Implementing a Public Health Objective for Alcohol Premises Licensing in Scotland: A Qualitative Study of Strategies, Values, and Perceptions of Evidence

Public health engagement in alcohol licensing in England and Scotland: the ExILEnS mixed-method, natural experiment evaluation

Background

International systematic reviews suggest an association between alcohol availability and increased alcohol-related harms. Alcohol availability is regulated through separate locally administered licensing systems in England and Scotland, in which local public health teams have a statutory role. The system in Scotland includes a public health objective for licensing. Public health teams engage to varying degrees in licensing matters but no previous study has sought to objectively characterise and measure their activity, examine their effectiveness, or compare practices between Scotland and England.

Aim

To critically assess the impact and mechanisms of impact of public health team engagement in alcohol premises licensing on alcohol-related harms in England and Scotland.

Methods

We recruited 39 diverse public health teams in England (n = 27) and Scotland (n = 12). Public health teams more active in licensing were recruited first and then matched to lower-activity public health teams. Using structured interviews (n = 66), documentation analysis, and expert consultation, we developed and applied the Public Health Engagement In Alcohol Licensing (PHIAL) measure to quantify six-monthly activity levels from 2012 to 2019. Time series of PHIAL scores, and health and crime outcomes for each area, were analysed using multivariable negative binomial mixed-effects models to assess correlations between outcome and exposure, with 18-month average PHIAL score as the primary exposure metric. In-depth interviews (n = 53) and a workshop (n = 10) explored public health team approaches and potential mechanisms of impact of alcohol availability interventions with public health team members and licensing stakeholders (local authority licensing officers, managers and lawyers/clerks, police staff with a licensing remit, local elected representatives).

Findings

Nineteen public health team activity types were assessed in six categories: (1) staffing; (2) reviewing and (3) responding to licence applications; (4) data usage; (5) influencing licensing stakeholders/policy; and (6) public involvement. Usage and intensity of activities and overall approaches varied within and between areas over time, including between Scotland and England. The latter variation could be explained by legal, structural and philosophical differences, including Scotland's public health objective. This objective was felt to legitimise public health considerations and the use of public health data within licensing. Quantitative analysis showed no clear evidence of association between level of public health team activity and the health or crime outcomes examined, using the primary exposure or other metrics (neither change in, nor cumulative, PHIAL scores). Qualitative data suggested that public health team input was valued by many licensing stakeholders, and that alcohol availability may lead to harms by affecting the accessibility, visibility and norms of alcohol consumption, but that the licensing systems have limited power to act in the interests of public health.

Conclusions

This study provides no evidence that public health team engagement in local licensing matters was associated with measurable downstream reductions in crime or health harms, in the short term, or over a 7-year follow-up period. The extensive qualitative data suggest that public health team engagement is valued and appears to be slowly reorienting the licensing system to better address health (and other) harms, especially in Scotland, but this will take time. A rise in home drinking, alcohol deliveries, and the inherent inability of the licensing system to reduce - or in the case of online sales, to contain - availability, may explain the null findings and will continue to limit the potential of these licensing systems to address alcohol-related harms.

Future work

Further analysis could consider the relative success of different public health team approaches in terms of changing alcohol availability and retailing. A key gap relates to the nature and impact of online availability on alcohol consumption, harms and inequalities, alongside development and study of relevant policy options. A national approach to licensing data and oversight would greatly facilitate future studies and public health input to licensing.

Limitations

Our interview data and therefore PHIAL scores may be limited by recall bias where documentary evidence of public health activity was not available, and by possible variability in grading of such activity, though steps were taken to minimise both. The analyses would have benefited from additional data on licensing policies and environmental changes that might have affected availability or harms in the study areas.

Study registration

The study was registered with the Research Registry (researchregistry6162) on 26 October 2020. The study protocol was published in BMC Medical Research Methodology on 6 November 2018.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/129/11.

Alcohol outlet density and marketing in Abeokuta, Nigeria

AIM

The physical availability of alcohol is a modifiable determinant of alcohol consumption and related harm. However, Nigeria currently does not have national regulations restricting the physical availability of alcohol. The study measured alcohol outlet density and marketing in Abeokuta, Nigeria.

METHODS

A descriptive community design was employed. Seven wards in Abeokuta South local government were surveyed street by street for functional alcohol outlets and nearby public institutions (schools and worship centres). Outlet characteristics were documented, and the location of outlets and public institutions was geocoded using a global positioning system app. The density and proximity of outlets and public institutions were analysed using QGIS 3.22.

RESULTS

Four hundred and seventy-six alcohol outlets and 194 public institutions (82 schools, 87 churches, and 25 mosques) were sampled across the 7 wards. The most common type of alcohol premises and outlets was on/off-premises and liquor/non-alcoholic drinks stores. Alcohol banners on liquor store lintels were the most prevalent marketing item. Alcohol outlet density ranged from 8.06 to 200 per km2. The smallest average distance between alcohol outlets was 28 m in Sodeke, while Ago Egun/Ijesa had the highest number of outlets and on/off premises. The shortest distance from an outlet to a school was 18.77 m in Ijaiye and 44 (14.7%) schools were located within ≤100 m of an outlet.

CONCLUSIONS

Findings indicate high alcohol density, resulting in short distances between alcohol outlets and public institutions in Abeokuta South local government area. These results underscore the importance of implementing evidence-based alcohol availability policies in Nigeria.

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.

'Give us the real tools to do our jobs': views of UK stakeholders on the role of a public health objective for alcohol licensing

OBJECTIVES

This study ascertains the views of UK stakeholders on the actual, and possible, impact of a public health licensing objective in their day-to-day work.

STUDY DESIGN AND METHODS

Twenty-eight interviews were conducted with members of public health teams who were actively engaged in alcohol licensing in their local area between 2017 and 2019. Six teams were based in Scotland (where there is a public health licensing objective) and 14 in England (where there is no similar objective).

RESULTS

Scottish participants reported that while challenges remained in applying the public health licensing objective, progress had been made and the objective was beneficial to their work. Participants in England felt that an objective would increase the legitimacy, value and impact of their contributions. In both Scotland and England, constructive relationships between PHTs, licensing authorities and other key stakeholders were developing suggesting that PHTs could have a sustainable and positive role in licensing.

CONCLUSIONS

In many Scottish areas, the alcohol licensing system is evolving to take constructive account of its public health objective. In England, PHTs that have invested resources in engaging in this area have demonstrated an ability to work effectively within licensing systems. Strong support for the adoption of a public health licensing objective among these PHTs adds weights to calls for the UK Government to reconsider its previous decision not to introduce such an objective.

Framings of risk and responsibility in newsprint media coverage of alcohol licensing regulations during the COVID-19 pandemic in England

INTRODUCTION

Licensing is recognised as a World Health Organization (WHO) 'best buy' for reducing alcohol harms. In response to the 2020 COVID-19 outbreak, many countries-imposed restrictions on outlets selling alcohol to reduce virus transmission. In England, while shops selling alcohol were deemed 'essential', multiple restrictions were imposed on licenced outlets such as pubs and bars. Media reporting of licensing restrictions during the pandemic might have shaped public discourses of alcohol risks and responsibilities.

METHODS

This study aimed to understand how alcohol licensing changes in England were framed in newsprint media. Two hundred and fifty-three relevant articles from UK newsprint publications were identified through the Nexis database, published within six time points between March and December 2020 reflecting key changes to licencing in England. Thematic analysis, drawing on framing theory, was conducted to identify 'problems' framed in the reporting of these changes.

RESULTS

Four dominant framings were identified: (i) licensed premises as 'risky' spaces; (ii) problematic drinking practices; (iii) problematic policy responses; and (iv) 'victimisation' of licensed premises. The presence of these framings shifted across the reporting period, but consistently, social disorder was constructed as a key risk relating to licensing changes over health harms from alcohol consumption.

DISCUSSION AND CONCLUSIONS

The analysis shows newsprint media reproduced narratives of 'inevitable' drinking culture and social disorder, but also emphasised expectations for evidence-based policy-making, in the context of licensing during the pandemic. Discourses of dissatisfaction with licensing decisions suggests potential for public health advocacy to push for licensing change to reduce alcohol health harms, in England and internationally.

How public health teams navigate their different roles in alcohol premises licensing: ExILEnS multistakeholder interview findings

Background

In England and Scotland, local governments regulate the sale of alcohol by awarding licences to premises to permit the sale of alcohol for consumption on or off the premises, under certain conditions; without such a licence, alcohol cannot be legally sold. In recent years, many local public health teams have become proactive in engaging with alcohol licensing, encouraging licensing authorities to act in ways intended to improve population health.

Objective

This research aimed to explore and understand the approaches and activities of public health stakeholders (i.e. NHS staff and other public health professionals) in seeking to influence local alcohol licensing policy and decisions, and the views of licensing stakeholders (i.e. licensing officers/managers, police staff with a licensing remit, elected members and licensing lawyers/clerks) on the acceptability and effectiveness of these approaches.

Participants

Local public health teams in England and Scotland were directly informed about this multisite study. Scoping calls were conducted with interested teams to explore their level of activity in alcohol licensing from 2012 across several categories. Twenty local authority areas with public health teams active in licensing matters were recruited purposively in England (n = 14) and Scotland (n = 6) to vary by region and rurality. Fifty-three in-depth telephone interviews (28 with public health stakeholders and 25 with licensing stakeholders outside health, such as local authority licensing teams/lawyers or police) were conducted. Interview transcripts were analysed thematically in NVivo 12 (QSR International, Warrington, UK) using inductive and deductive approaches.

Results

Public health stakeholders’ approaches to engagement varied, falling into three main (and sometimes overlapping) types. (1) Many public health stakeholders in England and all public health stakeholders in Scotland took a ‘challenging’ approach to influencing licensing decisions and policies. Reducing health harms was felt to necessitate a focus on reducing availability and generating longer-term culture change, citing international evidence on the links between availability and alcohol-related harms. Some of these stakeholders viewed this as being a narrow, ‘nanny state’ approach, whereas others welcomed public health expertise and its evidence-based approach and input. (2) Some public health stakeholders favoured a more passive, ‘supportive’ approach, with some reporting that reducing availability was unachievable. They reported that, within the constraints of current licensing systems, alcohol availability may be contained (at least in theory) but cannot be reduced, because existing businesses cannot be closed on availability grounds. In this ‘supportive’ approach, public health stakeholders supplied licensing teams with data on request or waited for guidance from licensing teams on when and how to get involved. Therefore, public health action supported the licensing team in their aim of promoting ‘safe’ and ‘responsible’ retailing of alcohol and/or focused on short-term outcomes other than health, such as crime. (3) Some public health stakeholders favoured a ‘collaborative’ approach in which they worked in close partnership with licensing teams; this could include a focus on containing availability or responsible retail of alcohol, or both.

Conclusions

In engaging with alcohol licensing, public health stakeholders adapted their approaches, sometimes resulting in a diminished focus on public health goals. Sampling did not include lower-activity areas, in which experiences might differ. The extent to which current licensing systems enable achievement of public health goals is questionable and the effectiveness of public health efforts merits quantitative evaluation.

Study registration

The study is registered with the Research Registry as researchregistry6162.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in Public Health Research. See the NIHR Journals Library website for further project information.

Barriers and Facilitators to the Implementation of Effective Alcohol Control Policies: A Scoping Review

Implementation of effective alcohol control policies is a global priority. However, at the global and national levels, implementing effective policies is still challenging, as it requires commitment from multiple stakeholders. This review provides a synthesis of barriers and facilitators to implementing effective alcohol control policies. We conducted a scoping review from two main databases: Scopus and Web of Science, and the grey literature from the World Health Organization's website. We included any studies investigating barriers and facilitators to implementing four effective policies: Alcohol pricing and taxation, control of physical availability, alcohol marketing control, and drink-driving policy. Articles published between 2000 and 2021 were included. The search yielded 11,651 articles, which were reduced to 21 after the assessment of eligibility criteria. We found five main barriers: resource constraint; legal loopholes; lack of evidence to support policy implementation, particularly local evidence; low priority of policy implementation among responsible agencies; and insufficient skills of implementers. Facilitators, which were scarce, included establishing monitoring systems and local evidence to support policy implementation and early engagement of implementing agencies and communities. We recommend that national governments pay more attention to potential barriers and facilitators while designing alcohol control regulations and implementing effective policies.

Exploring the implementation of public involvement in local alcohol availability policy: the case of alcohol licensing decision-making in England

BACKGROUND AND AIMS

In 2003, the UK government passed the Licensing Act for England and Wales. The Act provides a framework for regulating alcohol sale, including four licensing objectives with local governments having devolved responsibility for granting licences to sell alcohol. Members of the public can make representations of oppositions to licence applications. Applying the theories of the policy process, we explored the practices employed by licensing authorities when deciding on alcohol licences in situations of conflict between licence applicants and members of the public.

DESIGN

Qualitative study comprising a framework analysis of in-depth semi-structured interviews and application of the theories of institutionalism, the advocacy coalition framework and role of ideas.

SETTING

Eleven local authorities in five regions in England in 2019.

PARTICIPANTS

Purposive sample of 15 licensing officers, licensing subcommittee chairs, public health leads for licensing and police licensing officers.

MEASUREMENTS

The interview schedule included mechanisms of public involvement in licensing, parties involved, the subject of conflicts and how licensing authorities made decisions.

FINDINGS

When members of the public opposed licence applications, licensing authorities employed three key decision-making practices: procedural fairness, partnership working and framing. The normativity of procedural fairness was an important institutional structure within which conflicts were resolved. Licensing authorities also worked in partnership with the involved parties, who often appeared as advocacy coalitions that shared beliefs and advanced specific issues to determine mutually acceptable solutions. At times, licensing authorities framed issues through ideational processes to solve problems.

CONCLUSION

Licensing decision-making under the United Kingdom's Licensing Act for England and Wales appear in many cases to focus on resolution of conflicts between licence applicants and members of the public rather than on promotion of licensing objectives. This raises uncertainty regarding the impact of public involvement on reducing alcohol availability, but ultimately represents a pragmatic process that seeks to restore balance in powers, improve transparency in decision-making and empower communities.

Lockdown and licensed premises: COVID-19 lessons for alcohol policy

Introduction

The COVID‐19 pandemic necessitated unprecedented changes in alcohol availability, including closures, curfews and restrictions. We draw on new data from three UK studies exploring these issues to identify implications for premises licensing and wider policy.

Methods

(i) Semi‐structured interviews (n = 17) with licensing stakeholders in Scotland and England reporting how COVID‐19 has reshaped local licensing and alcohol‐related harms; (ii) semi‐structured interviews (n = 15) with ambulance clinicians reporting experiences with alcohol during the pandemic; and (iii) descriptive and time series analyses of alcohol‐related ambulance callouts in Scotland before and during the first UK lockdown (1 January 2019 to 30 June 2020).

Results

COVID‐19 restrictions (closures, curfews) affected on‐trade premises only and licensing stakeholders highlighted the relaxation of some laws (e.g. on takeaway alcohol) and a rise in home drinking as having long‐term risks for public health. Ambulance clinicians described a welcome break from pre‐pandemic mass public intoxication and huge reductions in alcohol‐related callouts at night‐time. They also highlighted potential long‐term risks of increased home drinking. The national lockdown was associated with an absolute fall of 2.14 percentage points [95% confidence interval (CI) −3.54, −0.74; P = 0.003] in alcohol‐related callouts as a percentage of total callouts, followed by a daily increase of +0.03% (95% CI 0.010, 0.05; P = 0.004).

Discussion and Conclusions

COVID‐19 gave rise to both restrictions on premises and relaxations of licensing, with initial reductions in alcohol‐related ambulance callouts, a rise in home drinking and diverse impacts on businesses. Policies which may protect on‐trade businesses, while reshaping the night‐time economy away from alcohol‐related harms, could offer a ‘win–win’ for policymakers and health advocates.

"Alcohol During Pregnancy? Nobody Does That Anymore": State Legislators' Use of Evidence in Making Policy on Alcohol Use in Pregnancy

OBJECTIVE

In recent years, U.S. states have passed many laws addressing alcohol use in pregnancy, despite limited evidence on the impact of such policies. This study explores how state legislators use evidence when making policy on alcohol use in pregnancy.

METHOD

Study data are drawn from semistructured interviews with 29 state lawmakers and their aides in Maryland, North Carolina, and Virginia, conducted in March through July 2017. Interview transcripts were coded and analyzed by inductive and deductive methods.

RESULTS

Despite evidence on the harms of alcohol use in pregnancy, most lawmakers did not express concern about this topic. Instead, they expressed concern about opioid use in pregnancy. Personal experiences, anecdotes, and known contacts influenced legislators' views on substance use in pregnancy, whereas evidence, for the most part, did not. The intermediaries who typically bring evidence about problems and solutions to legislators did not appear to be raising the issue of alcohol use in pregnancy on legislators' agenda.

CONCLUSIONS

Basic evidence on the prevalence and harms of alcohol use in pregnancy did not appear to influence state lawmakers' policy priorities. Concern over opioid use in general may provide a window of opportunity to educate legislators on the relative scope and harms of alcohol and opioid use in pregnancy. It remains unclear why states are passing alcohol-in-pregnancy policies. More research is needed to explore how state lawmakers form their understanding of substance use in pregnancy and related policies.

How did a lower drink-drive limit affect bar trade and drinking practices? A qualitative study of how alcohol retailers experienced a change in policy

Introduction and Aims

Reducing the legal drink‐drive limit from 0.08% to 0.05% blood alcohol concentration (BAC) can reduce road traffic accidents and deaths if properly enforced. Reduced limits may be opposed by alcohol retail and manufacturing industries on the basis of commercial impact. Our aim was to qualitatively explore how a reduction in the drink‐drive limit from 0.08% to 0.05% BAC in Scotland, was experienced by bar owners or managers, including any resultant changes in customer drinking or business practice. This is the first study of this type.

Design and Methods

Semi‐structured interviews were conducted with 16 owners and managers of on‐trade premises in Scotland in 2018, approximately three years after the drink‐drive limit was reduced. Data were analysed using thematic analysis.

Results

Most participants reported no long‐term financial impact on their business, but a few, mainly from rural areas, reported some reduction in alcohol sales. Observed drinking changes included fewer people drinking after work or leaving premises earlier on weekdays. Adaptations to businesses included improving the range of no/low‐alcohol drinks and food offered. Changes such as these were seen as key to minimising economic impact.

Discussion and Conclusions

Opposition to legislative measures that impact on commercial interests is often strong and receives significant public attention. This study found that Scottish businesses that adapted to the drink‐drive limit change reported little long‐term economic impact. These findings are of international relevance as potential BAC limit reductions in several other jurisdictions remain the subject of debate, including regarding the impact on business.

Local Alcohol Policy Implementation in Scotland: Understanding the Role of Accountability within Licensing

Scotland has been ambitious in its policy and legislative efforts to tackle alcohol-related harm, efforts which include the innovative feature of a ‘public health objective’ within local alcohol licensing. However, the persistence of alcohol-related harms and inequalities requires further examination of both the overarching Scottish alcohol strategy and its specific implementation. A qualitative case study was undertaken to explore how alcohol policy is implemented locally in Scotland, with data generated from (i) documentary analysis of 12 relevant policies, legislation, and guidance documents; and (ii) a thematic analysis of semi-structured interviews with 54 alcohol policy implementers in three Scottish localities and nine national-level stakeholders. The data suggest there is a tension between the intentions of licensing legislation and the way it is enacted in practice, and that accountability emerges as an important factor for understanding why this occurs. In particular, there are a lack of accountability mechanisms acting upon Scottish Licensing Boards to ensure they contribute to the public health goals of the Scottish alcohol strategy. From a public health perspective, this has perpetuated a system in which Licensing Boards continue to act with autonomy from the rest of the alcohol policy implementation system, creating a challenge to the achievement of public health goals. Alcohol policy in Scotland is likely to fall short of intended goals as long as the tension between licensing legislation and enacted licensing practices remains.

'A true partner around the table?' Perceptions of how to strengthen public health's contributions to the alcohol licensing process

INTRODUCTION

There are increased opportunities for public health practitioners (PHPs) in England to shape alcohol availability and reduce harms through a statutory role in licensing processes in local government. However, how public health can effectively influence alcohol licence decision-making is little understood.

METHODS

A mixed methods study was conducted to identify challenges faced by PHPs and mechanisms to strengthen their role. This involved a survey of practitioners across London local authorities (n = 18) and four focus group discussions with a range of licensing stakeholders (n = 36).

RESULTS

Survey results indicated a varied picture of workload, capacity to respond to licence applications and levels of influence over decision-making among PHPs in London. Practitioners described a felt lack of status within the licence process, and difficulties using and communicating public health evidence effectively, without a health licensing objective. Strategies considered supportive included engaging with other responsible authorities and developing understanding and relationships over time.

CONCLUSIONS

Against political and resource constraints at local and national government levels, pragmatic approaches for strengthening public health influence over alcohol licensing are required, including promoting relationships between stakeholders and offering opportunities for PHPs to share best practice about making effective contributions to licensing.

The handling of evidence in national and local policy making: a case study of alcohol industry actor strategies regarding data on on-premise trading hours and violence in Norway

BACKGROUND

Effective alcohol policy measures conflict with the interests of the alcohol industry. In this study we addressed how various alcohol industry actors in Norway have responded to research findings and police data relating to the possible impacts of changes in on-premise trading hours on violent offending.

METHODS

A content analysis of documents was undertaken. The documents comprised i) hearing statements from policy processes on on-premise trading hours at the national level, and in 15 Norwegian cities, and ii) newspaper articles and other media coverage of this topic in Norway.

RESULTS

Alcohol industry actors employed a range of strategies to shape the use of evidence regarding on-premise trading hours and violence. Nationally, the relevance of the international research literature was questioned before the publication of an unfavourable national study which was criticized directly. This led to commissioned attacks on the findings, constructing what were claimed to be disagreements between experts, emphasis on the complexity of violence and the role of confounding variables, and deflecting attention to alternative interventions. The handling of evidence at the local level was importantly different, where different industry actors and forms of evidence, notably police data, were involved in debates.

CONCLUSION

Alcohol industry actors employed various strategies to shape perceptions and use of evidence to advance their interests. The particular strategies and arguments changed over time as new data and research became available, and also varied between the national and the local levels, and by categories of industry actors.

Processes, practices and influence: a mixed methods study of public health contributions to alcohol licensing in local government

BACKGROUND

Public health in England has opportunities to reduce alcohol-related harms via shaping the availability and accessibility of alcohol through the licensing function in local government. While the constraints of licensing legislation have been recognised, what is currently little understood are the day-to-day realities of how public health practitioners enact the licensing role, and how they can influence the local alcohol environment.

METHODS

To address this, a mixed-methods study was conducted across 24 local authorities in Greater London between 2016 and 17. Data collection involved ethnographic observation of public health practitioners' alcohol licensing work (in eight local authorities); a survey of public health practitioners (n = 18); interviews with licensing stakeholders (n = 10); and analysis of public health licensing data from five local authorities. Fieldnotes and interview transcripts were analysed thematically, and quantitative data were analysed using descriptive statistics.

RESULTS

Results indicated that some public health teams struggle to justify the resources required to engage with licensing processes when they perceive little capacity to influence licensing decisions. Other public health teams consider the licensing role as important for shaping the local alcohol environment, and also as a strategic approach for positioning public health within the council. Practitioners use different processes to assess the potential risks of licence applications but also the potential strengths of their objections, to determine when and how actions should be taken. Identifying the direct influence of public health on individual licences is challenging, but the study revealed how practitioners did achieve some level of impact, for example through negotiation with applicants.

CONCLUSIONS

This study shows public health impact following alcohol licensing work is difficult to measure in terms of reducing alcohol-related harms, which poses challenges for justifying this work amid resource constraints. However, there is potential added value of the licensing role in strategic positioning of public health in local government to influence broader determinants of health.

Exploring the impact of public health teams on alcohol premises licensing in England and Scotland (ExILEnS): procotol for a mixed methods natural experiment evaluation

BACKGROUND

Recent regulatory changes in the system by which premises are licensed to sell alcohol, have given health representatives a formal role in the process in England and Scotland. The degree to which local public health teams engage with this process varies by locality in both nations, which have different licensing regimes. This study aims to critically assess the impact on alcohol-related harms - and mechanisms - of public health stakeholders' engagement in alcohol premises licensing from 2012 to 2018, comparing local areas with differing types and intensities of engagement, and examining practice in Scotland and England.

METHODS

The study will recruit 20 local authority areas where public health stakeholders have actively engaged with the alcohol premises licensing system (the 'intervention') and match them to a group of 20 lower activity areas using genetic matching. Four work packages are included: (1) Structured interviews and documentary analysis will examine the type and level of intervention activity from 2012 to 2018, creating a novel composite measure of the intensity of such activity and will assess the local licensing system and potential confounding activities over the same period. In-depth interviews with public health, licensing, police and others will explore perceived mechanisms of change, acceptability, and impact. (2) Using longitudinal growth models and time series analyses, the study will evaluate the impact of high and low levels of activity on alcohol-related harms using routine data from baseline 2009 to 2018. (3) Intervention costs, estimated National Health Service cost savings and health gains will be evaluated using the Sheffield Alcohol Policy Model to estimate impact on alcohol consumption and health inequalities. (4) The study will engage public health teams to create a new theory of change for public health involvement in the licensing process using our data. We will share findings with local, national and international stakeholders.

DISCUSSION

This interdisciplinary study examines, for the first time, whether and how public health stakeholders' involvement in alcohol licensing impacts on alcohol harms. Using mixed methods and drawing on complex systems thinking, it will make an important contribution to an expanding literature evaluating interventions not suited to traditional epidemiological research.