Harm from alcohol is increasing

Alcohol-related harm has been increasing steeply in the UK. Alcohol-related hospital admissions have doubled in England between 2002 and 2009 and now exceed 1 million per year, and deaths from liver disease have more than doubled in the UK since 1980, mostly due to alcoholic liver disease. ³ In 2010, alcohol had become 44% more affordable than in 1980 and consumption has increased by more than 10% in the past 15 years. ^{Reference Adams and Beenstock2} The change in affordability has not been uniform across all outlets. The affordability gap between off-sales (liquor stores) and on-sales (pubs and restaurants) has steadily grown and consequently the increase in consumption has been seen in off-sales, whereas consumption in pubs has declined. ^3,4

The UK experience over the past 25 years provides further evidence that increased alcohol affordability and accessibility leads to increased consumption producing greater levels of harm. ^{Reference Babor, Caetano, Casswell, Griffith, Giesbrecht and Graham5} There are, however, some early signs of downward trends in alcohol-related harm since 2008, a period when there has been a reduction in alcohol affordability due to economic recession, which is consistent with this model. ^{Reference Babor, Caetano, Casswell, Griffith, Giesbrecht and Graham5,Reference Beeston, Robinson, Craig and Graham6}

Historically, excise duty rates were seen as the key lever to control alcohol harm. ^{7,Reference Meier, Purshouse and Brennan8} In the UK, however, other mechanisms have been increasingly advocated for alcohol price control. ^{Reference Meier, Purshouse and Brennan8} There are two major reasons for this. First, successive UK governments from the mid 1980s until 2008 have been reluctant to increase alcohol excise duties. ⁷ Second, there has been an increasing dominance within the UK off-sales sector by the major supermarkets. Unlike many other countries, in the UK all alcohol can be sold alongside other goods. This allows alcohol, including spirits, to be used as a ‘loss leader’ or ‘footfall driver’ where the retailer accepts a low profit (or even a loss) on alcohol to attract business and profits are made on other goods. Supermarkets in the UK advertise to their customers that they will absorb duty rises in order to maintain low alcohol prices. Discounting of alcohol in the off-sales sector is common, and following a ban on discounts for multiple purchases in Scotland, from October 2011 there was an immediate fall in consumption in line with the predictions from the University of Sheffield econometric model. ^{Reference Chick9}

Why minimum unit price?

There has been particular interest in mechanisms which affect the price of the cheapest alcohol. The reasons for this will be obvious to clinicians who are familiar with the histories of patients who drink heavily, who change their choice of beverages to achieve maximum ‘bang for their buck’. A UK study of people in treatment for alcohol problems has shown that 83% of the alcohol they consumed is under 50p and 70% under 40p per unit. ^{Reference Black, Gill and Chick10} The potential value of a minimum unit price has been increasingly advocated by health professionals because compared with a general increase in tax on alcohol, setting a minimum unit price would have a targeted effect on the heaviest drinkers. ¹¹

Assessing the potential impact of minimum pricing requires complex econometric models. A study using sales data from Sweden predicted that price changes focused on the most expensive drinks, such as that produced by a VAT rise, led to increased consumption due to consumers moving to cheaper brands and increasing their consumption. ^{Reference Gruenewald, Ponicki, Holder and Romelsjö12} Price increases focused on the cheapest alcohol, as envisaged by minimum pricing, were predicted to be most effective in reducing consumption and harm. A major study commissioned by the UK Department of Health from the University of Sheffield used UK sales data to estimate the effect of a range of price mechanisms such as general price increases through excise duty, a ban on discounts for bulk purchases, and introduction of a minimum unit price ranging from 20 to 70p per unit. ^{Reference Brennan, Purshouse, Taylor, Rafia, Meier and Booth13} This modelling exercise showed minimum unit price as the best targeted approach to influence the consumption of the heaviest and most problematic drinkers, with significant beneficial effects starting from 40p per unit.

Research in Australia and Canada, where forms of minimum unit pricing have been introduced, showed a reduction of between 16% and 19% in alcohol consumption, accompanied by reductions in alcohol-related hospital admissions and alcohol-related offending. ^{Reference Gray, Saggers, Atkinson, Sputore, Bourbon, Gray and Saggers14,Reference Stockwell, Auld, Zhao and Martin15}

Conflict between health and industry interests

Minimum unit price has been strongly supported by a range of UK health organisations, including the Royal College of Psychiatrists (e.g. www.rcpsych.ac.uk/press/pressreleases2012/alcoholstrategy.aspx), and by the chief medical officers in England, Scotland, Wales and Northern Ireland. Minimum unit pricing also attracts support from the police, children's charities, the pub industry and most small, and some large, producers. Opposition to the policy has come from large retailers and organisations representing multinational alcohol producers. In Scotland, Wales and Northern Ireland where minimum unit price was a significant electoral issue, the elections were won by parties supporting the policy.

Some opponents of minimum unit pricing are concerned that the policy will generate revenue for retailers and not for the public purse. However, the policy is advocated as a public health measure and governments have a range of mechanisms to generate tax revenues, including raising alcohol duties, with which minimum pricing is compatible.

These recent debates in the UK have focused attention on the role of the alcohol industry in policy development. The industry has been shown to favour ineffective approaches such as public information campaigns and school-based education and to oppose regulatory approaches on price and availability of alcohol which are most effective in reducing harm. ^{Reference Drummond16} A number of health agencies, including the British Medical Association and Royal College of Physicians, refused to sign the UK government's ‘Responsibility Deal’ because they felt it had been too influenced by the industry. The Scottish government has come under considerable pressure from the whisky industry to drop its minimum price proposals, which it has resisted. Among the claims put forward by industry lobbyists is the potential for a detrimental impact on employment in the alcohol industry. However, in other countries a decline on overall consumption of cheaper alcohol combined with a shift to the more labour-intensive on-sales sector has been shown to have a net beneficial effect on employment and profitability. ^{Reference Anderson and Baumberg17}

Turning problem into action

The minimum price concept in the UK has now developed considerable momentum and it is difficult now to conceive that it will not be implemented. The details of the implementation are not yet clear, in particular whether the price level will vary across the UK. Great Britain may follow the example of Northern Ireland and Ireland where health ministers have agreed that a cross-border differential is undesirable. Although the legality and real-life effect of minimum price remain to be tested, to have reached this point is a significant achievement for the public health community in the face of concerted political lobbying by parts of the alcohol industry, which is reminiscent of the tobacco policy landscape in the UK 30 years ago. It is not surprising that UK alcohol retailers have been advised to start contingency planning for the introduction of minimum unit pricing. ^{Reference Arnot18}