In this blog Dr Peter Rice, President of the European Alcohol Policy Alliance and Chair of the Institute of Alcohol Studies, examines the final report from Public Health Scotland that evaluates the impact of minimum unit pricing in Scotland.
In June, Public Health Scotland (PHS) produced a report summarising 40 publications, some commissioned by PHS, some not, examining the impact of MUP. This report is likely to make a significant contribution to the report which the Government will lay before Parliament by May 2024 when a decision will be made on whether to retain the policy or not.
The test for the MUP law will be whether the policy has contributed to reducing the harms from alcohol in Scotland, and whether any reduction has been substantial enough to justify any negative effects on individuals, communities and businesses. There is no expectation from MUP advocates that alcohol problems will disappear from communities, but has MUP moved things in the right direction?
A call for action
It was evidence of rising health harms from alcohol which led Scottish Health Action on Alcohol Problems (SHAAP), of which I was one of the founders, to call for action on the price of alcohol, and specifically for a minimum price in 2007. Deaths directly due to alcohol in Scotland had risen from around 600 per year in the early 1990s to over 1500 per year when SHAAP called for action. Epidemiological research showed that the increase in deaths had been among people, in particular men, in the 20% lowest income groups. Clinicians had seen changes in drinking patterns as heavy drinkers increasingly drank at home rather than pubs, and whisky and high strength lagers were replaced by cheaper products specifically vodka which has low production costs and strong cider which had very favourable tax rates in the UK.
While heavy drinkers have increased risks of many illnesses, such as cancers, suicide and strokes, the most clear-cut indicator of trends in alcohol deaths are from those causes where alcohol is very likely to be the main factor. In Scotland around two thirds of these deaths, now known as alcohol specific deaths, are from liver disease.
MUP and Scotland’s health
Many people with alcohol related liver disease (ArLD), including those who die from the disease, are not highly dependent on alcohol. As with many diseases, ArLD is due to a combination of genetic and environmental factors. Some people are much more susceptible to the effects of alcohol on the liver than others and some of the very heaviest dependent drinkers, who may have a range of other conditions, show no symptoms of liver disease. They are at risk of premature death, but the cause of death may not meet the criteria to appear in the figures of alcohol specific mortality. So alcohol specific deaths and alcohol dependence are not as closely linked as might be expected.
For these reasons the clinicians who were campaigning for MUP were strongly motivated by evidence of increasing rates of deaths from alcohol related liver disease. One of the intended effects was to reduce consumption in those at greatest risk of developing sudden serious liver disease. The nature of liver disease is that many of the people close to the cliff edge of liver failure do not realise it, and the hope was that MUP would move them back to safer ground, perhaps without them realising it.
One reason for the focus on the health indicators of deaths and hospitalisations is that tracking the social harms from alcohol is difficult to do. The Criminal Justice system does not collect data in a systematic way and, for instance, the way police respond and record alcohol related offences varies with local policies which are subject to change. Likewise for the impact of alcohol on family life and employment. Other health measures such as the number of people asking for support and prescribing of medications are influenced by the provision of services and are not good measures of population level harm.
So, did MUP achieve its aims?
The conclusion of the Public Health Scotland report is mostly yes. Deaths wholly due to alcohol, mainly from liver disease, fell by 10% in 2019, the first full year of MUP, and Scotland experienced less of an increase in alcohol deaths than other countries during the COVID 19 pandemic leading Public Health Scotland to conclude that Scotland’s direct alcohol death numbers were reduced by over 150 per year by MUP.
In 21/22 Alcohol related hospital admissions showed the lowest rate for 25 years in Scotland. The COVID pandemic will have had an impact on the use of beds, but between the introduction of MUP and the start of the pandemic , Glasgow, the largest and most deprived city in Scotland, had the lowest rate of admissions for liver disease in 20 years.
The fall in deaths and hospital admissions was greatest among men and people on low incomes making MUP an important lever for tackling inequalities. The decline in alcohol sales was in off sales where the sales reduction was greatest in cider and perry at 20% and in spirits, so MUP affected the categories of alcohol favoured by the heaviest consumers as the policy intended. Analysis of market research data showed the same pattern. The hard numbers show that MUP worked as predicted by the modelling researchers, and as the clinicians had hoped for.
The research was evaluated by a quality control process by PHS and separately by the Evidence for Policy and Practice Implementation (EPPI) Centre at University College London. Even long-standing opponents of MUP, such as the free market Institute of Economic Affairs which generally opposes the regulation of alcohol, recognise the range and quality of the evaluation process.
Has there been any negative impact from MUP?
It is noticeable in the review of studies by Public Health Scotland that while the studies examining mortality and admission figures show positive findings, qualitative studies with consumers and practitioners in services tend to show a more negative perception, including when researchers ask participants to anticipate the impact of MUP on themselves and others. Perhaps it’s not surprising that people, including practitioners, are more conscious of potential problems . Those who are struggling will preoccupy those involved with them personally and professionally more than those who are improving. While some service users expressed fears that MUP would lead to a deterioration in their nutrition as they cut back food spending, Public Health Scotland cite research on household purchase patterns showing the only significant nutritional change after MUP was a beneficial reduction in sugar contained in alcoholic drinks.
There are people who will continue to struggle with alcohol despite the best prevention efforts. While there is good reason to expect that the removal of cheap alcohol will in time reduce the number of people moving into severe dependence and their consumption levels, in the short term the priority for dependent drinkers should be to close the substantial gaps in support and treatment.
What’s next for MUP?
The legislation passed by the Scottish Parliament in 2012 to introduce a Minimum Unit Price (MUP) for alcohol included that the Parliament needed to actively decide whether to continue the measure six years after MUP had been introduced. This “Sunset Clause” as it was described, was unusual in UK law. The commitment to review the measure was welcomed by the alcohol advocates who had campaigned for Minimum Unit Price, such as Scottish Health Action on Alcohol Problems (SHAAP) and Alcohol Focus Scotland, both members of the Alcohol Health Alliance (UK). Crucially, the Sunset Clause was also well regarded by the UK Supreme Court. The Supreme Court ended the five year legal challenge by the Scotch Whisky Association and their European allies with its judgement in November 2017 which found the MUP legislation an appropriate and proportionate measure to reduce harm from alcohol in Scotland. In the judgement, the Court described the Sunset Clause as “a significant factor” in its decision.
The Scottish Parliament will determine the future of Minimum Unit Price before May 2024. Part of that decision will be the future level of the price needed to achieve the reductions in alcohol harm which Parliament wishes to see. The test for MUP is whether the policy has moved population health and well being in the right direction, particularly through narrowing inequalities and whether the benefits justify the costs. The research so far suggests that the policy has been a success.
A previous blog from Dr Peter Rice on MUP can be found here.
Written by Dr Peter Rice, President of European Alcohol Policy Alliance, and Chair of Institute of Alcohol Studies.
This blog was published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Alcohol Health Alliance or its members.