Behaviour and Lifestyle

Glasses of alcoholic drinks


Behaviours, such as smoking, excessive use of alcohol, the use of illicit drugs, low levels of exercise and physical activity, engaging in unsafe sex, and a poor diet all impact on physical health and mental wellbeing.  It is known that each of these lifestyle risk factors is unequally distributed in the population and that there are differences in these behaviours associated with income, educational achievement and social class.

There is compelling evidence that lifestyle risk factors tend to cluster than present in isolation.  It is estimated that in England 70% of the adult population have two or more lifestyle risk factors (King’s Fund, 2012).  Whilst there has been an overall decline in the proportion of the population with three or four unhealthy risk factors from 33% of the population in 2003, to 25% in 2008, these reductions have not been equally distributed across the population. The percentage of people with three or more lifestyle risk factors is continues to increase for people from lower socio-economic and educational groups. For instance  people with no educational qualifications were  more than five times as likely as those with higher education to have four lifestyle risk factors in 2008, compared with only three times as likely in 2003.

This variation in the distribution of lifestyle risk factors contributes to the gaps in length and quality of life between deprived and affluent groups locally and nationally. The major causes of illness and premature deaths (deaths before age 75 years) in Middlesbrough are circulatory diseases, cancer, respiratory disease and digestive diseases (including liver disease).  Lifestyle risk factors such as smoking, excessive alcohol use, poor diet and physical inactivity are known to contribute to these major causes of premature deaths.

Alcohol misuse

  • Levels of alcohol-related harm in Middlesbrough are among the highest in England.  There are a higher number of alcohol-related hospital admissions and higher alcohol-specific mortality compared to the England average.
  • Alcohol misuse impacts upon physical and mental health, as well as having a detrimental effect on social cohesion, crime, violence and community safety.
  • Alcohol-related harm is a major problem in Middlesbrough impacting on individuals, families and communities.

Illicit drug use

  • Middlesbrough is estimated to have high levels of drug misuse.  It has the highest estimated rate in the country for opiate and crack users (25.13 per 1,000 adults), more than double both the North East (10.57) and England (8.67) rates.
  • Injecting drug use in Middlesbrough is estimated to be 9.10 per 1,000 adults, more than three times the national estimate (2.71).
  • The number of people accessing structured treatment continues to grow; this includes treatment for heroin and cocaine use. Overall there has been growth for both opiate (4%) and non-opiate (76%) clients in 2012/13 since 2011/12.


  • 26.6% of adults in Middlesbrough are estimated to smoke regularly. The smoking prevalence rises to almost one in two adults in some deprived wards and disadvantaged population groups.
  • In Middlesbrough, 27% of women smoke throughout their pregnancy posing a significant health risk both to mother and unborn child.  This is double the national average (13.5%) and higher than the regional average.
  • Nearly one in five (18%) of all deaths among adults over 35 in Middlesbrough are estimated to be as a result of smoking.


Diet and nutrition

  • Eighty percent of adults and 83% of school-aged children in Middlesbrough do not eat the recommended five daily portions of fruit and vegetables.
  • Breastfeeding rates in Middlesbrough are among the lowest in England and the gap is widening.
  • There is low uptake of healthy start vitamin supplements in babies and infants.
  • Poor oral health is a robust indicator of poor nutrition and the prevalence of dental decay for children in Middlesbrough children is almost double the national average.


Physical inactivity

  • Approximately half of the adult population of Middlesbrough is inactive, with only 11.5% taking part in the recommended weekly levels of physical activity.
  • The proportion of Middlesbrough school pupils doing three hours of PE per week is just above the national average.  In Middlesbrough, walking to school has fallen by 9% since 2008, but cycling has increased by 20%.
  • The groups with the lowest levels of physical activity are women (particularly those aged 14-24 years); black and minority ethnic (BME) groups; those with a limiting illness/disability; and lower socioeconomic groups.


  • Obesity rates in Middlesbrough adults continue to be significantly higher than the national average and increasing. There are inequalities in relation to the prevalence of obesity according to income, social deprivation, age, ethnicity and disability:
  • Childhood obesity doubles from 10% in reception year to almost 20% in year 6 pupils.
  • Maternal obesity in Middlesbrough is higher than the regional and national averages with  an increase in the number of pregnant women with a body mass index (BMI) greater than 40.  
  • The increasing prevalence rates of obesity increases demand on health services and costs to the NHS and wider economy.

Sexual health

  • Middlesbrough has higher than regional average rates for gonorrhoea, syphilis and HIV.
  • Local teenage pregnancy rates are higher than regional and national averages.
  • There is a lower uptake of termination of pregnancy (in under-18s) and a lower uptake for Long Acting Reversible Contraception (LARC) compared to the regional and national averages.
  • There is low uptake of screening and preventative services, particularly for chlamydia and HIV.

The recommendations below relate to the Marmot review: Fair Society, Healthy Lives, the former National Support Team recommendations for tackling Health Inequalities and latest national policy and professional guidance.

Short-term (1-2 years)
1. Commissioning and delivery of integrated public health services and programmes that address multiple lifestyle risk factors rather than taking an approach that focuses solely on single issues. Ensure that these interventions are accessible and acceptable to those at highest risk.
2. Ensure equitable access to sexual health services (prevention, early identification, awareness and treatment services) at address the high teenage pregnancy rates and sexually transmitted infections. 
3. Give all children the best start in life by tackling smoking in pregnancy, obesity in pregnancy, breast feeding and uptake of healthy start vitamins.

Medium-term (3-5 years)
1. Maximise the opportunities of creating a health promoting environment through enforcement, planning, regeneration and licence application processes.  This could include considering the restriction of planning permission for hot-food takeaways, alcohol premises (representations and cumulative impact areas), tackling availability, supply and demand for illicit drugs and tobacco.   
2. Strengthen the role of primary care, social care and VCS organisations in delivering lifestyle and behaviour modification programmes
3. Strengthen the use of community assets in addressing lifestyle risk factors

Long-term (over 5 years)
1. Ensure that all town planning, regeneration and transport programmes incorporate active transport routes and that future planning complements strategies to reduce alcohol related crime and violence in the town centre. 
2. Improve maternal and child health by addressing the social causes of poor health including; teenage pregnancy, educational attainment, unemployment, food poverty and maternal mental health

Heidi Douglas
Specialty Registrar Public Health
Middlesbrough Borough Council

Leon Green
Public Health Intelligence Specialist
Tees Valley Public Health Shared Service


King’s Fund (2012). Clustering of unhealthy behaviours over time: Implications for policy and practice.