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Risk Factors Chapter 3 Risk factors this page is intentionally blank Chief Medical Officer’s Report 2011 193 Chapter 3 – Overview Risk factors An understanding of the causal factors underlying patterns Tobacco use, for example, is the primary cause of early There is evidence that these proportions are falling, albeit at of health and well-being in the population is key to the death and ill health in England. Public health policies have a different rate across the socioeconomic gradient. But to commissioning and delivery of effective public health services. contributed to a progressive reduction in smoking rates effectively support people to make the change towards more in recent decades through a combination of measures healthy lives, those commissioning and delivering health Early death and disability do not occur in isolation: they are to regulate the promotion and supply of tobacco, and services need to recognise not only the varying prevalence of mediated through a complex interplay of social, economic to help smokers quit. Nevertheless, many young people, individual risk factors across groups in the population and the and environmental factors, as well as by individual specific particularly those from more deprived backgrounds and from life course, but also that the majority of people have multiple determinants of health. This chapter focuses on the risks to some ethnic groups, continue to be exposed to second- risks to their health. health presented by the lifestyles that people lead: factors hand smoke at home; many go on to become smokers such as smoking, poor diet and high risk alcohol consumption themselves because they perceive it to be a normal part of Fair Society, Healthy Lives notes that only 4% of NHS funding collectively constitute some of the most important direct adult life3. Combined with evidence that not all smokers is currently spent on prevention. Given the health burden causes of early death and disability in England, and are who want to quit make equal use of the sources of support attributable to risk factors, there is a clear case for arguing primary drivers of health inequalities. available to them, these social and cultural influences mean for this proportion to be increased. This is not new: the final that the burden of disease associated with smoking falls report of the review led by Sir Derek Wanless4 looking at the The World Health Organisation (WHO) report on Global disproportionately on specific groups in the population. resources required to provide high quality health services in 1 Health Risks and the associated burden of disease toolkit the future, projected that a substantial reduction in costs set the context for this chapter. Clearly, there are variations In recognition of this complex causal chain, Fair Society, could be achieved by an increased emphasis on prevention, across the world in the relative importance of different Healthy Lives recommends action across a range of policy coupled with higher levels of public engagement in relation behavioural risks, but the WHO toolkit estimates that the top areas, including prioritising the prevention and early detection to their health. ten risk factors for early death and disability in the UK are, in of those risk factors that contribute most to the conditions order of impact: that drive health inequalities. The changes resulting from the Health and Social Care Act 2012 also present an opportunity for local authorities (who tobacco use The data sources available to quantify the prevalence of already have responsibility for ‘the causes of the causes’ of harmful alcohol use the different behavioural risks provide a strong basis for poor health such as education, housing and the environment, understanding the varying health burden these factors place as well as for social care) to work in close partnership with high blood pressure on different groups in the population and across the life the NHS and the third sector to commission and deliver high cholesterol course. For example, alongside the age, sex, socioeconomic services that help people lead more healthy lives and reduce overweight and obesity and ethnic group differences in smoking rates, there are the health burden associated with behavioural risk factors. similar variations in alcohol consumption patterns and the physical inactivity distribution of alcohol related harms. illicit drug use low fruit and vegetable intake It is not the case, however, that the health burden associated occupational risks with the risk factors falls exclusively on the same groups. In the case of alcohol, for example, the highest hospital poor sexual health admission rates are found in some of the more deprived Chapter 3 considers each of these in turn, with the exception parts of England, but the areas with the worst increasing and of occupational risks (addressed in Chapter 4). Replacing this higher risk drinking rates are among the most affluent. is urban outdoor air pollution, which is identified by WHO as a risk factor in high income countries. Much of this understanding is based on estimates derived from sample surveys and the secondary use of data collected Finally, this chapter also considers the multiple interactions for other purposes, such as hospital admissions. As a between several of these risk factors and their cumulative consequence, there remain many gaps and uncertainties impact on health and wellbeing outcomes. in our understanding of the distribution of risk factors, and their associated health burden, across the population. The strategic review of health inequalities in England, Fair There is a pressing need for these gaps in our knowledge to Society, Healthy Lives2, led by Sir Michael Marmot, provides be addressed, in particular so that local areas have robust the second context for this chapter. This report highlights the information on the health needs of their population on which contribution that behavioural risks make to health inequalities, to base their service commissioning decisions. and makes it clear that effective action requires an understanding that these factors occur in a social and The majority of the data sources used to illustrate the cultural context and are not simply a product of individual behavioural risks focus on these factors separately and choice alone. individually. This approach has supported the development of a wide range of public health policies and programmes, which have been effective in reducing the prevalence of, and health burden attributable to, many of the risk factors. It is clear, however, that these factors often cluster together: more than a third of adults in England have two risk factors and a 1 Global Health Risks. World Health Organisation, 2009. further third have three or more. 2 Marmot Review Team (2010) Fair Society, Healthy Lives: Strategic review of health inequalities in England post-2010 (The Marmot Review). 3 Healthy Lives, Healthy People: A Tobacco Control Plan for England. London: Marmot Review Team. Department of Health, 2011. 4 Wanless D. Securing our future health: taking a long-term view. Final report. London: HM Treasury, 2002. Chief Medical Officer’s Report 2011 Chief Medical Officer’s Report 2011 194 195 Smoking (part 1) Risk factors Smoking is the single greatest cause of preventable illness and early death in England, and a major contributor to health inequalities. Tobacco use and second-hand exposure to tobacco smoke substantially increase the risk of death from lung and other cancers, heart disease, stroke, chronic respiratory disease and other conditions. While the proportion of adults who smoke has fallen from 39% in 1980 to 20% currently, there remain marked differences between groups in the population. Rates are highest among men, younger age groups and those working in routine and manual occupations. There are also marked geographical variations in smoking rates, with a substantial number of areas with high rates found in the north of England. Among those aged 35 and over, more than 79,000 deaths a year (or 18% of deaths) are attributable to smoking, with the highest rates again found in the north of England. A similar geographic pattern is apparent for smoking related admissions to hospital and among mothers smoking during pregnancy. The cost to the NHS of treating smoking related illness is estimated to be £5.2 billion per year in 2005/061. There is clear evidence that a range of interventions in primary care, pharmacy, local authority and workplace settings are effective in reducing smoking rates. 1 Statistics on Smoking, England 2009. The NHS Information Centre for Health and Social Care. 2009. Chief Medical Officer’s Report 2011 Chief Medical Officer’s Report 2011 196 197 Smoking (part 2) Risk factors Chief Medical Officer’s Report 2011 Chief Medical Officer’s Report 2011 198 199 Alcohol (part 1) Risk factors Alcohol is the second biggest lifestyle health risk factor after day in the North West, Yorkshire and The Humber, and the tobacco use. Regularly drinking more than the recommended North East. However, the picture for increasing and higher limits increases the risk of a range of chronic diseases risk drinkers is more complex with modelled estimates including liver disease, diabetes, cardiovascular disease, and suggesting that many areas in the South East, South West cancers of the breast and gastrointestinal tract. High risk and West Midlands have among the highest levels. drinking increases the risk of psychological ill-health, and is also associated with a range of social problems such as The highest hospital admission rates for alcohol-attributable violent crime. causes, both for adults and those aged under 18, are found in parts of the North West and North East, with Manchester, Drinking more than the higher risk limits is more common Middlesbrough, Salford and Liverpool having the highest among young adults: in 2008-10, 26.1% of males and 22% rates. of females aged 16 to 24 drank more than eight units and six units respectively on at least one day in the previous week, While there is evidence that alcohol consumption levels are compared to 6.2% of males and 2% of females aged 65 falling, there is a lagged effect in terms of the harms cause by and over.
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