Impact of public health team engagement in alcohol licensing on health and crime outcomes in England and Scotland: A comparative timeseries study between 2012 and 2019

BACKGROUND

Public health teams (PHTs) in England and Scotland engage to varying degrees in local alcohol licensing systems to try to reduce alcohol-related harms. No previous quantitative evidence is available on the effectiveness of this engagement. We aimed to quantify the effects of PHT engagement in alcohol licensing on selected health and crime outcomes.

METHODS

39 PHTs in England (n = 27) and Scotland (n = 12) were recruited (of 40 contacted) for diversity in licensing engagement level and region, with higher activity areas matched to lower activity areas. Each PHT's engagement in licensing for each 6 month period from April 2012 to March 2019 was quantified using a new measure (PHIAL) developed using structured interviews, documentary analyses, and expert consultation. Outcomes examined were ambulance callouts, alcohol-related hospital admissions, alcohol-related and alcohol-specific mortality and violent, sexual and public order offences. Timeseries were analysed using multivariable negative binomial mixed-effects models. Correlations were assessed between each outcome and 18-month average PHIAL score (primary metric), cumulative PHIAL scores and change in PHIAL scores. Additionally, 6-month lagged correlations were also assessed.

FINDINGS

There was no clear evidence of any associations between the primary exposure metric and the public health or crime outcomes examined, nor between cumulative PHIAL scores or change in PHIAL score and any outcomes. There were no significant associations in England or Scotland when analysed separately or between outcomes and lagged exposure metrics.

INTERPRETATION

There is no clear evidence that allocating PHT resources to engaging in alcohol licensing is associated with downstream reductions in alcohol-related health harms or crimes, in the short term or over a seven year follow-up period. Such engagement likely has benefits in shaping the licensing system to take account of health issues longer term, but as current systems cannot reduce alcohol availability or contain online sales, their potential benefits are somewhat constrained.

FUNDING

The ExILEnS project is funded by the NIHR Public Health Research Programme (project number 15/129/11). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Strategies to cut down drinking, alcohol consumption, and usual drinking frequency: Evidence from a British online market research survey

BACKGROUND

Relatively little is known about how risky drinkers attempt to moderate their drinking in the absence of specialist support. The broader literature has identified multiple potential strategies that people use to cope with temptation when trying to control health-risk behaviours. This study aims to identify types of alcohol moderation strategies used by British adults, and to explore how concurrent alcohol consumption differs across moderation strategies, focusing on the important role of usual drinking frequency.

METHODS

We use a continuous repeat cross-sectional survey and one-week drinking diary collected by the market research company Kantar; these provide detailed information on alcohol consumption during a diary week and on how individuals try to moderate alcohol use for 49,204 British adults trying to reduce their drinking from 2013 to 2019. We use Latent Class Analysis (LCA) to identify predominant types of moderation strategies. With a three-step method, we also analyse the associations between adopting different moderation strategies, measures of frequency and intensity of drinking events, and usual drinking frequency.

RESULTS

We found evidence of four alcohol moderation strategies: 29% of individuals use a pre-commitment-focused strategy (having fewer drinking occasions), two set of individuals adopt self-control strategies within drinking occasions (specifically 28% select smaller drinks and 5% have fewer drinks), while 38% adopt a mixed strategy that involves all three. Those using commitment tend to have a higher average consumption per drinking occasion but lower overall weekly consumption compared to those using self-control. Weekly alcohol consumption is particularly high among individuals who are usual everyday drinkers and use self-control to cut down drinking.

CONCLUSION

This analysis provides a useful platform for further work, using prospective or intervention designs, to test the relative effectiveness of different moderation strategies for alcohol consumers who want to reduce their alcohol consumption.

Efficacy of a theory-driven program to implement alcohol screening and brief interventions in primary health-care: a cluster randomized controlled trial

BACKGROUND AND AIMS

Screening and brief interventions (SBI) in primary health-care practices (PHCP) are effective in reducing reported alcohol consumption, but have not been routinely implemented. Most programs seeking to improve implementation rates have lacked a theoretical rationale. This study aimed to test whether a theory-based intervention for PHCPs could significantly increase alcohol SBI delivery.

DESIGN

Two-arm, cluster-randomized controlled, parallel, 12-month follow-up, trial.

SETTING

PHCPs in Portugal.

PARTICIPANTS

Staff from 12 PHCPs (n = 222, 81.1% women): nurses (35.6%), general practitioners (28.8%), receptionists (26.1%) and family medicine residents (9.5%); patients screened for alcohol use: intervention n = 8062; controls n = 58.

INTERVENTION AND COMPARATOR

PHCPs were randomized to receive a training and support program (n = 6; 110 participants) tailored to the barriers and facilitators for implementing alcohol SBIs following the principles of the Behavior Change Wheel/Theoretical Domains Framework approach, or to a waiting-list control (n = 6; 112 participants). Training was delivered over the first 12 weeks of the trial.

MEASUREMENTS

The primary outcome was the proportion of eligible patients screened (unit of analysis: patient list). Secondary outcomes included the brief intervention (BI) rate per screen-positive patient and the population-based BI rate (unit of analysis: patient list), and changes in health providers' perceptions of barriers to implementation and alcohol-related knowledge (unit of analysis: health provider).

FINDINGS

The implementation program had a significant effect on the screening activity in the intervention practices compared with control practices at the 12-month follow-up (21.7% vs. 0.16%, intention-to-treat analysis, p = 0.003). Although no significant difference was found on the BI rate per screen-positive patient (intervention 85.7% vs. control 63.6%, p = 0.55, Bayes factor = 0.28), the intervention was effective in increasing the population-based BI rate (intervention 0.69% vs. control 0.02%, p = 0.006). Health providers in the intervention arm reported fewer barriers to SBI implementation and higher levels of alcohol-related knowledge at 12-month follow-up than those in control practices.

CONCLUSION

A theory-based implementation program, which included training and support activities, significantly increased alcohol screening and population-based brief intervention rates in primary care.

Understanding long-term trends in smoking in England, 1972-2019: an age-period-cohort approach

BACKGROUND AND AIMS

Smoking prevalence has been falling in England for more than 50 years, but remains a prevalent and major public health problem. This study used an age-period-cohort (APC) approach to measure lifecycle, historical and generational patterns of individual smoking behaviour.

DESIGN

APC analysis of repeated cross-sectional smoking prevalence data obtained from three nationally representative surveys.

SETTING

England (1972-2019).

PARTICIPANTS

Individuals aged 18-90 years.

MEASUREMENTS

We studied relative odds of current smoking in relation to age in single years from 18 to 90, 24 groups of 2-year survey periods (1972-73 to 2018-19) and 20 groups of 5-year birth cohorts (1907-11 to 1997-2001). Age and period rates were studied for two groups of birth cohorts: those aged 18-25 years and those aged over 25 years.

FINDINGS

Relative to age 18, the odds of current smoking increased with age until approximately age 25 [odds ratio (OR) = 1.48, 95% confidence interval (CI) = 1.41-1.56] and then decreased progressively to age 90 (OR = 0.06, 95% CI = 0.04-0.08). They also decreased almost linearly with period relative to 1972-73 (for 2018-19: OR = 0.30, 95% CI = 0.26-0.34) and with birth cohort relative to 1902-06, with the largest decreased observed for birth cohort 1992-96 (OR = 0.44, 95% CI = 0.35-0.46) and 1997-2001 (OR = 0.35, 95% CI = 0.74-0.88). Smoking declined in the 18-25 age group by an average of 7% over successive 2-year periods and by an average of 5% in those aged over 25.

CONCLUSIONS

Smoking in England appears to have declined over recent decades mainly as a result of reduced smoking uptake before age 25, and to a lesser extent to smoking cessation after age 25.

Moderators of changes in smoking, drinking and quitting behaviour associated with the first COVID-19 lockdown in England

AIM

To estimate changes in smoking, drinking and quitting behaviour from before to during the first COVID-19 lockdown in England, and whether changes differed by age, sex or social grade.

DESIGN

Representative cross-sectional surveys of adults, collected monthly between August 2018 and July 2020.

SETTING

England.

PARTICIPANTS

A total of 36 980 adults (≥ 18 years).

MEASUREMENTS

Independent variables were survey month (pre-lockdown: August-February versus lockdown months: April-July) and year (pandemic: 2019/20 versus comparator: 2018/19). Smoking outcomes were smoking prevalence, cessation, quit attempts, quit success and use of evidence-based or remote cessation support. Drinking outcomes were high-risk drinking prevalence, alcohol reduction attempts and use of evidence-based or remote support. Moderators were age, sex and occupational social grade (ABC1 = more advantaged/C2DE = less advantaged).

FINDINGS

Relative to changes during the same time period in 2018/19, lockdown was associated with significant increases in smoking prevalence [+24.7% in 2019/20 versus 0.0% in 2018/19, adjusted odds ratio (aOR) = 1.35, 95% confidence interval (CI) = 1.12-1.63] and quit attempts (+39.9 versus -22.2%, aOR = 2.48, 95% CI = 1.76-3.50) among 18-34-year-olds, but not older groups. Increases in cessation (+156.4 versus -12.5%, aOR = 3.08, 95% CI = 1.86-5.09) and the success rate of quit attempts (+99.2 versus +0.8%, aOR = 2.29, 95% CI = 1.31-3.98) were also observed, and did not differ significantly by age, sex or social grade. Lockdown was associated with a significant increase in high-risk drinking prevalence among all socio-demographic groups (+39.5 versus -7.8%, aOR = 1.80, 95% CI = 1.64-1.98), with particularly high increases among women (aOR = 2.17, 95% CI = 1.87-2.53) and social grades C2DE (aOR = 2.34, 95% CI = 2.00-2.74). Alcohol reduction attempts increased significantly among high-risk drinkers from social grades ABC1 (aOR = 2.31, 95% CI = 1.78-3.00) but not C2DE (aOR = 1.25, 95% CI = 0.83-1.88). There were few significant changes in use of support for smoking cessation or alcohol reduction, although samples were small.

CONCLUSIONS

In England, the first COVID-19 lockdown was associated with increased smoking prevalence among younger adults and increased high-risk drinking prevalence among all adults. Smoking cessation activity also increased: more younger smokers made quit attempts during lockdown and more smokers quit successfully. Socio-economic disparities in drinking behaviour were evident: high-risk drinking increased by more among women and those from less advantaged social grades (C2DE), but the rate of reduction attempts increased only among the more advantaged social grades (ABC1).

Equity impact of minimum unit pricing of alcohol on household health and finances among rich and poor drinkers in South Africa

Introduction

South Africa experiences significant levels of alcohol-related harm. Recent research suggests minimum unit pricing (MUP) for alcohol would be an effective policy, but high levels of income inequality raise concerns about equity impacts. This paper quantifies the equity impact of MUP on household health and finances in rich and poor drinkers in South Africa.

Methods

We draw from extended cost-effectiveness analysis (ECEA) methods and an epidemiological policy appraisal model of MUP for South Africa to simulate the equity impact of a ZAR 10 MUP over a 20-year time horizon. We estimate the impact across wealth quintiles on: (i) alcohol consumption and expenditures; (ii) mortality; (iii) government healthcare cost savings; (iv) reductions in cases of catastrophic health expenditures (CHE) and household savings linked to reduced health-related workplace absence.

Results

We estimate MUP would reduce consumption more among the poorest than the richest drinkers. Expenditure would increase by ZAR 353 000 million (1 US$=13.2 ZAR), the poorest contributing 13% and the richest 28% of the increase, although this remains regressive compared with mean income. Of the 22 600 deaths averted, 56% accrue to the bottom two quintiles; government healthcare cost savings would be substantial (ZAR 3.9 billion). Cases of CHE averted would be 564 700, 46% among the poorest two quintiles. Indirect cost savings amount to ZAR 51.1 billion.

Conclusions

A MUP policy in South Africa has the potential to reduce harm and health inequality. Fiscal policies for population health require structured policy appraisal, accounting for the totality of effects using mathematical models in association with ECEA methodology.

Causal mechanisms proposed for the alcohol harm paradox-a systematic review

BACKGROUND AND AIMS

The alcohol harm paradox (AHP) posits that disadvantaged groups suffer from higher rates of alcohol-related harm compared with advantaged groups, despite reporting similar or lower levels of consumption on average. The causes of this relationship remain unclear. This study aimed to identify explanations proposed for the AHP. Secondary aims were to review the existing evidence for those explanations and investigate whether authors linked explanations to one another.

METHODS

This was a systematic review. We searched MEDLINE (1946-January 2021), EMBASE (1974-January 2021) and PsycINFO (1967-January 2021), supplemented with manual searching of grey literature. Included papers either explored the causes of the AHP or investigated the relationship between alcohol consumption, alcohol-related harm and socio-economic position. Papers were set in Organization for Economic Cooperation and Development high-income countries. Explanations extracted for analysis could be evidenced in the empirical results or suggested by researchers in their narrative. Inductive thematic analysis was applied to group explanations.

RESULTS

Seventy-nine papers met the inclusion criteria and initial coding revealed that these papers contained 41 distinct explanations for the AHP. Following inductive thematic analysis, these explanations were grouped into 16 themes within six broad domains: individual, life-style, contextual, disadvantage, upstream and artefactual. Explanations related to risk behaviours, which fitted within the life-style domain, were the most frequently proposed (n = 51) and analysed (n = 21).

CONCLUSIONS

While there are many potential explanations for the alcohol harm paradox, most research focuses on risk behaviours while other explanations lack empirical testing.

Quantile regression of tobacco tax pass-through in the UK 2013-2019. How have manufacturers passed through tax changes for different tobacco products?

BACKGROUND

The effectiveness of tax increases relies heavily on the tobacco industry passing on such increases to smokers (also referred to as 'pass-through'). Previous research has found heterogeneous levels of tax pass-through across the market segments of tobacco products available to smokers. This study uses retail sales data to assess the extent to which recent tax changes have been passed on to smokers and whether this varies across the price distribution.

METHODS

We use panel data quantile regression analysis on Nielsen commercial data of tobacco price and sales in the UK from January 2013 to March 2019 combined with official UK tax rates and inflation to calculate the rate of tax pass-through for factory made (FM) cigarettes and roll your own (RYO) tobacco.

RESULTS

Following increases in the specific tax payable on tobacco, we find evidence of overshifting across the price distribution for both FM and RYO. The rate of the overshift in tax increased the more expensive the products were. This was consistent for FM and RYO. Additionally, our findings suggest that the introduction of standardised packaging was not followed by changes in how the tobacco industry responded to tax increases.

CONCLUSIONS

Following the repeated introduction of increases in specific tobacco tax as well as standardised packaging, we show that the tobacco industry applies techniques to keep the cheapest tobacco cheaper relative to the more expensive products when passing on tax increases to smokers.

Has the increased participation in the national campaign 'Dry January' been associated with cutting down alcohol consumption in England?

AIMS

Dry January is a national multimedia campaign in the UK that encourages people to abstain from drinking alcohol during the month of January. The population-level campaign makes extensive use of email and social media to support participants and has reported a substantial increase in participation since 2015. This study aimed to assess whether the increase in participation in Dry January between 2015 and 2018 was associated with reduced alcohol consumption in England.

DESIGN

Repeat cross-sectional design.

SETTING

England, March 2014 to January 2018.

PARTICIPANTS

A total of 37,142 respondents to the Alcohol Toolkit Study, a monthly in-home survey of alcohol consumption among representative cross-sectional samples of people aged 16+ years in England.

MEASURES

Outcomes included i) percentage of adults reporting drinking monthly or less frequently in the last 6 months and ii) mean weekly alcohol consumption among drinkers derived from the Alcohol Use Disorders Identification Test questions on typical frequency and quantity in the last 6 months.

ANALYSES

For each outcome, regression models were fitted for month: January (2015 and 2018) vs March-December (2014 and 2017) and for year: 2014/15 vs 2017/18. Interaction terms were included in the models to examine whether the difference between January and the preceding months on each outcome measure depended upon the year (2014/15 vs 2017/18). For non-significant interactions, Bayes factors were calculated to assess the relative strength of evidence for large effects (OR = 1.80 on monthly drinking and β=-1.0 on mean consumption) compared with the null.

RESULTS

Differences between January and other months were similar in 2014/15 and 2017/18 for adults reporting drinking monthly or less frequently and the mean consumption among drinkers (OR = 0.91, 95 %CI 0.79-1.05, BF = 0.05; β = 0.55, 95 %CI=-0.14 to 1.25, BF = 0.13 respectively).

CONCLUSIONS

The increase in participation in Dry January between 2015 and 2018 was not associated with large corresponding changes in people drinking monthly or less frequently over the last 6 months, or in mean weekly consumption among drinkers.

Exoseketons: A Rehab Tech Consumer's Unexpected March to Action

This paper is both a stakeholder perspectives as well as a 'case study' describing a journey from sudden disability to participant and investor in exoskeleton design. It tells of my experiences and opinions, as a successful fashion designer, when my life took a drastic turn on becoming paralysed from the waist down over the course of 24 hours, by a spinal tumour. Getting this diagnosis was 'the worst day in my life', and it was quickly followed by the 'second worst' when, in my determination to walk again, I received Knee Ankle Foot Orthotics (KAFOs) and was shocked to learn that this appeared to be the best technology solution available on the market 'suitable' for use in the community. Initial anger at the system for not being better, at the rehab team for their complacency, and at myself for allowing a feeling of helplessness to take over led to questions such as: what does this say about our society? and what are we all willing to accept, for ourselves and others? This is professional opinion and an essay about how we see ourselves and how others see us. The journey from pre-injury 'consumer' to post-injury 'disabled' person and learning that being labeled 'disabled' leads to the additional handicap of the narrow vision of "cost" taken by the mobility industry where innovative ideas are stripped down to the bare minimum with the excuse that patients are "lucky" to have what they have been "given". Grappling with these labels and inequities and seeking a better outcome, I became an integral team member of an exoskeleton development team, leading to the design of The Next Generation Exoskeleton! This is MY story, the story of Chloe Angus. It is the story of inclusive, user focused design and is a call to include and respect the end users of all assistive device technology design early in the design process and it is being told from the perspective of a person having experience and success in the world of business.

Alcohol policy and gender: a modelling study estimating gender-specific effects of alcohol pricing policies

AIMS

To describe gender differences in alcohol consumption, purchasing preferences and alcohol-attributable harm. To model the effects of alcohol pricing policies on male and female consumption and hospitalizations.

DESIGN

Epidemiological simulation using the Sheffield Alcohol Policy Model version 4.

SETTING AND PARTICIPANTS

Adults aged 18+ years, England.

INTERVENTIONS

Three alcohol pricing policies: 10% duty increase and minimum unit prices (MUP) of £0.50 and £0.70 per UK unit.

MEASURES

Gender-specific baseline and key outcomes data: annual beverage-specific units of alcohol consumed and beverage-specific alcohol expenditure (household surveys). Alcohol-attributable hospital admissions (administrative data). Key model parameters: literature-based own- and cross-price elasticities for 10 beverage-by-location categories (e.g. off-trade beer). Sensitivity analysis with new gender-specific elasticities. Literature-based risk functions linking consumption and harm, gender-disaggregated where evidence was available. Population subgroups: 120 subgroups defined by gender (primary focus), age, deprivation quintile and baseline weekly consumption.

FINDINGS

Women consumed 59.7% of their alcohol as off-trade wine while men consumed 49.7% as beer. Women drinkers consumed fewer units annually than men (494 versus 895) and a smaller proportion of women were high-risk drinkers (4.8 versus 7.2%). Moderate drinking women had lower hospital admission rates than men (44 versus 547 per 100 000), but rates were similar for high-risk drinking women and men (14 294 versus 13 167 per 100 000). All three policies led to larger estimated reductions in consumption and admission rates among men than women. For example, a £0.50 MUP led to a 5.3% reduction in consumption and a 4.1% reduction in admissions for men but a 0.7% reduction in consumption and a 1.6% reduction in hospitalizations for women.

CONCLUSION

Alcohol consumption, purchasing preferences and harm show strong gender patterns among adult drinkers in England. Alcohol pricing policies are estimated to be more effective at reducing consumption and harm for men than women.

What Proportion of On-Trade Alcohol Is Served to Those Who Are Already Potentially Intoxicated? An Analysis of Event-Level Data

OBJECTIVE

Overservice (i.e., venues serving alcohol to intoxicated drinkers) is a major contributor to alcohol-related harm. This article estimates the proportion of all alcohol sold in on-trade premises in Great Britain that is drunk by people likely to already be intoxicated. Secondary analyses explore variations by age and gender and from 2009 to 2017.

METHOD

We used cross-sectional data from 1-week drinking diaries collected continuously from 2009 to 2017 via a nationally representative stratified quota sample of 90,968 adults resident in Britain who consumed alcohol in the on-trade across 139,938 occasions. We first identify the amount of pure alcohol consumed in occasions after individuals reach each of three consumption thresholds indicating potential intoxication: at least increasing risk (>48/64 g for women/men), at least high risk (>96/128 g), and very high risk (>144/192 g). We then calculate the proportion of all alcohol consumed in the on-trade each year that is accounted for by consumption beyond these thresholds.

RESULTS

In 2017, of all on-trade alcohol consumed, an estimated 43.3% was drunk by those who had already drunk to increasing risk levels, 20.5% by those who had already drunk to high risk levels, and 10.1% by those who had already drunk to very high risk levels. Greater proportions of the alcohol consumed by women and younger people was consumed beyond these levels, but the proportion did not change substantially from 2009 to 2017.

CONCLUSIONS

Depending on the consumption threshold used, potentially intoxicated drinkers consume between 10% and 43% of pure alcohol drunk in on-trade venues in Great Britain, suggesting that overservice is commonplace.

Do dual purchasers behave differently? An analysis of purchasing data for households that buy both alcohol and tobacco in the United Kingdom

BACKGROUND AND AIMS

Dual purchasers of alcohol and tobacco are at increased health risk from the interacting health impacts of alcohol and tobacco use. They are also at financial risk from exposure to the dual financial cost of policies that increase alcohol and tobacco prices. Understanding whose alcohol and tobacco use exposes them to these health and financial risks is important for understanding the inequality impacts of control policies. This study explores the extent to which household spending on alcohol and tobacco combined varies between socio-economic groups and compares this with results for households which purchase only one of the commodities.

DESIGN

Cross-sectional analysis of household-level alcohol and tobacco purchasing data.

SETTING

United Kingdom, 2012-17.

PARTICIPANTS/CASES

A total of 26 021 households.

MEASUREMENTS

We analysed transaction-level data from individual 14-day spending diaries in the Living Cost and Food Survey (LCFS). We used this to calculate expenditure, volumes of alcohol and tobacco purchased, and the price paid per unit of alcohol (1 unit = 8 g) and per stick of tobacco. This was compared with equivalized total expenditure and quintiles of equivalized household income. Prices were calibrated and pack sizes were imputed using empirical sales data from Nielsen/CGA to correct for reporting bias.

FINDINGS

Dual purchasing households spent [95% confidence interval] more on alcohol and more on tobacco than their single-purchasing counterparts. In general, lower-income households spent less on both alcohol and tobacco than higher-income households. Furthermore, dual purchasing households in the lowest income group were most exposed to potential increases in price than were other income groups, with (CI = 12.41-13.15%) of their total household budget spent on alcohol and tobacco.

CONCLUSIONS

Dual purchasers of alcohol and tobacco in the United Kingdom appear to be concentrated evenly among income groups. However, dual purchasers may experience particularly large effects from pricing policies, as they spend a substantially higher proportion of their overall household expenditure on alcohol and tobacco than do households that purchase only one of the commodities.

Effects of minimum unit pricing for alcohol in South Africa across different drinker groups and wealth quintiles: a modelling study

OBJECTIVES

To quantify the potential impact of minimum unit pricing (MUP) for alcohol on alcohol consumption, spending and health in South Africa. We provide these estimates disaggregated by different drinker groups and wealth quintiles.

DESIGN

We developed an epidemiological policy appraisal model to estimate the effects of MUP across sex, drinker groups (moderate, occasional binge, heavy) and wealth quintiles. Stakeholder interviews and workshops informed model development and ensured policy relevance.

SETTING

South African drinking population aged 15+.

PARTICIPANTS

The population (aged 15+) of South Africa in 2018 stratified by drinking group and wealth quintiles, with a model time horizon of 20 years.

MAIN OUTCOME MEASURES

Change in standard drinks (SDs) (12 g of ethanol) consumed, weekly spend on alcohol, annual number of cases and deaths for five alcohol-related health conditions (HIV, intentional injury, road injury, liver cirrhosis and breast cancer), reported by drinker groups and wealth quintile.

RESULTS

We estimate an MUP of R10 per SD would lead to an immediate reduction in consumption of 4.40% (-0.93 SD/week) and an increase in spend of 18.09%. The absolute reduction is greatest for heavy drinkers (-1.48 SD/week), followed by occasional binge drinkers (-0.41 SD/week) and moderate drinkers (-0.40 SD/week). Over 20 years, we estimate 20 585 fewer deaths and 9 00 332 cases averted across the five health-modelled harms.Poorer drinkers would see greater impacts from the policy (consumption: -7.75% in the poorest quintile, -3.19% in richest quintile). Among the heavy drinkers, 85% of the cases averted and 86% of the lives saved accrue to the bottom three wealth quintiles.

CONCLUSIONS

We estimate that MUP would reduce alcohol consumption in South Africa, improving health outcomes while raising retail and tax revenue. Consumption and harm reductions would be greater in poorer groups.

Estimating the burden of the COVID-19 pandemic on mortality, life expectancy and lifespan inequality in England and Wales: a population-level analysis

BACKGROUND

Deaths directly linked to COVID-19 infection may be misclassified, and the pandemic may have indirectly affected other causes of death. To overcome these measurement challenges, we estimate the impact of the COVID-19 pandemic on mortality, life expectancy and lifespan inequality from week 10 of 2020, when the first COVID-19 death was registered, to week 47 ending 20 November 2020 in England and Wales through an analysis of excess mortality.

METHODS

We estimated age and sex-specific excess mortality risk and deaths above a baseline adjusted for seasonality with a systematic comparison of four different models using data from the Office for National Statistics. We additionally provide estimates of life expectancy at birth and lifespan inequality defined as the SD in age at death.

RESULTS

There have been 57 419 (95% prediction interval: 54 197, 60 752) excess deaths in the first 47 weeks of 2020, 55% of which occurred in men. Excess deaths increased sharply with age and men experienced elevated risks of death in all age groups. Life expectancy at birth dropped 0.9 and 1.2 years for women and men relative to the 2019 levels, respectively. Lifespan inequality also fell over the same period by 5 months for both sexes.

CONCLUSION

Quantifying excess deaths and their impact on life expectancy at birth provide a more comprehensive picture of the burden of COVID-19 on mortality. Whether mortality will return to-or even fall below-the baseline level remains to be seen as the pandemic continues to unfold and diverse interventions are put in place.

Estimating the burden of the COVID-19 pandemic on mortality, life expectancy and lifespan inequality in England and Wales: a population-level analysis

BACKGROUND

Deaths directly linked to COVID-19 infection may be misclassified, and the pandemic may have indirectly affected other causes of death. To overcome these measurement challenges, we estimate the impact of the COVID-19 pandemic on mortality, life expectancy and lifespan inequality from week 10 of 2020, when the first COVID-19 death was registered, to week 47 ending 20 November 2020 in England and Wales through an analysis of excess mortality.

METHODS

We estimated age and sex-specific excess mortality risk and deaths above a baseline adjusted for seasonality with a systematic comparison of four different models using data from the Office for National Statistics. We additionally provide estimates of life expectancy at birth and lifespan inequality defined as the SD in age at death.

RESULTS

There have been 57 419 (95% prediction interval: 54 197, 60 752) excess deaths in the first 47 weeks of 2020, 55% of which occurred in men. Excess deaths increased sharply with age and men experienced elevated risks of death in all age groups. Life expectancy at birth dropped 0.9 and 1.2 years for women and men relative to the 2019 levels, respectively. Lifespan inequality also fell over the same period by 5 months for both sexes.

CONCLUSION

Quantifying excess deaths and their impact on life expectancy at birth provide a more comprehensive picture of the burden of COVID-19 on mortality. Whether mortality will return to-or even fall below-the baseline level remains to be seen as the pandemic continues to unfold and diverse interventions are put in place.

Estimating the Burden of Alcohol on Ambulance Callouts through Development and Validation of an Algorithm Using Electronic Patient Records

BACKGROUND

Alcohol consumption places a significant burden on emergency services, including ambulance services, which often represent patients' first, and sometimes only, contact with health services. We aimed to (1) improve the assessment of this burden on ambulance services in Scotland using a low-cost and easy to implement algorithm to screen free-text in electronic patient record forms (ePRFs), and (2) present estimates on the burden of alcohol on ambulance callouts in Scotland.

METHODS

Two paramedics manually reviewed 5416 ePRFs to make a professional judgement of whether they were alcohol-related, establishing a gold standard for assessing our algorithm performance. They also extracted all words or phrases relating to alcohol. An automatic algorithm to identify alcohol-related callouts using free-text in EPRs was developed using these extracts.

RESULTS

Our algorithm had a specificity of 0.941 and a sensitivity of 0.996 in detecting alcohol-related callouts. Applying the algorithm to all callout records in Scotland in 2019, we identified 86,780 (16.2%) as alcohol-related. At weekends, this percentage was 18.5%.

CONCLUSIONS

Alcohol-related callouts constitute a significant burden on the Scottish Ambulance Service. Our algorithm is significantly more sensitive than previous methods used to identify alcohol-related ambulance callouts. This approach and the resulting data have potential for the evaluation of alcohol policy interventions as well as for conducting wider epidemiological research.

The effect of alcohol tax changes on retail prices: how do on-trade alcohol retailers pass through tax changes to consumers?

The effectiveness of alcohol duty increases relies on alcohol retailers passing the tax increase on to consumers. This study uses sales data from a market research company to investigate tax pass-through over 11 years for on-premise retailers in England and whether this varies across the price distribution, for different beverage categories and outlet types. Panel data quantile regression analysis is used to estimate the impact of 12 excise duty changes and 3 sales tax changes between 2007 and 2017 on prices. We use product-level quarterly panel data from for 777 alcoholic products. We undertake the regression at all outlets level separating products are analysed in seven broad beverage categories (Beer, Cider, RTDs, Spirits, Wine, Sparkling Wine, and Fortified Wine). We further test sensitivity by disaggregating outlets into seven outlet types. For all seven broad beverage categories, we find that there exists significant differences in tax pass-through across the price distribution. Retailers appear to "undershift" cheaper beverages (prices rise by less than the tax increase) and subsidise this loss in revenue with an "overshift" in the relatively more expensive products. Future modelling of tax change impacts on population subgroups could incorporate this evidence, and this is important because different socio-economic and drinker groups purchase alcohol at different points on the price distribution and hence are affected differently by tax changes. Governments could also potentially incorporate this evidence into future impact assessments.

Potential effects of minimum unit pricing at local authority level on alcohol-attributed harms in North West and North East England: a modelling study

Background

In 2018, Scotland implemented a 50p-per-unit minimum unit price for alcohol. Previous modelling estimated the impact of minimum unit pricing for England, Scotland, Wales and Northern Ireland. Decision-makers want to know the potential effects of minimum unit pricing for local authorities in England; the premise of this study is that estimated effects of minimum unit pricing would vary by locality.

Objective

The objective was to estimate the potential effects on mortality, hospitalisations and crime of the implementation of minimum unit pricing for alcohol at local authority level in England.

Design

This was an evidence synthesis, and used computer modelling using the Sheffield Alcohol Policy Model (local authority version 4.0). This study gathered evidence on local consumption of alcohol from the Health Survey for England, and gathered data on local prices paid from the Living Costs and Food Survey and from market research companies’ actual sales data. These data were linked with local harms in terms of both alcohol-attributable mortality (from the Office for National Statistics) and alcohol-attributable hospitalisations (from Hospital Episode Statistics) for 45 conditions defined by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. These data were examined for eight age–sex groups split by five Index of Multiple Deprivation quintiles. Alcohol-attributable crime data (Office for National Statistics police-recorded crimes and uplifts for unrecorded offences) were also analysed.

Setting

This study was set in 23 upper-tier local authorities in North West England, 12 upper-tier local authorities in the North East region and nine government office regions, and a national summary was conducted.

Participants

The participants were the population of England aged ≥ 18 years.

Intervention

The intervention was setting a local minimum unit price. The base case is 50p per unit of alcohol. Sensitivity analyses were undertaken using minimum unit prices of 30p, 40p, 60p and 70p per unit of alcohol.

Main outcome measures

The main outcome measures were changes in alcohol-attributable deaths, hospitalisations and crime. Savings in NHS costs, changes in alcohol purchasing and consumption, changes in revenue to off-trade and on-trade retailers and changes in the slope index of inequality between most and least deprived areas were also examined.

Results

The modelling has proved feasible at the upper-tier local authority level. The resulting estimates suggest that minimum unit pricing for alcohol at local authority level could be effective in reducing alcohol-attributable deaths, hospitalisations, NHS costs and crime. A 50p minimum unit price for alcohol at local authority level is estimated to reduce annual alcohol-related deaths in the North West region by 205, hospitalisations by 5956 (–5.5%) and crimes by 8528 (–2.5%). These estimated reductions are mostly due to the 5% of people drinking at high-risk levels (e.g. men drinking > 25 pints of beer or five bottles of wine per week, women drinking > 17 pints of beer or 3.5 bottles of wine per week, and who spend around £2500 per year currently on alcohol). Model estimates of impact are bigger in the North West and North East regions than nationally because, currently, more cheap alcohol is consumed in these regions and because there are more alcohol-related deaths and hospitalisations in these areas. A 30p minimum unit price has estimated effects that are ≈ 90% lower than those of a 50p minimum unit price, and a 40p minimum unit price has estimated effects that are ≈ 50% lower. Health inequalities are estimated to reduce with greater health gains in the deprived areas, where more cheap alcohol is purchased and where there are higher baseline harms.

Limitations

The approach requires synthesis of evidence from multiple sources on alcohol consumption; prices paid; and incidence of diseases, mortality and crime. Price elasticities used are from previous UK analysis of price responsiveness rather than specific to local areas. The study has not estimated ‘cross-border effects’, namely travelling to shops outside the region.

Conclusions

The modelling estimates suggest that minimum unit pricing for alcohol at local authority level would be an effective and well-targeted policy, reducing inequalities.

Future work

The Sheffield Alcohol Policy Model for Local Authorities framework could be further utilised to examine the local impact of national policies (e.g. tax changes) or local policies (e.g. licensing or identification and brief advice). As evidence emerges from the Scottish minimum unit price implementation, this will further inform estimates of impact in English localities. The methods used to estimate drinking and purchasing patterns in each local authority could also be used for other topics involving unhealthy products affecting public health, for example to estimate local smoking or high-fat, high-salt food consumption patterns.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Evaluating the effectiveness of the smartphone app, Drink Less, compared with the NHS alcohol advice webpage, for the reduction of alcohol consumption among hazardous and harmful adult drinkers in the UK at 6-month follow-up: protocol for a randomised controlled trial

BACKGROUND AND AIMS

Digital interventions are effective for reducing alcohol consumption but evidence is limited regarding smartphone apps. Drink Less is a theory- and evidence-informed app to help people reduce their alcohol consumption that has been refined in terms of its content and design for usability across the sociodemographic spectrum. We aim to evaluate the effectiveness and cost-effectiveness of recommending Drink Less at reducing alcohol consumption compared with usual digital care.

DESIGN

Two-arm individually randomised controlled trial.

SETTING

Online trial in the United Kingdom (UK).

PARTICIPANTS

Hazardous or harmful drinkers (Alcohol Use Disorders Identification Test [AUDIT] score ≥8) aged 18+ who want to drink less alcohol (n = 5562). Participants will be recruited from July 2020 to May 2022 using multiple strategies with a focus on remote digital methods.

INTERVENTION AND COMPARATOR

Participants will be randomised to receive either an email recommending that they use Drink Less (intervention) or view the National Health Service (NHS) webpage on alcohol advice (comparator).

MEASUREMENTS

The primary outcome is change in self-reported weekly alcohol consumption, assessed using the extended AUDIT-Consumption, between baseline and 6-month follow-up. Secondary outcomes include change in self-reported weekly alcohol consumption assessed at 1- and 3-month follow-ups, and the proportion of hazardous drinkers; alcohol-related problems and injury; health-related quality of life; and use of health services assessed at 6-month follow-up. Effectiveness will be examined with adjusted regression models, adjusting for baseline alcohol consumption and using an intention-to-treat approach. A mixed-methods process evaluation will assess engagement, acceptability and mechanism of action. Economic evaluations will be conducted using both a short- and longer-term time horizon.

COMMENTS

This study will establish the effectiveness and cost-effectiveness of the Drink Less app at reducing alcohol consumption among hazardous and harmful adult drinkers and will be the first randomised controlled trial of an alcohol reduction app for the general population in the United Kingdom. This study will inform the decision on whether it is worth investing resources in large-scale implementation.

The SPECTRUM Consortium: a new UK Prevention Research Partnership consortium focussed on the commercial determinants of health, the prevention of non-communicable diseases, and the reduction of health inequalities

The main causes of non-communicable diseases (NCDs), health inequalities and health inequity include consumption of unhealthy commodities such as tobacco, alcohol and/or foods high in fat, salt and/or sugar. These exposures are preventable, but the commodities involved are highly profitable. The economic interests of 'Unhealthy Commodity Producers' (UCPs) often conflict with health goals but their role in determining health has received insufficient attention. In order to address this gap, a new research consortium has been established. This open letter introduces the SPECTRUM ( S haping  Public h Ealth poli Cies  To  Reduce ineq Ualities and har M)Consortium: a multi-disciplinary group comprising researchers from 10 United Kingdom (UK) universities and overseas, and partner organisations including three national public health agencies in Great Britain (GB), five multi-agency alliances and two companies providing data and analytic support. Through eight integrated work packages, the Consortium seeks to provide an understanding of the nature of the complex systems underlying the consumption of unhealthy commodities, the role of UCPs in shaping these systems and influencing health and policy, the role of systems-level interventions, and the effectiveness of existing and emerging policies. Co-production is central to the Consortium's approach to advance research and achieve meaningful impact and we will involve the public in the design and delivery of our research. We will also establish and sustain mutually beneficial relationships with policy makers, alongside our partners, to increase the visibility, credibility and impact of our evidence. The Consortium's ultimate aim is to achieve meaningful health benefits for the UK population by reducing harm and inequalities from the consumption of unhealthy commodities over the next five years and beyond.

Assessing the contribution of alcohol-specific causes to socio-economic inequalities in mortality in England and Wales 2001-16

BACKGROUND AND AIMS

When measuring inequalities in health, public health and addiction research has tended to focus on differences in average life-span between socio-economic groups. This does not account for the extent to which age of death varies between individuals within socio-economic groups or whether this variation differs between groups. This study assesses (1) socio-economic inequalities in both average life-span and variation in age at death, (2) the extent to which these inequalities can be attributed to alcohol-specific causes (i.e. those attributable only to alcohol) and (3) how this contribution has changed over time.

DESIGN

Cause-deleted life table analysis of national mortality records.

SETTING

England and Wales, 2001-16.

CASES

All-cause and alcohol-specific deaths for all adults aged 18+, stratified by sex, age and quintiles of the index of multiple deprivation (IMD).

MEASUREMENTS

Life expectancy at age 18 yearss and standard deviation in age at death within IMD quintiles and the contribution of alcohol to overall differences in both measures between the highest and lowest IMD quintiles by comparing observed and cause-deleted inequality 'gaps'.

FINDINGS

In 2016, alcohol-specific causes reduced life expectancy for men and women by 0.26 and 0.14 years, respectively, and increased the standard deviation in age at death. These causes also increased the inequality gap in life expectancy by 0.33 years for men and 0.17 years for women, and variation in age at death by 0.14 years and 0.13 years, respectively. For both measures, the contribution of alcohol to mortality inequalities rose after 2001 and subsequently fell back. For women, alcohol accounted for 3.6% of inequality in age at death and 6.0% of life-span uncertainty, suggesting that using only the former may underestimate alcohol-induced inequalities. There was no comparable difference for men.

CONCLUSIONS

Deaths from alcohol-specific causes increase inequalities in both life expectancy and variation in age of death between socio-economic groups. Using both measures can provide a fuller picture of overall inequalities in health.