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CANCER IN SCOTLAND: ACTION FOR CHANGE

02 PREVENTING CANCER

THE BEST POSSIBLE OUTCOME IS TO PREVENT CANCER FROM EVER STARTING.

This usually requires people to change their lifestyle. Stopping smoking, eating a healthier diet and taking regular exercise all contribute to a greatly reduced risk of getting cancer.

However, the effectiveness of most prevention measures will be affected by social and economic factors that often encourage the adoption of unhealthy or cancer-causing behaviours. Poverty, unemployment and other causes of ill health are linked to an increased likelihood of cancer developing and of death from cancer.

Failure to improve life circumstances is likely to impair the effectiveness of prevention policies, particularly for deprived groups. For all these reasons, reducing inequalities remains one of the highest priorities for the Scottish Executive.

We have already pledged to develop:

• a coherent attack on health inequalities based on comprehensive and co-ordinated use of health and related resources
• a focused programme of initiatives aimed at improving and sustaining the health of children and young people
• major initiatives aimed at the prevention of Scotland's two main killer diseases, cancer and coronary heart disease

To support the biggest ever drive to improve health in Scotland, the Scottish Executive last year announced the creation of a new Health Improvement Fund. This Fund will invest the entire Scottish allocation of extra tobacco tax revenues each year in public health. After widespread consultation, its 4-year programme was announced in August 2000.

Smoking

Smoking is by far the largest preventable cause of cancer. At present among Scots aged between 16 and 74, 34% of men and 32% of women are regular smokers. Tobacco use is the main cause of lung cancer accounting for at least 90% of cases in high incidence populations. The risk is so high that the benefit of any reduction in smoking would have a rapid impact.

Many smokers start as teenagers. For adults of all ages, giving up smoking has immediate and longer term benefits. If adults who smoke were to give up cigarettes now, within a short time lung cancer incidence in Scotland would fall and so would the incidence of other cancers, such as those of the head and neck, oesophagus, bladder, kidney and pancreas.

Targets for reductions in adult smoking have already been set. These are to reduce the rate of smoking from an average of 35% to 33% between 1995 and 2005 and to an average of 31% by 2010. While it appears that the 2005 target has already been met it is too early to say whether this trend will be maintained. The situation will therefore continue to be monitored through the Scottish Health Survey.

A major part of this effort is targeted on children, young people and pregnant women.

Efforts to get people to change behaviour tend to be hardest to achieve in the most under-privileged sections of society. Cigarette smoking is no exception. While overall smoking rates have fallen over the decades, amongst the least advantaged they have barely fallen at all.

We will therefore continue to direct particular effort to help low-income groups to ensure that they are supported in their efforts to stop smoking.

• The Executive remains committed to helping smokers to stop and encouraging others not to start. Smoking cessation is a priority for Health Boards - and services are available throughout Scotland to support those who wish to quit. It is recognised that, with the help of Nicotine Replacement Therapy (NRT) products and drugs such as bupropion (Zyban) as part of a smoking cessation support programme, smokers are more likely to quit smoking for good.
• The recent decision by the Executive to make NRT available on prescription to smokers is therefore an important step forward.
• Smoking cessation support is crucial to success. We will therefore continue to roll out best practice in the provision of these services in collaboration with HEBS and Action on Smoking in Health (ASH) Scotland.
• We will audit smoking cessation services across Scotland and take further action as required.

Diet

We know that the Scottish diet is far from healthy and that dietary factors may be responsible for up to 30% of cancers. Scots eat too much fat, salt and sugar, and do not eat enough fruit, vegetables and complex carbohydrates such as starches.

In 1995, a number of key national dietary targets were set to be achieved by 2005. These were endorsed by both the 1996 Diet Action Plan for Scotland, Eating for Health, and the 1999 White Paper, Towards a Healthier Scotland. These targets are to:

• double the average consumption of fruit and vegetables;
• increase by nearly half the intake of bread (mainly wholemeal and brown breads);
• double the daily intake of breakfast cereals;
• reduce the proportion of total fat and of saturated fat by over five percentage points;
• reduce average salt intake by over a third;
• halve child intake of non-milk sugar;
• increase the intake of non-sugar carbohydrates by a quarter;
• double the consumption of oily fish.

Although many initiatives are already improving the Scottish diet, the factors which affect it are more than simply a matter of personal choice and, as with smoking, socio-economic and geographical factors are very important. For example, if you have no car you may be reliant on local shops for food and the wide choice of foods available in supermarkets may not be available for reasons beyond simply lack of cash. Local availability of fresh fruit and vegetables as well as efficient public transport are major considerations in deprived and rural communities.

The appointment of a National Diet Action Co-ordinator will support further implementation of the Diet Action Plan, with an initial focus on supporting primary producers, manufacturers, retailers (particularly the supermarkets) and the catering sector to realise their full potential in contributing to the implementation of the Diet Action Plan's recommendations. The Co-ordinator will have a high profile, championing the need for improvement in the Scottish diet and identifying and disseminating best practice across the country.

As the national Scottish agency for health education expertise and information, HEBS plays a key role in implementing Government policies and strategies, with a particular focus on health inequalities. Together with the 'top tips' healthy eating campaign, the 'Big 3' media campaign, which targets Scotland's principal killer diseases (cancer, CHD and stroke), has been successful in raising awareness of the changes which can be made to lifestyles, including diet, to help prevent cancer.

There is evidence that breastfeeding reduces the risk of later ovarian cancer and pre-menopausal breast cancer.

• To support the drive to encourage and increase consumption of fruit and vegetables by children, we recently allocated resources to all Health Boards from the £100m Health Improvement Fund. This will enable them to work with their local partners, for example local authorities, to introduce a range of additional initiatives to improve public health, such as support for the provision of fruit for infants in pre-school settings, fruit/salad bars and breakfast clubs in schools. Each of these will be designed specifically to stimulate children's interest in, and enjoyment of, fruit and vegetables.

Exercise

Exercise can protect against a range of diseases including cancers (for example, colorectal and breast), as well as promoting good mental health. For some years, health promotion in the UK has included the aim of increasing physical activity among adults.

Regular moderate activity is recommended as an achievable target for those with most to gain from increasing their physical activity. The current guidelines suggest that at least 30 minutes of moderate activity (which leaves you slightly out of breath) on most days will benefit health. Vigorous activity (leaving the participant sweating and breathing heavily), for 20 minutes on three days per week will provide much greater benefits.

In 1995, the proportions of men and women aged 16-64 who were active at these levels were 32% and 22% respectively. We aim to increase these figures to 50% and 40% by 2005 and to 60% and 50% by 2010.

• A National Physical Activity Task Force is currently being established to take forward action aimed at raising levels of regular physical activity amongst all age groups in Scotland.

Alcohol Consumption

Excessive alcohol consumption is associated with several types of cancer, for example cancers of the head and neck.

Clear targets have been set for achieving a reduction in excess drinking levels for adults and young people. A range of measures, including alcohol education programmes, is currently underway to reduce alcohol misuse.

• To build upon existing efforts, Our National Health confirmed that following extensive public consultation a Plan for Action on alcohol misuse will be published by the end of 2001.

Environmental factors

Several forms of radiation and industrial chemicals have been linked with cancer. Most concerns in this area have been addressed and risks eliminated in terms of occupational or environmental exposure, such that their contribution to the overall cancer burden is now very small. However, a small number of cancers related to such exposures still occur, for example mesothelioma as a consequence of past exposure to asbestos.

But the single most important outstanding environmental issue is sunlight. Ultraviolet radiation from sun exposure is a major risk factor for skin cancers including malignant melanoma even in a country with Scotland's climate. The risk is particularly high in children. HEBS and others have promoted effective campaigns warning of the risks of unnecessary exposure and particularly of sunburn at home and abroad.

Chemo-prevention of cancer

The possibility that some medicines may help prevent the development of specific cancers is currently the subject of active research. Until these outcomes are known it is not possible to make specific recommendations for the future. We are determined not to miss out on the potential of ground-breaking scientific developments.

• An expert advisory group will therefore be established to maintain a watching brief for the NHSScotland. It will advise the Scottish Executive Health Department on the outcomes of research in this area which may impact on cancer services. This group will report to the Scottish Cancer Group.

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