1. From Evidence to Action: a case study of Minimum Unit Price Dr Lesley Graham Associate Specialist, Public Health ISD, NHSNSS 13 th November 2012 Royal Statistical Society

2. Minimum Price Would establish a minimum retail price for a unit of alcohol Linked to alcohol content, not type of product Would apply to all licensed premises Minimum price would be set in regulation by Scottish Parliament, independently of retailers, producers or anyone else connected with alcohol industry Easy to vary price and easy to administer

3. Policy Development Problem identification Agenda setting Potential actions Implementation Evaluation

4. Problem Identification Pre 2002 -no routine statistics on alcohol from ISD or (then) GRO 2002 -national alcohol plan published with accompanying statistics e.g. in 1990, alcohol-related deaths accounted for 1 in 100 deaths in Scotland. By 1999, this had risen to one in 40. -ISD funded to set up dedicated alcohol team 2005 -first Alcohol Statistics Scotland publication -alcohol information website

5. Alcohol-related mortality, Scotland 1982- 2011

6. Alcohol-related mortality by deprivation, Scotland [Source: ISD]

7. Chronic liver disease and cirrhosis mortality rates per 100,000 population, men and women 45-64 yrs, 1950- 2010 [Source: updated from Leon and McCambridge, Lancet, 2006]

8. Agenda Setting 2006 -Royal Colleges funded by then Scottish Executive to set up a public health advocacy group -secured assurance from the Health Minister that would be independent 2007 -SHAAP manifesto calls for stronger pricing policies -alcohol increasingly covered in the media

9. Agenda Setting Sept 2007 -expert workshop Dec 2007 -published report proposing MUP -underpinned by an extensive evidence base

10. The relationship between alcohol price, consumption and harm As the price of alcohol falls, consumption rises and so does harm A systematic review [Wagenaar 2009] of over 100 studies found a consistent relationship between alcohol, price and consumption The RAND Europe report [Rabinovich et al 2009] supports the direct link between price, consumption and harm Evidence from natural experiments in individual countries e.g. Switzerland and Finland

11. Consumption of alcohol in the UK (age 15+) relative to its price

12. Affordability of On and Off-Sales Alcohol: UK, 1987-2010 [Source:ONS]

13. Agenda Setting -crucial re-framing of policy with a public health paradigm, a ‘whole population approach’ (as opposed to ‘industry/often preferred government’ paradigm the problem is to target the ‘small’ minority of heavy drinkers) -paradoxically MUP will have an enhanced effect on the heaviest drinkers -SHAAP forms alliances with rest of UK and internationally

14. Potential Action 2007 -SNP win election (minority government) -political will to tackle alcohol problems -political champions -SHAAP advocates for MUP which is adopted as policy idea -proposal to introduce through amendments to Licensing Act -resistance from Parliament (minority government) 2008 -MUP moves to Health

15. Potential Action 2008 -consultation on alcohol strategy (including on MUP) -extensive evidence cited (nearly 100 references) -effect of price and reduction of population consumption reinforced by logic modelling from Health Scotland

16. Increased knowledge and changed attitudes to alcohol + drinking Reduced acceptability of hazardous drinking and drunkenness Reduced availability of alcohol Individuals in need receive timely, sensitive & appropriate support A culture in which low alcohol consumption is valued and accepted as the norm Less absenteeism + presenteeism the workplace. Less alcohol related incapacity Reduced alcohol related injuries, physical and psychological morbidity + mortality Fewer brain-damaged children Increased educational attainment Safer & happier families and communities Reduced health, social care, justice costs Healthier individuals and populations Intermediate outcomesLong term outcomes Children in need receive timely and appropriate support Safer drinking + wider environments Increased workplace productivity Less alcohol related violence/abuse, offences and ASB Less absenteeism + presenteeism in educational establishments Fewer children affected by parental drinking Reduction in Individual and population consumption Changed patterns of consumption Reduced affordability of alcohol National outcomes Reduce significant inequalities Model 2: Model 3: Model 4: Model 5: Model 6: Model 7:

17. Potential Action 2009 -national alcohol strategy launched -comprehensive strategy with a whole population approach -MUP one of 42 measures -Sheffield University commissioned to model MUP -purchase of alcohol sales data from Neilsen

18. Potential Action ‘A considerable body of evidence shows not only that alcohol policies and interventions targeted at vulnerable populations can prevent alcohol-related harm but that policies targeted at the population at large can have a protective effect on vulnerable populations and reduce the overall level of alcohol problems. Thus, both population-based strategies and interventions, and those targeting particular groups.. are indicated’ [WHO Evidence based strategies and interventions to reduce alcohol related harm 2007]

19. Litres of pure alcohol sold per capita (adults aged 16+) in Scotland and England & Wales, 1994-2011 [Source: Neilsen/CGA, Health Scotland] Source: Nielsen/CGA sales dataset (off-trade sales in 2011 adjusted to account for the loss of discount retailers).

20. Price distribution (%) of pure alcohol sold off-trade in Scotland, England and Wales 2010 [Source:Neilsen/CGA, NHS Health Scotland] 73%

21. Reduction in alcohol consumption by drinking group(%) [Source:Meng et al 2012]

22. MUP of 50p will… Reduce consumption by 5.7% In year 1: Reduce deaths by 60 1,600 fewer hospital admissions Around 3,500 fewer crimes per year A total value of harm reduction of £64 million By year 10 Over 300 fewer deaths annually 6,500 fewer hospital admissions A cumulative value of harm reduction of £942 million

23. Implementation of Agreed Action 2009 -Alcohol (etc) Scotland Bill introduced -evidence (and perceived ‘lack’ of it) at the heart of the debate -MUP opposed by all opposition parties so withdrawn 2011 -SNP returned with a majority (MUP in manifesto) in May -Lib Dems change position -Alcohol (Minimum Pricing) (Scotland) Bill introduced in Oct 2012 -Scottish Conservatives drop opposition in March -Bill passed in May

24. Implementation of Agreed Action 2012 -UK Gov announce intention to introduce MUP -SWA launch legal challenge in Scotland -EC notified of intention to set an MUP of 50p -’opinions’ lodged by Member States

25. Evaluation 2008 -Health Scotland lead on development of a portfolio of studies to evaluate the national strategy (including MUP) 2010 -first sales data published 2011 -MESAS first (baseline) report published 2012 -new studies being developed to evaluate MUP -first empirical evidence from Stockwell on effect of variant of MUP in Canada (effect very similar to Sheffield model)

26. Barriers for Evidence to Action -minority government -unpopular measure (nanny state/health ‘fascism’) -translating ‘science’ into policy messages -short time frame (not understood) -powerful industry -money not going to government -’regressive’ -legal challenges -multi-layer government (Scotland/UK/EC)

27. Enablers for Evidence to Action -extensive, sound evidence base -rising levels of harm -effective public health advocacy (including forming alliances) -long term differences in Licensing policy (public health objective in 2005 Licensing Act) -devolved government -change of government -political champion

28. Enablers for Evidence to Action -close links between government and public health -small civil service -interdepartmental working -split in the alcohol industry -growing support

29. Is Evidence Enough? -a ‘perfect storm’ where problems, policy and politics converge -re-framing, an ‘idea’ rather than just evidence -evidence at the heart of the debate (now literally ‘in the dock’) -to be continued….

30. Contact Dr Lesley Graham lesley.graham@nhs.net