From Evidence to Action:a case study of Minimum

Unit Price

Dr Lesley GrahamAssociate Specialist, Public Health

ISD, NHSNSS

13th November 2012Royal Statistical Society

Minimum Price

Would establish a minimum retail price for a unit of alcohol

Linked to alcohol content, not type of product

Would apply to all licensed premises

Minimum price would be set in regulation by Scottish Parliament, independently of retailers, producers or anyone else connected with alcohol industry

Easy to vary price and easy to administer

Policy Development

Problem identification Agenda setting Potential actions Implementation Evaluation

Problem Identification

Pre 2002-no routine statistics on alcohol from ISD or

(then) GRO2002-national alcohol plan published with

accompanying statistics e.g. in 1990, alcohol-related deaths accounted for 1 in 100 deaths in Scotland. By 1999, this had risen to one in 40.

-ISD funded to set up dedicated alcohol team2005-first Alcohol Statistics Scotland publication-alcohol information website

Alcohol-related mortality, Scotland 1982-Alcohol-related mortality, Scotland 1982-20112011

0

5

10

15

20

25

30

35

40

45

Year

EA

SR

per

100,0

00 p

op

ula

tio

n

Male

Female

Scotland

Alcohol-related mortality by deprivation, Scotland

[Source: ISD]

0

10

20

30

40

50

60

70

5 4 3 2 1

SIMD quintile

EA

SR

per

100

,000

po

pu

lati

on

2001

2005

2009

Chronic liver disease and cirrhosis mortality rates per 100,000 population, men and women 45-64

yrs, 1950-2010[Source: updated from Leon and McCambridge, Lancet,

2006]

0

10

20

30

40

50

60

70

80

1950 1960 1970 1980 1990 2000 2010

Age

sta

ndar

dise

d m

orta

lity

rate

per

100

,000

0

10

20

30

40

50

60

70

80

1950 1960 1970 1980 1990 2000 2010

Scotland

England and Wales

Scotland

England and Wales

Other Europeancountries

Other Europeancountries

Men aged 45-64 years Women aged 45-64 years

0

10

20

30

40

50

60

70

80

1950 1960 1970 1980 1990 2000

0

50

100

1950 1960 1970 1980 1990 2000

Ag

e s

tan

da

rdis

ed

mo

rta

lity

ra

te p

er

10

0,0

00

0

10

20

30

40

50

60

70

80

1950 1960 1970 1980 1990 2000

Agenda Setting

2006-Royal Colleges funded by then Scottish

Executive to set up a public health advocacy group

-secured assurance from the Health Minister that would be independent

2007-SHAAP manifesto calls for stronger

pricing policies-alcohol increasingly covered in the media

Agenda Setting

Sept 2007-expert workshopDec 2007-published report

proposing MUP-underpinned by an

extensive evidence base

The relationship between alcohol price, consumption and harm

As the price of alcohol falls, consumption rises and so does harm

A systematic review [Wagenaar 2009] of over 100 studies found a consistent relationship between alcohol, price and consumption

The RAND Europe report [Rabinovich et al 2009] supports the direct link between price, consumption and harm

Evidence from natural experiments in individual countries e.g. Switzerland and Finland

Consumption of alcohol in the UK Consumption of alcohol in the UK (age 15+) relative to its price(age 15+) relative to its price

Affordability of On and Off-Sales Alcohol: UK, 1987-2010

[Source:ONS]

0

20

40

60

80

100

120

140

% m

ore

aff

ord

able

(1987 =

base)

Beer - on

Beer - off

Wine & spirits - on

Wine & spirits - off

Agenda Setting

-crucial re-framing of policy with a public health paradigm, a ‘whole population approach’ (as opposed to ‘industry/often preferred government’ paradigm the problem is to target the ‘small’ minority of heavy drinkers)

-paradoxically MUP will have an enhanced effect on the heaviest drinkers

-SHAAP forms alliances with rest of UK and internationally

Potential Action

2007-SNP win election (minority government)-political will to tackle alcohol problems-political champions-SHAAP advocates for MUP which is adopted as

policy idea-proposal to introduce through amendments to

Licensing Act-resistance from Parliament (minority

government)2008-MUP moves to Health

Potential Action

2008-consultation on alcohol

strategy (including on MUP)

-extensive evidence cited (nearly 100 references)

-effect of price and reduction of population consumption reinforced by logic modelling from Health Scotland

Increased knowledge and changed

attitudes to alcohol + drinking

Reduced acceptability of

hazardous drinking and drunkenness

Reduced availability of alcohol

Individuals in need receive timely,

sensitive & appropriate support

A culture in which low alcohol consumption is valued and accepted as the norm

Less absenteeism + presenteeism the

workplace.

Less alcohol related incapacity

Reduced alcohol related injuries,

physical and psychological

morbidity + mortality

Fewer brain-damaged children

Increased educational attainment

Safer & happier

families and communities

Reduced health, social care, justice

costs

Healthier individuals

and populations

Intermediate outcomes Long term outcomes

Children in need receive timely and

appropriate support

Safer drinking + wider environments

Increased workplace

productivity

Less alcohol related violence/abuse,

offences and ASB

Less absenteeism + presenteeism in

educational establishments

Fewer children affected by parental

drinking

Reduction in Individual and

population consumption

Changed patterns of

consumption

Reduced affordability of alcohol

National outcomes

Reduce significant inequalities

Model 2:

Model 3:

Model 4:

Model 5:

Model 6:

Model 7:

Potential Action 2009-national alcohol

strategy launched -comprehensive

strategy with a whole population approach

-MUP one of 42 measures

-Sheffield University commissioned to model MUP

-purchase of alcohol sales data from Neilsen

Potential Action

‘A considerable body of evidence shows not only that alcohol policies and interventions targeted at vulnerable populations can prevent alcohol-related harm but that policies targeted at the population at large can have a protective effect on vulnerable populations and reduce the overall level of alcohol problems. Thus, both population-based strategies and interventions, and those targeting particular groups.. are indicated’ [WHO Evidence based strategies and interventions to reduce alcohol related harm 2007]

Litres of pure alcohol sold per capita (adults aged 16+) in Scotland and England & Wales, 1994-2011[Source: Neilsen/CGA, Health Scotland]

0

1

2

3

4

5

6

7

8

9

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

L p

er

ad

ult

Scotland off-trade E&W off-trade

Scotland on-trade E&W on-trade

Source: Nielsen/CGA sales dataset (off-trade sales in 2011 adjusted to account for the loss of discount retailers).

Price distribution (%) of pure alcohol sold off-trade in Scotland, England and Wales 2010

[Source:Neilsen/CGA, NHS Health Scotland]

0

2

4

6

8

10

12

14

16

18

20

<15 15-19.9

20-24.9

25-29.9

30-34.9

35-39.9

40-44.9

45-49.9

50-54.9

55-59.9

60-64.9

65-69.9

70-74.9

75-79.9

80-84.9

?85

Price band (ppu)

% o

f al

l o

ff-t

rad

e al

coh

ol

(L p

ure

alc

oh

ol)

ScotlandEngland & Wales

73%

Reduction in alcohol consumption by drinking group(%)

[Source:Meng et al 2012]

0.7

2.8

6.1

2.0

4.3

0.1

1.2

4.8

10.5

3.3

7.3

1.2

4.5

10.7

18.6

3.9

12.8

0

2

4

6

8

10

12

14

16

18

20

MUP 30p MUP 40p MUP 50p MUP 60p Total discountban

MUP 50p + totaldiscount ban

%

Moderate

Hazardous

Harmful

MUP of 50p will…

Reduce consumption by 5.7%In year 1: Reduce deaths by 60 1,600 fewer hospital admissions Around 3,500 fewer crimes per year A total value of harm reduction of £64 million By year 10 Over 300 fewer deaths annually 6,500 fewer hospital admissions A cumulative value of harm reduction of £942

million

Implementation of Agreed Action2009-Alcohol (etc) Scotland Bill introduced-evidence (and perceived ‘lack’ of it) at the heart of

the debate-MUP opposed by all opposition parties so withdrawn2011-SNP returned with a majority (MUP in manifesto) in

May-Lib Dems change position-Alcohol (Minimum Pricing) (Scotland) Bill introduced

in Oct2012-Scottish Conservatives drop opposition in March-Bill passed in May

Implementation of Agreed Action

2012-UK Gov announce intention to

introduce MUP-SWA launch legal challenge in

Scotland-EC notified of intention to set an MUP

of 50p-’opinions’ lodged by Member States

Evaluation

2008-Health Scotland lead on development of a portfolio

of studies to evaluate the national strategy (including MUP)

2010-first sales data published2011-MESAS first (baseline) report published2012-new studies being developed to evaluate MUP-first empirical evidence from Stockwell on effect of

variant of MUP in Canada (effect very similar to Sheffield model)

Barriers for Evidence to Action

-minority government-unpopular measure (nanny state/health

‘fascism’)-translating ‘science’ into policy messages-short time frame (not understood)-powerful industry-money not going to government-’regressive’-legal challenges-multi-layer government (Scotland/UK/EC)

Enablers for Evidence to Action

-extensive, sound evidence base-rising levels of harm-effective public health advocacy (including

forming alliances)-long term differences in Licensing policy

(public health objective in 2005 Licensing Act)

-devolved government-change of government-political champion

Enablers for Evidence to Action

-close links between government and public health

-small civil service-interdepartmental working-split in the alcohol industry-growing support

Is Evidence Enough?

-a ‘perfect storm’ where problems, policy and politics converge

-re-framing, an ‘idea’ rather than just evidence

-evidence at the heart of the debate (now literally ‘in the dock’)

-to be continued….

Contact

Dr Lesley Grahamlesley.graham@nhs.net