Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5274 (Published 25 September 2019) Cite this as: BMJ 2019;366:l5274
All rapid responses
Scotland the brave and glad Vlad. Re: Immediate impact of minimum unit pricing on alcohol purchases in Scotland.
On 1 May 2018, Scotland courageously (after years of legal challenge by alcohol companies) implemented a world’s first: a national minimum unit pricing (MUP) policy with a mandatory lowest retail price (floor price) per unit of alcohol [1,2,3]. O’Donnell et al. provide encouraging data that Scotland’s MUP policy is effective, with reduced weekly purchases of 9.5 g of alcohol per adult per household . In the linked editorial, Mooney and Carlin argue that the rest of the UK should follow suit .
O’Donnell et al.’s article is a helpful immediate assessment of Scotland’s MUP policy – comprehensive impact assessment will follow. NHS Health Scotland will undertake an independent multi-component assessment of the impact of MUP on a range of outcomes, reporting their complete results in 2023 (for more information, see Rapid Response: https://www.bmj.com/content/366/bmj.l5274/rr-0).
Meanwhile in Russia, as featured in The Lancet , the World Health Organization (WHO) reports that total per capita alcohol consumption has dropped by 43% since 2003 (2003-2016 data) . The WHO’s report provides a timeline of alcohol policies mapped to changes in mortality rates (Table 2 and Figure 14) . An MUP for vodka was introduced in 2003 and certain other alcoholic beverages have since been subject to MUP. Although MUP is not alcoholic beverage-wide and Russia’s MUP long-term strategy was abandoned for a period, evidence-based measures (including MUP), mainly targeting availability and affordability, have coincided with reductions in mortality rates – particularly in those of working age .
I agree with Mooney and Carlin  that the rest of the UK should follow Scotland’s lead – mounting evidence suggests that MUP is effective [1,6,7,8] and cost-effective (particularly when combined with tax increases ).
Although alcohol consumption remains high in Russia (total per capita alcohol consumption of 11.7 litres of pure ethanol in 2016, versus the WHO European average of 9.8 litres ), we can also learn from their success to date [4,5].
For more background on Scotland’s MUP policy, see the 14th Research and Policy Briefing from Scottish Health Action on Alcohol Problems (SHAAP).
Footnote: Opinions expressed are the author's own and do not necessarily reflect the view of the University of Manchester or the Royal College of Physicians of Edinburgh.
1. O’Donnell A, Anderson P, Jané-Llopis E, et al. Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18. BMJ 2019; 366: l5274. doi: https://doi.org/10.1136/bmj.l5274
2. Mooney JD, Carlin E. Minimum unit pricing for alcohol in Scotland. BMJ 2019; 366: l5603. doi: https://doi.org/10.1136/bmj.l5603
3. Scottish Health Action on Alcohol Problems (SHAAP). 14th Research and Policy Briefing. Scotland, UK: Scottish Health Action on Alcohol Problems (SHAAP); 2018. Available from: http://www.shaap.org.uk/images/web_version5_MUP_issue_14_2018.pdf (Accessed 07/10/19).
4. The Lancet. Russia’s alcohol policy: a continuing success story. Lancet 2019; 394: l10205. doi: https://doi.org/10.1016/S0140-6736(19)32265-2
5. Alcohol policy impact case study. The effects of alcohol control measures on mortality and life expectancy in the Russian Federation; Copenhagen: WHO Regional Office for Europe; 2019. Licence: CC BY-NC-SA 3.0 IGO. Available from: http://www.euro.who.int/en/health-topics/disease-prevention/alcohol-use/...
6. Boniface S, Scannell JW, Marlow S. Evidence for the effectiveness of minimum pricing of alcohol: a systematic review and assessment using the Bradford Hill criteria for causality. BMJ Open 2017;7:e013497. doi: https://doi.org/10.1136/bmjopen-2016-013497
7. Burton R, Henn C, Lavoie D, et al. A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective. Lancet 2017; 389: 1558–1580. doi: https://doi.org/10.1016/S0140-6736(16)32420-5
8. Stockwell T, Zhao J, Martin G, et al. Minimum alcohol prices and outlet densities in British Columbia, Canada: estimated impacts on alcohol-attributable hospital admissions. Am J Public Health. 2013; 103(11): 2014–2020. doi: https://doi.org/10.2105/AJPH.2013.301289
Competing interests: I work full-time at the Royal College of Physicians of Edinburgh (RCPE). Scottish Health Action on Alcohol Problems (SHAAP) is based within the RCPE. Dr Eric Carlin is the Director of SHAAP.
NHS Health Scotland’s mixed method portfolio evaluation of MUP across a number of outcomes Re: Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18.
This paper provides useful evidence of the short-term impact of minimum unit pricing (MUP) on alcohol purchasing in Scotland. As O’Donnell et al note, and at the request of the Scottish Government, NHS Health Scotland is leading an independent multi-component evaluation of the impact of MUP in Scotland across a number of outcomes.
The evaluation will form the basis of the review report required by legislation to assess the impact of MUP, which must be provided to the Scottish Parliament during the 6th year of implementation. The Scottish Parliament will then vote on whether or not MUP will continue beyond 31 April 2024.
A robust and comprehensive evaluation of MUP in Scotland is important. Much of the current empirical evidence on the impact of minimum pricing comes from Canada, where various forms of the policy exist in each of the Provinces. However, Scotland is the first country in the world to introduce MUP, whereby the floor-price below which alcoholic drinks cannot be sold applies to all alcohol and is based on the strength of the alcohol.
Our evaluation takes a theory-based approach to answer two overarching questions:
1. To what extent has implementing MUP in Scotland contributed to reducing alcohol-related health and social harms?
2. Are some people and businesses more affected (positively or negatively) than others?
The evaluation comprises quantitative studies of changes in a range of outcomes and qualitative studies of the mechanisms that underpin any changes in outcomes and people’s lived experience of MUP. The evaluation will provide evidence across four outcome areas: compliance and implementation, the alcohol market, alcohol consumption and health and social harms.
As highlighted in the O’Donnell et al article, assessing the change in health outcomes is essential. The evaluation is using administrative data to evaluate the impact of MUP on hospitalisations and deaths caused by alcohol in Scotland. Before the end of 2019, we will publish a descriptive analysis of alcohol sales made through the off-trade in Scotland in the 12 months post MUP, to be followed up with a statistical analysis. We are also looking at the longer term impacts. For example, we will analyse sales data for the three years post implementation of MUP. This is important because the Kantar data analysed by O’Donnell et al suggest that the initial step change in the difference between the volume of alcohol purchased in Scotland and England/Wales was less marked by the end of their 8 month post-MUP time period.
We are assessing the impact of MUP not only on its intended, beneficial outcomes but also on unintended or adverse outcomes. For example, we are exploring and will publish our findings on the best way to quantify cross-border purchase of alcohol. Other studies in the portfolio will also provide insights into the extent of cross-border purchasing.
Individual studies will publish their findings when complete. Our final report is due in late 2023. This report will draw on all robust, relevant studies, including the O’Donnell et al study, not just those undertaken as part of the NHS Health Scotland work.
NHS Health Scotland is committed to working with the researchers we have commissioned and those undertaking separately funded studies to provide impartial, timely and robust evidence on the impact of MUP in Scotland. Full details on the NHS Health Scotland evaluation and some of the separately funded studies can be found on our website1 and in the evaluation protocol.2
Competing interests: NHS Health Scotland, and the evaluation of MUP, is funded by Scottish Government.
Measuring what people buy to drink is genuinely difficult, for soft drinks as well as high strength beers. The authors of the evaluation of Scotland’s Minimum Unit Price (MUP) for alcohol used the best source available, the Kantar Worldpanel. But it is incapable of assesssing the impact on the alcoholics who were the principal focus of the initiative -- the heaviest drinkers who account for the country's 22 alcohol-specific deaths and 697 hospital admissions every week, and who cost NHS Scotland £3.6bn a year.
Worldpanel records only purchases brought into homes, not those consumed on the street, in parks or derelict buildings. And panel members must scan the barcodes of all products they buy, then upload digital images of receipts --- improbably disciplined behaviours for habitual boozers.
So while these initial results of the MUP are encouraging, they are a poor guide to the effects on the key group it was designed to change. As with all health-related policies, a persuasive assessment depends of what happens to health in the long term. And that depends on statistics, not from Scotland’s shops, but from its hospitals and morgues.
Competing interests: No competing interests