking more heavily if already drinking, and more likely to drink at harmful levels. Children have no control over what they are exposed to and therefore limiting exposure to alcohol is crucial. We feel this should be a key driver for the licensing policy. We strongly support the objective in relation to protecting children and young people and feel this
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16 should include involving young people in discussions about the licensing system and protecting them from exposure to alcohol and alcohol related harm. A recent Scottish study stated that alcohol use is the leading cause of harm in young people and increases the risk of alcohol dependency in adulthood27 Key messages from the study were that: • Off sale alcohol outlets accounted for 47% of children’s exposure. • Children living in the most deprived communities were almost 5 times more likely to be exposed to off sale alcohol outlets than children in the least deprived areas. • Children living in the most deprived communities were almost 3 times more likely to be exposed to on sale alcohol outlets than children in the least deprived areas. • Children in deprived areas experienced 31% of their exposure to off sales outlets within 500 m of their homes compared to 7% for children from less deprived areas. • Children from all areas received 22—32% of their exposure within 500 m of schools, but the proportion of this from off sales outlets increased with area deprivation. Foetal alcohol syndrome disorder (FASD) The impact on children before they are born should also be considered. Alcohol consumption in pregnancy has the potential to cause significant foetal damage and alcohol consumption in women of childbearing age is common (with many drinking before they even realise, they are pregnant). There is some evidence to suggest that more mature pregnant women are more likely to drink alcohol and be sceptical of the current “no safe use” advice; potentially due to changing guidance over time or having drank throughout previous pregnancies28. It is estimated that 3-5% of people in Scotland will be living with Foetal Alcohol Syndrome Disorder – a preventable condition, which will affect people life long and is life limiting29. It is difficult to obtain reliable data about the prevalence of FASD as it is difficult to diagnose and often people are diagnosed or assumed to have a different condition that might mirror symptoms of FASD, such as Autistic Spectrum Disorder (ASD) or attention deficit hyperactivity disorder (ADHD). The National Records of Scotland recorded that in 2022, there were 1,040 births in Midlothian30. Using the 3-5% FASD estimates this would mean that in 2022 approximately between 31 and 52 children were born with some level of FASD in Midlothian. It is widely recognised that the challenge of formal diagnosis makes the true extent hard to predict, however it is more common than autism spectrum disorder31. One study who surveyed professionals in the UK highlighted a need for training and education regarding the risks of alcohol in pregnancy and FASD in children for health professionals.32 In addition to being a life limiting condition FASD is also associated with poor educational attainment outcomes, poor mental wellbeing, more likely to experience homelessness and entering the criminal justice system 31.
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17 Summary In summary, alcohol continues to contribute to poor health outcomes for people living in Midlothian and most importantly the inequality gap, where those residing in the most deprived areas continue to experience significantly worse health outcomes than those in the least deprived areas. The licensing board should ensure licensing policy is assessed in terms of its impact on children’s rights, health and wellbeing, and that decision making respects, protects and fulfils children’s rights as set out by the United Nations Convention on the Rights of the Child. Midlothian recorded higher rates of alcohol-related hospital admissions than drug-related admissions. Overall, there has been a 22% increase in alcohol related deaths over 2020 and 2021 which would indicate that alcohol availably and use continues to be a significant public health concern15. To establish a true picture of alcohol provision, a robust recording system should be in place, not only around the number of licences held, but the “reach” of where the establishment delivers to (by post code area). This would inform a true picture of provision and accessibility. Alcohol licensing hours should follow Scottish Government’s guidance and extended hours should be granted only in exceptional circumstances. Alcohol licensing should promote the use the environmentally sustainable practices such as sustainable produced drinking cups instead of plastic. Further work can be done to provide A&E attendance by intermediate zone to determine the levels of alcohol harm in specific areas and correlate with alcohol outlets and type. Also, further information that may assist the board as part of the review could be data held by the Scottish Ambulance Service on the number of alcohol related call outs, location and time of the call outs. A key recommendation from the Scottish Government’s Alcohol Prevention Framework (2018) is that reducing availability and affordability of alcohol will result in safer drinking patterns and a reduction in individual and population-level consumption of alcohol. If this was achieved, longer-term outcomes would potentially include a reduction in health, social care and justice costs, increased workplace productivity, healthier and happier individuals and communities, improved population health and a reduction in health inequalities. Availability, affordability, and consumption are key areas to help reduce alcohol problems33.
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18 References 1 Fitzgerald N, Egan M, de Vocht F, Angus C, Nicholls J, Shortt N et al Exploring the impact of public health teams on alcohol premises licensing in England and Scotland (ExILEnS): procotol for a mixed methods natural experiment evaluation. BMC Medical Research Methodology, 2018, 18 (1), Art. No.: 123. https://doi.org/10.1186/s12874-018-0573-z 2 Scottish Government. Raising Scotland's tobacco-free generation: our tobacco control action plan 2018. Available from: https://www.gov.scot/publications/raising-scotlands-tobacco-free-generation-tobacco- control-action-plan-2018/ 3 World Health Organization, Department for Management of NCDs, Disability, Violence, and Injury Prevention. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI- 17.9-eng.pdf 4 Scottish Government. Alcohol Framework 2018: Preventing Harm. Available from: https://www.gov.scot/publications/alcohol-framework-2018-preventing-harm-next-steps-changing- relationship-alcohol/ 5 Scottish Government. Scotland’s Public Health Priorities 2018. Available from: https://www.gov.scot/publications/scotlands-public-health-priorities/ 6 Scottish Government. Scottish Liquor Licensing Statistics 2022. Available from: https://www.gov.scot/publications/scottish-liquor-licensing-statistics/ 7 University of Edinburgh, School of GeoSciences IT Support. CRESHmap 2023. Available from: https://creshmap.com/ 8 Public Health Scotland. Midlothian Alcohol Overprovision 2023. Available from: file:///C:/Users/Ruth.Flynn2/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/T1QUG8LY/midl othian_report.html 9 Campbell C, Hahn R, Elder R et al. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. American Journal of Preventive Medicine 2009; 37(6):556–569. https://pubmed.ncbi.nlm.nih.gov/19775927/ 10 Ellaway A, Macdonald L, Forsyth A, Macintyre S. The socio-spatial distribution of alcohol outlets in Glasgow city. Health Place. 2010 Jan;16(1):167-72. https://doi.org/10.1016/j.healthplace.2009.08.007 11 Richardson EA, Hill SE, Mitchell R, Pearce J, Shortt NK. Is local alcohol outlet density related to alcohol- related morbidity and mortality in Scottish cities? Health Place. 2015 May;33:172-80. https://doi.org/10.1016%2Fj.healthplace.2015.02.014 12 Shortt NK, Rhynas SJ, Holloway A. Place and recovery from alcohol dependence: A journey through photovoice. Health Place. 2017 Sep;47:147-155. https://doi.org/10.1016/j.healthplace.2017.08.008 13 Public Health Scotland. Scottish Burden of Disease study Forecasting the future burden of disease: Incorporating the impact of demographic transition over the next 20 years, 2022. Available from: Scottish Burden of Disease Forecasting Briefing (scotpho.org.uk) 14 Fraser C, Giles L. The impact of the COVID-19 pandemic on alcohol consumption and harm in Scotland and England: An evidence summary. Edinburgh: Public Health Scotland; 2023. Available from:
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19 https://publichealthscotland.scot/media/18516/the-impact-of-the-covid-19-pandemic-on-alcohol- consumption-and-harm-in-scotland-and-england-an-evidence-summary-english-march2023.pdf 15 National Records of Scotland. Alcohol-specific deaths. Available from: https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/alcohol- deaths 16 Fraser C, Giles L. The impact of the COVID-19 pandemic on alcohol consumption and harm in Scotland and England: An evidence summary. Edinburgh: Public Health Scotland; 2023. Available from: https://publichealthscotland.scot/media/18516/the-impact-of-the-covid-19-pandemic-on-alcohol- consumption-and-harm-in-scotland-and-england-an-evidence-summary-english-march2023.pdf 17 Public Health Scotland. Alcohol related hospital statistics Scotland financial year 2021 to 2022. Available from: https://publichealthscotland.scot/publications/alcohol-related-hospital-statistics/alcohol-related- hospital-statistics-scotland-financial-year-2021-to-2022/ 18 Manca F, Lewsey J, Waterson R, Kernaghan SM, Fitzpatrick D, Mackay D, et al. Estimating the Burden of Alcohol on Ambulance Callouts through Development and Validation of an Algorithm Using Electronic Patient Records. Int J Environ Res Public Health. 2021 Jun 11;18(12):6363. https://doi.org/10.3390/ijerph18126363 19 Audit Scotland. Drug and alcohol services an update, 2022. Available from: https://www.audit- scotland.gov.uk/uploads/docs/report/2022/briefing_220308_drugs_alcohol.pdf 20 Public Health Scotland. Alcohol related hospital statistics Scotland financial year 2021 to 2022. Available from: https://publichealthscotland.scot/media/17953/2023-02-28-arhs-summary.pdf 21 : Ponce Hardy V, Giles L. Monitoring and Evaluating Scotland’s Alcohol Strategy: Monitoring Report 2022. Edinburgh: Public Health Scotland; 2022. Available from: https://publichealthscotland.scot/media/13693/mesas-2022_english_jun2022.pdf 22 Grant I, Springbett, Graham L. Alcohol attributable mortality and morbidity: alcohol population attributable fractions for Scotland. Edinburgh:ISD & ScotPHO, 2019. Available from: http://www.scotpho.org.uk/alcoholPAFreport/ 23 National Records of Scotland. Alcohol-specific deaths, 2023. Available from: https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/alcohol- deaths 24 PubIic Health Scotland. ScotPHO Profiles. Available from: https://scotland.shinyapps.io/ScotPHO_profiles_tool/ 25 Public Health Scotland. The Scottish Burden of Disease (SBoD) study, 2023. Available from: https://scotland.shinyapps.io/phs-local-trends-scottish-burden-diseases/ 26 Unicef. The UN Convention on the Rights of the Child (UNCRC). Available from: https://www.unicef.org.uk/what-we-do/un-convention-child-rights/ 27 Scottish Government, Health and Social Care. Young people experiencing harms from alcohol and drugs: literature and evidence review, 2021. Available from: https://www.gov.scot/publications/review-existing- literature-evidence-young-people-experiencing-harms-alcohol-drugs-scotland/pages/2/ 28 Mårdby A-C, Lupattelli A, Hensing G, Nordeng H. Consumption of alcohol during pregnancy—A multinational European study. 2017, Volume 30, Issue 4, E207-E213, https://doi.org/10.1016/j.wombi.2017.01.003
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20 29 Alcohol Focus Scotland. Fetal Alcohol Spectrum Disorder in Scotland. Available from: https://www.alcohol- focus-scotland.org.uk/alcohol-information/fetal-alcohol-spectrum-disorder-in-scotland/ 30National Records of Scotland. Midlothian Council Area Profile, 2023. Available from: https://www.nrscotland.gov.uk/files//statistics/council-area-data-sheets/midlothian-council- profile.html#Births 31 Scottish Intercollegiate Guidelines Network (SIGN). Children and young people exposed prenatally to alcohol A national clinical guideline 2019. Available from: https://www.sign.ac.uk/media/1092/sign156.pdf 32 Howlett H, Mackenzie S, Strehle EM, Rankin J, Gray WK. A Survey of Health Care Professionals' Knowledge and Experience of Foetal Alcohol Spectrum Disorder and Alcohol Use in Pregnancy. Clin Med Insights Reprod Health. 2019 Mar 27;13:1179558119838872. https://doi.org/10.1177%2F1179558119838872 33 World Health Organization. Addressing alcohol consumption and socioeconomic inequalities: how a health promotion approach can help; 2022. (Snapshot series on alcohol control policies and practice. Brief 1, 4 June 2021.) https://iris.who.int/bitstream/handle/10665/352515/9789240043312-eng.pdf?sequence=1