Sheron et al1 suggested strong cider (>6.0% alcohol by volume) in the UK was particularly associated with alcohol-related illnesses.
Beeston et al2reported that in 2012 in Scotland 326,975 litres of pure alcohol were sold as strong cider off-licence, excluding unknown sales in discount supermarkets Lidl and Aldi, whose share of total alcohol sales was thought to be 10%.
To estimate the contribution made by ill drinkers’ purchases of strong cider to total purchases of strong cider in Scotland, we extrapolate from information obtained from two samples.
1. Acute general hospitals
In 2011–12, 24,742 unique patients over 19 years of age were discharged from Scottish acute general hospitals with alcohol-related diagnoses.3
In that year, we interviewed 190 of these patients in acute general hospitals in Glasgow and Edinburgh admitted with an alcohol-related condition. 4 The age range mirrored national hospital data except for a slightly lower proportion over the age of 65. The mean strong cider consumption across all patients, in the past and/or during a typical week, was 42 units/patient (1 unit = 8g ethanol).
If drinking that way for 1 in 4 weeks (ie, 13 weeks/year), the year’s consumption of strong cider is 550 units per patient, which extrapolated for the 24,742 such patients admitted across Scotland amounts to 14,293,550 units (142,936 L pure alcohol) sold as strong cider. This accounts for 43.7% of sales of strong cider in that year.
2. Alcohol treatment services
We interviewed 449 patients attending or admitted to NHS alcohol services in Glasgow and Edinburgh (no patient was interviewed twice; if they were also seen in the general hospital they were not re-interviewed). Such patients overwhelmingly meet clinical criteria for ‘alcohol dependence’. They had consumed, on average, 59 units per patient as strong cider in the past week and/or during a typical drinking week. At 13 such weeks in a year, that is 767 units/year.
The Scottish Health Survey5 estimates that 1% of the population are ‘dependent’ drinkers (scoring 20+ on AUDIT (Alcohol Use Disorders Identification Test)) across the age span that corresponds to that of our sample (ie mainly 30–65 years). Using the census estimate for that age group in Scotland, that extrapolates to 55,410 individuals. If their consumption of cider was similar to that of our patients, this would account for 767 x 55,410 units (424,994 L pure alcohol) sold as strong cider per annum, slightly more than the reported national strong cider sales for that period.
Discussion
Our finding from sample 2 suggests that purchases of strong cider in national sales data could all be accounted for by people dependent on alcohol. However, only some scored in surveys as ‘dependent’ would consume as heavily as those who attend treatment, making our extrapolation somewhat excessive. Furthermore, a tiny proportion of strong cider is expensive craft cider purchased by aficionados.
On the other hand, if our conservative 13 weeks/year for their cider consumption was low, estimates of cider purchased by dependent drinkers in Scotland over a year might exceed the amount in national sales, even allowing for sales in Lidl/Aldi; and we are not adding our estimate obtained in sample 1 above to the estimated total for dependent drinkers from sample 2. However, the estimate given in 1 adds weight to our conclusion from 2 that most, if not all, customers of the cheap strong cider industry are dependent, and possibly ill, drinkers.
Conflicts of interest
JC is a member of the Medical Advisory Panel, Drinkaware Trust.
- © 2016 Royal College of Physicians
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