Are Alcohol Taxation and Pricing Policies Regressive? Product-Level Effects of a Specific Tax and a Minimum Unit Price for Alcohol

Estimating the effect of transitioning to a strength-based alcohol tax system on alcohol consumption and health outcomes: a modelling study of tax reform in England

BACKGROUND

Increasing the amount of alcohol taxation is among the most effective measures for addressing the rising global burden of alcohol harm. However, less is known about the effect of changing alcohol tax structures. Substantial reforms to UK alcohol taxation structures enacted in August, 2023, mean that all alcohol is taxed based on its ethanol content, beers and ciders sold in on-trade premises (eg, public houses) are taxed at a reduced rate (hereafter called draught relief), and beer and particularly cider remain taxed at lower rates than other alcohol of equivalent strength. We aimed to model the effect of these reforms on alcohol consumption and health and economic outcomes, and the effects of hypothetical alternative scenarios.

METHODS

The Sheffield Tobacco and Alcohol Policy Model was used to estimate policy effects on alcohol consumption. The model is an individual-based microsimulation that uses data from the Health Survey for England, Living Costs and Food Survey, Hospital Episode Statistics, and the Office for National Statistics. Spending and revenues to retailers and the Government were estimated cumulatively for a 5-year period post-intervention. Policy effects on all-cause deaths, years of life lost, hospital admissions, and admissions costs were estimated cumulatively for a 20-year period post-intervention.

FINDINGS

The reform was estimated to decrease mean weekly alcohol consumption per drinker by less than 0·05 (-0·34%) units (1 unit=8 g/10 mL ethanol), and prevent 2307 deaths and 11 510 hospital admissions during 20 years compared with no policy change. Removing draught relief was estimated to prevent 1441 further deaths and 14 247 further admissions. Hypothetical scenarios showed that removing draught relief would only slightly improve public health outcomes, and increasing tax rates for beer and ciders to match other drinks of equivalent strength would reduce consumption by a further 2·5 units per week (-17%) and deaths by approximately 74 465.

INTERPRETATION

Alcohol tax structures based on alcohol strength enable tax policy to improve public health in a targeted way. However, the UK reforms are unlikely to substantially improve health outcomes as they do not raise taxes overall. Raising tax rates for the lowest taxed beer and ciders, which are favoured by those who consume harmful amounts of alcohol, could achieve substantially greater public health benefits and reduce health inequalities.

FUNDING

National Institute for Health and Care Research and UK Prevention Research Partnership.

Alcoholic beverage types consumed by population subgroups in the United States: Implications for alcohol policy to address health disparities

INTRODUCTION

We aimed to identify alcoholic beverage types more likely to be consumed by demographic subgroups with greater alcohol-related health risk than others, mainly individuals with low socio-economic status, racial/ethnic minority status and high drinking levels.

METHODS

Fractional logit modelling was performed using a nationally representative sample of US adult drinkers (analytic N = 37,657) from the National Epidemiologic Survey on Alcohol and Related Conditions Waves 2 (2004-2005) and 3 (2012-2013). The outcomes were the proportions of pure alcohol consumed as beer, wine, liquor and coolers (defined as wine-/malt-/liquor-based coolers, hard lemonade, hard cider and any prepackaged cocktails of alcohol and mixer).

RESULTS

Adults with lower education and low or medium income were more likely to drink beer, liquor and coolers, while those with a 4-year college/advanced degree and those with high income preferred wine. Excepting Asian adults, racial/ethnic minority adults were more likely to drink beer (Hispanics) and liquor (Blacks), compared with White adults. High- or very-high-level drinkers were more likely to consume liquor and beer and less likely to consume wine (and coolers), compared with low-level drinkers. High-level and very-high-level drinkers, who were less than 10% of all drinkers, consumed over half of the total volume of beer, liquor and coolers consumed by all adults.

DISCUSSION AND CONCLUSIONS

Individuals with low socio-economic status, racial/ethnic minority status or high drinking level prefer liquor and beer. As alcohol taxes, sales and marketing practices all are beverage-specific, targeted approaches to reduce consumption of these beverages, particularly among individuals with these profiles, are warranted.

Taxation of tobacco, alcohol, and sugar-sweetened beverages: reviewing the evidence and dispelling the myths

The article reviews the large body of evidence on how taxation affects the consumption of tobacco, alcohol, and sugar-sweetened beverages (SSB). There is abundant evidence that demand for tobacco, alcohol, and SSB is price-responsive and that tax changes are quickly passed on to consumers. This suggests that taxes can be highly effective in changing consumption and reducing the burden of diseases associated with consuming these products. Tobacco, alcohol, and SSB industries oppose taxation on similar grounds, mostly on the regressivity of taxes since regressive taxes take a larger percentage of income from low income earners than from middle and high income earners; but also on the effects taxes might have on employment and economic activity; and, in the case of tobacco, the effects taxation has on illicit trade.Contrary to industry arguments, evidence shows that taxation may have short-term negative financial consequences for low-income households. However, medium and long-term financial benefits from reduced healthcare costs, better health, and welfare largely compensate for such consequences. Moreover, taxation does not negatively affect aggregate economic activity or employment, as consumers switch demand to other products that generate employment and may compensate for any employment loss in taxed sectors. Evidence also shows the revenues generated are generally spent on labour-intensive services. In the case of illicit trade in tobacco, evidence shows that illicit trade has not increased globally (rather the opposite) despite increases in tobacco taxes. Profit-maximising smugglers increase illicit cigarette prices along with the increases in licit cigarette prices. This implies that even when increased taxes divert some demand to the illicit market, they push prices up in the illicit market, discouraging consumption.

Is minimum unit pricing for alcohol having the intended effects on alcohol consumption in Scotland?

BACKGROUND AND AIMS

The Scottish Government introduced minimum unit pricing (MUP) for alcohol on 1 May 2018. This means retailers in Scotland cannot sell alcohol to consumers for less than £0.50 per unit (1 UK unit = 8 g ethanol). The Government intended the policy to increase the price of cheap alcohol, cut alcohol consumption overall and particularly among those drinking at hazardous or harmful levels, and ultimately reduce alcohol-related harm. This paper aims to summarise and assess the evidence to date evaluating the impact of MUP on alcohol consumption and related behaviours in Scotland.

ARGUMENT

Evidence from analyses of population-level sales data suggest, all else being equal, MUP reduced the volume of alcohol sold in Scotland by ~ 3.0% to 3.5%, with the largest reductions affecting cider and spirits sales. Analyses of two time series datasets on household-level alcohol purchasing and individual-level alcohol consumption suggest reductions in purchasing and consumption among those drinking at hazardous and harmful levels, but offer conflicting results for those drinking at the most harmful levels. These subgroup analyses are methodologically robust, but the underlying datasets have important limitations as they rely on non-random sampling strategies. Further studies identified no clear evidence of reduced alcohol consumption among those with alcohol dependence or those presenting to emergency departments and sexual health clinics, some evidence of increased financial strain among people with dependence and no evidence of wider negative outcomes arising from changes in alcohol consumption behaviours.

CONCLUSIONS

Minimum unit pricing for alcohol in Scotland has led to reduced consumption, including among heavier drinkers. However, there is uncertainty regarding its impact on those at greatest risk and some limited evidence of negative outcomes, specifically financial strain, among people with alcohol dependence.

Alcohol: No Ordinary Commodity-a summary of the third edition

BACKGROUND AND AIMS

This article summarizes the findings and conclusions of the third edition of Alcohol: No Ordinary Commodity. The latest revision of this book is part of a series of monographs designed to provide a critical review of the scientific evidence related to alcohol control policy from a public health perspective.

DESIGN

A narrative summary of the contents of the book according to five major issues.

FINDINGS

An extensive amount of epidemiological evidence shows that alcohol is a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. Trends in alcohol products and marketing are described, indicating that a large part of the global industry has been consolidated into a small number of transnational corporations that are expanding their operations in Asia, Africa and Latin America. The main part of the book is devoted to a review of strategies and interventions designed to prevent or minimize alcohol-related harm. Overall, the most effective strategies to protect public health are taxation that decreases affordability and restrictions on the physical availability of alcohol. A total ban on alcohol marketing is also an effective strategy to reduce consumption. In addition, drink-driving counter-measures, brief interventions with at-risk drinkers and treatment of drinkers with alcohol dependence are effective in preventing harm in high-risk contexts and groups of hazardous drinkers.

CONCLUSION

Alcohol policy is often the product of competing interests, values and ideologies, with the evidence suggesting that the conflicting interests between profit and health mean that working in partnership with the alcohol industry is likely to lead to ineffective policy. Opportunities for implementation of evidence-based alcohol policies that better serve the public good are clearer than ever before as a result of accumulating knowledge on which strategies work best.

Impact of minimum unit pricing on youth alcohol consumption: insights from Lebanon

This paper analyses the impact of introducing an alcohol minimum unit pricing policy on youth's off-premise alcohol consumption. We rely on price elasticities derived using stated preference alcohol purchase data from a survey of 1024 university students in Lebanon. Selectively targeting drinks with high ethanol concentration by applying a minimum unit pricing (MUP) corresponding to the maximum price that respondents are willing to pay per beverage achieves a reduction in ethanol intake close to 0.23 l/month (∼28% of pre-MUP ethanol intake). Imposing a flat MUP corresponding to the average price respondents are willing to pay for all alcoholic beverages decreases ethanol intake by nearly half the reduction from the previous targeted MUP. This work provides evidence in favour of MUP in conjunction with taxation capable of substantially reducing alcohol consumption. We also document a positive welfare benefit of MUP.

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.

Alcohol control policies in Former Soviet Union countries: A narrative review of three decades of policy changes and their apparent effects

Issues.

The last Soviet anti-alcohol campaign of 1985 resulted in considerably reduced alcohol consumption and saved thousands of lives. But once the campaign’s policies were abandoned and the Soviet alcohol monopoly broken up, a steep rise in mortality was observed in many of the newly formed successor countries, although some kept their monopolies. Almost 30 years after the campaign’s end, the region faces diverse challenges in relation to alcohol.

Approach.

The present narrative review sheds light on recent drinking trends and alcohol policy developments in the 15 Former Soviet Union (FSU) countries, highlighting the most important setbacks, achievements and best practices. Vignettes of alcohol control policies in Belarus, Estonia, Kazakhstan, Lithuania and Uzbekistan are presented to illustrate the recent developments.

Key Findings.

Over the past decade, drinking levels have declined in almost all FSU countries, paralleled by the introduction of various alcohol-control measures. The so-called three ‘best buys’ put forward by the World Health Organization to reduce alcohol-attributable burden (taxation and other measures to increase price, restrictions on alcohol availability and marketing) are relatively well implemented across the countries.

Implications.

In recent years, evidence-based alcohol policies have been actively implemented as a response to the enormous alcohol-attributable burden in many of the countries, although there is big variance across and within different jurisdictions.

Conclusion.

Strong declines in alcohol consumption were observed in the 15 FSU countries, which have introduced various alcohol control measures in recent years, resulting in a reduction of alcohol consumption in the World Health Organization European region overall.

Modelling the effects of alcohol pricing policies on alcohol consumption in subpopulations in Australia

AIMS

To model the effects of a range of alcohol pricing policies on alcohol consumption in subpopulation groups (e.g. alcohol consumption pattern, and age and income groups) in Australia.

DESIGN

We used estimated price elasticities to model the effects of proposed pricing policies on consumption for 11 beverage categories among subpopulation groups.

SETTING

Australia.

PARTICIPANTS

A total of 1789 adults (16+ years) who reported they purchased and consumed alcohol in the 2013 Australian International Alcohol Control Study, an adult population survey.

MEASUREMENTS

Mean and percentage changes in alcohol consumption were estimated for each scenario across subgroups. The policy scenarios evaluated included: (1) increasing the excise rate 10% for all off-premise beverages; (2) replacing the wine equalization tax with a volumetric excise rate equal to the current spirits tax rate; (3) applying a uniform excise tax rate to all beverages equal to the current sprits tax rate and a 10 or 20% increase in it; and(4) introducing a minimum unit price (MUP) on all beverages categories at $1.00, 1.30 or 1.50.

FINDINGS

The effects of different tax and MUP policies varied greatly across different subgroups. The effects of the MUP policy on alcohol consumption increased rapidly in the range from $1.00 to $1.50. Applying a uniform tax rate across all beverages equal to current spirits tax rate, or a 10 or 20% increase beyond that, could generate large reductions in overall alcohol consumption in Australia. Compared with the uniform tax rate with or without further tax increase, introducing a MUP at $1.30 or $1.50 could reduce consumption particularly among harmful drinkers and lower-income drinkers, with comparatively smaller impacts on moderate and higher-income drinkers.

CONCLUSIONS

Both uniform excise tax and minimum unit price policies are predicted to reduce alcohol consumption in Australia. Minimum unit price policies are predicted to have a greater impact on drinking among harmful drinkers than moderate drinkers.

The impact of broad-based vs targeted taxation on youth alcohol consumption in Lebanon

This study aims to model youth’s off-premise alcohol demand and forecasts ethanol intake responsiveness to alcohol taxes. Using stated preference alcohol purchase data from a survey of 1024 university students in Lebanon, we derive price elasticities that we use to forecast the effects of two excise tax scenarios on overall ethanol intake. The first scenario imposes a broad-based 20% tax on all types of alcoholic beverages, and the second scenario imposes a targeted 20% tax only on the high ethanol content, while exempting the lower ethanol beverages. Overall, targeted taxes are found to achieve a reduction in ethanol intake that is nearly three times that achieved by broad taxes (15.7% vs 5.3%). For ‘past-month binge drinkers’, targeted taxes would decrease alcohol intake by 16.3%, while broad taxes increase it by 3.3%. Finally, ethanol intake among participants who prefer low ethanol content would decrease under targeted taxes by more than five times as much as under broad taxes. For ‘high-ethanol drinkers’, targeted taxes decrease alcohol intake by an even larger proportion than for ‘low-ethanol drinkers’ (19.0% vs 15.6%), while broad taxes increase their ethanol intake by ∼16.0%. This study contributes evidence that taxation policy substantially reduces alcohol consumption and that alcohol consumption patterns should be accounted for when designing taxes.

Increasing the Price of Alcohol as an Obesity Prevention Measure: The Potential Cost-Effectiveness of Introducing a Uniform Volumetric Tax and a Minimum Floor Price on Alcohol in Australia

The objective of this study was to estimate, from an obesity prevention perspective, the cost-effectiveness of two potential policies that increase the price of alcohol in Australia: a volumetric tax applied to all alcohol (Intervention 1) and a minimum unit floor price (Intervention 2). Estimated changes in alcoholic drink consumption and corresponding changes in energy intake were calculated using the 2011-12 Australian Health Survey data, published price elasticities, and nutrition information. The incremental changes in body mass index (BMI), BMI-related disease outcomes, healthcare costs, and Health Adjusted Life Years (HALYs) were estimated using a validated model. Costs associated with each intervention were estimated for government and industry. Both interventions were estimated to lead to reductions in mean alcohol consumption (Intervention 1: 20.7% (95% Uncertainty Interval (UI): 20.2% to 21.1%); Intervention 2: 9.2% (95% UI: 8.9% to 9.6%); reductions in mean population body weight (Intervention 1: 0.9 kg (95% UI: 0.84 to 0.96); Intervention 2: 0.45 kg (95% UI: 0.42 to 0.48)); HALYs gained (Intervention 1: 566,648 (95% UI: 497,431 to 647,262); Intervention 2: 317,653 (95% UI: 276,334 to 361,573)); and healthcare cost savings (Intervention 1: $5.8 billion (B) (95% UI: $5.1B to $6.6B); Intervention 2: $3.3B (95% UI: $2.9B to $3.7B)). Intervention costs were estimated as $24M for Intervention 1 and $30M for Intervention 2. Both interventions were dominant, resulting in health gains and cost savings. Increasing the price of alcohol is likely to be cost-effective from an obesity prevention perspective in the Australian context, provided consumers substitute alcoholic beverages with low or no kilojoule alternatives.

Heterogenous wealth effects of minimum unit price on purchase of alcohol: Evidence using scanner data

One of the key arguments given to oppose the "sin taxes" is that they are regressive in nature and place disproportionately higher cost on the poor thereby reducing their net wealth. The response to a reduction in net wealth attributed to tax can potentially have significant effects through an increase in alcohol purchase by heavy drinkers reinforcing or even offsetting the direct price or substitution effect of these taxes in reducing alcohol consumption. Comparatively little is known empirically about the net wealth effect associated with changes in alcohol tax policy, and this study aims to help fill this gap in the literature. In this study we aim to estimate how the wealth effects of introducing a minimum unit price (MUP) of A$2.00 per standard drink vary over the distribution (quantiles) of alcohol consumers. The data used in this study is a longitudinal panel of 1,395 households' daily alcohol purchases (scanner data) recorded over a full year. Our analysis involves (i) quantile regression to estimate income elasticity over the distribution of consumption, and (ii) using these elasticities to estimate the potential wealth effects of a hypothetical change in alcohol prices from introducing an MUP policy. We control for consumer demographic characteristics, alcohol product prices and prices of close substitutes, and quarterly seasonal effects. We find that the estimated wealth effect from increasing the price of alcohol under a MUP policy is not significant at any point over the distribution of alcohol consumers. The policy increases per capita tax impact by less than A$5.00 per week for light/moderate consumers (50th-80th quantile) and decreases their daily per capita alcohol consumption by less than 0.02 standard drinks. Wealth effects attributable to an MUP policy are likely to be negligible. Substitution effects of the policy dominate the wealth effects in generating key health related outcomes such as reductions in alcohol consumption.

Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18

OBJECTIVE

To assess the immediate impact of the introduction of minimum unit pricing in Scotland on household alcohol purchases.

DESIGN

Controlled interrupted time series analysis.

SETTING

Purchase data from Kantar Worldpanel's household shopping panel for 2015-18.

PARTICIPANTS

5325 Scottish households, 54 807 English households as controls, and 10 040 households in northern England to control for potential cross border effects.

INTERVENTIONS

Introduction of a minimum price of 50p (€0.55; $0.61) per UK unit (6.25p per gram) for the sale of alcohol in Scotland on 1 May 2018.

MAIN OUTCOME MEASURES

Price per gram of alcohol, number of grams of alcohol purchased from off-trade by households, and weekly household expenditure on alcohol.

RESULTS

The introduction of minimum unit pricing in Scotland was associated with an increase in purchase price of 0.64p per gram of alcohol (95% confidence interval 0.54 to 0.75), a reduction in weekly purchases of 9.5 g of alcohol per adult per household (5.1 to 13.9), and a non-significant increase in weekly expenditure on alcohol per household of 61p (-5 to 127). The increase in purchase price was higher in lower income households and in households that purchased the largest amount of alcohol. The reduction in purchased grams of alcohol was greater in lower income households and only occurred in the top fifth of households by income that purchased the greatest amount of alcohol, where the reduction was 15 g of alcohol per week (6 to 24). Changes in weekly expenditure were not systematically related to household income but increased with increasing household purchases.

CONCLUSIONS

In terms of immediate impact, the introduction of minimum unit pricing appears to have been successful in reducing the amount of alcohol purchased by households in Scotland. The action was targeted, in that reductions of purchased alcohol only occurred in the households that bought the most alcohol.

Minimum unit prices for alcohol

Minimum unit prices (MUPs) have been proposed on the grounds that they can reduce alcohol consumption of the heaviest drinkers, without significantly burdening moderate drinkers. This paper examines the case for MUPs in an optimal tax framework. Such a policy can improve welfare when two conditions are both satisfied. First, beverage quality and quantity should be substitutes. Second, there should be more distortion to consumption of cheaper alcohol than to more expensive varieties. The consequences of a MUP for the optimal corrective tax are explored with a calibrated numerical example. This example illustrates how the optimal tax rate might be higher when used in isolation, than when a MUP is also being used.

The effects of alcohol pricing policies on consumption, health, social and economic outcomes, and health inequality in Australia: a protocol of an epidemiological modelling study

INTRODUCTION

Alcohol use and misuse are associated with substantial health and social issues in Australia and internationally. Pricing policy is considered as one of the most effective means to reduce risky drinking and related harms. This protocol paper describes a study that will model and estimate the effects, effectiveness and cost-benefit of alcohol pricing policy initiatives in reducing risky drinking, health and social harms, and health inequalities among subpopulations in Australia.

METHODS AND ANALYSIS

The study is a modelling and epidemiological study using data from various resources, such as survey, previous literatures and response agencies. A number of statistical procedures will be undertaken to evaluate the impact of different alcohol pricing policy initiatives on various outcomes, including alcohol consumption in population subgroups, and health and social problems, and to measure health inequalities and cost-effectiveness of those proposed pricing policies, such as a 10% tax increase on all alcohol beverages or introduction of a minimum unit price.

ETHICS AND DISSEMINATION

The ethics approval of this study was obtained from the College Human Ethics Sub-Committee of the La Trobe University on 9 November 2017 (Ref: S17-206). While examining the heterogeneous effects of price policy across population subgroups, this study will provide the first comprehensive estimates of the likely impacts of alcohol price changes on health inequalities. The study will also provide sophisticated economic analyses of the impact of price policy changes, which is critical information for policy makers and will assist policy makers in directing resources to a more efficient alcohol strategy. Results will be made available to communities and societies, health departments and other researchers.

Use of financial incentives and text message feedback to increase healthy food purchases in a grocery store cash back program: a randomized controlled trial

Background

The HealthyFood (HF) program offers members up to 25% cash back monthly on healthy food purchases. In this randomized controlled trial, we tested the efficacy of financial incentives combined with text messages in increasing healthy food purchases among HF members.

Methods

Members receiving the lowest (10%) cash back level were randomized to one of six arms: Arm 1 (Usual Care): 10% cash back, no weekly text, standard monthly text; Arm 2: 10% cash back, generic weekly text, standard monthly text; Arm 3: 10% cash back, personalized weekly text, standard monthly text; Arm 4: 25% cash back, personalized weekly text, standard monthly text; Arm 5: 10 + 15%NET cash back, personalized weekly text, standard monthly text; and, Arm 6: 10 + 15%NET cash back, personalized weekly text, unbundled monthly text. In the 10 + 15%NET cash back, the cash back amount was the baseline 10% plus 15% of the net difference between healthy and unhealthy spending. The generic text included information on HF and healthy eating, while the personalized text had individualized feedback on purchases. The standard monthly text contained the cash back amount. The unbundled monthly text included the amount lost due to unhealthy purchases. The primary outcome was the average monthly percent healthy food spending. Secondary outcomes were the percent unhealthy food spending, and the percent healthy and unhealthy food items.

Results

Of the members contacted, 20 opted out, and 2841 met all inclusion criteria. There were no between-arm differences in the examined outcomes. The largest mean (standard deviation) difference in percent healthy spending was between Arm 1 (24.8% [11%]) and Arm 2 (26.8% [13%]), and the largest mean difference in percent unhealthy spending was also between Arm 1 (24.4% [20%]) and Arm 2 (21.7% [17%]), but no differences were statistically significant after correction for multiple comparisons.

Conclusions

None of the tested financial incentive structures or text strategies differentially affected food purchasing. Notably, more than doubling the cash back amount and introducing a financial disincentive for unhealthy purchases did not affect purchasing. These findings speak to the difficulty of changing shopping habits and to the need for innovative strategies to shift complex health behaviors.

Trial registration

NCT02486588 Increasing Engagement with a Healthy Food Benefit. The trial was prospectively registered on July 1, 2015.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6936-5) contains supplementary material, which is available to authorized users.

The potential for using alcohol and tobacco taxes to fund prevention and control of noncommunicable diseases in Caribbean Community countries

OBJECTIVES

To determine the extent to which increased taxes on alcohol and tobacco products in Caribbean Community (CARICOM) countries might successfully reduce consumption of those products and raise revenues, which could then be channeled into noncommunicable disease (NCD) prevention and control initiatives.

METHODS

The Tobacco Tax Simulation (TaXSiM) model, which was developed by the World Health Organization (WHO), was used to simulate the impact of tax changes on alcohol and tobacco products in three CARICOM member countries. Estimates of the NCD response cost in the 15 countries that are full members of CARICOM were also produced.

RESULTS

For the 15 full-member CARICOM countries, the revenues from increased excise taxes on beer, rum, and cigarettes associated with a 5.0% reduction in consumption were estimated at US$ 86.32 million. This expected revenue intake from excise taxes exceeded the estimated US$ 52.73 million required to respond to NCDs in those 15 CARICOM countries. The amount also exceeds US$ 78.87 million, which will be required if there is a 50.0% increase in the per capita NCD response cost.

CONCLUSIONS

The findings showed that for CARICOM countries, there is a substantial potential for revenue generation from increases in taxes on alcohol and tobacco, as well as for decreases in consumption of the products. Although increased taxes on alcohol and cigarettes can sufficiently cover the cost of controlling NCDs among CARICOM countries, a comprehensive response also requires widespread participation from various sectors.

Text message intervention to reduce frequency of binge drinking among disadvantaged men: the TRAM RCT

Background

Socially disadvantaged men are more likely to binge drink frequently and to experience high levels of alcohol-related harm.

Objectives

To test the effectiveness and cost-effectiveness of a text message intervention in reducing the frequency of binge drinking among disadvantaged men.

Study design

A four-centre, parallel-group, pragmatic, individually randomised controlled trial was conducted. Randomisation was carried out using a secure remote web-based system. It was stratified by participating centre and recruitment method and restricted using block sizes of randomly varying lengths.

Setting

The study was conducted in the community. Members of the public helped to develop the study methods.

Participants

Participants were men aged 25–44 years who had ≥ 2 episodes of binge drinking (> 8 units of alcohol in a single session) in the preceding 28 days. Men were recruited from areas of high deprivation.

Interventions

An empirically and theoretically based text message intervention was delivered by 112 interactive text messages over a 12-week period. The control group received an attentional control comprising 89 text messages on general health.

Primary outcome measure

The primary outcome measure was the proportion of men consuming > 8 units of alcohol on ≥ 3 occasions (in the previous 28 days) at 12 months post intervention.

Results

The recruitment target of 798 was exceeded and 825 men were randomised. Retention was high and similar in the intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged enthusiastically with the text messages: almost all (92%) replied to text messages and over two-thirds (67%) replied more than 10 times. The intervention was estimated to have had a modest, statistically non-significant effect on the primary outcome at the 12-month follow-up [odds ratio 0.79, 95% confidence interval (CI) 0.57 to 1.08]. This corresponds to a net reduction of 5.7% in regular binge drinking. Five secondary outcomes showed small non-significant and inconsistent effects on alcohol consumption, with one suggesting a positive effect and four suggesting an adverse effect. Both the short- and the long-term cost per quality-adjusted life-year (QALY) analysis suggested that the brief intervention was dominated by a ‘do-nothing’ option. The intervention’s impacts on patterns of alcohol consumption, QALYs and downstream costs were inconsistent and uncertain.

Limitations

The study used an active control that, combined with the recruitment procedures and baseline assessments, could have biased the treatment effect towards the null. The measurement of alcohol consumption relied on self-reported drinking.

Conclusions

The trial has demonstrated that it is possible to recruit and retain large numbers of socially disadvantaged men in a research study. The text messages delivered a complex theoretically and empirically based intervention that fostered enthusiastic engagement with the key components of the behaviour change sequence. The intervention produced a modest, statistically non-significant effect on the primary outcome, with wide CIs. Further research is needed to reduce uncertainty about the treatment effect. The methods developed for this study provide a platform for the design and testing of interventions to reduce inequalities in health.

Future work

A future trial could reduce the uncertainty around the treatment effect of the intervention.

Trial registration

Current Controlled Trials ISRCTN07695192.

Funding

This study 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. 6, No. 6. See NIHR Journals Library website for further information.

A qualitative exploration of Thai alcohol policy in regulating availability and access

BACKGROUND

Despite abundant alcohol control regulations and measures in Thailand, prevalence of alcohol consumption has been relatively steady for the past decade and alcohol-related harm remains high. This study aims to explore, through the perspectives of key public health stakeholders, the current performance of regulations controlling alcohol availability and access, and the future directions for the implementation of Thai alcohol policy.

METHODS

Semi-structured interviews were conducted with public health stakeholders from three sectors; the government, academia and civil society. Their perceptions about the current alcohol situation, gaps in the current policies, and future directions of alcohol policy were discussed. Audio data were transcribed verbatim, systematically coded and analysed.

RESULTS

The three key concerning issues were physical availability, economic availability and commercial access, which referred to outlet density, taxation and pricing, and compliance to stipulated regulations, respectively. First, Thailand failed to control the number of alcohol outlets. The availability problem was exacerbated by the increased numbers of liquor licences issued, without delineating the need for the outlets. Second, alcohol tax rates, albeit occasionally adjusted, are disproportionate to the economic dynamic, and there is yet a minimum pricing. Finally, compliance to age and time restrictions was challenging.

CONCLUSIONS

The lack of robustness of enforcement and disintegration of government agencies in regulating availability and access hampers effectiveness of alcohol policy. Comprehensive regulations for the control of availability of and access to alcohol are required to strengthen alcohol policy. Consistent monitoring and surveillance of the compliances are recommended to prevent significant effects of the regulations diminish over time.

Pricing as a means of controlling alcohol consumption

BACKGROUND

Reducing the affordability of alcohol, by increasing its price, is the most effective strategy for controlling alcohol consumption and reducing harm.

SOURCES OF DATA

We review meta-analyses and systematic reviews of alcohol tax/price effects from the past decade, and recent evaluations of tax/price policies in the UK, Canada and Australia.

AREAS OF AGREEMENT

While the magnitudes of price effects vary by sub-group and alcoholic beverage type, it has been consistently shown that price increases lead to reductions in alcohol consumption.

AREAS OF CONTROVERSY

There remains, however, a lack of consensus on the most appropriate taxation and pricing policy in many countries because of concerns about effects by different consumption level and income level and disagreement on policy design between parts of the alcoholic beverage industries.

GROWING POINTS

Recent developments in the research highlight the importance of obtaining accurate alcohol price data, reducing bias in estimating price responsiveness, and examining the impact on the heaviest drinkers.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is a need for further research focusing on the substitution effects of taxation and pricing policies, estimation of the true tax pass-through rates, and empirical analysis of the supply-side response (from alcohol producers and retailers) to various alcohol pricing strategies.

Policy lessons from health taxes: a systematic review of empirical studies

BACKGROUND

Taxes on alcohol and tobacco have long been an important means of raising revenues for public spending in many countries but there is increasing interest in using taxes on these, and other unhealthy products, to achieve public health goals. We present a systematic review of the research on health taxes, and aim to generate insights into how such taxes can: (i) reduce consumption of targeted products and related harms; (ii) generate revenues for health objectives and distribute the tax burden across income groups in an efficient and equitable manner; and (iii) be made politically sustainable.

METHODS

Six scientific and four grey-literature databases were searched for empirical studies of 'health taxes' - defined as those intended to increase the costs of manufacturing, distributing, retailing and/or consuming health-damaging products. Since reviews already exist of the evidence relating to traditional alcohol and tobacco excise taxes, we focus on other taxes such as taxes on retailers and manufacturers of unhealthy products, and consumer taxes targeting unhealthy foods, such as sugar-sweetened beverages.

RESULTS

Ninety-one peer-reviewed and 11 grey-literature studies met our inclusion criteria. The review highlights a recent, rapid rise in research in this area, most of which focuses on high-income countries and on taxes on food products or nutrients. Findings demonstrate that high tax rates on sugar-sweetened beverages are likely to have a positive impact on health behaviours and outcomes, and, while taxes on products reduce demand, they add to fiscal revenues. Common concerns about health taxes are also discussed.

CONCLUSIONS

If the primary policy goal of a health tax is to reduce consumption of unhealthy products, then evidence supports the implementation of taxes that increase the price of products by 20% or more. However, where taxes are effective in changing health behaviours, the predictability of the revenue stream is reduced. Hence, policy actors need to be clear about the primary goal of any health tax and frame the tax accordingly - not doing so leaves taxes vulnerable to hostile lobbying. Conversely, earmarking health taxes for health spending tends to increase public support so long as policymakers follow through on specified spending commitments.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42016048603.

Evidence for the effectiveness of minimum pricing of alcohol: a systematic review and assessment using the Bradford Hill criteria for causality

OBJECTIVES

To assess the evidence for price-based alcohol policy interventions to determine whether minimum unit pricing (MUP) is likely to be effective.

DESIGN

Systematic review and assessment of studies according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, against the Bradford Hill criteria for causality. Three electronic databases were searched from inception to February 2017. Additional articles were found through hand searching and grey literature searches.

CRITERIA FOR SELECTING STUDIES

We included any study design that reported on the effect of price-based interventions on alcohol consumption or alcohol-related morbidity, mortality and wider harms. Studies reporting on the effects of taxation or affordability and studies that only investigated price elasticity of demand were beyond the scope of this review. Studies with any conflict of interest were excluded. All studies were appraised for methodological quality.

RESULTS

Of 517 studies assessed, 33 studies were included: 26 peer-reviewed research studies and seven from the grey literature. All nine of the Bradford Hill criteria were met, although different types of study satisfied different criteria. For example, modelling studies complied with the consistency and specificity criteria, time series analyses demonstrated the temporality and experiment criteria, and the analogy criterion was fulfilled by comparing the findings with the wider literature on taxation and affordability.

CONCLUSIONS

Overall, the Bradford Hill criteria for causality were satisfied. There was very little evidence that minimum alcohol prices are not associated with consumption or subsequent harms. However the overall quality of the evidence was variable, a large proportion of the evidence base has been produced by a small number of research teams, and the quantitative uncertainty in many estimates or forecasts is often poorly communicated outside the academic literature. Nonetheless, price-based alcohol policy interventions such as MUP are likely to reduce alcohol consumption, alcohol-related morbidity and mortality.