title: Explaining trends in alcohol-related harms in Scotland 1991-2011 (II): policy, social norms, the alcohol market, clinical changes and a synthesis.
abstract: OBJECTIVE
  To provide a basis for evaluating post-2007 alcohol policy in Scotland, this paper tests the extent to which pre-2007 policy, the alcohol market, culture or clinical changes might explain differences in the magnitude and trends in alcohol-related mortality outcomes in Scotland compared to England & Wales (E&W).
  
  
  METHODS
  Rapid literature reviews, descriptive analysis of routine data and narrative synthesis.
  
  
  METHODS
  We assessed the impact of pre-2007 Scottish policy and policy in the comparison areas in relation to the literature on effective alcohol policy. Rapid literature reviews were conducted to assess cultural changes and the potential role of substitution effects between alcohol and illicit drugs. The availability of alcohol was assessed by examining the trends in the number of alcohol outlets over time. The impact of clinical changes was assessed in consultation with key informants. The impact of all the identified factors were then summarised and synthesised narratively.
  
  
  RESULTS
  The companion paper showed that part of the rise and fall in alcohol-related mortality in Scotland, and part of the differing trend to E&W, were predicted by a model linking income trends and alcohol-related mortality. Lagged effects from historical deindustrialisation and socio-economic changes exposures also remain plausible from the available data. This paper shows that policy differences or changes prior to 2007 are unlikely to have been important in explaining the trends. There is some evidence that aspects of alcohol culture in Scotland may be different (more concentrated and home drinking) but it seems unlikely that this has been an important driver of the trends or the differences with E&W other than through interaction with changing incomes and lagged socio-economic effects. Substitution effects with illicit drugs and clinical changes are unlikely to have substantially changed alcohol-related harms: however, the increase in alcohol availability across the UK is likely to partly explain the rise in alcohol-related mortality during the 1990s.
  
  
  CONCLUSIONS
  Future policy should ensure that alcohol affordability and availability, as well as socio-economic inequality, are reduced, in order to maintain downward trends in alcohol-related mortality in Scotland.
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: gmccartney@nhs.net.
authors.forename: G
authors.initials: G
authors.lastname: McCartney
authors.affiliation: Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom. Electronic address: Janet.Bouttell@glasgow.ac.uk.
authors.forename: J
authors.initials: J
authors.lastname: Bouttell
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: neil.craig@nhs.net.
authors.forename: N
authors.initials: N
authors.lastname: Craig
authors.affiliation: MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Top Floor, 200 Renfield Street, Glasgow, G2 3QB, United Kingdom. Electronic address: Peter.Craig@glasgow.ac.uk.
authors.forename: P
authors.initials: P
authors.lastname: Craig
authors.affiliation: Public Health and Intelligence, NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB, United Kingdom. Electronic address: lesley.graham@nhs.net.
authors.forename: L
authors.initials: L
authors.lastname: Graham
authors.affiliation: NHS Lothian, Waverley Gate, 2-4 Waterloo Place, Edinburgh EH1 3EG, United Kingdom. Electronic address: fatim.lakha@nhs.net.
authors.forename: F
authors.initials: F
authors.lastname: Lakha
authors.affiliation: Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom. Electronic address: jim.lewsey@glasgow.ac.uk.
authors.forename: J
authors.initials: J
authors.lastname: Lewsey
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: rachel.mcadams@nhs.net.
authors.forename: R
authors.initials: R
authors.lastname: McAdams
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: megan.macpherson@nhs.net.
authors.forename: M
authors.initials: M
authors.lastname: MacPherson
authors.affiliation: Urban Studies, School of Social and Political Sciences, University of Glasgow, 25 Bute Gardens, Glasgow, United Kingdom. Electronic address: nate.minton@gmail.com.
authors.forename: J
authors.initials: J
authors.lastname: Minton
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: jane.parkinson@nhs.net.
authors.forename: J
authors.initials: J
authors.lastname: Parkinson
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: markrobinson1@nhs.net.
authors.forename: M
authors.initials: M
authors.lastname: Robinson
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: deborah.shipton@nhs.net.
authors.forename: D
authors.initials: D
authors.lastname: Shipton
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: martintaulbut@nhs.net.
authors.forename: M
authors.initials: M
authors.lastname: Taulbut
authors.affiliation: Glasgow Centre for Population Health, Olympia Building, Bridgeton Cross, Glasgow, G40 2QH, United Kingdom. Electronic address: david.walsh.2@glasgow.ac.uk.
authors.forename: D
authors.initials: D
authors.lastname: Walsh
authors.affiliation: NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom. Electronic address: clare.beeston@nhs.net.
authors.forename: C
authors.initials: C
authors.lastname: Beeston
mesh_terms: D019973:Alcohol-Related Disorders / Q000401:mortality*; D000438:Alcohols / Q000600:supply & distribution; D003132:Commerce / Q000639:trends; D003466:Cultural Characteristics; D006801:Humans; D007182:Income / Q000639:trends; D057766:Policy; D012606:Scotland / Q000453:epidemiology; D066262:Social Norms
chemical_list: D000438:Alcohols
keywords: Alcohol; Availability; Culture; England; Evaluation; Excess mortality; Scotland; Scottish effect; Substitution