Statistics on Public Health, England 2021

The statistical sources used in this publication fall into one of three categories: National Statistics, Official Statistics or neither:

National Statistics are produced to high professional standards set out in the Code of Practice for Statistics. It is a statutory requirement that National Statistics (NS) should observe the Code of Practice for Official Statistics. The United Kingdom Statistics Authority (UKSA) assesses all National Statistics for compliance with the Code of Practice.

Official Statistics should still conform to the Code of Practice for Statistics, although this is not a statutory requirement. 

Those that are neither National Statistics nor Official Statistics may not conform to the Code of Practice for Statistics. However, unless otherwise stated, all sources contained within this publication are considered robust.

Further information on the sources used in this publication is provided below.

Hospital Episode Statistics (HES) processes over 125 million admitted patient, outpatient and accident and emergency records each year.

HES is a data warehouse containing details of all admissions, outpatient appointments and A&E attendances at NHS commissioned hospitals in England. This data is collected during a patient's time at hospital and is submitted to allow hospitals to be paid for the care they deliver. HES data is designed to enable secondary use of this administrative data, i.e. use for non-clinical purposes.

It is a records-based system that covers all NHS commissioned secondary care providers in England, primarily acute hospitals.  HES information is stored as a large collection of separate records, one for each period of care, in a secure data warehouse.

A detailed record is collected for each 'episode' of admitted patient care delivered in England, either by NHS hospitals or delivered in the independent sector but commissioned by the NHS.

Admitted patient care data is available for every financial year from 1989-90 onwards. HES data is now collected monthly.

Admitted patient care data is converted to smoking attributable hospital admissions using the methodology explained in Appendix B.

Hospital Episode Statistics, Admitted Patient Care Activity publications are National Statistics.

The Office for National Statistics produce an annual extract of mortality statistics to NHS England detailing the numbers of registered deaths by cause in England. Registered deaths in England are classified using ICD-10 (10th edition of the International Statistical Classification of Diseases and Related Health Problems).

Mortality data is converted to smoking and drug misuse attributable deaths using the methodology explained in Appendix B.

The prescription data included in this report combines is taken from Prescribing Analysis and Cost Tool (ePACT2).

The number of prescriptions is not the same as the volume of drugs prescribed.  Each single item prescribed is counted as a prescription item and volume is not available within the prescribing data. There will be different practices locally on the duration of supply for a prescription.  Prescriptions are written on a prescription form known as FP10 and each single item on the form is counted as a prescription item. Net Ingredient Cost (NIC) is the basic cost of a drug. It does not take account of discounts, dispensing costs, fees or prescription charges income.

The affordability of and expenditure on alcohol and smoking have been calculated using economic data published by the Office for National Statistics (ONS).

Affordability of alcohol and smoking uses two sources:

• Inflation and Price Indices are National Statistics made up of a series of publications and datasets showing the rate of increase in prices for goods and services. Measures of inflation and prices include consumer price inflation, producer price inflation, the house price index, index of private housing rental prices, and construction output price indices. 
• Consumer trends are National Statistics on the spending on goods and services by UK households including household final consumption expenditure (HHFCE) as a measure of economic growth.

Appendix B provides details on how the affordability statistics have been calculated.

These notes help to explain some of the measurements used and presented in this report.

The number of hospital admissions, attributable to alcohol consumption, is estimated by applying alcohol-attributable fractions (AAFs) to Hospital Episode Statistics (HES) data. AAFs are the proportion of disease cases that can be attributable to alcohol. In 2020 new AAFs were calculated based on updated alcohol consumption rates and the latest evidence linking alcohol consumption to disease outcomes. 

Alcohol-attributable fractions for England: an update

The AAFs are dependent on the condition the patient is suffering from and their age and sex. Some conditions such as mental and behavioural disorders due to the use of alcohol have an AAF of 1 for all patients, i.e. all admissions are related to alcohol. Others have an AAF of less than 1 such as hypertensive disease which has a fraction of 0.17 for men aged 55-64. This means that 17 per cent of all admissions for men in that age group are estimated to be related to alcohol.

Hospital Episode Statistics (HES) is a data warehouse containing details of all admissions, outpatient appointments and A&E attendances commissioned by the NHS in England.

Hospital Episode Statistics (HES)

Within this publication, two measures of alcohol-related hospital admissions are presented:

1. A “broad” measure is derived by summing the alcohol attributable fraction associated with each admission based on the diagnosis most strongly associated with alcohol out of all diagnoses (both primary and secondary).
2. A “narrow” measure which is constructed in a similar way but counts only the fraction associated with the diagnosis in the primary position or alcohol-related external causes recorded in secondary diagnosis fields.

The “broad” measure is a better indicator of the total burden that alcohol has on health services as it takes more account of secondary diagnoses than the “narrow” measure. However, since secondary diagnosis fields have become better populated over time, this impacts upon time series comparisons for the “broad” measure as increases can be partly due to an improvement in data quality rather than a real effect. Consequently, the “narrow” measure is a better indicator of changes over time.

Within each of these measures, the data is broken down into admissions that are wholly and partially attributable to alcohol.

The number of admissions per 100,000 head of population has been calculated by using direct standardisation and the European Standard population. This removes the impact of different age/sex compositions within local authorities and allows for more meaningful comparisons between local authorities.

The report presents three measures for the number of drug misuse related hospital admissions:

1. Admissions for drug-related mental and behavioural disorders: This represents NHS hospital finished admission episodes with a primary diagnosis of drug related mental and behavioural disorders (ICD10 codes F11-F16, F18, F19).
2. Admissions for poisoning by drug misuse: This represents NHS hospital finished admission episodes with a primary diagnosis of poisoning by drugs that are listed as controlled under the Misuse of Drugs Act 1971 (ICD10 codes T40.0 to T40.9, T43.6). This includes both intentional and unintentional poisoning.
3. Admissions where drug-related mental and behavioural disorders were a factor: This represents NHS hospital finished admission episodes with a primary or secondary diagnosis of drug related mental and behavioural disorders (ICD10 codes F11-F16, F18, F19).

The number of admissions is a count of the records meeting the required criteria for the measure.

A finished admission episode is the first period of in-patient care under one consultant within one healthcare provider. Please note that admissions do not represent the number of in-patients, as a person may have more than one admission within the year.

The primary diagnosis is the first of up to 20 diagnosis fields in the Hospital Episode Statistics (HES) dataset and provides the main reason why the patient was in hospital. The secondary diagnosis is one of up to 19 secondary diagnosis fields that show other diagnoses relevant to the episode of care.

HES data are classified using the International Classification of Diseases (ICD). The tenth revision of this classification is currently in use (ICD-10).

These measures do not include outpatient data. Outpatient data is not used as the quality of diagnosis codes are not sufficient to be sure the activity carried out was related to drug misuse.

Data has been suppressed in line with the latest HES suppression methodology in order that individuals can’t be identified in the data. This means that in LA tables, the number of admissions have been rounded to the nearest 5, with small numbers between 1 and 7 suppressed. Age standardised rates have been rounded to the nearest whole number.

Age-standardised rates

Rates per population for hospital admissions have been directly age-standardised using the European standard population. This involves adjusting the number of admissions to account for variations in age profiles between areas. Changes in the values of an age-standardised rate should not be affected by any changes in the distribution of an area’s population by age.

The European Age Standardised Rate is given by:

\(\small EASR = \frac {\sum_1^i(a_i \times e_i)}{100,000}\)

where:

i = age group
a_i = age specific rate per 100,000
e_i = age specific European standard population

For more information on the European Standard Population see: Eurostat European Standard Population 2013

Hospital admission rates by level of deprivation

The Index of Multiple Deprivation (IMD) is the official measure of relative deprivation for Lower Super Output Areas (LSOAs) in England.

It is made up of seven LSOA level domain indices. These relate to income deprivation, employment deprivation, health deprivation and disability, education skills and training deprivation, barriers to housing and services, living environment deprivation, and crime which reflect the broad range of deprivation that people can experience. IMD is a measure of the overall deprivation experienced by people living in a neighbourhood, although not everyone who lives in a deprived neighbourhood will be deprived themselves.

Further details can be found here:

English indices of deprivation

Using this information, LSOA level admissions (based on patient residence) and population data have been be allocated to an IMD decile, and admission rates calculated. These have been age standardised using the European standard populations.

The report presents four measures for the number of obesity related hospital admissions:

1. Admissions directly attributable to obesity: NHS hospital finished admission episodes with a primary diagnosis of obesity (code E66).
2. Admissions where obesity was a factor: NHS hospital finished admission episodes with a primary or secondary diagnosis of obesity (code E66).
3. Obesity admissions for bariatric surgery: NHS hospital finished consultant episodes with a primary diagnosis of obesity (code E66), and a primary or secondary procedure for bariatric surgery (the full list of bariatric surgery procedure codes used is shown below).
4. Obesity admissions for primary bariatric surgery: As per measure 3 but excluding episodes where the only bariatric surgery procedure(s) were maintenance, revisional, or removal procedures. The number of admissions is a count of the records meeting the required criteria for the measure.

A finished admission episode (FAE) is the first period of in-patient care under one consultant within one healthcare provider. A finished consultant episode (FCE) is a continuous period of admitted patient care under one consultant within one healthcare provider.

Please note that admissions do not represent the number of in-patients, as a person may have more than one admission within the year.

The primary diagnosis is the first of up to 20 diagnosis fields in the Hospital Episode Statistics (HES) dataset and provides the main reason why the patient was in hospital. The secondary diagnosis is one of up to 19 secondary diagnosis fields. A secondary diagnosis does not necessarily indicate obesity as a contributing factor for the admission, but may instead mean that it was relevant to a patient’s episode of care.

HES data are classified using the International Classification of Diseases (ICD). The tenth revision of this classification is currently in use (ICD-10). Details of ICD-10 codes used for each of the three measures are included in the excel table footnotes.

These measures do not include outpatient data. Outpatient data is not used as the quality of diagnosis codes are not sufficient to be sure the activity carried out was related to obesity.

Data only includes admissions for residents of England, and for persons with no fixed abode.

Age-standardised rates

Rates per population for hospital admissions have been directly age-standardised using the European standard populations. This involves adjusting the number of admissions to account for variations in age profiles between areas. Changes in the values of an age-standardised rate should not be affected by any changes in the distribution of an area’s population by age.

The European Age Standardised Rate is given by:

\(\small EASR = \frac {\sum_1^i(a_i \times e_i)}{100,000}\)

where:

i = age group
a_i = age specific rate per 100,000
e_i = age specific European standard population

Coding for bariatric surgery

The term “bariatric surgery” is often used to define a group of procedures that can be performed to facilitate weight loss although these procedures can be performed for conditions other than weight loss. It includes stomach stapling, gastric bypasses, sleeve gastrectomy and gastric band maintenance. Using Hospital Episode Statistics (HES) data held at NHS England, the number of FCEs for bariatric surgery has been determined where the primary diagnosis was obesity (ICD-10 code E66) and the main or secondary procedure was for bariatric surgery, based on the OPCS code for the relevant time periods. This data includes removals and/or maintenance following an initial procedure, so the counting of the same patient is more likely (where removal and/or maintenance occurred during a later episode of care).

Also presented are admissions for ‘primary bariatric surgery’. This excludes those episodes where the only bariatric surgery procedure(s) related to removals and/or maintenance. In this data, patients are likely to only be counted once, for the initial bariatric surgery procedure.

Since 2012/13 the OPCS codes included in the bariatric surgery definition have been aligned with the methodology used for NHS Healthcare Resource Groups (HRGs). The new HRGs were created as a result of work between the National Casemix Office at NHS England, the British Obesity and Metabolic Surgery Society (BOMSS) and the Chapter F Digestive System Expert Working Group (EWG). Details of that change can be found in the methodological change notice. 

Latest data are based on the tenth revision of the International Classification of Diseases (ICD-10). The FCE data for bariatric surgery are based on the Office for Population, Censuses and Surveys: Classification of Intervention and Procedures, 4th Revision (OPCS4) codes.

The table below shows the current list of OPCS codes used.

Introduction

Estimates of national smoking attributable NHS hospital admissions given in Tables S.1.1 to S.1.3 are based on the following information:

1. Estimates of smoking prevalence for both smokers and ex-smokers
2. Relative risks for non-fatal disease for both smokers and ex-smokers compared to someone who has never smoked for those diseases known to be associated with smoking. 
3. Observed numbers of hospital admissions caused by those diseases which can be caused by smoking.

LA level smoking attributable NHS hospital admissions are available in the PHE Tobacco Control Profiles.

Note: The LA level admissions will not sum to give the same national estimates in Tables S.1.1 to S.1.3.  This is because three years of prevalence data is used to increase the APS sample size at LA level, to ensure the prevalence estimates are robust. Work between NHS England and OHID is ongoing to harmonise methodologies.

Smoking Prevalence

Estimates of the prevalence in England of current and ex-smokers by age and sex have been taken from the results of Annual Population Survey (APS) from 2016/17 onwards. The latest smoking prevalence information used in this report is presented in Tables S.B.1.

Prior to 2016/17, the smoking prevalence data used to calculate national level estimates of admissions was taken from the Opinions and Lifestyle Survey (OPN). It is now based on the Annual Population Survey (APS) in order to take advantage of the much larger sample size and to be more consistent with the data sources used to produce the LA level estimates. The impact of the change was found to be negligible and more information is given in the methodological change notice (June 2018).

Relative risks: Non-fatal diseases

The relative risks for non-fatal diseases (Crohn’s disease; Periodontal disease/Periodontitis; Age-related cataract; Hip fracture and Spontaneous abortion) are also presented in Table S.B.2 to estimate the numbers of smoking-attributable hospital admissions in England. These risks have been taken from diseases used by Hughes and Atkinson in the report Choosing Health in the South East: Smoking, which was based on an update of a 1996 epidemiological study. These diseases have not since been reclassified by the DHSC review as fatal.

The risks for these non-fatal diseases are presented in the same way as those for fatal disease, however they are not sex-specific (with the exception of hip fracture among the 75+ age group) and so the same risks are used to calculate the attributable proportions for both men and women. In the case of spontaneous abortion, the risk is only given for current female smokers.

In order to be consistent with the methodology for fatal diseases, the risks for non-fatal conditions were only applied for hospital admissions of people aged 35 and over.

For fatal diseases, the risks of death were also applied to calculate smoking-related hospital admissions in England. There are some drawbacks to using mortality risks for health outcomes and these are discussed by Callum and White in Tobacco in London: The Preventable burden (ISBN-13: 978-0954295622)

Admissions

Figures on hospital admissions are from NHS England Hospital Episode Statistics (HES). The data refer to finished admission episodes of people who are resident in England for the specified period, based on the primary diagnosis.

The tenth revision of the International Classification of Diseases (ICD) was used to identify hospital admissions from the diseases of interest.

Calculation of Smoking-Attributable Admissions

For each of the diseases or groups of diseases shown in , the attributable proportion is calculated as follows:

\(a = \frac{p_c (r_c-1)+p_x(r_x-1)}{1+p_c (r_c-1)+p_x(r_x-1)}\)

where:

a = attributable proportion for each disease
p_c = proportion of current smokers
p_x = proportion of ex-smokers
r_c = relative risk of current smokers
r_x = relative risk of ex-smokers.

The equation is reduced where the risks are only given for ‘all smokers’ or ‘current smokers’ (as is the case for some non-fatal conditions).

The estimated number of smoking-attributable hospital admissions in England is found by multiplying the observed number by the attributable proportion.

Introduction

Estimates of national smoking attributable deaths given in Table S.1.4 to S.1.6 are based on the information below:

1. Estimates of smoking prevalence for both smokers and ex-smokers
2. Relative risks for deaths for both smokers and ex-smokers compared to someone who has never smoked for those diseases known to be associated with smoking. 
3. Observed numbers of deaths caused by those diseases which can be caused by smoking.

LA level smoking attributable deaths are available in the PHE Tobacco Control Profiles.

Note: The LA level deaths will not sum to give the same national estimates in Tables S.1.4 to S.1.6. This is because for deaths three years of prevalence data is used to increase the APS sample size at LA level, to ensure the prevalence estimates are robust and so that the LA level death fluctuations smooth out any year on year changes at LA level. Work between NHS England and OHID is ongoing to harmonise methodologies.

Smoking Prevalence

Estimates of the prevalence in England of current and ex-smokers by age and sex have been taken from the results of Annual Population Survey (APS) from 2016/17 onwards. The latest smoking prevalence information used in this report is presented in Table S.B.1.

Prior to 2016/17, the smoking prevalence data used to calculate national level estimates of deaths was taken from the Opinions and Lifestyle Survey (OPN). It is now based on the Annual Population Survey (APS) in order to take advantage of the much larger sample size and to be more consistent with the data sources used to produce the LA level estimates. The impact of the change was found to be negligible and more information is given in the methodological change notice (June 2018).

Relative risks: Fatal diseases

In 2007 a review of the existing methodologies was undertaken by the Department of Health (DH) which resulted in a revised list of diseases for which there was an excess risk of death for current and ex-smokers compared to those people who have never smoked. This was then used to estimate numbers of smoking attributable fatalities in the Health Profile for England (HPE). This revised approach has been adopted for this report.

The methodology employed in this report is identical to that used by the DH in the HPE 2008 and HPE 2009. The method differs slightly from the HPE 2007 as it does not reduce the deaths figure to take account of those diseases for which smoking decreases the relative risk, specifically Parkinson’s disease and cancer of the uterus.

The values presented in Table S.B.2 represent the risk of a person who smokes or is an ex-smoker, dying from that disease (unless listed as a non-fatal disease) compared to someone who has never smoked. That is, a value greater than 1 represents an increased risk of death. The risks are only applicable to people aged 35 and over and therefore only deaths of people aged 35 and over have been used in calculating the estimates.

Deaths

The number of deaths for men and women in each of the specified age groups are taken from an annual extract of Office for National Statistics (ONS) mortality statistics by cause and by registrations. The data used refer to the number of registered deaths in England.

The tenth revision of the International Classification of Diseases (ICD) was used to identify deaths from the diseases of interest.

In January 2011 ONS introduced a new version of ICD-10 (version 2010) which replaced version 2001.2. This means that some figures for the number of deaths for 2011 onwards will not be directly comparable to figures for 2001 to 2010. Further details are available from ONS.

Calculation of Smoking-Attributable Deaths

For each of the diseases or groups of diseases shown in , the attributable proportion is calculated as follows:

\(a = \frac{p_c (r_c-1)+p_x(r_x-1)}{1+p_c (r_c-1)+p_x(r_x-1)}\)

where:

a = attributable proportion for each disease
p_c = proportion of current smokers
p_x = proportion of ex-smokers
r_c = relative risk of current smokers
r_x = relative risk of ex-smokers.

The estimated number of smoking-attributable deaths in England is found by multiplying the observed number by the attributable proportion.

The two main drugs prescribed for the treatment of alcohol dependence are Acamprosate Calcium (Campral) and Disulfiram (Antabuse). In May 2013 a new drug Nalmefene (Selincro) was launched. Details of how these drugs work is provided below:

Acamprosate Calcium (Campral) – helps restore chemical balance in the brain and prevents the feelings of discomfort associated with not drinking, therefore reducing the desire or craving to consume alcohol.

Disulfiram (Antabuse) – produces an acute sensitivity to alcohol resulting in a highly unpleasant reaction when the patient under treatment ingests even small amounts of alcohol.

Nalmefene (Selincro) – is the first medicine to be granted a licence for the reduction of alcohol consumption in people with alcohol dependence. It helps reduce the urge to drink in people accustomed to large amounts of alcohol but does not prevent the intoxicating effects of alcohol.

Naltrexone is also prescribed for alcohol dependence. It is not included in this report however, as it can also be used to treat drug dependence and the condition that Naltrexone is prescribed to treat is not available within the prescribing data.

Since 2010, Orlistat (Xenical®) is the only drug available in the UK that is recommended specifically for the management of obesity. It is a lipase inhibitor and reduces the absorption of dietary fat in the intestines and so promotes weight loss. Clinical guidelines state that pharmacological interventions should only be used in conjunction with other interventions (exercise, diet).

Semaglutide or Liraglutide - can be used for weight management, including weight loss and weight maintenance, alongside a reduced-calorie diet and increased physical activity in adults, however, they are also used for the management of type 2 diabetes.

Further details are available from NICE

There are three main pharmacotherapies prescribed for the treatment of smoking dependence in England:

Nicotine Replacement Therapy (NRT) provides a low level of nicotine, without the tar, carbon monoxide and other poisonous chemicals present in tobacco smoke. It can help reduce unpleasant withdrawal effects, such as bad moods and cravings, which may occur when you stop smoking.

Bupropion (Zyban) - can be effective in the early stages of smoking cessation withdrawal by attenuating the effects of nicotine withdrawal and works in combination with motivational support in nicotine-dependent patients.

Varenicline (Champix) - works by blocking the pleasant effects of nicotine (from smoking) on the brain. As an aid to smoking cessation it is used along with education and counseling to help people stop smoking.

Affordability of alcohol gives a measure of the relative affordability of alcohol, by comparing the relative changes in the price of alcohol, with changes in households’ disposable income per capita over the same period (with both allowing for inflation).

Relative changes in the price of alcohol are calculated using the Relative Alcohol Price Index (RAPI) which shows how the average price of alcohol has changed compared with the price of all other items and is calculated as follows:

\(\small RAPI = {API \over RPI} \times 100\)

where:

API = Alcohol Price Index
RPI = Retail Prices Index

Changes in households’ disposable income are calculated using the Adjusted Real Households’ Disposable Income (ARHDI) index which tracks changes in real disposable income per capita.

The Relative Affordability of Alcohol Index (RAAI) is calculated as follows:

\(\small RAAI = {ARHDI \over RAPI} \times 100\)

where:

ARHDI = Adjusted Real Households’ Disposable Income
RAPI = Relative Alcohol Price Index

If the affordability index is above 100, then alcohol is relatively more affordable than in the base year, January 1987.

Affordability of Tobacco Index

The Affordability of Tobacco Index, as seen in Table S.3.1 of this publication, gives a measure of the relative affordability of tobacco, by comparing the relative changes in the price of tobacco, with changes in households’ disposable income per capita over the same period (with both allowing for inflation).

The Tobacco Price Index (TPI) shows how much the average price of tobacco has changed compared with the base price (1987).

The Retail Prices Index (RPI) shows by how much the prices of all items have changed compared with the base price (1987).

Both the above indices are produced by ONS.

From this information, we calculate the Relative Tobacco Price Index (RTPI) as follows:

\(\small RTPI = {TPI \over RPI} \times 100\)

where:

TPI = Tobacco Price Index
RPI = Retail Prices Index

This shows how the average price of tobacco has changed since the base year (1987) compared with prices of all other items. A value greater than 100 shows that the price of tobacco has increased by more than inflation, during that period.

The Real Households’ Disposable Income (RHDI) measure, produced by ONS, is based on the total households’ income, minus payments of income tax and other taxes, social contributions, and other current transfers. By dividing this by the total number of UK adults (aged 18 and over) gives a per capita measure: the Adjusted Real Households’ Disposable Income (ARHDI) measure. Revisions to original population estimates published by ONS are applied to the time series when applicable. As population estimates for the most recent year of data do not become available until after publication, the most recent year of estimates available are used for the most recent year of the ARHDI.

The ARHDI is then converted to an index, based on 1987 as the index year, by dividing the ARHDI value for each year by the value for the index year.  The value is then multiplied by 100 to create the Adjusted Real Households’ Disposable Income Index (ARHDII).

As described above, a general price index, Relative Tobacco Price Index (RTPI) can be created, to remove the effect of inflation, by dividing the Tobacco Prices Index (TPI) by the Retail Prices Index - all items (RPI) and multiplying by 100, both are available from ONS.

The Affordability of Tobacco Index (ATI) is then calculated as follows:

\(\small ATI = {ARHDII \over RTPI} \times 100\)

where:

ATI = Affordability of Tobacco index
ARHDII = Adjusted Real Households’ Disposable Income Index
RTPI = Relative Tobacco Price Index

If the affordability index is above 100, then tobacco is relatively more affordable than January 1987.

More information on the creation of indices used in this calculation can be found on the ONS website.

Affordability of tobacco: Forestalling

Forestalling is a tax avoidance practice; whereby excessive quantities of goods are removed for home-use on payment of duty because an increase in the rate of duty is expected. (HMRC 2014).

Receipts were high in December 1998 following the November Budget and associated forestalling. The next Budget took place in March 1999 but as stocks were still available from the November forestalling, no further forestalling took place. The next Budget took place in March 2000. Manufacturers forestalled against this affecting April receipts. There was therefore no forestalling in the financial year 1999/2000.

The UK Chief Medical Officers’ low risk drinking guidelines

In 2016, the UK chief medical officers issued new guidelines on how to keep health risks from drinking alcohol to a low level.

UK chief medical officers’ low risk drinking guidelines

In 2017 guidance was published setting out how the UK chief medical officers' advice on alcohol and its health risks can be communicated to the public on product labels.

Communicating the UK chief medical officers’ alcohol guidelines

Policing and Crime Act

The Policing and Crime Act includes alcohol licensing provisions.

Policing and Crime Act: alcohol licensing

Modern Crime Prevention Strategy

The modern crime prevention strategy builds on new research, techniques and technology to update the way we think about crime prevention. The strategy includes research on the links between alcohol and crime.

Modern crime prevention strategy

NHS Health Check programme

NHS Health Check programme includes an alcohol risk assessment to provide support where needed ranging from brief advice to a referral to specialist alcohol service.

NHS Health Check

Commissioning for Quality and Innovation

The Commissioning for Quality and Innovation (CQUIN) framework supports improvements in the quality of services and the creation of new, improved patterns of care. This includes the delivery of advice to hospital patients on alcohol consumption and where appropriate referral to treatment.

Commissioning for Quality and Innovation

Making Every Contact Count

Making every contact count (MECC) is an approach to behaviour change that utilises the millions of day to day interactions that organisations and people have with other people to encourage changes in behaviour that have a positive effect on the health and wellbeing of individuals, communities and populations. This includes reducing alcohol consumption.

Making Every Contact Count

NHS: Better Health

Better Health provides free tools and support to encourage people to make healthy changes, including drinking less.

Better Health: Drink less

UK Drug Laws

a) The Misuse of Drugs Act 1971

Offences under the Act include:

• Possession of a controlled drug unlawfully.
• Possession of a controlled drug with intent to supply it.
• Supplying or offering to supply a controlled drug (even where no charge is made for the drug).
• Allowing premises you occupy or manage to be used unlawfully for the purpose of producing or supplying controlled drugs.

Misuse of Drugs Act 1971

b) The Drugs Act 2005

This Act came into force on 1st January 2006 and includes the following clauses:

• A reversal of the burden of proof in cases where suspects are found in possession of a quantity of drugs greater than that which would be required for personal use.
• Compulsory drug-testing of arrestees where police have “reasonable grounds” for believing that Class A drugs were involved in the commission of an offence.
• The inclusion of fresh Liberty Cap or “magic” mushrooms in Class A of the Misuse of Drugs Act.

Before this Bill, only dried or prepared mushrooms were considered illegal. The Act has also linked drug legislation with measures to deal with Anti-Social Behaviour so that anyone given an Anti-Social Behaviour Order must undergo compulsory testing and drug treatment.

Drugs Act 2005

c) The Psychoactive Substances Act 2016

This Act came into force on 26 May 2016 and is intended to restrict the production, sale and supply of new psychoactive substances, previously referred to as "legal highs", and nitrous oxide (laughing gas).

Psychoactive Substances Act 2016

Policy

a) Drug Strategy 2017

The Drug Strategy 2017 sets out how the government and its partners, at local, national and international levels, will take new action to tackle drug misuse and the harms it causes.

Drug Strategy 2017

Obesity

Childhood Obesity Plan 

The Government launched its new Childhood Obesity Plan in August 2016. The plan aims to significantly reduce England’s rate of childhood obesity within the next 10 years. Key measures include a sugar reduction programme, including a soft drinks industry levy, helping children to enjoy an hour of physical activity every day and a healthy rating scheme for primary schools.

The Government published the second chapter of the Childhood Obesity plan in June 2018, setting out the ambition to halve childhood obesity and significantly reduce the gap in obesity between children from the most and least deprived areas by 2030. 

Sugar Reduction: achieving the 20% (Public Health England)

The Sugar Reduction: achieving the 20% report sets out guidelines for all sectors of the food industry on how to achieve a 20% sugar reduction across the top 9 categories of food that contribute most to intakes of children up to the age of 18 years.

Change4Life 

Change4Life is the Government’s social marketing programme supporting the ambition to halt the rise in childhood obesity.  Change4Life aims to inspire a social movement through which government, the NHS, local authorities, businesses, charities, schools, families and community leaders can all play a part in changing behaviour to help improve children’s diets and activity levels.

One You 

Public Health England’s One You social marketing campaign, launched in March 2016, aims to inform, energise and engage millions to make changes to improve their health by eating well, moving more, quitting smoking and drinking less. One You provides tools and on-going support to help people reappraise their health and make and sustain changes. The campaign is supported by an extensive range of commercial and public sector partners so adults will encounter One You on their high streets and local services, in pharmacies and GP surgeries.

National Child Measurement Programme (NHS England)

The National Child Measurement Programme (NCMP) is a mandatory public health function of local authorities. The programme provides robust data on the weight status, including obesity and underweight prevalence, of over a million children in reception year and year 6 each year.  This is around 95 per cent of those eligible. The data enable local areas to plan services to tackle child obesity and monitor progress. In most local authorities, parents also receive feedback on their child’s weight status along with the offer of further advice and support on achieving a healthy weight for their child.

NHS Health Checks

The NHS Health Checkis a health check-up for adults in England aged 40 to 74. It's designed to spot early signs of stroke, kidney disease, heart disease, type 2 diabetes or dementia. As we get older, we have a higher risk of developing one of these conditions. An NHS Health Check helps find ways to lower this risk.

NHS Diabetes Prevention Programme

There are currently five million people in England at high risk of developing Type 2 diabetes. If these trends persist, one in three people will be obese by 2034 and one in 10 will develop Type 2 diabetes.

There is strong international evidence which demonstrates how behavioural interventions, which support people to maintain a healthy weight and be more active, can significantly reduce the risk of developing the condition.

The Healthier You: NHS Diabetes Prevention Programme (NHS DPP) identifies those at high risk and refers them onto a behaviour change programme.

The NHS DPP is a joint commitment from NHS England, Public Health England and Diabetes UK.

Physical Activity

Sporting Future - A New Strategy for an Active Nation (Department for Digital, Culture, Media and Sport)

Sporting Future: A New Strategy for an Active Nation was published in December 2015 and set out a new government vision for sport concentrating on five key outcomes physical wellbeing, mental wellbeing, individual development, social and community development and economic development.

The government published its second annual progress report on the sport strategy in 2018, which highlights important achievements such as the new Active Lives survey which will help to develop a fuller understanding of how people engage with sport and physical activity. It also sets out how Sport England is meeting its new responsibility for children’s engagement in sport and physical activity from the age of five.

Sport England’s own strategy Towards an Active Nation highlights Sport England’s new approach, including investing over £194 million into projects focused on improving children’s capability and enjoyment and tripling its current investment in tackling inactivity to around £250 million.

Physical activity guidelines 

A report from the Chief Medical Officers in the UK on the amount and type of physical activity people should be doing to improve their health.

Children and Young People in Schools

As announced in the 2016 budget, revenue generated from the ‘soft drinks levy’ will be used to double the PE and sports premium for primary schools from £160m a year to £320m from September 2017, and to increase the funding for breakfast clubs. Department for Education have also announced a new £415m Healthy Pupils Capital Fund for 2018/19 to be funded through the soft drinks industry levy to provide new facilities to support sports, after-school clubs and activities to promote healthy eating. Government will also continue to invest in the School Games which provides competitive sporting opportunities for children across the country.

Everybody Active, Every Day: framework for physical activity

In October 2014, Public Health England published a national physical activity framework, Everybody Active, Every Day, following a nine-month co-production process with other 1,000 national and local stakeholders and with full ministerial involvement. This framework presented an evidence-based approach to increase levels of physical activity and reduce physical inactivity in local communities based on international evidence of what works to increase population level physical activity.

Cycling and Walking Investment Strategy

Active travel, such as cycling and walking, has a crucial role to play in improving public health. Walking and cycling are some of the easiest ways for people to build physical activity into their daily lives. The Government’s Infrastructure Act 2015 made a commitment to supporting cycling and walking over the long term by requiring Department for Transport to put a strategy in place which sets out the financial resources the Government will make available towards meeting the objectives.

The Cycling and Walking Investment Strategy (CWIS) was published in 2017.

Diet

Eatwell Guide

The Eatwell Guide is a policy tool used to define government recommendations on eating healthily and achieving a balanced diet.

Five-A-Day

Current recommendations are that everyone should eat at least 5 portions of a variety of fruit and vegetables each day, to reduce the risks of chronic illnesses such as heart disease, stroke and some cancers. The 5 A Day programme aims to increase fruit and vegetable consumption.

Government Buying Standards for food and catering services (GBS)

Central government procurers directly or through their catering contractors are required to apply the GBS. Others are encouraged to follow it. It includes a set of minimum mandatory standards for inclusion in tender specifications and contract performance conditions. It also includes some best practice standards which are recommended but not required.

Targets

The Tobacco Control Plan, 'Towards a smoke-free generation: a tobacco control plan for England', was published on 18 July 2017.

This set out how tobacco control was to be delivered in the context of the new public health system, and set out to achieve the following national ambitions in England by the end of 2022:

• reduce the number of 15-year olds who regularly smoke from 8% to 3% or less.
• reduce smoking among adults in England from 15.5% to 12% or less.
• reduce the inequality gap in smoking prevalence, between those in routine and manual occupations and the general population.
• reduce the prevalence of smoking in pregnancy from 10.5% to 6% or less.

Regulation

The Tobacco and Related Products Regulations 2016 came into force on 20 May 2016, implementing the rules set out in the revised Tobacco Products Directive (TPD), which was published in April 2014, and cover tobacco and smokeless tobacco products, herbal products and for the first time regulate e-cigarettes. The Regulations establish new specific product standards and rules for the safety and quality of ingredients, presentation and advertising of consumer e-cigarettes and refill containers.

E-cigarettes that contain more than 20 mg/ml of nicotine and/or make medicinal claims, such as “This product helps you to quit smoking”, will be regulated under existing medicines legislation, for which the Medicines and Healthcare products Regulatory Agency (MHRA) is responsible. Such products would be considered medicinal and manufacturers must obtain a license from the MHRA before placing on the market.

Those e-cigarettes not captured by medicines regulation will be regulated as consumer products with additional safeguards. These requirements include six month prior notification of a range of information before e-cigarettes or refills are placed on the market; a size limit for e-liquids of 10ml for dedicated refill containers and 2ml for disposable e-cigarettes, cartridges and tanks; the inclusion of health warnings and an information leaflet; child and tamper resistant packaging; and restrictions on the advertisement or promotion of e-cigarettes and refill containers on a number of media platforms.

The Government has adopted regulations to require standardised (plain) packaging of tobacco products for cigarettes and hand rolling tobacco, effective from May 2016. There was a one year transitional period for the sell-through of old stock and from May 2017 all tobacco products on sale in the UK had to comply with these regulations. These new packs also feature larger graphic warnings and are sold in a minimum pack size for cigarettes at 20 sticks and for hand rolling tobacco at 30g weight.

New legislation came into force in England and Wales on 1 October 2015, introducing a minimum age of sale of 18 for e-cigarettes and prohibiting the purchase of these products and tobacco products on behalf of someone under the age of 18.

In addition, legislation to protect children from second-hand smoke by ending smoking in private vehicles carrying children also came into force on 1 October 2015.

Local Stop Smoking Services

Stop Smoking Services were first set up in 1999/2000 and rolled out across England from 2000/01. Services provide free, tailored support to all smokers wishing to stop offering a combination of recommended stop smoking pharmacotherapies and behavioural support.

Following a change in the guidance in December 2005, Nicotine Replacement Therapy (NRT) was made available for the first time to adolescents over 12 years, pregnant or breast feeding women and patients with heart, liver and kidney disease. In September 2006, the European Commission approved Champix, generic name Varenicline, as a new pharmacotherapy to help adults quit smoking. The National Institute for Health and Clinical Excellence (NICE) issued guidance in, recommending the use of Champix as an aid to stopping smoking in the NHS.

NICE has since published a range of guidance to support the commissioning and delivery of stop smoking services and this is available

The National Centre for Smoking Cessation and Training (NCSCT) was established by the Department of Health in 2008 to standardise training for those providing support for and delivering stop smoking services. The full range of training is available.

The service and delivery guidance for local stop smoking services was updated in 2014 and is available on the NCSCT website.

In addition, the local stop smoking services return now includes the use of unlicensed nicotine containing products, such as e-cigarettes, and these have shown to be effective, in combination with behavioural support, in helping people to stop smoking.

Review of electronic cigarette use

In 2015, Public Health England (PHE) published an independent evidence review on electronic cigarettes which concluded that the devices are significantly less harmful than smoking.

The review also found no evidence that electronic cigarettes act as a route into smoking for children or non-smokers. In addition to the evidence review PHE has published its position on electronic cigarettes:

In July 2016, PHE and other public health organisations, issued a consensus statement on e-cigarettes.

New combined publication

In 2015 a consultation was carried out to gain feedback on how to make the report more user-friendly and accessible while also producing it in the most cost-effective way.

Findings of the 2015 Consultation

In response to the feedback received, the format of the report was changed for the 2016 report.

This publication has been created following a further user consultation conducted in 2022 to gain further feedback on how to make the report more user-friendly and accessible while also producing it in the most cost-effective way. The proposal adopted was to combine the four compendia publications, listed below, into this single publication:

• Statistics on Alcohol
• Statistics on Drug Misuse
• Statistics on Obesity, Physical Activity and Diet
• Statistics on Smoking

Findings of the 2022 Consultation

Users and uses of the report

From our engagement with customers, we have many known users of the four compendia publications. However, since these publications are free to access through the NHS England website, there are also many unknown users of these statistics. We are continually aiming to improve our understanding of who our users are to enhance our knowledge on how they use our data. This is carried out via consultations and feedback forms available online.

Below is listed our current understanding of the known users and uses of these statistics. Also included are the methods we use to attempt to engage with the unknown users.

a) Known users and uses

Department of Health and Social Care (DHSC) - use these statistics to inform policy and planning as shown in Appendix C.

Office for Health Improvement and Disparities (OHID) - use these data for secondary analyses.

NHS - a wide range of organisations use the information to monitor and target services. The aim is to provide a key source of information for public health, commissioning and performance management colleagues at a national level.

Public Health Campaign Groups - data are used to inform policy and decision making and to examine trends and behaviours.

Academia and Researchers - a number of academic papers have cited these statistics as a source of information in peer reviewed papers.

Media - these data are used to underpin articles in newspapers, journals and other articles.

Public - all information is accessible for general public use for any particular purpose.

Ad-hoc requests – the statistics are used by NHS England to answer Parliamentary Questions (PQs), Freedom of Information (FOI) request and ad-hoc queries. Ad-hoc requests are received from health professionals; research companies; public sector organisations, and members of the public, showing the statistics are widely used and not solely within the profession.

b) Unknown users

This publication is free to access via the NHS England website and consequently, the majority of users will access the report without being known to us. Therefore, it is important to put mechanisms in place to try to understand how these additional users are using the statistics and to gain feedback on how we can make these data more useful to them. On the webpage where the publication appears there is a contact us link at the bottom of the page. Any feedback is passed to the team responsible for the report to consider.

Comments on this report would be welcomed. Any questions concerning any data in this publication, or requests for further information, should be addressed to:

The Contact Centre
NHS England
7 and 8 Wellington Place
Leeds
West Yorkshire
LS1 4AP
Telephone: 0300 303 5678
Email: [email protected]

Press enquiries should be made to:

Media Relations Manager:
Telephone: 0300 303 5678
Email: [email protected]