Changing policy framing as a deliberate strategy for public health advocacy: a qualitative policy case study of minimum unit pricing of alcohol

The role of metaphor in the corporate political strategies of health harming industries: Comparing the concept of balance in the gambling and opioid industry discourses

Scholars have identified notable similarities between the political strategies employed by health-harming industries. This includes similarities in the narratives employed by industry actors seeking to oppose public health regulations that threaten their commercial interests. This study seeks to examine the use of a specific concept - the balance metaphor - in the policy discourses of two health-harming industries. Namely, the pharmaceutical industry implicated in the prescription opioid crisis in the US, and the UK gambling industry, whose products and practices are associated with a serious, but largely neglected, series of harms. We first review research on metaphors, demonstrating how this provides additional theoretically-informed concepts with which to understand how industry discourse circumscribes the terrain of policy debates in ways amenable to commercial interests. Building from these insights, we conducted a rhetorical analysis, examining how the concept of balance is employed by different actors in distinct contexts to shape understandings of the social and policy problems associated with gambling and opioid products and to promote industry-favourable regulatory responses to these. This brings a micro-level of analysis to supplement previous meso- and macro-level scholarship in this space. We use our findings to argue that the depoliticization of the policy process and objectivization of the policy space - in ways that obscure its contingent and political nature - through discourses of balance is itself an arch political act. Examining the metaphors used in policy debates and their functions provides important insights that can be used to inform the construction of counter-narratives to industry-favourable discourses, including the creative use of novel metaphors in the service of public health goals.

Continuities and change in alcohol policy at the global level: a documentary analysis of the 2010 Global Strategy for Reducing the Harmful Use of Alcohol and the Global Alcohol Action Plan 2022-2030

BACKGROUND

There are only two major statements which define alcohol policy development at the global level. There has not been any comparative analysis of the details of these key texts, published in 2010 and 2022 respectively, including how far they constitute similar or evolving approaches to alcohol harm.

METHODS

Preparatory data collection involved examination of documents associated with the final policy statements. A thematic analysis across the two policy documents was performed to generate understanding of continuity and change based on comparative study. Study findings are interpreted in the contexts of the evolving conceptual and empirical literatures.

RESULTS

Both documents exhibit shared guiding principles and identify similar governance challenges, albeit with varying priority levels. There is more emphasis on the high-impact interventions on price, availability and marketing in 2022, and more stringent targets have been set for 2030 in declaring alcohol as a public health priority therein, reflecting the action-oriented nature of the Plan. The identified roles of policy actors have largely remained unchanged, albeit with greater specificity in the more recent statement, appropriately so because it is concerned with implementation. The major exception, and the key difference in the documents, regards the alcohol industry, which is perceived primarily as a threat to public health in 2022 due to commercial activities harmful to health and because policy interference has slowed progress.

CONCLUSIONS

The adoption of the Global Alcohol Action Plan 2022-30 potentially marks a pivotal moment in global alcohol policy development, though it is unclear how fully it may be implemented. Perhaps, the key advances lie in advancing the ambitions of alcohol policy and clearly identifying that the alcohol industry should not be seen as any kind of partner in public health policymaking, which will permit progress to the extent that this influences what actually happens in alcohol policy at the national level.

Policy action points and approaches to promote fertility care in The Gambia: Findings from a mixed-methods study

INTRODUCTION

In the Global South, (in)fertility care is scarcely recognized as a priority, yet the government of The Gambia has recently included it as one of the key priorities in its reproductive health strategic plan. This inclusion appears to be the result of years of engagement between policy actors, academic researchers, and activists in the field of reproductive health and specifically of infertility. However, the operationalization of the strategic plan may be hampered by multiple factors. The research aims to identify and analyze challenges that may impede the effective implementation of the strategic plan, thereby providing policy action points and practical guidance into the operationalization of (in)fertility care in the context of The Gambia's health system.

METHODS

This is a mixed-methods study with data from a survey and semi-structured interviews collected between 2020 and 2021 in The Gambia that were separately published. In this paper, we present the triangulation of quantitative and qualitative data using a convergence coding matrix to identify relevant policy action points.

RESULTS

Six fertility care policy action points, driven by data, arose from the triangulation and interpretation process, specifically: (i) establishing and maintaining political commitment and national priority for fertility care; (ii) creating awareness and increasing the involvement of men in SRH and fertility; (iii) ensuring data-driven health policymaking; (iv) offering and regulating affordable IVF alternatives; (v) improving knowledge of and means for fertility care provision; and (vi) enhancing the collaboration among stakeholders and building links with the private healthcare sector.

CONCLUSION

This study found the implementation of the fertility care-related activities in the reproductive health strategic plan may face challenges that require careful mitigation through a holistic approach. Such an approach conceptualizes infertility not just as a biomedical issue but as a broader one that incorporates educational and socio-emotional aspects, including male and (not only) female involvement in sexual and reproductive health. Moreover, it is supported by a comprehensive health management information system that includes capturing data on the demand for, and access to, infertility services in The Gambia health system.

Reframing the wicked problem of pre-harvest burning: A case study of Thailand's sugarcane

Pre-harvest sugarcane burning persists in many countries though there are policies prohibiting the practice. As problems related to sugarcane harvesting are complex, a thorough understanding of the problems for policy formulation is required. The objective of this study was to reanalyze or reframe problems of sugarcane harvesting and pre-harvest sugarcane burning. Concepts of wicked problems, practical reasoning and policy reframing were applied. The study used a participatory modeling approach to illustrate the case of Thailand. Wickedness was shown by complexity and uncertainties of factors intertwining with values related to adoption of harvesting methods; green mechanical, green manual and burnt manual. As timeliness of harvest was the top priority, the burnt method was considered more efficient. It was easier, faster, cheaper and more suitable under unfavorable circumstances for the green methods. The policy to reduce burnt-harvested sugarcane was not so effective and also led to the undesired 'green but unclean' method. To frame harvesting problems based on emissions of fine particulates (PM2.5) from sugarcane burning was not a good choice. Incomplete problem sense-making and poor problem frame were indicated. Most farmers were unable to associate sugarcane burning with environmental problems of PM2.5 (and also global warming/climate change) and livelihood impacts. Nevertheless, a larger concern over climate variations was perceived by a majority of farmers. Farmers who adapted relied primarily on green harvesting and the use of residues as trash blankets. Through policy reframing, inefficient green harvesting was seen as a better frame. The new frame enabled farmers linking agricultural practices to sustainability of environment, productivity and livelihoods in the context of climate change. Using participatory modeling for reframing policy problems in general and wicked problems in particular was shown to be powerful and contributing to originality.

The confluence of legacy, corporate social responsibility, and public health: The case of Migros and alcohol-free retailing in Switzerland

BACKGROUND

Alcohol policy studies have traditionally focused on formal policymaking processes. Retail cooperatives, however, have rarely been studied as sites of public health interventions. Migros, a cooperatively owned chain of supermarkets in Switzerland, has long forbidden alcohol sales in its supermarkets. Focusing on processes of framing, this study explores a recent unsuccessful attempt to reverse the long-standing ban via membership vote in 2022.

METHODS

The study draws on a range of data sources, including company documents, a televised debate, and the results of a large online survey among the general population conducted ahead of the referendum. Using thematic analysis, it investigates various campaign-related arguments, including those made by Migros management, NGOs, and other key campaign participants.

RESULTS

Proponents and opponents used a combination of public health, economic/market-oriented, and corporate social responsibility (CSR) frames. Migros's longstanding dedication to CSR, its participatory governance structure, and the regional political dynamics in the Swiss context are essential in understanding the nature and impact of framing.

CONCLUSIONS

Alcohol-related harm arises from a complex interaction between different social, political, and economic factors. Reducing harm requires approaches that consider the range of contexts and measures that can shape alcohol availability.

Policy Actors' Perceptions of Conflicts of Interest and Alcohol Industry Engagement in UK Policy Processes

BACKGROUND

Alcohol industry organisations occupy a prominent position in UK alcohol policy, but their involvement has been contested by public health bodies on the basis that a conflict of interest (COI) exists between their economic objectives and those of public health. There are ongoing debates in the research literature about how to conceptualise COI and mitigate this in health research and practise. However, less attention has been paid to these issues in relation to the alcohol industry specifically. This article explores similarities and differences in beliefs among alcohol policy actors regarding COI and the implications of engagement with the alcohol industry in the context of UK public health policy.

METHODS

Semi-structured interviews with a range of policy actors (n=26) including medical professionals, parliamentarians, civil servants, academic researchers, health campaigners, and alcohol industry representatives. Interviews with alcohol industry representatives were supplemented with an analysis of industry responses to a public consultation. All data was thematically coded using NVivo software.

RESULTS

Two competing "coalitions" were identified, expressing beliefs about COI linked to alcohol industry engagement. Both divergent and convergent beliefs were expressed by the two coalitions in relation to the type of industry actor, form of engagement, the policy issue under discussion and the stage of policy process.

CONCLUSION

Alcohol policy is a complex and contested space in which policy actors have differing, nuanced and contingent understandings of COI and identify varying risks associated with alcohol industry engagement. In identifying the areas of convergence and diversion in both understanding and evaluation of COI in alcohol-specific settings, these findings will assist both decision-makers and non-governmental actors in developing policies and guidelines to manage potential COI in future.

Alcohol policy framing in South Africa during the early stages of COVID-19: using extraordinary times to make an argument for a new normal

INTRODUCTION

Public health and alcohol industry actors compete to frame alcohol policy problems and solutions. Little is known about how sudden shifts in the political context provide moments for policy actors to re-frame alcohol-related issues. South Africa's temporary bans on alcohol sales during the COVID-19 pandemic offered an opportunity to study this phenomenon.

METHODS

We identified Professor Charles Parry from the South African Medical Research Council as a key policy actor. Parry uses a Twitter account primarily to comment on alcohol-related issues in South Africa. We harvested his tweets posted from March 18 to August 31, 2020, coinciding with the first two alcohol sales bans. We conducted a thematic analysis of the tweets to understand how Parry framed alcohol policy evidence and issues during these 'extraordinary times.'

RESULTS

Parry underlined the extent of alcohol-related harm during 'normal times' with scientific evidence and contested industry actors' efforts to re-frame relevant evidence in a coherent and well-constructed argument. Parry used the temporary sales restrictions to highlight the magnitude of the health and social harms resulting from alcohol consumption, particularly trauma, rather than the COVID-19 transmission risks. Parry portrayed the sales ban as a policy learning opportunity (or 'experiment') for South Africa and beyond.

CONCLUSIONS

Crisis conditions can provide new openings for public health (and industry) actors to make salient particular features of alcohol and alcohol policy evidence.

Framing the policy debate over tobacco control legislation and tobacco taxation in South Africa

BACKGROUND

In 2018, South Africa opened public consultations on its newly proposed tobacco control bill, resulting in substantial public debate in which a range of arguments, either in favour of or against the Bill, was advanced. These were accompanied by the recurring discussions about the annual adjustments in tobacco taxation. This study uses the concept of framing to examine the public debate in South African print media on the potential effects of the legislation, as well as tobacco tax regulations, between their proponents and detractors.

METHODS

A systematic search of news articles using multiple data sources identified 132 media articles published between January 2018 and September 2019 that met the inclusion criteria.

RESULTS

Seven overarching frames were identified as characterising the media debate, with the three dominant frames being Economic, Harm reduction and vaping, and Health. The leading Economic frame consisted primarily of arguments unsupportive of tobacco control legislation. Economic arguments were promoted by tobacco industry spokespeople, trade unions, organisations of retailers, media celebrities and think tanks-several of which have been identified as front groups or third-party lobbyists for the tobacco industry.

CONCLUSION

The dominance of economic arguments opposing tobacco control legislation risks undermining tobacco control progress. Local and global tobacco control advocates should seek to build relationships with media, as well as collate and disseminate effective counterarguments to those advanced by the industry.

Mechanisms of impact of alcohol availability interventions from the perspective of 63 diverse alcohol licensing stakeholders: a qualitative interview study

Aims

Interventions restricting temporal and spatial availability of alcohol are associated with reduced harm, but the pathways by which specific interventions have impact are poorly understood. We examined mechanisms of impact from the perspective of diverse licensing stakeholders.

Methods

Fifty-three in-depth interviews were conducted with licensing stakeholders (from public health teams [PHTs], police, local authority licensing teams and lawyers, and alcohol premises licensing committees) from 20 local government areas. Interviewees were recruited as part of the Exploring the impact of alcohol licensing in England and Scotland (ExILEnS) study. Data were analyzed thematically and preliminary themes/subthemes were discussed during online groups with a different sample of public health and licensing professionals (n = 10).

Findings

Most interviewees struggled to articulate how availability interventions might lead to changes in alcohol consumption or harms. Five overarching mechanisms were identified: access, visibility, premises and area-level norms, affordability, and management of the night-time economy, with specific pathways identified for certain subgroups/premises types. The mechanisms by which alcohol availability interventions may impact on alcohol consumption and harms are diverse, but were poorly understood.

Conclusions

These findings will inform licensing and availability policy and advocacy, highlighting the need for further scrutiny of the evidence underpinning identified mechanisms, and primary research to address knowledge gaps.

Distilling the distillers: examining the political activities of the Distilled Spirits Council of the United States

BACKGROUND

Understanding of the alcohol industry's means of influencing public policy is increasingly well established. Less is known, however, about the specific organisations that lead the political strategies of the alcohol industry. To fill this gap, this paper explores the Distilled Spirits Council of the United States (DISCUS), a key trade association in the United States (US), which also operates internationally.

METHODS

This study explores how DISCUS is organised and the main political activities it pursues to advance its policy interests. The study triangulates data from several sources, including DISCUS documents, as well as federal lobbying and election expenditure data.

RESULTS

This study demonstrates that DISCUS is a key political actor in the US and global alcohol policymaking context. There are identifiable strategies used by DISCUS to shape alcohol policy debates, including framing and lobbying. We also find key synergies between these strategies and identify their operation at varying levels of policy decision-making.

CONCLUSIONS

Generating more secure inferences about the nature of the alcohol industry's efforts to advance its interests, and with what success and at what cost, requires researchers to investigate other trade associations in different contexts, and use other data sources.

Understanding the Political Organization and Tactics of the Alcohol Industry in Ireland 2009-2018

OBJECTIVE

This study examines how the alcohol industry responded to developments in Irish alcohol policy leading to the 2018 Public Health (Alcohol) Act, a set of measures designed to reduce overall alcohol consumption in order to reduce harm to health and society. Previous research has emphasized the political and economic strengths of the alcohol industry in Ireland and elsewhere. This study examines the origins of and the debates over this legislation to better understand the political tactics of the alcohol industry.

METHOD

The study focuses on developments between 2009 and 2018, tracing activities by industry actors to shape the policy process at different junctures. Data for the study are drawn from 18 semi-structured interviews with politicians, government advisors, public health experts, and advocates as well as from relevant primary documents, public statements, and newspaper articles.

RESULTS

The study identifies three interrelated tactics used by alcohol industry actors--obstruction through participation, coalition-building and mobilizing proxies, and making use of extensive political resources in lobbying--and traces their impacts at different points in the policy process. We find that industry actors had some success in influencing policy, defeating particular provisions by averting their inclusion, and winning amendments to others, but ultimately failed to defeat the legislation. Specific opportunities and constraints present in the Irish context for alcohol industry actors are identified.

CONCLUSIONS

Public health considerations withstood a range of challenges from alcohol industry interests in passing public health legislation in Ireland. The findings have important implications for the study of the alcohol industry's political tactics in Ireland and elsewhere, including the use of lobbying registry data as a potential data source.

Understanding the Political Organization and Tactics of the Alcohol Industry in Ireland 2009-2018

OBJECTIVE

This study examines how the alcohol industry responded to developments in Irish alcohol policy leading to the 2018 Public Health (Alcohol) Act, a set of measures designed to reduce overall alcohol consumption in order to reduce harm to health and society. Previous research has emphasized the political and economic strengths of the alcohol industry in Ireland and elsewhere. This study examines the origins of and the debates over this legislation to better understand the political tactics of the alcohol industry.

METHOD

The study focuses on developments between 2009 and 2018, tracing activities by industry actors to shape the policy process at different junctures. Data for the study are drawn from 18 semi-structured interviews with politicians, government advisors, public health experts, and advocates as well as from relevant primary documents, public statements, and newspaper articles.

RESULTS

The study identifies three interrelated tactics used by alcohol industry actors--obstruction through participation, coalition-building and mobilizing proxies, and making use of extensive political resources in lobbying--and traces their impacts at different points in the policy process. We find that industry actors had some success in influencing policy, defeating particular provisions by averting their inclusion, and winning amendments to others, but ultimately failed to defeat the legislation. Specific opportunities and constraints present in the Irish context for alcohol industry actors are identified.

CONCLUSIONS

Public health considerations withstood a range of challenges from alcohol industry interests in passing public health legislation in Ireland. The findings have important implications for the study of the alcohol industry's political tactics in Ireland and elsewhere, including the use of lobbying registry data as a potential data source.

The alcohol industry, the tobacco industry, and excise taxes in the US 1986-89: new insights from the tobacco documents

BACKGROUND

The UCSF Industry Documents Library has provided public health researchers with key insights into the organization of political activities in the tobacco industry. Much less is known about the alcohol industry. In the US, there is some existing evidence of cooperation between the two industries, particularly in areas where there are mutual interests and/or policy goals at stake. Efforts to raise excise taxes on tobacco and alcohol products are one such example.

METHODS

We systematically searched the UCSF Industry Documents Library for data on alcohol industry actors and their political activities. Using content generated by alcohol and tobacco actors, we sought to identify new evidence of collaborations to shape excise tax policy debates in the US in the 1980s and 1990s.

RESULTS

We uncover evidence of the alcohol industry's efforts to shape excise tax policy debates, both at the national and state level. Excise taxes were defined by both alcohol and tobacco companies and related organisations as a key threat to profits. We show how the alcohol industry confronted this challenge in the late 1980s in the US, uncovering the range of monitoring, coordinating, and public-facing activities used to defeat proposed tax increases at both state and federal levels. The former draws particular attention to Oregon, where alcohol industry actors were not simply operating at the behest of the tobacco industry, but actively led a campaign to advance both brewing and tobacco interests.

CONCLUSIONS

The tobacco documents offer a key resource for studying economic interests beyond that of the tobacco industry, operating in collaboration with tobacco companies. Here, brewers advanced shared interests with tobacco, and these findings have implications for advancing understanding of alcohol and tobacco industry political strategies. The findings also suggest that financial documents from other public repositories could be used to generate new inferences about corporate political activities.

Framing tobacco control: the case of the Nigerian tobacco tax debates

Studies have shown that the tobacco industry exerts significant policy-framing efforts to undermine tobacco control (TC) policies. However, most of this evidence is from high-income settings. This study applies framing analysis to the debate surrounding the 2016 tobacco import duty raise in Nigeria and subsequent rise in excise duty on tobacco, alcohol and selected food products in 2018 to understand why policy changes occurred. Print media documents and relevant actor publications published between 2016 and 2018 were analysed interpretively to identify key actors and arguments for and against the tax raise. Key opponents included tobacco companies, trade groups and allies. In contrast, the Ministries of Health and Finance, non-governmental organizations and international bodies like the World Health Organization advocated for the policy. The framing efforts of opponents were largely coordinated with significant alcohol industry involvement, while TC advocates lacked a unified front. Actors on both sides of the debate predominantly focused on economic and 'global ranking' arguments, and advocates also employed health and 'vulnerable groups' framing among others. The tax policy was sustained despite the framing and litigation efforts of opponents, and this is attributed principally to economic factors. The findings also suggest that tobacco is grouped with less harmful products, and advocates need to intensify efforts to diminish this legitimacy in low- and middle-income country settings. Additionally, there may be some benefits to jointly addressing alcohol and TC in this setting. Summarily, it is recommended that public health advocates coordinate their framing efforts to better articulate clear policy positions to the government, gain public support and ensure full Framework Convention on Tobacco Control compliance.

Coordination, framing and innovation: the political sophistication of public health advocates in Ireland

BACKGROUND AND AIMS

This study explores the role of the public health advocacy coalition in alcohol policy development in Ireland. Compared with industry actors, much less is known about the membership, activities and influence of public health advocates in alcohol policymaking. To address this gap, this paper identifies several advocacy strategies, drawn from the advocacy coalition framework and other policy theories, and then analyses them in the context of recent Irish developments.

METHODS

The study used theory-building process-tracing to construct a record of the public health advocacy coalition and its campaign to promote the Public Health (Alcohol) Act 2018 in Ireland. Specifically, we drew upon 131 primary documents produced by advocates, 464 newspaper articles and 18 semi-structured interviews with key advocates, public health experts and elected officials to undertake a thematic analysis.

RESULTS

Public health advocates in Ireland have developed sophisticated political strategies to foster major alcohol policy change. First, public health advocates led the formation of a broad-based advocacy coalition that helped members to effectively pool their limited resources as well as coordinate their strategy and messaging. Secondly, issue-framing and message discipline played a key role in the coalition's success. Advocates strategically focused upon the policy problem, specifically health harms, rather than the detailed content of the proposed measures. Finally, there is evidence of political learning, where advocates' prior experiences and knowledge of the political system in Ireland spurred innovations in campaigning. These strategies were interdependent and mutually reinforcing, and succeeded in building support for public health advocates' preferred policies among politicians and the general public.

DISCUSSION/CONCLUSION

There are distinct capabilities that public health actors can mobilize in the policy process to win alcohol policy debates and capitalize on the constraints on industry influence on alcohol policymaking.

Prospective Analysis of Minimum Pricing Policies to Reduce Excessive Alcohol Use and Related Harms in U.S. States

OBJECTIVE

Increasing the price of alcohol is an effective strategy for reducing excessive consumption and alcohol-related harms. Limited research is available on how the establishment of a minimum price for alcoholic beverages might be an effective strategy to reduce this health risk behavior and what impact that might have in the United States. This study describes alcohol minimum pricing (MP) policy options for consideration in the United States, assesses implementation feasibility and effectiveness, and discusses implications for implementation.

METHOD

Three alcohol pricing policy options for reducing excessive drinking were compared in this prospective analysis: alcohol taxation (status quo in states), minimum unit pricing (MUP) by unit of alcohol (e.g., 0.6 oz. [14 g] of pure alcohol), and MP by specified amount of an alcoholic beverage type (e.g., liter of beer). For each policy, five implementation-related domains were analyzed: political feasibility, public acceptability, implementation cost, health equity, and legal feasibility. Effectiveness was also evaluated based on literature.

RESULTS

Alcohol MP policies, particularly MUP, could be feasible to implement and cost-efficient for reducing excessive alcohol consumption and related harms in the United States. MP policies are likely to have modest public acceptability in the United States. Although the political feasibility of MP policies is uncertain and would likely vary across states, international research suggests that MP might be a feasible pricing strategy that can be used in conjunction with alcohol taxes.

CONCLUSIONS

Alcohol MP can be part of a comprehensive approach for reducing excessive drinking and related harms; however, factors such as state-level differences in alcohol control regulation may influence policy implementation.

Prospective Analysis of Minimum Pricing Policies to Reduce Excessive Alcohol Use and Related Harms in U.S. States

OBJECTIVE

Increasing the price of alcohol is an effective strategy for reducing excessive consumption and alcohol-related harms. Limited research is available on how the establishment of a minimum price for alcoholic beverages might be an effective strategy to reduce this health risk behavior and what impact that might have in the United States. This study describes alcohol minimum pricing (MP) policy options for consideration in the United States, assesses implementation feasibility and effectiveness, and discusses implications for implementation.

METHOD

Three alcohol pricing policy options for reducing excessive drinking were compared in this prospective analysis: alcohol taxation (status quo in states), minimum unit pricing (MUP) by unit of alcohol (e.g., 0.6 oz. [14 g] of pure alcohol), and MP by specified amount of an alcoholic beverage type (e.g., liter of beer). For each policy, five implementation-related domains were analyzed: political feasibility, public acceptability, implementation cost, health equity, and legal feasibility. Effectiveness was also evaluated based on literature.

RESULTS

Alcohol MP policies, particularly MUP, could be feasible to implement and cost-efficient for reducing excessive alcohol consumption and related harms in the United States. MP policies are likely to have modest public acceptability in the United States. Although the political feasibility of MP policies is uncertain and would likely vary across states, international research suggests that MP might be a feasible pricing strategy that can be used in conjunction with alcohol taxes.

CONCLUSIONS

Alcohol MP can be part of a comprehensive approach for reducing excessive drinking and related harms; however, factors such as state-level differences in alcohol control regulation may influence policy implementation.

Intended and unintended consequences of the implementation of minimum unit pricing of alcohol in Scotland: a natural experiment

Background

Scotland was the first country to implement minimum unit pricing for alcohol nationally. Minimum unit pricing aims to reduce alcohol-related harms and to narrow health inequalities. Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. This study comprised three components.

Objectives

This study comprised three components assessing alcohol consumption and alcohol-related attendances in emergency departments, investigating potential unintended effects of minimum unit pricing on alcohol source and drug use, and exploring changes in public attitudes, experiences and norms towards minimum unit pricing and alcohol use.

Design

We conducted a natural experiment study using repeated cross-sectional surveys comparing Scotland (intervention) and North England (control) areas. This involved comparing changes in Scotland following the introduction of minimum unit pricing with changes seen in the north of England over the same period. Difference-in-difference analyses compared intervention and control areas. Focus groups with young people and heavy drinkers, and interviews with professional stakeholders before and after minimum unit pricing implementation in Scotland allowed exploration of attitudes, experiences and behaviours, stakeholder perceptions and potential mechanisms of effect.

Setting

Four emergency departments in Scotland and North England (component 1), six sexual health clinics in Scotland and North England (component 2), and focus groups and interviews in Scotland (component 3).

Participants

Research nurses interviewed 23,455 adults in emergency departments, and 15,218 participants self-completed questionnaires in sexual health clinics. We interviewed 30 stakeholders and 105 individuals participated in focus groups.

Intervention

Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers.

Results

The odds ratio for an alcohol-related emergency department attendance following minimum unit pricing was 1.14 (95% confidence interval 0.90 to 1.44; p = 0.272). In absolute terms, we estimated that minimum unit pricing was associated with 258 more alcohol-related emergency department visits (95% confidence interval –191 to 707) across Scotland than would have been the case had minimum unit pricing not been implemented. The odds ratio for illicit drug consumption following minimum unit pricing was 1.04 (95% confidence interval 0.88 to 1.24; p = 0.612). Concerns about harms, including crime and the use of other sources of alcohol, were generally not realised. Stakeholders and the public generally did not perceive price increases or changed consumption. A lack of understanding of the policy may have caused concerns about harms to dependent drinkers among participants from more deprived areas.

Limitations

The short interval between policy announcement and implementation left limited time for pre-intervention data collection.

Conclusions

Within the emergency departments, there was no evidence of a beneficial impact of minimum unit pricing. Implementation appeared to have been successful and there was no evidence of substitution from alcohol consumption to other drugs. Drinkers and stakeholders largely reported not noticing any change in price or consumption. The lack of effect observed in these settings in the short term, and the problem-free implementation, suggests that the price per unit set (£0.50) was acceptable, but may be too low. Our evaluation, which itself contains multiple components, is part of a wider programme co-ordinated by Public Health Scotland and the results should be understood in this wider context.

Future work

Repeated evaluation of similar policies in different contexts with varying prices would enable a fuller picture of the relationship between price and impacts.

Trial registration

Current Controlled Trials ISRCTN16039407.

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. 11. See the NIHR Journals Library website for further project information.

Alcohol policy, multi-level governance and corporate political strategy: The campaign for Scotland's minimum unit pricing in Edinburgh, London and Brussels

The Scottish government's plans for a minimum unit price for alcohol were vehemently opposed by the alcohol industry leading to a 6-year delay in implementation after legislation was passed. This article seeks to explain the consequences of devolution and European Union membership for the development of minimum unit price in Scotland through the concepts of multi-level governance, veto points and venue shifting. Systems of multi-level governance create policy interdependencies between settings, an increased number of veto points at which policies can be blocked, and the potential for policy actors to shift decision-making to forums where favourable outcomes are more likely to be attained. In the minimum unit price debates, the alcohol industry engaged in multiple forms of venue shifting and used regulatory compliance procedures and legal challenges at the EU level to try to prevent and delay the policy. This has led to a 'chilling effect' on subsequent alcohol policy developments across the United Kingdom.

Waiting for the wave: Political leadership, policy windows, and alcohol policy change in Ireland

Existing research has identified numerous barriers to the adoption of public health policies for alcohol, including the cross-cutting nature of the policy problem and industry influence. Recent developments in Ireland suggest that while formidable, such barriers can be overcome. Ireland's 2018 alcohol legislation adopts key evidence-based measures, introducing pricing, availability and marketing regulations that are world-leading in public health terms. Drawing primarily on the Multiple Streams Approach (MSA), this study investigates the adoption of the Public Health (Alcohol) Act 2018. We draw data from 20 semi-structured interviews with politicians, government advisors, public health experts, and advocates, as well as from relevant primary documents, newspaper articles, and other material in the public domain. We find that increased public attention to alcohol-related harms in Ireland (problem stream), developments within the institutional location of policymaking (the policy stream), and the political pressure exerted by politicians and advocates (the political stream) all combined to open a policy window. Unlike previous alcohol policy reform efforts in Ireland, several personally committed and well-positioned leaders championed policy change. This study suggests that political leadership might be important in understanding why public health approaches to alcohol have been embraced in some contexts but not in others.

Co-regulation and alcohol industry political strategy: A case study of the Public Health England-Drinkaware Drink Free Days Campaign

This article examines the Drink Free Days (DFD) campaign run by Public Health England and the industry funded alcohol education charity, Drinkaware, in eight English regions in 2018-2019. More specifically, it examines uses, and usefulness, of the campaign to the alcohol producers which fund Drinkaware. It draws on 36 semi-structured interviews with policy actors and a framing analysis of industry social media accounts and news coverage of the campaign. Industry-associated bodies such as Drinkaware have been identified as key components of alcohol industry strategies to influence policy and shape the regulatory contexts in which they operate in three ways. First, funding such bodies forms part of corporate social responsibility programmes which allow companies to position themselves as legitimate policy actors and 'part of the solution' to alcohol related harms. Second, reliance on industry funding incentivises governments to co-operate with industry actors and provides leverage in policy debates. Third, their programmes absorb policy bandwidth and deflect from more effective, evidence based interventions (e.g. on pricing and advertising) which affect industry sales and profits. This is particularly effective if the perception of independence from the industry is created. The analysis presented below suggests that the DFD was not used explicitly by the industry actors for public relations purposes. However, it was useful to their broader strategic aims. It reinforced the position of Drinkaware as a key policy actor and promoted the particular, industry-favoured understanding of alcohol harms and their solutions which it promotes. This is in keeping with the previous insights from international research literature on corporate political activity in health harming industries which finds that policy influence is often subtle, indirect and designed to embed organisations within the policy architecture. It suggests that government agencies should proceed with great caution in entering into such partnerships with industry associated bodies.

A long-brewing crisis: The historical antecedents of major alcohol policy change in Ireland

INTRODUCTION

The Public Health (Alcohol) Act 2018 in Ireland has been hailed as a world-leading package of alcohol policy reforms. Existing studies have identified the events that led to alcohol emerging onto the high-level policy agenda in Ireland, particularly after 2009. Using policy feedback theory, this study specifically investigates the political consequences of accumulating alcohol-related health and social harms for processes of policy change prior to 2009.

METHODS

The study traces the development of alcohol policy in Ireland over the past three decades. It draws on primary documents, secondary literature and interviews with public health advocates, medical doctors, public health experts and key decision-makers.

RESULTS

The study documents a decades-long struggle to have alcohol recognised as a public health issue in Ireland. We identify 2008/2009 as the key turning point, where policy conditions decisively shifted in a public health direction. We show how insufficient institutional authority and the accumulation of the effects of earlier policy failures helped foster this dynamic. These two factors elevated the visibility of alcohol-related harm for key stakeholders, helping spur greater demand for major policy change.

DISCUSSION AND CONCLUSIONS

Not acting on the population health harms caused by alcohol can produce significant societal costs, particularly when consumption is rising, and entail subsequent political consequences. Understanding of innovations in alcohol policy decision making requires an appreciation of the historical context, including earlier policy failures.

Policy communities, devolution and policy transfer: The case of alcohol pricing in Wales

This study investigates how processes of horizontal policy transfer can unfold in the context of devolution, examining the development of legislation on minimum unit pricing (MUP) in Wales, following on from Scotland's earlier policy decision. The study draws on a range of sources, including primary documents, media coverage, and interviews with policy participants. Our analysis identifies the importance of the specific character of Welsh political institutions, particularly the emphasis given to participation and consultation in policymaking. In the case of MUP, we document a process of policy-oriented learning, where policymakers made a concerted effort to draw on an assortment of expertise and experiences, including but not limited to the Scottish model. We also find that the Welsh public health policy community was well placed to support the framing of MUP and to address limitations in policy capacity. The findings hold implications for future studies of learning, devolution, and alcohol policy more generally.

The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID-19 Pandemic, Economic Downturn, and Racial Inequity

Policy Points  The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.  While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.  In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.  On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post-COVID-19 world.

'Sweet talk': framing the merits of a sugar tax in Australia

Although rising rates of obesity are recognized as a major concern for Australian public health, debate on what (if any) responsive action should be undertaken is conceptually and normatively complex. It is shaped by diverse values and interests; different representations of the problem; and many options for action by government, the private sector or individuals. This paper presents research documenting arguments for and against implementing a sugar tax in Australia. It is based on semi-structured interviews with representatives from industry (n = 4), public health (n = 4), policy think tanks (n = 2); and document and media analyses. The research design was informed by framing and agenda setting theory with results reported under four main themes: framing economic impacts, framing equity, framing obesity and framing the 'nanny state' versus individual liberty argument. We found that proposals for a sugar tax as part of policy responses to the issue of overweight and obesity in Australia are framed very differently by actors who either support or oppose it. A conclusion is that policy makers and public health advocates involved in policy debates on a sugar tax need to understand the role of problem and 'solution' framing, and develop positions based on protecting the public interest as a basic ethical responsibility of governments and public agencies.

Message framing to inform cancer prevention pricing interventions in the UK and USA: a factorial experiment, 2019

OBJECTIVES

To advance understanding of how message framing can be used to maximise public support across different pricing policies for alcohol, tobacco and sugary drinks/foods that prevent consumption of cancer-causing products.

DESIGN

We designed a 3×4×3 randomised factorial experiment to test responses to messages with three pricing policies, four message frames and three products.

SETTING

Online survey panel (Qualtrics) in 2019.

PARTICIPANTS

Adults (N=1850) from the UK and USA.

INTERVENTIONS

Participants randomly viewed one of 36 separate messages that varied by pricing policy (increasing taxes, getting rid of price discounts, getting rid of low-cost products), four frames and product (alcohol, tobacco, sugary drinks/foods).

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed the relationship between the message characteristics and four dependent variables. Three were related to policy support: (1) increasing taxes on the product mentioned in the message, (2) getting rid of price discounts and special offers on the product mentioned in the message and (3) getting rid of low-cost versions of the product mentioned in the message. One was related to reactance, a psychological response to having one's freedom limited.

RESULTS

We found no effect for pricing policy in the message. Frames regarding children and reducing cancer risk moderated some outcomes, showing promise for real-world use. We found differences in support by product and reactance with greatest support and least reactance for tobacco policies, less support and more reactance for alcohol policies, and the least support and most reactance for sugary drinks/foods policies.

CONCLUSIONS

Cancer prevention efforts using policy interventions can be informed by the message framing literature. Our results offer insights for cancer prevention advocacy efforts across the UK and USA and highlight that tax versus non-tax approaches to increasing the cost of cancer-causing products result in similar responses from consumers.

Understanding Government Decisions to De-fund Medical Services Analyzing the Impact of Problem Frames on Resource Allocation Policies

Many medical services lack robust evidence of effectiveness and may therefore be considered "unnecessary" care. Proactively withdrawing resources from, or de-funding, such services and redirecting the savings to services that have proven effectiveness would enhance overall health system performance. Despite this, governments have been reluctant to discontinue funding of services once funding is in place. The focus of this study is to understand how the framing of an issue or problem influences government decision-making related to de-funding of medical services. To achieve this, a framework describing how problem frames, or explanatory naratives, influence government policy decisions was developed and applied to actual cases. The two cases selected were the Ontario government's decisions to de-fund the drug Oxycontin and blood glucose test strips used by patients with diabetes. A qualitative content analysis of public discourse (political debate and media coverage) surrounding these two resource withdrawal examples was conducted and described using the framework. In the framework, government decision-making is a partial reflection of the visibility of the policy issue and complexity of the causal story told within a problem frame. By applying this framework and considering these two key characteristics of problem frames, we can better understand, and possibly predict, the shape and timing of government policy decisions to withdraw resources from medical services.

Reconceptualising the study of alcohol policy decision-making: the contribution of political science

In this article, we demonstrate the applicability of a 3-I (interests, institutions, and ideas) framework to alcohol policy research. The analysis uses literature from political science research to provide a core theoretical framework. To help illustrate the argument, we draw on relevant examples from alcohol policy in the UK as well as initial findings from an ongoing research study on minimum-unit pricing in Wales. The Welsh case study provides an opportunity to examine the value of the framework in generating testable hypotheses in alcohol policy research. We find that several interrelated factors promoted policy change in Wales, including the government's power to legislate on matters of public health (institutionally), a relatively weak alcohol industry (a key interest group), and a public health community with specific policy arguments on why and how to tackle alcohol-related harms (ideas). Our analysis has important implications for public health research and evidence-based policymaking. It suggests that the uptake of new ideas depends on the existing configuration of interests, institutions and ideas. This analysis provides alcohol policy researchers with a portable framework for analysing the policy context.

Changing the Conversation, Why We Need to Reframe Corruption as a Public Health Issue Comment on "We Need to Talk About Corruption in Health Systems"

There has been slow progress with finding practical solutions to health systems corruption, a topic that has long languished in policy-makers "too difficult tray." Efforts to achieve universal health coverage (UHC) provide a new imperative for addressing the long-standing problem of corruption in health systems making fighting corruption at all levels and in all its forms a priority. In response, health system corruption should be classified as a risk to public health and addressed by adopting a public health approach. Taking a public health approach to health systems corruption could promote a new paradigm for working on health system anti-corruption efforts. A public health approach could increase the space for policy dialogue about corruption, focus work to address corruption on prevention, help generate and disseminate evidence about effective interventions strategies, and because of its focus on multisectoral action would provide new opportunities for promoting cooperation on anti-corruption work across multiple agencies and sectors. Using a public health approach to tackle health system corruption could help address the current inertia around the topic and create a new positive mindset among policy-makers who would come to see corruption as a manageable public health problem rather than an intractable one.

Advancing public health policy making through research on the political strategies of alcohol industry actors

Development and implementation of evidence-based policies is needed in order to ameliorate the rising toll of non-communicable diseases (NCDs). Alcohol is a key cause of the mortality burden and alcohol policies are under-developed. This is due in part to the global influence of the alcohol industry. We propose that a better understanding of the methods and the effectiveness of alcohol industry influence on public health policies will support efforts to combat such influence, and advance global health. Many of the issues on the research agenda we propose will inform, and be informed by, research into the political influence of other commercial actors.

'Tied up in a legal mess': The alcohol industry's use of litigation to oppose minimum alcohol pricing in Scotland

This article examines the alcohol industry's legal challenges to minimum unit pricing (MUP) in Scotland through the stages heuristic of the policy process. It builds on previous studies of alcohol pricing policy in Scotland and across the UK, and of the use of legal challenges by health harming industries to oppose health policy globally. Having failed to prevent MUP passing into law, industry actors sought to frustrate the implementation of the legislation via challenges in the Scottish, European and UK courts. However, the relevance of legal challenges is not limited to the post-legislative stage of the policy process but was foreshadowed in all earlier stages of the policy process. The potential for a legal challenge to MUP, and the alcohol industry's clearly articulated intention to pursue such action, was used by industry actors to seek to prevent the adoption of MUP in the agenda setting, policy formulation and legislative stages and created significant 'regulatory chill' in other areas of Scottish and UK alcohol policy. Litigation, and the prospect of it, was thus part of a coherent and integrated long-term strategy which adapted to changes in the political climate and to different stages in the policy process. While both the rhetoric and reality of litigation failed to prevent policy implementation, it succeeded in causing a delay of six years, imposing significant costs on the Scottish government and creating policy inertia in Scottish alcohol policy subsequently. Moreover, the inclusion of a 'sunset clause' in the legislation, requiring ongoing evaluation of the policy's effects, presents additional opportunities for the industry to reverse MUP. Thus, industry strategies to undermine MUP and delay further alcohol policy developments require ongoing attention by policy actors and scholars.

A public health advocacy approach for preventing and reducing gambling related harm

OBJECTIVE

To develop a framework to guide the application of public health advocacy strategies aimed at preventing and reducing gambling-related harm.

METHODS

A narrative review of theories of change and public health advocacy literature.

RESULTS

An eight-step public health advocacy framework was created, which outlines the critical steps and considerations when developing and implementing successful change efforts. Implications for public health: To date, a clear public health advocacy approach to gambling harm prevention and reduction has not been well established. This study proposes a gambling-specific framework to guide future public health advocacy efforts to prevent and reduce gambling harm.

Public-private partnerships and the politics of alcohol policy in England: the Coalition Government's Public Health 'Responsibility Deal'

BACKGROUND

The 2010-2015 Conservative-led Coalition Government launched their flagship Public Health Responsibility Deal (PHRD) for England in 2011; a year before their alcohol strategy. This co-regulatory regime placed alcohol industry actors at the heart of policy-making, but was viewed with scepticism by public health actors. This article examines the ways in which the PHRD structured the alcohol policy environment throughout this period, which included the rejection of evidence-based policies such as minimum unit pricing.

METHODS

This article draws on 26 semi-structured interviews with policy actors (parliamentarians, civil servants, civil society actors and academics) in 2018. Respondents were identified and recruited using purposive sampling. Interviews were recorded, transcribed and analysed using thematic coding.

RESULTS

The PHRD shaped the context of alcohol policy development at Westminster throughout this period. It circumscribed the policy space by taking evidence-based measures not amenable to industry partnership off the agenda. While the PHRD created important opportunities for industry engagement with policy-makers, it undermined public health actors' access to government, particularly following their withdrawal from the process. Moreover, the PHRD demonstrates the enduring appeal of partnership as a policy idea for governments, despite a lack of evidence of their effectiveness.

CONCLUSIONS

This study of the PHRD demonstrates the ways in which industry actors are able to influence policy through long-term relationship building and partnership working on policy decision-making. Whilst such partnership approaches may appear to have the potential to mitigate some of alcohol harms, they create fundamental conflicts of interest, and may undermine the very causes they seek to further.

Research on media framing of public policies to prevent chronic disease: A narrative synthesis

Media coverage plays a key role in shaping public and political attitudes towards policy interventions to improve health. We reviewed studies of news media to identify the arguments used to frame policies that address risk factors for chronic disease, and the impact of different arguments on attitudes to policy. Drawing on a previous scoping review, we identified a subsample of 49 studies of media framing of policies to address risk factors for lifestyle-related chronic disease for further analysis. We extracted and synthesised data to explore key themes. Of the limited research that has been undertaken, most studies have focused on tobacco policy, followed by alcohol, with a small number of studies of food and beverage policies. Studies have primarily used content analysis. Our synthesis demonstrated that advocates and opponents draw on five frames: health, social, economic, practical and ideological. Only a small number of studies have examined the impact of framing on public attitudes towards policy interventions, although such studies have tended to focus on the impact of how problems, rather than solutions (i.e. policies) are framed. Media research is crucial to understanding the complex ways in which attitudes towards policy interventions shape, and are shaped by, public discourses and can provide public health advocates with insights into strategies to successfully position policy arguments. This review highlights key insights and gaps in the hope that this will stimulate further research that will enhance public health advocates' abilities to promote effective public health policy.

Evaluating possible intended and unintended consequences of the implementation of alcohol minimum unit pricing (MUP) in Scotland: a natural experiment protocol

INTRODUCTION

Scotland is the first country to carry out a national implementation of minimum unit pricing (MUP) for alcohol. MUP aims to reduce alcohol-related harms, which are high in Scotland compared with Western Europe, and to improve health equalities. MUP is a minimum retail price per unit of alcohol. That approach targets high-risk alcohol users. This work is key to a wider evaluation that will determine whether MUP continues. There are three study components.

METHODS AND ANALYSIS

Component 1 sampled an estimated 2800 interviewees at a baseline and each of two follow-ups from four Emergency Departments in Scotland and Northern England. Research nurses administered a standardised survey to assess alcohol consumption and the proportion of attendances that were alcohol-related.Component 2 covered six Sexual Health Clinics with similar timings and country allocation. A self-completion survey gathered information on potential unintended effects of MUP on alcohol source and drug use.Using a natural experiment design and repeated cross-sectional audit, difference between Scotland (intervention) and North England (control) will be tested for outcomes using regression adjusting for differences at baseline. Differential impacts by age, gender and socioeconomic position will be investigated.Component 3 used focus groups with young people and heavy drinkers and interviews with stakeholders before and after MUP implementation. The focus groups will allow exploration of attitudes, experiences and behaviours and the potential mechanisms by which impacts arise. The interviews will help characterise the implementation process.

ETHICS AND DISSEMINATION

Study components 1 and 2 have been ethically approved by the NHS, and component 3 by the University of Stirling. Dissemination plans include peer-reviewed journal articles, presentations, policy maker briefings and, in view of high public interest and the high political profile of this flagship policy, communication with the public via media engagement and plain language summaries.

TRIAL REGISTRATION NUMBER

ISRCTN16039407; Pre-results.

Following in the footsteps of tobacco and alcohol? Stakeholder discourse in UK newspaper coverage of the Soft Drinks Industry Levy

OBJECTIVE

In politically contested health debates, stakeholders on both sides present arguments and evidence to influence public opinion and the political agenda. The present study aimed to examine whether stakeholders in the Soft Drinks Industry Levy (SDIL) debate sought to establish or undermine the acceptability of this policy through the news media and how this compared with similar policy debates in relation to tobacco and alcohol industries.

DESIGN

Quantitative and qualitative content analysis of newspaper articles discussing sugar-sweetened beverage (SSB) taxation published in eleven UK newspapers between 1 April 2015 and 30 November 2016, identified through the Nexis database. Direct stakeholder citations were entered in NVivo to allow inductive thematic analysis and comparison with an established typology of industry stakeholder arguments used by the alcohol and tobacco industries.

SETTING

UK newspapers.

PARTICIPANTS

Proponents and opponents of SSB tax/SDIL cited in UK newspapers.

RESULTS

Four hundred and ninety-one newspaper articles cited stakeholders' (n 287) arguments in relation to SSB taxation (n 1761: 65 % supportive and 35 % opposing). Stakeholders' positions broadly reflected their vested interests. Inconsistencies arose from: changes in ideological position; insufficient clarity on the nature of the problem to be solved; policy priorities; and consistency with academic rigour. Both opposing and supportive themes were comparable with the alcohol and tobacco industry typology.

CONCLUSIONS

Public health advocates were particularly prominent in the UK newspaper debate surrounding the SDIL. Advocates in future policy debates might benefit from seeking a similar level of prominence and avoiding inconsistencies by being clearer about the policy objective and mechanisms.

Mapping discourse coalitions in the minimum unit pricing for alcohol debate: a discourse network analysis of UK newspaper coverage

BACKGROUND AND AIMS

Minimum unit pricing (MUP) for alcohol was introduced in Scotland on 1 May 2018, and is now on the policy agenda in other devolved administrations and at Westminster. Previous research has explored the arguments deployed for and against MUP, but the congruence between actors in the MUP debate has not been sufficiently examined. This study identified and mapped the discourse coalitions that emerged in the UK MUP debate through an analysis of actors' use of arguments in media coverage of the policy debates.

DESIGN

A sample of print media coverage of MUP was obtained from the LexisNexis newspaper database. The resulting sample was imported into discourse network analysis (DNA) software for coding and subsequent visualization of actor networks.

SETTING

United Kingdom.

OBSERVATIONS

A total of 348 articles from eight UK-wide and three Scottish newspapers from an 18-month period, ending in November 2012, were analysed.

MEASUREMENTS

Actors' arguments were coded to generate structured data for conversion into a weighted actor network where ties represent similarities among actors in terms of arguments in support of or opposition to MUP.

FINDINGS

Two polarized discourse coalitions, Opponents and Proponents of MUP, emerged in media coverage. The Proponents coalition consisted mainly of health advocacy groups, charities, political parties and academic institutions. In the Opponents coalition, the networks were formed of key alcohol manufacturers and economic think-tanks. While producer organizations were central to the Opponents coalition, some commercial actors were more favourable to MUP, highlighting divisions within the industry overall.

CONCLUSIONS

Media coverage of minimum unit pricing (MUP) in Scotland from June 2011 to November 2012 showed alignment between the policy positions of (1) alcohol producers and think-tanks opposed to MUP; and (2) public health advocates and health charities in favour of the policy. Some alcohol industry actors were supportive of MUP indicating divisions among the industry. Discourse network analysis may be usefully applied to study other highly contested policy issues in health and beyond.

Alcohol Industry CSR Organisations: What Can Their Twitter Activity Tell Us about Their Independence and Their Priorities? A Comparative Analysis

There are concerns about the accuracy of the health information provided by alcohol industry (AI)-funded organisations and about their independence. We conducted a content analysis of the health information disseminated by AI-funded organisations through Twitter, compared with non-AI-funded charities, to assess whether their messages align with industry and/or public health objectives. We compared all tweets from 2016 from Drinkaware (UK); Drinkaware.ie (Ireland); and DrinkWise (Australia), to non-AI-funded charities Alcohol Concern (UK), Alcohol Action Ireland, and FARE (Australia). Industry-funded bodies were significantly less likely to tweet about alcohol marketing, advertising and sponsorship; alcohol pricing; and physical health harms, including cancers, heart disease and pregnancy. They were significantly more likely to tweet about behavioural aspects of drinking and less likely to mention cancer risk; particularly breast cancer. These findings are consistent with previous evidence that the purpose of such bodies is the protection of the alcohol market, and of the alcohol industry's reputation. Their messaging strongly aligns with AI corporate social responsibility goals. The focus away from health harms, particularly cancer, is also consistent with previous evidence. The evidence does not support claims by these alcohol-industry-funded bodies about their independence from industry.

Early Identification of Locally Emerging Trends in Psychoactive Substance Use - Experience and Best Practice in Four European Localities

Background: Timely information about trends in psychoactive substance use could yield tailored interventions and reduce potential harms. However, conventional epidemiological tools might have limited capacity to detect trends emerging on a local level. Objectives: The aim of this study was to explore best practice in the identification of new drug trends at the local level. Methods: A total of 33 key informants from seven European municipalities/regions were interviewed to describe trends in substance use in their locality and to provide expert insights on how these were identified. Semi-structured interviews were analyzed with open coding method. Results: Four case studies that described local trends and responses were compiled: onset of problematic GHB use in the Dutch municipality of Breda (1); emerging retail shops selling new psychoactive substances (NPS) across the regions of Czech Republic (2) and in the Portuguese Agueda and Coimbra (3); and use of drugs with unknown content in the Italian region of Emilia Romagna, and its city Bologna (4). "Early identifiers" in the four case studies were organizations that work directly with people who use drugs (PWUD), emergency departments, and local police. Efficient methods of horizontal and vertical information sharing, sometimes facilitated by communication platforms, were in place, such that included early warning systems on local, national, and supra-local level. Local-level identification systems appeared as best suited to provide locally relevant information. Conclusions: Best practice in identifying emerging trends should involve all relevant "early identifiers", should consist of supra-local exchange platforms, integrate the qualities of local-level identification, and be facilitated by local-level coordinators.

Framing the policy debate over spirits excise tax in Poland

Industry lobbying remains an obstacle to effective health-oriented alcohol policy. In 2013, an increase in excise tax on spirits was announced by the Polish government. This article presents a qualitative analysis of the public debate that ensued on the potential economic, health and social effects of the policy. It focuses on how competing groups, including industry actors, framed their position and sought to dominate the debate. Online archives of five Polish national newspapers, two spirits trade associations, and parliamentary and ministerial archives were searched. A thematic content analysis of the identified sources was conducted. The overall findings were compared with existing research on the framing of the Minimum Unit Pricing (MUP) debate in the UK. A total of 155 sources were analysed. Two main frames were identified: health, and economic. The spirits industry successfully promoted the economic frame in their own publications and in the media. The debate was dominated by arguments about potential growth of the grey market and losses in tax revenue that might result from the excise tax increase. The framing of the debate in Poland differed from the framing of the MUP debate in the United Kingdom. The Polish public health community was unsuccessful in making health considerations a significant element of the alcohol policy debate. The strategies pursued by UK health advocates offer lessons for how to make a more substantial impact on media coverage and promote health-oriented legislation.

Ireland’s Public Health (Alcohol) Bill

The proposal to introduce a Public Health (Alcohol) Bill marks a significant development in Ireland’s alcohol policymaking landscape. While the Bill has generated support from public health advocates, it has also raised considerable opposition, particularly from industry. This analysis aims to examine the debate around this Bill using the theoretical framework of critical discourse analysis and applying Carol Bacchi’s What’s the Problem Represented To Be critical mode of analysis. A key objective is to analyze the current prevailing representations of alcohol and its regulation in Ireland but also to consider what they reveal about the underlying governing rationality in relation to alcohol regulation. In particular, it questions whether the Bill signals a shift in the official governing rationality regarding alcohol regulation. The analysis illustrates how alcohol is problematized in markedly different ways in the debates and how such debates are often underpinned by multifaceted elements. Despite such differences, it argues that there are still signs of a neoliberal rhetoric emerging within the public health discourses, raising a question over whether the Bill and its supporting discourses signal a paradigmatic shift or are more indicative of a policy embracing hybrid forms of rule.

Alcohol industry involvement in policymaking: a systematic review

AIMS

To summarize the substantive findings of studies of alcohol industry involvement in national or supranational policymaking, and to produce a new synthesis of current evidence.

METHODS

This study examined peer-reviewed journal reports published in the English language between 1980 and 2016 of studies of alcohol industry involvement in policymaking. Included studies were required to provide information on data collection and analysis and to have sought explicitly to investigate interventions by alcohol industry actors within the process of public policymaking. Eight electronic databases were searched on 27 February 2017. The methodological strengths and limitations of individual studies and the literature as a whole were examined. A thematic synthesis using an inductive approach to the generation of themes was guided by the research aims and objectives.

RESULTS

Twenty reports drawn from 15 documentary and interview studies identify the pervasive influence of alcohol industry actors in policymaking. This evidence synthesis indicates that industry actors seek to influence policy in two principal ways by: (1) framing policy debates in a cogent and internally consistent manner, which excludes from policy agendas issues that are contrary to commercial interests; and (2) adopting short- and long-term approaches to managing threats to commercial interests within the policy arena by building relationships with key actors using a variety of different organizational forms. This review pools findings from existing studies on the range of observed impacts on national alcohol policy decision-making throughout the world.

CONCLUSIONS

Alcohol industry actors are highly strategic, rhetorically sophisticated and well organized in influencing national policymaking.

'Nothing can be done until everything is done': the use of complexity arguments by food, beverage, alcohol and gambling industries

BACKGROUND

Corporations use a range of strategies to dispute their role in causing public health harms and to limit the scope of effective public health interventions. This is well documented in relation to the activities of the tobacco industry, but research on other industries is less well developed. We therefore analysed public statements and documents from four unhealthy commodity industries to investigate whether and how they used arguments about complexity in this way.

METHODS

We analysed alcohol, food, soda and gambling industry documents and websites and minutes of reports of relevant health select committees, using standard document analysis methods.

RESULTS

Two main framings were identified: (i) these industries argue that aetiology is complex, so individual products cannot be blamed; and (ii) they argue that population health measures are 'too simple' to address complex public health problems. However, in this second framing, there are inherent contradictions in how industry used 'complexity', as their alternative solutions are generally not, in themselves, complex.

CONCLUSION

The concept of complexity, as commonly used in public health, is also widely employed by unhealthy commodity industries to influence how the public and policymakers understand health issues. It is frequently used in response to policy announcements and in response to new scientific evidence (particularly evidence on obesity and alcohol harms). The arguments and language may reflect the existence of a cross-industry 'playbook', whose use results in the undermining of effective public health policies - in particular the undermining of effective regulation of profitable industry activities that are harmful to the public's health.

Adjustment for survey non-representativeness using record-linkage: refined estimates of alcohol consumption by deprivation in Scotland

BACKGROUND AND AIMS

Analytical approaches to addressing survey non-participation bias typically use only demographic information to improve estimates. We applied a novel methodology which uses health information from data linkage to adjust for non-representativeness. We illustrate the method by presenting adjusted alcohol consumption estimates for Scotland.

DESIGN

Data on consenting respondents to the Scottish Health Surveys (SHeSs) 1995-2010 were linked confidentially to routinely collected hospital admission and mortality records. Synthetic observations representing non-respondents were created using general population data. Multiple imputation was performed to compute adjusted alcohol estimates given a range of assumptions about the missing data. Adjusted estimates of mean weekly consumption were additionally calibrated to per-capita alcohol sales data.

SETTING

Scotland.

PARTICIPANTS

13 936 male and 18 021 female respondents to the SHeSs 1995-2010, aged 20-64 years.

MEASUREMENTS

Weekly alcohol consumption, non-, binge- and problem-drinking.

FINDINGS

Initial adjustment for non-response resulted in estimates of mean weekly consumption that were elevated by up to 17.8% [26.5 units (18.6-34.4)] compared with corrections based solely on socio-demographic data [22.5 (17.7-27.3)]; other drinking behaviour estimates were little changed. Under more extreme assumptions the overall difference was up to 53%, and calibrating to sales estimates resulted in up to 88% difference. Increases were especially pronounced among males in deprived areas.

CONCLUSIONS

The use of routinely collected health data to reduce bias arising from survey non-response resulted in higher alcohol consumption estimates among working-age males in Scotland, with less impact for females. This new method of bias reduction can be generalized to other surveys to improve estimates of alternative harmful behaviours.

Does public health advocacy seek to redress health inequities? A scoping review

The public health (PH) sector is ideally situated to take a lead advocacy role in catalysing and guiding multi-sectoral action to address social determinants of health inequities, but evidence suggests that PH's advocacy role has not been fully realised. The purpose of this review was to determine the extent to which the PH advocacy literature addresses the goal of reducing health and social inequities, and to increase understanding of contextual factors shaping the discourse and practice of PH advocacy. We employed scoping review methods to systematically examine and chart peer-reviewed and grey literature on PH advocacy published from January 1, 2000 to June 30, 2015. Databases and search engines used included: PubMed, CINAHL, PsycINFO, Social Sciences Citation Index, Google Scholar, Google, Google Books, ProQuest Dissertations and Theses, Grey Literature Report. A total of 183 documents were charted, and included in the final analysis. Thematic analysis was both inductive and deductive according to the objectives. Although PH advocacy to address root causes of health inequities is supported theoretically and through professional practice standards, the empirical literature does not reflect that this is occurring widely in PH practice. Tensions within the discourse were noted and multiple barriers to engaging in PH advocacy for health equity were identified, including a preoccupation with individual responsibilities for healthy lifestyles and behaviours, consistent with the emergence of neoliberal governance. If the PH sector is to fulfil its advocacy role in catalysing action to reduce health inequities, it will be necessary to address advocacy barriers at multiple levels, promote multi-sectoral efforts that implicate the state and corporations in the production of health inequities, and rally state involvement to redress these injustices.