Minimum unit pricing for alcohol in ScotlandBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5603 (Published 25 September 2019) Cite this as: BMJ 2019;366:l5603
- 1Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
- 2Scottish Health Action on Alcohol Problems (SHAAP), Royal College of Physicians of Edinburgh, Edinburgh, UK
- Correspondence to: J D Mooney:
As the seventh most important global risk factor for premature death and accounting for a wide range of acute and chronic morbidities,12 alcohol deservedly attracts the attention of public health policy makers. The need for effective interventions at the population level is urgent not only in Scotland—which has among the highest levels of alcohol attributable harm in Europe,3 but also across the rest of the UK.
The most effective and cost effective policies to reduce the harm from alcohol are measures that constrain the price, availability, and marketing of alcohol.4 From the empirical and econometric modelling studies available to date, it is clear that minimum unit pricing (MUP),5 which sets a floor price per unit of alcohol, has the potential to be more effective than other pricing options in reducing sales and consumption of high strength, low cost products, that cause the most health harms.
In 2018, after six years of legal challenges by global alcohol producers, Scotland became the first country in the world to implement a national MUP policy, setting a limit of 50p ($0.62; €0.56) per unit (10 mL/8 g alcohol) below which alcohol cannot be sold. NHS Health Scotland are leading a comprehensive evaluation of the impact in advance of a 2023 review of the policy, as specified in a sunset clause in the legislation. Of course, in an age when complex public health issues such as harm from alcohol require whole system approaches,6 no single policy lever should be seen as a panacea, and MUP is still regarded in Scotland as one component of the overall strategy, as set out for example in the World Health Organization’s SAFER initiative.7
As described in the linked paper by O’Donnell and colleagues (doi:10.1136/bmj.l5274),8 previous modelling estimates around the introduction of 50p MUP in Scotland suggested a reduction in alcohol consumption of around 3.5% for each drinker annually. This would correspond in the 20 years after implementation to more than 2000 fewer deaths and around 39 000 fewer hospital admissions for Scotland as a whole.9 The authors examined the impact of the MUP policy on the amount and price of alcohol purchased in Scotland in the 34 weeks immediately after implementation. Using a controlled interrupted time series design, they analysed shopping data for 2015-18 from a large and representative panel of British households. They also examined whether changes in alcohol purchases differed by type of alcoholic beverage or household income. Purchases over the equivalent period before MUP implementation were used as controls, as well as purchases in the north of England to assess any cross border effects.
The main analysis found that the introduction of MUP was followed by a price increase of 6.4p per gram of alcohol (7.9%) and a reduction of 9.5 g (95% confidence interval 5.1 to 13.9) in off-trade alcohol purchased for each adult per household. Immediate reductions were most notable for beer, spirits, and cider, including own brand spirits and high strength white ciders. The 9.5 g reduction overall is equivalent to slightly more than one unit of alcohol—roughly half a pint of beer, a third of a can of strong cider, or one measure of spirits.
The observed reductions of up to 7.6% in purchases were more than double the modelling based estimates, confirming the authors’ conservative assumptions and highlighting that health benefits could be substantially greater. Most compelling from a targeting perspective is that the price increases of alcohol were largest for the higher rather than lower purchasing households and among the lower rather than higher income groups. Figures show a striking contrast in purchasing trends between households in Scotland and England, along with clear incremental differences by household purchasing fifth (doi:10.1136/bmj.l5274).
The study by O’Donnell and colleagues therefore supports previous modelling assumptions that cheap, high strength alcoholic beverages have the highest price elasticity in terms of responsiveness to price hikes, as do the findings that more economically disadvantaged people are more sensitive to such increases. Additionally, the minimal increases in expenditure for most households are also consistent with modelling estimates,10 supporting the proposition that MUP effectively targets those most at risk of harm from alcohol with a minimal impact on household budgets.
Although MUP detractors have argued that the policy is regressive, these first real results around the impact in Scotland offer little to support that contention. In the words of the Scottish novelist Val McDermid, on BBC television’s Question Time in 2017: “There is nothing regressive about preventing people in Scotland’s poorest communities drinking themselves to death with cheap alcohol.” Surely it is time to follow Scotland’s lead and implement MUP across the rest of the UK. Action is especially pressing for those regions, such as north east England, with comparable levels of harm from alcohol.
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: JDM has received research funding from Drinkaware, as well as from Alcohol Concern UK and Public Health England.
The BMJ policy on financial interests is here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.
Provenance and peer review: Commissioned; not peer reviewed.