Estimation of usual occasion-based individual drinking patterns using diary survey data

Effectiveness of subnational implementation of minimum unit price for alcohol: policy appraisal modelling for local authorities in England

AIMS

Evidence exists on the potential impact of national level minimum unit price (MUP) policies for alcohol. This study investigated the potential effectiveness of implementing MUP at regional and local levels compared with national implementation.

DESIGN

Evidence synthesis and computer modelling using the Sheffield Alcohol Policy Model (Local Authority version 4.0; SAPMLA).

SETTING

Results are produced for 23 Upper Tier Local Authorities (UTLAs) in North West England, 12 UTLAs in North East England, 15 UTLAs in Yorkshire and Humber, the nine English Government Office regions and England as a whole.

CASES

Health Survey for England (HSE) data 2011-13 (n = 24 685).

MEASUREMENTS

Alcohol consumption, consumer spending, retailers' revenues, hospitalizations, National Health Service costs, crimes and alcohol-attributable deaths and health inequalities.

FINDINGS

Implementing a local £0.50 MUP for alcohol in northern English regions is estimated to result in larger percentage reductions in harms than the national average. The reductions for England, North West, North East and Yorkshire and Humber regions, respectively, in annual alcohol-attributable deaths are 1024 (-10.4%), 205 (-11.4%), 121 (-17.4%) and 159 (-16.9%); for hospitalizations are 29 943 (-4.6%), 5956 (-5.5%), 3255 (-7.9%) and 4610 (-6.9%); and for crimes are 54 229 (-2.4%), 8528 (-2.5%), 4380 (-3.5%) and 8220 (-3.2%). Results vary among local authorities; for example, annual alcohol-attributable deaths estimated to change by between -8.0 and -24.8% throughout the 50 UTLAs examined.

CONCLUSIONS

A minimum unit price local policy for alcohol is likely to be more effective in those regions, such as the three northern regions of England, which have higher levels of alcohol consumption and higher rates of alcohol harm than for the national average. In such regions, the minimum unit price policy would achieve larger reductions in alcohol consumption, alcohol-attributable mortality, hospitalization rates, NHS costs, crime rates and health inequalities.

Concordance Between Point-of-Care Urine Ethyl Glucuronide Alcohol Tests and Self-Reported Alcohol Use in Persons with HIV in Uganda

Screening and assessing alcohol use accurately to maximize positive treatment outcomes remain problematic in regions with high rates of alcohol use and HIV and TB infections. In this study, we examined the concordance between self-reported measures of alcohol use and point-of-care (POC) urine ethyl glucuronide (uEtG) test results among persons with HIV (PWH) in Uganda who reported drinking in the prior 3 months. For analyses, we used the screening data of a trial designed to examine the use of incentives to reduce alcohol consumption and increase medication adherence to examine the concordance between POC uEtG (300 ng/mL cutoff) and six measures of self-reported alcohol use. Of the 2136 participants who completed the alcohol screening, 1080 (50.6%) tested positive in the POC uEtG test, and 1756 (82.2%) self-reported using alcohol during the prior 72 h. Seventy-two percent of those who reported drinking during the prior 24 h had a uEtG positive test, with lower proportions testing uEtG positive when drinking occurred 24-48 h (64.7%) or 48-72 h (28.6%) prior to sample collection. In multivariate models, recency of drinking, number of drinks at last alcohol use, and Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) score were associated with uEtG positivity. The highest area under the curve (AUC) for a uEtG positive test was for recency of drinking. Overall, we concluded that several measures of drinking were associated with POC uEtG positivity, with recency of drinking, particularly drinking within the past 24 h, being the strongest predictor of uEtG positivity.

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.

Change in alcohol outlet density and alcohol-related harm to population health (CHALICE): a comprehensive record-linked database study in Wales

Background

Excess alcohol consumption has serious adverse effects on health and results in violence-related harm.

Objective

This study investigated the impact of change in community alcohol availability on alcohol consumption and alcohol-related harms to health, assessing the effect of population migration and small-area deprivation.

Design

A natural experiment of change in alcohol outlet density between 2006 and 2011 measured at census Lower Layer Super Output Area level using observational record-linked data.

Setting

Wales, UK; population of 2.5 million aged ≥ 16 years.

Outcome measures

Alcohol consumption, alcohol-related hospital admissions, accident and emergency (A&E) department attendances from midnight to 06.00 and violent crime against the person.

Data sources

Licensing Act 2003 [Great Britain.Licensing Act 2003. London: The Stationery Office; 2003. URL:www.legislation.gov.uk/ukpga/2003/17/contents(accessed 8 June 2015)] data on alcohol outlets held by the 22 local authorities in Wales, alcohol consumption data from annual Welsh Health Surveys 2008–12, hospital admission data 2006–11 from the Patient Episode Database for Wales (PEDW) and A&E attendance data 2009–11 were anonymously record linked to the Welsh Demographic Service age–sex register within the Secure Anonymised Information Linkage Databank. A final data source was recorded crime 2008–11 from the four police forces in Wales.

Methods

Outlet density was estimated (1) as the number of outlets per capita for the 2006 static population and the per quarterly updated population to assess the impact of population migration and (2) using new methods of network analysis of distances between each household and alcohol outlets within 10 minutes of walking and driving. Alcohol availability was measured by three variables: (1) the previous quarterly value; (2) positive and negative change over the preceding five quarters; and (3) volatility, a measure of absolute quarterly changes during the preceding five quarters. Longitudinal statistical analysis used multilevel Poisson models of consumption and Geographically Weighted Regression (GWR) spatial models of binge drinking, Cox regression models of hospital admissions and A&E attendance and GWR models of violent crime against the person, each as a function of alcohol availability adjusting for confounding variables. The impact on health inequalities was investigated by stratifying models within quintiles of the Welsh Index of Multiple Deprivation.

Results

The main finding was that change in walking outlet density was associated with alcohol-related harms: consumption, hospital admissions and violent crime against the person each tracked the quarterly changes in outlet density. Alcohol-related A&E attendances were not clinically coded and the association was less conclusive. In general, social deprivation was strongly associated with the outcome measures but did not substantially modify the associations between the outcomes and alcohol availability. We found no evidence for an important effect of population migration.

Limitations

Limitations included the absence of any standardised methods of alcohol outlet data collation, processing and validation, and incomplete data on on-sales and off-sales. We were dependent on the quality of clinical coding and administrative records and could not identify alcohol-related attendances in the A&E data set.

Conclusion

This complex interdisciplinary study found that important alcohol-related harms were associated with change in alcohol outlet density. Future work recommendations include defining a research standard for recording outlet data and classification of outlet type, the methodological development of residence-based density measures and a health economic analysis of model-predicted harms.

Funding

The National Institute for Health Research Public Health Research programme. Additional technical and computing support was provided by the Farr Institute at Swansea University, made possible by the following grant:

Centre for the Improvement of Population Health through E-records Research (CIPHER) and Farr Institute capital enhancement. CIPHER and the Farr Institute are funded by Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Chief Scientist Office (Scottish Government Health Directorates), the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the Medical Research Council, the National Institute for Health Research, the National Institute for Social Care and Health Research (Welsh Government) and the Wellcome Trust (grant reference MR/K006525/1).

Estimated Effects of Different Alcohol Taxation and Price Policies on Health Inequalities: A Mathematical Modelling Study

INTRODUCTION

While evidence that alcohol pricing policies reduce alcohol-related health harm is robust, and alcohol taxation increases are a WHO "best buy" intervention, there is a lack of research comparing the scale and distribution across society of health impacts arising from alternative tax and price policy options. The aim of this study is to test whether four common alcohol taxation and pricing strategies differ in their impact on health inequalities.

METHODS AND FINDINGS

An econometric epidemiological model was built with England 2014/2015 as the setting. Four pricing strategies implemented on top of the current tax were equalised to give the same 4.3% population-wide reduction in total alcohol-related mortality: current tax increase, a 13.4% all-product duty increase under the current UK system; a value-based tax, a 4.0% ad valorem tax based on product price; a strength-based tax, a volumetric tax of £0.22 per UK alcohol unit (= 8 g of ethanol); and minimum unit pricing, a minimum price threshold of £0.50 per unit, below which alcohol cannot be sold. Model inputs were calculated by combining data from representative household surveys on alcohol purchasing and consumption, administrative and healthcare data on 43 alcohol-attributable diseases, and published price elasticities and relative risk functions. Outcomes were annual per capita consumption, consumer spending, and alcohol-related deaths. Uncertainty was assessed via partial probabilistic sensitivity analysis (PSA) and scenario analysis. The pricing strategies differ as to how effects are distributed across the population, and, from a public health perspective, heavy drinkers in routine/manual occupations are a key group as they are at greatest risk of health harm from their drinking. Strength-based taxation and minimum unit pricing would have greater effects on mortality among drinkers in routine/manual occupations (particularly for heavy drinkers, where the estimated policy effects on mortality rates are as follows: current tax increase, -3.2%; value-based tax, -2.9%; strength-based tax, -6.1%; minimum unit pricing, -7.8%) and lesser impacts among drinkers in professional/managerial occupations (for heavy drinkers: current tax increase, -1.3%; value-based tax, -1.4%; strength-based tax, +0.2%; minimum unit pricing, +0.8%). Results from the PSA give slightly greater mean effects for both the routine/manual (current tax increase, -3.6% [95% uncertainty interval (UI) -6.1%, -0.6%]; value-based tax, -3.3% [UI -5.1%, -1.7%]; strength-based tax, -7.5% [UI -13.7%, -3.9%]; minimum unit pricing, -10.3% [UI -10.3%, -7.0%]) and professional/managerial occupation groups (current tax increase, -1.8% [UI -4.7%, +1.6%]; value-based tax, -1.9% [UI -3.6%, +0.4%]; strength-based tax, -0.8% [UI -6.9%, +4.0%]; minimum unit pricing, -0.7% [UI -5.6%, +3.6%]). Impacts of price changes on moderate drinkers were small regardless of income or socioeconomic group. Analysis of uncertainty shows that the relative effectiveness of the four policies is fairly stable, although uncertainty in the absolute scale of effects exists. Volumetric taxation and minimum unit pricing consistently outperform increasing the current tax or adding an ad valorem tax in terms of reducing mortality among the heaviest drinkers and reducing alcohol-related health inequalities (e.g., in the routine/manual occupation group, volumetric taxation reduces deaths more than increasing the current tax in 26 out of 30 probabilistic runs, minimum unit pricing reduces deaths more than volumetric tax in 21 out of 30 runs, and minimum unit pricing reduces deaths more than increasing the current tax in 30 out of 30 runs). Study limitations include reducing model complexity by not considering a largely ineffective ban on below-tax alcohol sales, special duty rates covering only small shares of the market, and the impact of tax fraud or retailer non-compliance with minimum unit prices.

CONCLUSIONS

Our model estimates that, compared to tax increases under the current system or introducing taxation based on product value, alcohol-content-based taxation or minimum unit pricing would lead to larger reductions in health inequalities across income groups. We also estimate that alcohol-content-based taxation and minimum unit pricing would have the largest impact on harmful drinking, with minimal effects on those drinking in moderation.

Social disparities in hazardous alcohol use: self-report bias may lead to incorrect estimates

BACKGROUND

Self-report bias in surveys of alcohol consumption is widely documented; however, less is known about the distribution of such bias by socioeconomic status (SES) and about the possible impact on social disparities. This study aims to assess social disparities in hazardous drinking (HD) and to analyze how correcting alcohol consumption data for self-report bias may affect estimates of disparities.

METHODS

National survey data from 13 countries, Canada, England, Finland, France, Germany, Hungary, Ireland, Japan, Korea, New Zealand, Spain, Switzerland and USA, are used to examine social disparities in HD by SES and education level. Defining HD as drinking above 3 drinks/day for men and 2 for women, social disparities were assessed by calculating country-level concentration indexes. Aggregate consumption data were used to correct survey-based estimates for self-report bias.

RESULTS

Survey data show that more-educated women are more likely than less-educated women to engage in HD, while the opposite is observed in men in most countries. Large discrepancies in alcohol consumption between survey-based and aggregate estimates were found. Correcting for self-report bias increased estimates of social disparities in women, and decreased them in men, to the point that gradients were reversed in several countries (from higher rates in low education/SES men to an opposite pattern).

CONCLUSION

This study provides evidence of a likely misestimation of social disparities in HD, in both men and women, due to self-report bias in alcohol consumption surveys. This study contributes to a better knowledge of the social dimensions of HD and to the targeting of alcohol policies.

Potential benefits of minimum unit pricing for alcohol versus a ban on below cost selling in England 2014: modelling study

OBJECTIVE

To evaluate the potential impact of two alcohol control policies under consideration in England: banning below cost selling of alcohol and minimum unit pricing.

DESIGN

Modelling study using the Sheffield Alcohol Policy Model version 2.5.

SETTING

England 2014-15.

POPULATION

Adults and young people aged 16 or more, including subgroups of moderate, hazardous, and harmful drinkers.

INTERVENTIONS

Policy to ban below cost selling, which means that the selling price to consumers could not be lower than tax payable on the product, compared with policies of minimum unit pricing at £0.40 (€0.57; $0.75), 45 p, and 50 p per unit (7.9 g/10 mL) of pure alcohol.

MAIN OUTCOME MEASURES

Changes in mean consumption in terms of units of alcohol, drinkers' expenditure, and reductions in deaths, illnesses, admissions to hospital, and quality adjusted life years.

RESULTS

The proportion of the market affected is a key driver of impact, with just 0.7% of all units estimated to be sold below the duty plus value added tax threshold implied by a ban on below cost selling, compared with 23.2% of units for a 45 p minimum unit price. Below cost selling is estimated to reduce harmful drinkers' mean annual consumption by just 0.08%, around 3 units per year, compared with 3.7% or 137 units per year for a 45 p minimum unit price (an approximately 45 times greater effect). The ban on below cost selling has a small effect on population health-saving an estimated 14 deaths and 500 admissions to hospital per annum. In contrast, a 45 p minimum unit price is estimated to save 624 deaths and 23,700 hospital admissions. Most of the harm reductions (for example, 89% of estimated deaths saved per annum) are estimated to occur in the 5.3% of people who are harmful drinkers.

CONCLUSIONS

The ban on below cost selling, implemented in the England in May 2014, is estimated to have small effects on consumption and health harm. The previously announced policy of a minimum unit price, if set at expected levels between 40 p and 50 p per unit, is estimated to have an approximately 40-50 times greater effect.