Evaluating the impact of minimum unit pricing (MUP) on alcohol sales after 3 years of implementation in Scotland: A controlled interrupted time-series study

BACKGROUND AND AIMS

On 1 May 2018, Scotland introduced minimum unit pricing (MUP), a strength-based floor price below which alcohol cannot be sold, throughout all alcoholic beverages. The legislation necessitates an evaluation of its impact across a range of outcomes that will inform whether MUP will continue beyond its sixth year. We measured the impact of MUP on per-adult alcohol sales (as a proxy for consumption) after 3 years of implementation.

DESIGN, SETTING AND PARTICIPANTS

Controlled interrupted time-series regression was used to assess the impact of MUP on alcohol sales in Scotland after 3 years of implementation, with England and Wales (EW) being the control group. In adjusted analyses, we included household disposable income, on-trade alcohol sales (in off-trade analyses) and substitution between drink categories (in drink category analyses) as covariates.

MEASUREMENTS

Weekly data were assessed on the volume of pure alcohol sold in Scotland and EW between January 2013 and May 2021, expressed as litres of pure alcohol per adult. The impact of MUP on total (on- and off-trade combined), off-trade and on-trade alcohol sales was assessed separately.

RESULTS

The introduction of MUP in Scotland was associated with a 3.0% (95% confidence interval = 1.8-4.2%) net reduction in total alcohol sales per adult after adjustment for the best available geographical control, disposable income and substitution. This reflects a 1.1% fall in Scotland in contrast to a 2.4% increase in EW. The reduction in total alcohol sales in Scotland was driven by reduced sales of beer, spirits, cider and perry. The reduction in total sales was due to reductions in sales of alcohol through the off-trade. There was no evidence of any change in on-trade alcohol sales.

CONCLUSION

Minimum unit pricing has been effective in reducing population-level alcohol sales in Scotland in the 3 years since implementation.

Preventing liver disease with policy measures to tackle alcohol consumption and obesity: The HEPAHEALTH II study

BACKGROUND & AIMS

Chronic liver disease (CLD) causes 1.8% of all deaths in Europe, many of them from liver cancer. We estimated the impact of several policy interventions in France, the Netherlands, and Romania.

METHODS

We used a validated microsimulation model to assess seven different policy scenarios in 2022-2030: a minimum unit price (MUP) of alcohol of €0.70 or €1, a volumetric alcohol tax, a sugar-sweetened beverage (SSB) tax, food marketing restrictions, plus two different combinations of these policies compared against current policies (the 'inaction' scenario).

RESULTS

All policies reduced the burden of CLD and liver cancer. The largest impact was observed for a MUP of €1, which by 2030 would reduce the cumulative incidence of CLD by between 7.1% to 7.3% in France, the Netherlands, and Romania compared with inaction. For liver cancer, the corresponding reductions in cumulative incidence were between 4.8% to 5.8%. Implementing a package containing a MUP of €0.70, a volumetric alcohol tax, and an SSB tax would reduce the cumulative incidence of CLD by between 4.29% to 4.71% and of liver cancer by between 3.47% to 3.95% in France, the Netherlands, and Romania. The total predicted reduction in healthcare costs by 2030 was greatest with the €1 MUP scenario, with a reduction for liver cancer costs of €8.18M and €612.49M in the Netherlands and France, respectively.

CONCLUSIONS

Policy measures tackling primary risk factors for CLD and liver cancer, such as the implementation of a MUP of €1 and/or a MUP of €0.70 plus SSB tax could markedly reduce the number of Europeans with CLD or liver cancer.

IMPACT AND IMPLICATIONS

Policymakers must be aware that alcohol and obesity are the two leading risk factors for chronic liver disease and liver cancer in Europe and both are expected to increase in the future if no policy interventions are made. This study assessed the potential of different public health policy measures to mitigate the impact of alcohol consumption and obesity on the general population in three European countries: France, the Netherlands, and Romania. The findings support introducing a €1 minimum unit price for alcohol to reduce the burden of chronic liver disease. In addition, the study shows the importance of targeting multiple drivers of alcohol consumption and obesogenic products simultaneously via a harmonized fiscal policy framework, to complement efforts being made within health systems. These findings should encourage policymakers to introduce such policy measures across Europe to reduce the burden of liver disease. The modeling methods used in this study can assist in structuring similar modeling in other regions to expand on this study's findings.

Assessing the early influence of COVID-19 in an analysis of the immediate implementation of Minimum Pricing for Alcohol on drinkers in Wales

Background: The Welsh Government has commissioned a number of projects to consider the influence their implementation of Minimum Pricing for Alcohol (MPA) legislation in March 2020 had on the alcohol consumption and related behaviours of drinkers. Given the MPA's overlap with the COVID-19 pandemic and its related lockdown measures and restrictions, this rapidly became a story about the early impact of COVID-19 as it did MPA. This paper captures the core thematic messages from this specific strand of work, and in doing so reflects on (1) how early experiences of COVID-19 and the first lockdown influenced consumption and purchasing of alcohol behaviours and, in turn, (2) how relevant the introduction of MPA was for any of these. Methods: Semi-structured interviews were conducted by telephone with 32 drinkers 9 months after the implementation of the legislation in March 2020. The sample was recruited from three sources: the National Survey for Wales; a third sector organisation offering housing support to the homeless; and through an online survey on MPA. Results: COVID-19 had more relevance than MPA to drinkers. Furthermore, when MPA did have an influence on their behaviour, it was felt most keenly by the harmful drinkers in the study. These drinkers described spending more on alcohol, switching to other potentially more harmful substances, such as crack cocaine and synthetic cannabinoids, and more involvement in acquisitive crime and begging after the price increase. While our results might be an early indication of the influence of MPA on harmful drinkers, the small sample of this group in our study limits the generalisability of the findings. Conclusion: To date, the implementation of MPA has had little influence on the drinking patterns or lives of the drinkers in our sample. It is important that future research examines the longer-term influences of MPA before any conclusions on its effectiveness can be drawn.

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

BACKGROUND AND AIMS

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

ARGUMENT

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

CONCLUSIONS

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

Views on minimum unit pricing for alcohol before its introduction among people with alcohol dependence in Scotland: A qualitative interview study

INTRODUCTION

Scotland implemented a minimum price per unit of alcohol (MUP) of £0.50 in May 2018 (1 UK unit = 10 mL/8 g ethanol). Some stakeholders expressed concerns about the policy having potential negative consequences for people with alcohol dependence. This study aimed to investigate anticipated impacts of MUP on people presenting to alcohol treatment services in Scotland before policy implementation.

METHODS

Qualitative interviews were conducted with 21 people with alcohol dependence accessing alcohol treatment services in Scotland between November 2017 and April 2018. Interviews examined respondents' current and anticipated patterns of drinking and spending, effects on their personal life, and their views on potential policy impact. Interview data were thematically analysed using a constant comparison method.

RESULTS

Three key themes were identified: (i) strategies used to manage the cost of alcohol and anticipated responses to MUP; (ii) broader effects of MUP; and (iii) awareness and preparedness for MUP. Respondents expected to be impacted by MUP, particularly those on low incomes and those with more severe dependence symptoms. They anticipated using familiar strategies including borrowing and reprioritising spending to keep alcohol affordable. Some respondents anticipated negative consequences. Respondents were sceptical about the short-term benefits of MUP for current drinkers but felt it might prevent harm for future generations. Respondents had concerns about the capacity of treatment services to meet support needs.

DISCUSSION AND CONCLUSIONS

People with alcohol dependence identified immediate concerns alongside potential long-term benefits of MUP before its introduction. They also had concerns over the preparedness of service providers.

Scotland's alcohol crisis: A clinician's perspective on a public health emergency

Worldwide, alcohol causes a death every 10 seconds. The harmful effects are much wider in terms of impaired health and wellbeing of those affected and their families, particularly the most disadvantaged. The wider societal impact and financial costs are huge. Scotland, which has a particularly unhealthy relationship with alcohol and where the cost of alcohol harm is estimated at £3.6 billion, has introduced innovative public health measures such as minimum unit pricing (MUP). However, the COVID-19 pandemic has seen the death toll rising. This article examines the history of alcohol harm and policy interventions in Scotland in recent decades. The lessons learned provide a range of measures of proven efficacy that clinicians and government should employ to tackle Scotland's on-going alcohol crisis, and should be of interest to clinicians and policy makers everywhere.

Alcohol minimum unit pricing and people experiencing homelessness: A qualitative study of stakeholders' perspectives and experiences

INTRODUCTION

Minimum unit pricing (MUP) may reduce harmful drinking in the general population, but there is little evidence regarding its impact on marginalised groups. Our study is the first to explore the perceptions of MUP among stakeholders working with people experiencing homelessness following its introduction in Scotland in May 2018.

METHODS

Qualitative semi-structured interviews were conducted with 41 professional stakeholders from statutory and third sector organisations across Scotland. We explored their views on MUP and its impact on people experiencing homelessness, service provision and implications for policy. Data were analysed using thematic analysis.

RESULTS

Participants suggested that the introduction of MUP in Scotland had negligible if any discernible impact on people experiencing homelessness and services that support them. Most service providers felt insufficiently informed about MUP prior to its implementation. Participants reported that where consequences for these populations were evident, they were primarily anticipated although some groups were negatively affected. People experiencing homelessness have complex needs in addition to alcohol addiction, and changes in the way services work need to be considered in future MUP-related discussions.

DISCUSSION AND CONCLUSIONS

This study suggests that despite initial concerns about potential unintended consequences of MUP, many of these did not materialise to the levels anticipated. As a population-level health policy, MUP is likely to have little beneficial impact on people experiencing homelessness without the provision of support to address their alcohol use and complex needs. The additional needs of certain groups (e.g., people with no recourse to public funds) need to be considered.

Adapting existing behaviour: Perceptions of substance switching and implementation of minimum pricing for alcohol in Wales

Aim

Minimum Pricing for Alcohol (MPA) was enacted in Wales on March 2^nd 2020. During the legislative process (i.e. consultation and parliamentary discussion), concern was expressed about the possibility of some drinkers switching to using other substances in response to any rise in the cost of alcohol. This paper reports on findings from a study which explored these pre-implementation concerns and how the policy was shaped.

Method

The research involved surveys (n=193) and interviews (n=87) with drinkers (predominantly harmful or treatment seeking) and providers of services. Survey responses were detailed, thus when combined with the interviews, provided a wealth of qualitative data, which are drawn upon in this paper.

Results

The findings highlight an expectation that most drinkers would respond to the new policy with adaptations of their coping mechanisms to maintain alcohol use at pre-legislative levels. This was either by switching alcohol products and adjusting their lifestyle to maintain an affordable drinking habit or developing new behaviours to manage additional costs. A small group of those with previous experience of drug use were identified as likely to switch from using alcohol to some other substances.

Conclusions

Prior to the legislation being implemented awareness of the detail of the policy was found to be low, and the perceptions of increased potential harm for certain groups, including switching, were linked to concern about a lack of treatment capacity.

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

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

Commentary on Robinson et al. (2021): Evaluating theories of change for public health policies using computer model discovery methods

Recent developments in computer modelling—known as model discovery—could help to confirm the mechanisms underpinning Robinson and colleagues’ important early findings for the effectiveness of minimum unit pricing, and to test the complete theory of change underpinning this crucial evaluation.

Evaluating the impact of minimum unit pricing (MUP) on off-trade alcohol sales in Scotland: an interrupted time-series study

BACKGROUND AND AIMS

On 1 May 2018, Scotland became the first country in the world to introduce minimum unit pricing (MUP), a strength-based floor price below which alcohol cannot be sold, across all alcoholic beverages. The legislation contains a sunset clause meaning a comprehensive mixed-methods evaluation of its impact across a range of outcomes will inform whether it will continue beyond its sixth year. In this study, we assessed the impact of MUP on off-trade alcohol sales (as a proxy for consumption) after its first year.

DESIGN, SETTING AND PARTICIPANTS

Controlled interrupted time-series regression was used to assess the impact of MUP on alcohol sales among off-trade retailers in Scotland in the year after it was introduced, with England and Wales (EW) being the control group. In adjusted analyses, we included household disposable income, on-trade alcohol sales and substitution between beverage categories as covariates.

MEASUREMENTS

Weekly data on the volume of pure alcohol sold by off-trade retailers in Scotland and EW between January 2013 and May 2019, expressed as litres of pure alcohol per adult.

FINDINGS

The introduction of MUP in Scotland was associated with a 3.5% [95% confidence interval (CI) = 2.2-4.9%] reduction in off-trade alcohol sales per adult after adjustment for the best available geographical control, disposable income and substitution. In unadjusted analysis, the introduction of MUP was associated with a 2.0% (95% CI = 0.4-3.6%) reduction in off-trade alcohol sales per adult in Scotland. In EW, there was a 2.4% (95% CI = 0.8-4.0%) increase during the same time-period. The reduction in off-trade alcohol sales in Scotland was driven by reduced sales of spirits, cider and perry beverage categories.

CONCLUSION

The implementation of minimum unit pricing for alcohol in Scotland in 2018 appears to have been associated with a reduction in off-trade alcohol sales after its first year.

What on-line searches tell us about public interest and potential impact on behaviour in response to minimum unit pricing of alcohol in Scotland

AIMS

To investigate whether the introduction of minimum unit pricing (MUP) in Scotland on 1 May 2018 was reflected in changes in the likelihood of alcohol-related queries submitted to an internet search engine, and in particular whether there was any evidence of increased interest in purchasing of alcohol from outside Scotland.

DESIGN

Observational study in which individual queries to the internet Bing search engine for 2018 in Scotland and England were captured and analysed. Fluctuations over time in the likelihood of specific topic searches were examined. The patterns seen in Scotland were contrasted with those in England.

SETTING

Scotland and England.

PARTICIPANTS

People who used the Bing search engine during 2018.

MEASUREMENTS

Numbers of daily queries submitted to Bing in 2018 on eight alcohol-related topics expressed as a proportion of queries on that day on any topic. These daily likelihoods were smoothed using a 14-day moving average for Scotland and England separately.

FINDINGS

There were substantial peaks in queries about MUP itself, cheap sources of alcohol and online alcohol outlets at the time of introduction of MUP in May 2018 in Scotland, but not England. These were relatively short-lived. Queries related to intoxication and alcohol problems did not show a MUP peak, but were appreciably higher in Scotland than in England throughout 2018.

CONCLUSIONS

Analysis of internet search engine queries appears to show that a fraction of people in Scotland may have considered circumventing minimum unit pricing in 2018 by looking for on-line alcohol retailers. The overall higher levels of queries related to alcohol problems in Scotland compared with England mirrors the corresponding differences in alcohol consumption and harms between the countries.

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

AIMS

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

DESIGN

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

SETTING

Australia.

PARTICIPANTS

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

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

How many alcohol-attributable deaths and hospital admissions could be prevented by alternative pricing and taxation policies? Modelling impacts on alcohol consumption, revenues and related harms in Canada

INTRODUCTION

In 2017, Canada increased alcohol excise taxes for the first time in over three decades. In this article, we describe a model to estimate various effects of additional tax and price policies that are predicted to improve health outcomes.

METHODS

We obtained alcohol sales and taxation data for 2016/17 for all Canadian jurisdictions from Statistics Canada and product-level sales data for British Columbia. We modelled effects of alternative price and tax policies - revenue-neutral taxes, inflation-adjusted taxes and minimum unit prices (MUPs) - on consumption, revenues and harms. We used published price elasticities to estimate impacts on consumption and revenue and the International Model for Alcohol Harms and Policies (InterMAHP) to estimate impacts on alcohol-attributable mortality and morbidity.

RESULTS

Other things being equal, revenue-neutral alcohol volumetric taxes (AVT) would have minimal influence on overall alcohol consumption and related harms. Inflation-adjusted AVT would result in 3.83% less consumption, 329 fewer deaths and 3762 fewer hospital admissions. A MUP of $1.75 per standard drink (equal to 17.05mL ethanol) would have reduced consumption by 8.68% in 2016, which in turn would have reduced the number of deaths by 732 and the number of hospitalizations by 8329 that year. Indexing alcohol excise taxes between 1991/92 and 2016/17 would have resulted in the federal government gaining approximately $10.97 billion. We estimated this could have prevented 4000-5400 deaths and 43 000-56 000 hospitalizations.

CONCLUSION

Improved public health outcomes would be made possible by (1) increasing alcohol excise tax rates across all beverages to compensate for past failures to index rates, and (2) setting a MUP of at least $1.75 per standard drink. While reducing alcohol-caused harms, these tax policies would have the added benefit of increasing federal government revenues.

Evaluation of Minimum Unit Pricing of Alcohol: A Mixed Method Natural Experiment in Scotland

In May 2018, Scotland became the first country in the world to implement minimum unit pricing (MUP) for all alcoholic drinks sold in licensed premises in Scotland. The use of a Sunset Clause in the MUP legislation was a factor in successfully resisting legal challenges by indicating that the final decision on a novel policy would depend on its impact. An overarching evaluation has been designed and the results will provide important evidence to inform the parliamentary vote on the future of MUP in Scotland. The evaluation uses a mixed methods portfolio of in-house, commissioned, and separately funded studies to assess the impact of MUP across multiple intended and unintended outcomes related to compliance, the alcoholic drinks industry, consumption, and health and social harms. Quantitative studies to measure impact use a suitable control where feasible. Qualitative studies assess impact and provide an understanding of the lived experience and mechanism of change for key sub-groups. As well as providing important evidence to inform the parliamentary vote, adding to the international evidence on impact and experience of alcohol pricing policy across a broad range of outcomes, this approach to evaluating novel policy interventions may provide guidance for future policy innovations.

Pricing as a means of controlling alcohol consumption

BACKGROUND

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

SOURCES OF DATA

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

AREAS OF AGREEMENT

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

AREAS OF CONTROVERSY

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

GROWING POINTS

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

AREAS TIMELY FOR DEVELOPING RESEARCH

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

Media Coverage of Alcohol Issues: A Critical Political Economy Framework-A Case Study from Ireland

There is a growing literature on news media representations of alcohol-related issues. However, current scholarship has neglected critical political economic frameworks to interpret media coverage of alcohol. This paper presents such a framework that conceives of news organisations as corporations that share the values and interests of political and economic elites. The media are thus expected to present viewpoints that are more aligned with the alcohol industry than the scientific consensus on public health policy would warrant. The media are also expected, but to a lesser extent, to present a certain amount of support for public health perspectives because these are supported by a few socioeconomic elite groups (the medical professions, progressive politicians). The case of Ireland from 2012 to 2017 illustrates the framework empirically. Four main newspapers’ coverage of the Public Health (Alcohol) Bill and related policies is examined. Results show that, overall, 44.0% of articles support public health measures and 56.0% are opposed or remain neutral. It is argued that the media are not strong proponents of public health for multiple reasons: there are more articles opposed to or neutral toward public health measures than supporting them; the number of supportive articles remains relatively small and there are still many pieces presenting drinks industry views; there are virtually no calls in the media for stronger measures; supportive coverage is partially explained by the pub owners lobby’s support for minimum unit pricing; the media often downplay or ignore the negative consequences of alcohol, such as its role in accidents; many news articles normalise drinking and promote events sponsored by the industry; there is not a single Irish journalist covering alcohol issues systematically; and other policy issues that are prioritised by elites receive multiple times more media coverage than public health measures. In short, the media reflect the views of the political and economic establishment on public health measures: there is some support from the medical professions and progressive politicians, but overall, there is a clear reluctance to support strong public health strategies. One main recommendation for public health advocates to promote their perspectives is to diversify the mass media and make them less commercial in nature, as well as to engage with non-corporate, so-called progressive “alternative media” outlets.

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

OBJECTIVES

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

DESIGN

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

CRITERIA FOR SELECTING STUDIES

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

RESULTS

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

CONCLUSIONS

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

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

CONTEXT

Scotland is the first country in the world to pass legislation introducing a minimum unit price (MUP) for alcohol in an attempt to reduce consumption and associated harms by increasing the price of the cheapest alcohol. We investigated the competing ways in which policy stakeholders presented the debate. We then established whether a change in framing helped explain the policy's emergence.

METHODS

We conducted a detailed policy case study through analysis of evidence submitted to the Scottish parliament, and in-depth, one-to-one interviews (n = 36) with politicians, civil servants, advocates, researchers, and industry representatives.

FINDINGS

Public- and voluntary-sector stakeholders tended to support MUP, while industry representatives were more divided. Two markedly different ways of presenting alcohol as a policy problem were evident. Critics of MUP (all of whom were related to industry) emphasized social disorder issues, particularly among young people, and hence argued for targeted approaches. In contrast, advocates for MUP (with the exception of those in industry) focused on alcohol as a health issue arising from overconsumption at a population level, thus suggesting that population-based interventions were necessary. Industry stakeholders favoring MUP adopted a hybrid framing, maintaining several aspects of the critical framing. Our interview data showed that public health advocates worked hard to redefine the policy issue by deliberately presenting a consistent alternative framing.

CONCLUSIONS

Framing alcohol policy as a broad, multisectoral, public health issue that requires a whole-population approach has been crucial to enabling policymakers to seriously consider MUP, and public health advocates intentionally presented alcohol policy in this way. This reframing helped prioritize public health considerations in the policy debate and represents a deliberate strategy for consideration by those advocating for policy change around the world and in other public health areas.