How can agent-based modelling provide new insights into the impact of minimum unit pricing in Scotland?

In recent years we have gained insight into the impact of minimum unit pricing (MUP)-a legal floor price below which a given volume of alcohol cannot be sold-on population-level reductions in alcohol sales, consumption and harm. However, several questions remain unanswered including how individual-level purchasing changes impact the local economy (e.g., balance between on-licence and off-licence outlets), lead to long-term population-level trends (e.g., youth drinking) and social harms (e.g., violence). Agent-based modelling captures heterogeneity, emergence, feedback loops and adaptive and dynamic features, which provides an opportunity to understand the nuanced effects of MUP. Agent-based models (ABM) simulate heterogeneous agents (e.g., individuals, organisations) often situated in space and time that interact with other agents and/or with their environment, allowing us to identify the mechanisms underlying social phenomena. ABMs are particularly useful for theory development, and testing and simulating the impacts of policies and interventions. We illustrate how ABMs could be applied to generate novel insights and provide best estimates of social network effects, and changes in purchasing behaviour and social harms, due to the implementation of MUP. ABMs like other modelling approaches can simulate alternative implementations of MUP (e.g., policy intensity [£0.50, £0.60] or spatial scales [local, national]) but can also provide an understanding of the potential impact of MUP on different population groups (e.g., alcohol exposure of young people who are not yet drinking). Using ABMs to understand the impact of MUP would provide new insights to complement those from traditional epidemiological and other modelling methods.

Evaluating the influence of taxation and social security policies on psychological distress: A microsimulation study of the UK during the COVID-19 economic crisis.

Economic determinants are important for population health, but actionable evidence of how policies can utilise these pathways remains scarce. This study employs a microsimulation framework to evaluate the effects of taxation and social security policies on population mental health. The UK economic crisis caused by the COVID-19 pandemic provides an informative context involving an economic shock accompanied by one of the strongest discretionary fiscal responses amongst OECD countries. The analytical setup involves a dynamic, stochastic, discrete-time microsimulation model (SimPaths) projecting changes in psychological distress given predicted economic outcomes from a static tax-benefit microsimulation model (UKMOD) based on different policy scenarios. We contrast projections of psychological distress for the working-age population from 2017 to 2025 given the observed policy environment against a counterfactual scenario where pre-crisis policies remained in place. Levels of psychological distress and potential cases of common mental disorders (CMDs) were assessed with the 12-item General Health Questionnaire (GHQ-12). The UK policy response to the economic crisis is estimated to have prevented a substantial fall (over 12 percentage points, %pt) in the employment rate in 2020 and 2021. In 2020, projected psychological distress increased substantially (CMD prevalence increase >10%pt) under both the observed and the counterfactual policy scenarios. Through economic pathways, the policy response is estimated to have prevented a further 3.4%pt [95%UI 2.8%pt, 4.0%pt] increase in the prevalence of CMDs, approximately 1.2 million cases. Beyond 2021, as employment levels rapidly recovered, psychological distress returned to the pre-pandemic trend. Sustained preventative effects on poverty are estimated, with projected levels 2.1%pt [95%UI 1.8%pt, 2.5%pt] lower in 2025 than in the absence of the observed policy response. The study shows that policies protecting employment during an economic crisis are effective in preventing short-term mental health losses and have lasting effects on poverty levels. This preventative effect has substantial public health benefits.

Estimating quality-adjusted life expectancy (QALE) for local authorities in Great Britain and its association with indicators of the inclusive economy: a cross-sectional study.

OBJECTIVES: Quantifying area-level inequalities in population health can help to inform policy responses. We describe an approach for estimating quality-adjusted life expectancy (QALE), a comprehensive health expectancy measure, for local authorities (LAs) in Great Britain (GB). To identify potential factors accounting for LA-level QALE inequalities, we examined the association between inclusive economy indicators and QALE. SETTING: 361/363 LAs in GB (lower tier/district level) within the period 2018-2020. DATA AND METHODS: We estimated life tables for LAs using official statistics and utility scores from an area-level linkage of the Understanding Society survey. Using the Sullivan method, we estimated QALE at birth in years with corresponding 80% CIs. To examine the association between inclusive economy indicators and QALE, we used an open access data set operationalising the inclusive economy, created by the System Science in Public Health and Health Economics Research consortium. RESULTS: Population-weighted QALE estimates across LAs in GB were lowest in Scotland (females/males: 65.1 years/64.9 years) and Wales (65.0 years/65.2 years), while they were highest in England (67.5 years/67.6 years). The range across LAs for females was from 56.3 years (80% CI 45.6 to 67.1) in Mansfield to 77.7 years (80% CI 65.11 to 90.2) in Runnymede. QALE for males ranged from 57.5 years (80% CI 40.2 to 74.7) in Merthyr Tydfil to 77.2 years (80% CI 65.4 to 89.1) in Runnymede. Indicators of the inclusive economy accounted for more than half of the variation in QALE at the LA level (adjusted R2 females/males: 50%/57%). Although more inclusivity was generally associated with higher levels of QALE at the LA level, this association was not consistent across all 13 inclusive economy indicators. CONCLUSIONS: QALE can be estimated for LAs in GB, enabling further research into area-level health inequalities. The associations we identified between inclusive economy indicators and QALE highlight potential policy priorities for improving population health and reducing health inequalities.

Using the Doughnut Economics framework to structure whole-system thinking in socioecological wellbeing with multidisciplinary stakeholders: an applied case study in Glasgow, Scotland.

BACKGROUND: Human and environmental health are inseparable and interdependent. Doughnut Economics is a conceptual framework combining the Sustainable Development Goals with Planetary Boundaries, thereby simultaneously considering human and planetary wellbeing. The vision is to "meet the needs of all people within the means of the living planet, for the benefit of both current and future generations". Glasgow City Council has committed to becoming a Green Wellbeing Economy, with a socially just transition to Net Zero by 2030. Through our City-University partnership, we are exploring whether Doughnut Economics can drive transformative action towards a sustainable, healthy, and equitable future. METHODS: Glasgow is a pilot site for the C40 Cities' Thriving City Portrait methodology that downscales Doughnut Economics to cities. The Portrait process combined desk-based research and policy review (from January to April, 2022) with participatory workshops to enrich initial findings. The five participatory workshops took place between April, 2022, and February, 2023, and involved about 130 stakeholders. Participants included civil servants, politicians, scientists, community representatives, employees and representatives of private and third-sector organisations, and social enterprises, identified through an iterative stakeholder mapping process with City Council partners. Workshop aims were to create pluralistic definitions of what thriving means for each of the Doughnut's social and ecological dimensions. Ethics approval for the study was granted by The University of Glasgow, College of Medical Veterinary and Life Sciences. FINDINGS: The workshops produced a shared, holistic vision for Glasgow's future as a thriving city. The Doughnut demonstrated potential as a tool for both understanding the city's socioecological impacts, and as a compass by which the city might set its policy agenda. It allows the multiple goals and priorities of a city system to congregate around a cohesive goal. The Portrait process led to a widening of stakeholders' perspectives, applying systems thinking to policy priorities, cross-sector discussion and collaboration, and significant buy-in from a diverse range of changemakers. INTERPRETATION: The Doughnut framework offered a starting point for Public and Planetary Health researchers to understand connections, co-benefits and trade-offs across different parts of the policy and intervention system. Applying this framework in cities could generate support for whole-system interventions and sustainable solutions to the complex and interconnected climate and social challenges we face. One of the limitations is that we do not yet know whether stakeholders can translate support for this co-created framework into tangible whole-systems action. FUNDING: UKRI Natural Environment Research Council and University of Glasgow.

Systems science methods in public health: what can they contribute to our understanding of and response to the cost-of-living crisis?

BACKGROUND: Many complex public health evidence gaps cannot be fully resolved using only conventional public health methods. We aim to familiarise public health researchers with selected systems science methods that may contribute to a better understanding of complex phenomena and lead to more impactful interventions. As a case study, we choose the current cost-of-living crisis, which affects disposable income as a key structural determinant of health. METHODS: We first outline the potential role of systems science methods for public health research more generally, then provide an overview of the complexity of the cost-of-living crisis as a specific case study. We propose how four systems science methods (soft systems, microsimulation, agent-based and system dynamics models) could be applied to provide more in-depth understanding. For each method, we illustrate its unique knowledge contributions, and set out one or more options for studies that could help inform policy and practice responses. RESULTS: Due to its fundamental impact on the determinants of health, while limiting resources for population-level interventions, the cost-of-living crisis presents a complex public health challenge. When confronted with complexity, non-linearity, feedback loops and adaptation processes, systems methods allow a deeper understanding and forecasting of the interactions and spill-over effects common with real-world interventions and policies. CONCLUSIONS: Systems science methods provide a rich methodological toolbox that complements our traditional public health methods. This toolbox may be particularly useful in early stages of the current cost-of-living crisis: for understanding the situation, developing solutions and sandboxing potential responses to improve population health.

The public-private decision for alcohol retail systems: Examining the economic, health, and social impacts of alternative systems in Finland.

Background: Organising alcohol retail systems with more or less public ownership has implications for health and the economy. The aim of the present study was to estimate the economic, health, and social impacts of alcohol use in Finland in 2018 (baseline), and in two alternative scenarios in which current partial public ownership of alcohol retail sales is either increased or fully privatised. Methods: Baseline alcohol-attributable harms and costs were estimated across five categories of death, disability, and criminal justice. Two alternate alcohol retail systems were defined as privately owned stores selling: (1) only low strength alcoholic beverages (public ownership scenario, similar to Sweden); or (2) all beverages (private ownership scenario). Policy analyses were conducted to estimate changes in alcohol use per capita. Health and economic impacts were modelled using administrative data and epidemiological modelling. Results: In Finland in 2018, alcohol use was estimated to be responsible for €1.51 billion (95% Uncertainty Estimates: €1.43 billion, €1.58 billion) in social cost, 3,846 deaths, and 270,652 criminal justice events. In the public ownership scenario, it was estimated that alcohol use would decline by 15.8% (11.8%, 19.7%) and social cost by €384.3 million (€189.5 million, €559.2 million). Full privatisation was associated with an increase in alcohol use of 9.0% (6.2%, 11.8%) and an increase in social cost of €289.7 million (€140.8 million, €439.5 million). Conclusion: The outcome from applying a novel analytical approach suggests that more public ownership of the alcohol retail system may lead to significant decreases in alcohol-caused death, disability, crime, and social costs. Conversely, full privatisation of the ownership model would lead to increased harm and costs.

The public health implications of the cost-of-living crisis: outlining mechanisms and modelling consequences.

The UK, and other high-income countries, are experiencing substantial increases in living costs. Several overlapping and intersecting economic crises threaten physical and mental health in the immediate and longer term. Policy responses may buffer against the worst effects (e.g. welfare support) or further undermine health (e.g. austerity). We explore fundamental causes underpinning the cost-of-living crisis, examine potential pathways by which the crisis could impact population health and use a case study to model potential impacts of one aspect of the crisis on a specific health outcome. Our modelling illustrates how policy approaches can substantially protect health and avoid exacerbating health inequalities. Targeting support at vulnerable households is likely to protect health most effectively. The current crisis is likely to be the first of many in era of political and climate uncertainty. More refined integrated economic and health modelling has the potential to inform policy integration, or 'health in all policies'.

Guidance on the use of complex systems models for economic evaluations of public health interventions.

To help health economic modelers respond to demands for greater use of complex systems models in public health. To propose identifiable features of such models and support researchers to plan public health modeling projects using these models. A working group of experts in complex systems modeling and economic evaluation was brought together to develop and jointly write guidance for the use of complex systems models for health economic analysis. The content of workshops was informed by a scoping review. A public health complex systems model for economic evaluation is defined as a quantitative, dynamic, non-linear model that incorporates feedback and interactions among model elements, in order to capture emergent outcomes and estimate health, economic and potentially other consequences to inform public policies. The guidance covers: when complex systems modeling is needed; principles for designing a complex systems model; and how to choose an appropriate modeling technique. This paper provides a definition to identify and characterize complex systems models for economic evaluations and proposes guidance on key aspects of the process for health economics analysis. This document will support the development of complex systems models, with impact on public health systems policy and decision making.

Effective alcohol policies are associated with reduced consumption among demographic groups who drink heavily.

BACKGROUND: Alcohol policies stand out among other noncommunicable disease-relevant policies for the lack of uptake. Composite indicators have been developed to measure the effects of alcohol control policy. We investigated whether drinking patterns among demographic groups from general population samples of drinkers from diverse countries are associated with alcohol control policy as measured by the International Alcohol Control (IAC) Policy Index. METHODS: Representative samples of adult drinkers from 10 countries (five high-income and five middle-income) were surveyed about alcohol consumption, using beverage and location-specific questions. MEASUREMENTS: The IAC Policy Index was analyzed with frequency, typical occasion quantity, and volume consumed. Analyses used mixed models that included interactions between country IAC Policy Index score and age group, gender, and education level. FINDINGS: Each increase in IAC policy index score (reflecting more effective alcohol policy) was associated with a 13.9% decrease in drinking frequency (p = 0.006) and a 16.5% decrease in volume (p = 0.001). With each increase in IAC Policy Index score, both genders decreased for all three measures, but men less so than women. Women decreased their typical occasion quantity by 1.2% (p = 0.006), frequency by 3.1% (p < 0.001), and total volume by 4.2% (p < 0.001) compared to men. Low and mid-education groups decreased their typical occasion quantity by 2.6% (p < 0.001) and 1.6% (p = 0.001), respectively, compared to high education, while for drinking frequency the low education group increased by 7.0% (p < 0.001). There was an overall effect of age (F = 19.27, p < 0.0001), with 18-19 and 20-24-year-olds showing the largest decreases in typical occasion quantity with increasing IAC policy index score. CONCLUSIONS: The IAC Policy Index, reflecting four effective policies, was associated with volume and frequency of drinking across 10 diverse countries. Each increase in the IAC Policy Index was associated with lower typical quantities consumed among groups reporting heavy drinking: young adults and less well-educated. There is value in implementing such alcohol policies and a need to accelerate their uptake globally.

Effective alcohol policies and lifetime abstinence: An analysis of the International Alcohol Control policy index.

INTRODUCTION: Alcohol abstinence remains common among adults globally, although low and middle-income countries are experiencing declines in abstention. The effect of alcohol policies on lifetime abstinence is poorly understood. The International Alcohol Control (IAC) policy index was developed to benchmark and monitor the uptake of effective alcohol policies and has shown strong associations with alcohol per capita consumption and drinking patterns. Uniquely, the index incorporates both policy 'stringency' and 'impact', reflecting policy implementation and enforcement, across effective policies. Here we assessed the association of the IAC policy index with lifetime abstinence in a diverse sample of jurisdictions. METHODS: We conducted a cross-sectional analysis of the relationship between the IAC policy index score, and its components, and lifetime abstinence among adults (15+ years) in 13 high and middle-income jurisdictions. We examined the correlations for each component of the index and stringency and impact separately. RESULTS: Overall, the total IAC policy index scores were positively correlated with lifetime abstinence (r = 0.76), as were both the stringency (r = 0.62) and impact (r = 0.82) scores. Marketing restrictions showed higher correlations with lifetime abstinence than other policy domains (r = 0.80), including restrictions on physical availability, pricing policies and drink-driving prevention. DISCUSSION AND CONCLUSION: Our findings suggest that restricting alcohol marketing could be an important policy for the protection of alcohol abstention. The IAC policy index may be a useful tool to benchmark the performance of alcohol policy in supporting alcohol abstention in high and middle-income countries.

Effectiveness of subnational implementation of minimum unit price for alcohol: policy appraisal modelling for local authorities in England.

AIMS: Evidence exists on the potential impact of national level minimum unit price (MUP) policies for alcohol. This study investigated the potential effectiveness of implementing MUP at regional and local levels compared with national implementation. DESIGN: Evidence synthesis and computer modelling using the Sheffield Alcohol Policy Model (Local Authority version 4.0; SAPMLA). SETTING: Results are produced for 23 Upper Tier Local Authorities (UTLAs) in North West England, 12 UTLAs in North East England, 15 UTLAs in Yorkshire and Humber, the nine English Government Office regions and England as a whole. CASES: Health Survey for England (HSE) data 2011-13 (n = 24 685). MEASUREMENTS: Alcohol consumption, consumer spending, retailers' revenues, hospitalizations, National Health Service costs, crimes and alcohol-attributable deaths and health inequalities. FINDINGS: Implementing a local £0.50 MUP for alcohol in northern English regions is estimated to result in larger percentage reductions in harms than the national average. The reductions for England, North West, North East and Yorkshire and Humber regions, respectively, in annual alcohol-attributable deaths are 1024 (-10.4%), 205 (-11.4%), 121 (-17.4%) and 159 (-16.9%); for hospitalizations are 29 943 (-4.6%), 5956 (-5.5%), 3255 (-7.9%) and 4610 (-6.9%); and for crimes are 54 229 (-2.4%), 8528 (-2.5%), 4380 (-3.5%) and 8220 (-3.2%). Results vary among local authorities; for example, annual alcohol-attributable deaths estimated to change by between -8.0 and -24.8% throughout the 50 UTLAs examined. CONCLUSIONS: A minimum unit price local policy for alcohol is likely to be more effective in those regions, such as the three northern regions of England, which have higher levels of alcohol consumption and higher rates of alcohol harm than for the national average. In such regions, the minimum unit price policy would achieve larger reductions in alcohol consumption, alcohol-attributable mortality, hospitalization rates, NHS costs, crime rates and health inequalities.

Agent-Based Modelling of Health Inequalities following the Complexity Turn in Public Health: A Systematic Review.

There is an increasing focus on the role of complexity in public health and public policy fields which has brought about a methodological shift towards computational approaches. This includes agent-based modelling (ABM), a method used to simulate individuals, their behaviour and interactions with each other, and their social and physical environment. This paper aims to systematically review the use of ABM to simulate the generation or persistence of health inequalities. PubMed, Scopus, and Web of Science (1 January 2013-15 November 2022) were searched, supplemented with manual reference list searching. Twenty studies were included; fourteen of them described models of health behaviours, most commonly relating to diet (n = 7). Six models explored health outcomes, e.g., morbidity, mortality, and depression. All of the included models involved heterogeneous agents and were dynamic, with agents making decisions, growing older, and/or becoming exposed to different health risks. Eighteen models represented physical space and in eleven models, agents interacted with other agents through social networks. ABM is increasingly contributing to our understanding of the socioeconomic inequalities in health. However, to date, the majority of these models focus on the differences in health behaviours. Future research should attempt to investigate the social and economic drivers of health inequalities using ABM.

Economics for people and planet-moving beyond the neoclassical paradigm.

Despite substantial attention within the fields of public and planetary health on developing an economic system that benefits both people's health and the environment, heterodox economic schools of thought have received little attention within these fields. Ecological economics is a school of thought with particular relevance to public and planetary health. In this article, we discuss implications of key ecological economics ideas for public and planetary health, especially those related to critiques of gross domestic product as a measure of progress and economic growth as the dominant goal for economic and policy decision making. We suggest that ecological economics aligns well with public health goals, including concern for equality and redistribution. Ecological economics offers an opportunity to make the transition to an economic system that is designed to promote human and planetary health from the outset, rather than one where social and environmental externalities must be constantly corrected after the fact. Important ideas from ecological economics include the use of a multidimensional framework to evaluate economic and social performance, the prioritisation of wellbeing and environmental goals in decision making, policy design and evaluation that take complex relationships into account, and the role of provisioning systems (the physical and social systems that link resource use and social outcomes). We discuss possible interventions at the national scale that could promote public health and that align with the prioritisation of social and ecological objectives, including universal basic income or services and sovereign money creation. Overall, we lay the foundations for additional integration of ecological economics principles and pluralist economic thinking into public and planetary health scholarship and practice.

Governance of Intersectoral Collaborations for Population Health and to Reduce Health Inequalities in High-Income Countries: A Complexity-Informed Systematic Review.

BACKGROUND: A 'Health in All Policies' (HiAP) approach has been widely advocated as a way to involve multiple government sectors in addressing health inequalities, but implementation attempts have not always produced the expected results. Explaining how HiAP-style collaborations have been governed may offer insights into how to improve population health and reduce health inequalities. METHODS: Theoretically focused systematic review. Synthesis of evidence from evaluative studies into a causal logic model. RESULTS: Thirty-one publications based on 40 case studies from nine high-income countries were included. Intersectoral collaborations for population health and equity were multi-component and multi-dimensional with collaborative activity spanning policy, strategy, service design and service delivery. Governance of intersectoral collaboration included structural and relational components. Both internal and external legitimacy and credibility delivered collaborative power, which in turn enabled intersectoral collaboration. Internal legitimacy was driven by multiple structural elements and processes. Many of these were instrumental in developing (often-fragile) relational trust. Internal credibility was supported by multi-level collaborations that were adequately resourced and shared power. External legitimacy and credibility was created through meaningful community engagement, leadership that championed collaborations and the identification of 'win-win' strategies. External factors such as economic shocks and short political cycles reduced collaborative power. CONCLUSION: This novel review, using systems thinking and causal loop representations, offers insights into how collaborations can generate internal and external legitimacy and credibility. This offers promise for future collaborative activity for population health and equity; it presents a clearer picture of what structural and relational components and dynamics collaborative partners can focus on when planning and implementing HiAP initiatives. The limits of the literature base, however, does not make it possible to identify if or how this might deliver improved population health or health equity.

Equity impact of minimum unit pricing of alcohol on household health and finances among rich and poor drinkers in South Africa.

INTRODUCTION: South Africa experiences significant levels of alcohol-related harm. Recent research suggests minimum unit pricing (MUP) for alcohol would be an effective policy, but high levels of income inequality raise concerns about equity impacts. This paper quantifies the equity impact of MUP on household health and finances in rich and poor drinkers in South Africa. METHODS: We draw from extended cost-effectiveness analysis (ECEA) methods and an epidemiological policy appraisal model of MUP for South Africa to simulate the equity impact of a ZAR 10 MUP over a 20-year time horizon. We estimate the impact across wealth quintiles on: (i) alcohol consumption and expenditures; (ii) mortality; (iii) government healthcare cost savings; (iv) reductions in cases of catastrophic health expenditures (CHE) and household savings linked to reduced health-related workplace absence. RESULTS: We estimate MUP would reduce consumption more among the poorest than the richest drinkers. Expenditure would increase by ZAR 353 000 million (1 US$=13.2 ZAR), the poorest contributing 13% and the richest 28% of the increase, although this remains regressive compared with mean income. Of the 22 600 deaths averted, 56% accrue to the bottom two quintiles; government healthcare cost savings would be substantial (ZAR 3.9 billion). Cases of CHE averted would be 564 700, 46% among the poorest two quintiles. Indirect cost savings amount to ZAR 51.1 billion. CONCLUSIONS: A MUP policy in South Africa has the potential to reduce harm and health inequality. Fiscal policies for population health require structured policy appraisal, accounting for the totality of effects using mathematical models in association with ECEA methodology.

A synthetic population dataset for estimating small area health and socio-economic outcomes in Great Britain.

In order to understand the health outcomes for distinct sub-groups of the population or across different geographies, it is advantageous to be able to build bespoke groupings from individual level data. Individuals possess distinct characteristics, exhibit distinct behaviours and accumulate their own unique history of exposure or experiences. However, in most disciplines, not least public health, there is a lack of individual level data available outside of secure settings, especially covering large portions of the population. This paper provides detail on the creation of a synthetic micro dataset for individuals in Great Britain who have detailed attributes which can be used to model a wide range of health and other outcomes. These attributes are constructed from a range of sources including the United Kingdom Census, survey and administrative datasets. It provides a rationale for the need for this synthetic population, discusses methods for creating this dataset and provides some example results of different attribute distributions for distinct sub-population groups and over different geographical areas.

Causal mechanisms proposed for the alcohol harm paradox-a systematic review.

BACKGROUND AND AIMS: The alcohol harm paradox (AHP) posits that disadvantaged groups suffer from higher rates of alcohol-related harm compared with advantaged groups, despite reporting similar or lower levels of consumption on average. The causes of this relationship remain unclear. This study aimed to identify explanations proposed for the AHP. Secondary aims were to review the existing evidence for those explanations and investigate whether authors linked explanations to one another. METHODS: This was a systematic review. We searched MEDLINE (1946-January 2021), EMBASE (1974-January 2021) and PsycINFO (1967-January 2021), supplemented with manual searching of grey literature. Included papers either explored the causes of the AHP or investigated the relationship between alcohol consumption, alcohol-related harm and socio-economic position. Papers were set in Organization for Economic Cooperation and Development high-income countries. Explanations extracted for analysis could be evidenced in the empirical results or suggested by researchers in their narrative. Inductive thematic analysis was applied to group explanations. RESULTS: Seventy-nine papers met the inclusion criteria and initial coding revealed that these papers contained 41 distinct explanations for the AHP. Following inductive thematic analysis, these explanations were grouped into 16 themes within six broad domains: individual, life-style, contextual, disadvantage, upstream and artefactual. Explanations related to risk behaviours, which fitted within the life-style domain, were the most frequently proposed (n = 51) and analysed (n = 21). CONCLUSIONS: While there are many potential explanations for the alcohol harm paradox, most research focuses on risk behaviours while other explanations lack empirical testing.

Is disinvestment from alcohol and drug treatment services associated with treatment access, completions and related harm? An analysis of English expenditure and outcomes data.

INTRODUCTION: The positive impact of substance use treatment is well-evidenced but there has been substantial disinvestment from publicly funded treatment services in England since 2013/2014. This paper examines whether this disinvestment from adult alcohol and drug treatment provision was associated with changes in treatment and health outcomes, including: treatment access, successful completions from treatment, alcohol-specific hospital admissions, alcohol-specific mortality and drug-related deaths. METHODS: Annual administrative data from 2013/2014 to 2018/2019 was matched at local government level and multi-level time series analysis using linear mixed-effect modelling conducted for 151 upper-tier local authorities in England. RESULTS: Between 2013/2014 and 2018/2019, £212.2 million was disinvested from alcohol and drug treatment services, representing a 27% decrease. Concurrently, 11% fewer people accessed, and 21% fewer successfully completed, treatment. On average, controlling for other potential explanatory factors, a £10 000 disinvestment from alcohol and drug treatment services was associated with reductions in all treatment outcomes, including 0.3 fewer adults in treatment (95% confidence interval 0.16-0.45) and 0.21 fewer adults successfully completing treatment (95% % confidence interval 0.12-0.29). A £10 000 disinvestment from alcohol treatment was not significantly associated with changes in alcohol-specific hospital admissions or mortality, nor was disinvestment from drug treatment associated with the rate of drug-related deaths. DISCUSSION AND CONCLUSIONS: Local authority spending cuts to alcohol and drug treatment services in England were associated with fewer people accessing and successfully completing alcohol and drug treatment but were not associated with changes in related hospital admissions and deaths.

Effects of minimum unit pricing for alcohol in South Africa across different drinker groups and wealth quintiles: a modelling study.

OBJECTIVES: To quantify the potential impact of minimum unit pricing (MUP) for alcohol on alcohol consumption, spending and health in South Africa. We provide these estimates disaggregated by different drinker groups and wealth quintiles. DESIGN: We developed an epidemiological policy appraisal model to estimate the effects of MUP across sex, drinker groups (moderate, occasional binge, heavy) and wealth quintiles. Stakeholder interviews and workshops informed model development and ensured policy relevance. SETTING: South African drinking population aged 15+. PARTICIPANTS: The population (aged 15+) of South Africa in 2018 stratified by drinking group and wealth quintiles, with a model time horizon of 20 years. MAIN OUTCOME MEASURES: Change in standard drinks (SDs) (12 g of ethanol) consumed, weekly spend on alcohol, annual number of cases and deaths for five alcohol-related health conditions (HIV, intentional injury, road injury, liver cirrhosis and breast cancer), reported by drinker groups and wealth quintile. RESULTS: We estimate an MUP of R10 per SD would lead to an immediate reduction in consumption of 4.40% (-0.93 SD/week) and an increase in spend of 18.09%. The absolute reduction is greatest for heavy drinkers (-1.48 SD/week), followed by occasional binge drinkers (-0.41 SD/week) and moderate drinkers (-0.40 SD/week). Over 20 years, we estimate 20 585 fewer deaths and 9 00 332 cases averted across the five health-modelled harms.Poorer drinkers would see greater impacts from the policy (consumption: -7.75% in the poorest quintile, -3.19% in richest quintile). Among the heavy drinkers, 85% of the cases averted and 86% of the lives saved accrue to the bottom three wealth quintiles. CONCLUSIONS: We estimate that MUP would reduce alcohol consumption in South Africa, improving health outcomes while raising retail and tax revenue. Consumption and harm reductions would be greater in poorer groups.

Combinations of Drinking Occasion Characteristics Associated with Units of Alcohol Consumed among British Adults: An Event-Level Decision Tree Modeling Study.

BACKGROUND: Alcohol consumption is influenced by the characteristics of drinking occasions, for example, location, timing, or the composition of the drinking group. However, the relative importance of occasion characteristics is not yet well understood. This study aims to identify which characteristics, and combinations of characteristics, are associated with units consumed within drinking occasions. It also tests whether accounting for occasion characteristics improves the prediction of consumption compared to using demographic information only. METHODS: The data come from a cross-sectional, nationally representative, online market research survey. Our sample includes 18,409 British drinkers aged 18 + who recorded the characteristics of 46,072 drinking occasions using 7-day retrospective drinking diaries in 2018. We used decision tree modeling and nested linear regression to predict units consumed in occasions using information on drinking location/venue, occasion timing, company, occasion type (e.g., a quiet night in), occasion motivation, drink type and packaging, food eaten and entertainment/ other activities during the occasion. We estimated models separately for 6 age-sex groups and controlled for usual drinking frequency, and social grade in nested linear regression models. Open Science Framework preregistration: https://osf.io/42epd. RESULTS: Our 6 final models accounted for between 55% and 71% of the variance in drinking occasion alcohol consumption. Beyond demographic characteristics (1 to 9%) and occasion duration (24 to 60%), further occasion characteristics and combinations of characteristics accounted for 31 to 70% of the total explained variance. The characteristics most strongly associated with heavy alcohol consumption were long occasion duration, drinking spirits as doubles, and drinking wine. Spirits were also consumed in light occasions, but as singles. This suggests that the serving size is an important differentiator of light and heavy occasions. CONCLUSIONS: Combinations of occasion duration and drink type are strongly predictive of alcohol consumption in adults' drinking occasions. Accounting for characteristics of drinking occasions, both individually and in combination, substantially improves the prediction of alcohol consumption.