The use of Reflectance Confocal Microscopy to diagnose Malignant Melanoma and Lentigo Maligna in the United Kingdom: A Prospective Observational Trial at a Single Centre.

BACKGROUND: Previous work with Reflectance Confocal Microscopy (RCM) imaging has shown high sensitivity and specificity for Malignant Melanoma (MM), but to date there have been no studies on a UK cohort. OBJECTIVES: The study hypothesised that RCM could be used prospectively to accurately diagnose MM and lentigo maligna (LM) in a private UK secondary care, single clinician setting. The study assessed the potential for RCM to be used as a routine screening procedure. METHODS: 597 patients were recruited consecutively where MM or LM featured in the differential diagnosis after clinical examination. A sequential record was made of the clinical, dermoscopic, and RCM findings by a single dermatologist [HS] prior to biopsy. Imaging used the arm-mounted confocal microscope unless access was restricted and required the handheld probe. The likelihood of MM was scored for each modality, each diagnosis building on the last. Histology was assessed by a single blinded histopathologist [JJ]. RESULTS: 734 lesions were included in the analysis, including 86 MM and LM with a median diameter of 7.0 mm. The benign to malignant ratio was 3 to 1 (non-melanocytic malignancies included) and 8.3 to 1 for MM and LM only. The sensitivity and specificity for MM and LM was 62.8% (95% CI 51.70% to 72.98%) and 63.2% (59.27% to 66.84%) for clinical examination; 91.9% (83.95% to 96.66%) and 42.1% (38.14% to 45.88%) for dermoscopy; 94.2% (86.95% to 98.09%) and 83.2% (79.91% to 85.84%) for RCM. For RCM, PPV was 42.4% (38.13% to 46.81%) and NPV was 99.1% (97.87% to 99.60%). CONCLUSION: This study demonstrates that RCM can reliably diagnose MM and is fast enough to be integrated into UK pigmented lesion clinics by dermatologists trained in RCM. "Number needed to treat" dropped from 3.9 with clinical examination to 3.0 with dermoscopy to 1.3 with RCM.

The use of Reflectance Confocal Microscopy to diagnose Basal Cell Carcinoma in the United Kingdom: A Prospective Observational Trial at a Single Centre.

BACKGROUND: Previous work with Reflectance Confocal Microscopy (RCM) imaging has shown high sensitivity and specificity for Basal Cell Carcinoma (BCC), but to date there have been few studies on a UK cohort. OBJECTIVES: The study hypothesised that RCM could be used prospectively to accurately diagnose BCC in a private UK secondary care, single clinician setting. The study assessed the potential for RCM to be used as a routine diagnostic procedure. METHODS: 522 lesions were recruited prospectively where BCC featured in the differential diagnosis after clinical examination. 78 were subsequently excluded. Imaging used the arm-mounted confocal microscope unless access was restricted and required the handheld probe. The likelihood of BCC was scored for each modality, each diagnosis building on the last. Histology was assessed by a single blinded histopathologist [JJ]. RESULTS: 444 lesions from 326 patients were included in the analysis, including 327 BCCs. Median maximum diameter was 6 mm. The sensitivity and specificity for BCC was 69.42% (64.11% to 74.37%) and 52.99% (43.55% to 62.28%) for clinical examination alone; 91.77% (88.25% to 94.51%) and 41.03% (32.02% to 50.50%) plus dermoscopy; 98.78% (96.91% to 99.67%) and 85.47% (77.76% to 91.30%) plus RCM. For RCM PPV was 95.01% (92.14% to 97.07%) and NPV was 96.15% (90.44% to 98.94%). Area under the curve increased from 0.61 to 0.66 to 0.92 as modalities were added. CONCLUSION: This study demonstrates that RCM can, reliably and quickly, diagnose BCC, and that the addition of RCM to dermoscopy permits higher diagnostic accuracy for BCC in the UK. The specificity and sensitivity of the RCM diagnosis did not alter significantly with experience, reflecting the ease and speed of acquiring the skill. CLINICAL TRIAL REGISTRATION: NCT03509415.

Geographical differences in the financial impacts of different forms of tobacco licence fees on small retailers in Scotland.

OBJECTIVE: Retailer licencing fees are a promising avenue to regulate tobacco availability. However, they face strong opposition from retailers and the tobacco industry, who argue significant financial impacts. This study compares the impacts of different forms of tobacco licence schemes on retailers' profits in Scotland. METHODS: We calculated gross profits from tobacco sales in 179 convenience stores across Scotland using 1 099 697 electronic point-of-sale records from 16 weeks between 2019 and 2022. We estimated different fees using universal, volumetric and separate urban/rural schemes. We identified the point at which 50% of retailers would no longer make a gross profit on tobacco sales for each scheme and modelled the financial impact of 10 incremental fee levels. The financial impact was assessed based on changes in retailers' tobacco gross profits. Differences by neighbourhood deprivation and urban/rural status were examined. RESULTS: The gross profit from tobacco per convenience store averaged £15 859/year. Profits were 2.29 times higher in urban (vs rural) areas and 1.59 times higher in high-deprivation (vs low-deprivation) areas, attributable to higher sales volumes. Tobacco gross profit decreased proportionally with increasing fee levels. Universal and urban/rural fees had greater gross profit reductions in rural and/or less deprived areas, where profits were lower, compared with volumetric fees. CONCLUSION: The introduction of tobacco licence fees offers a potential opportunity for reducing the availability of tobacco retailers. The likely impact of a tobacco licence fee is sensitive to the type of licence scheme implemented, the level at which fees are set and the retailers' location in relation to neighbourhood deprivation and rurality.

Modelling the longer-term health and health inequality impacts of changes in alcohol consumption during the COVID-19 pandemic in England.

BACKGROUND: Alcohol consumption changed substantially during the COVID-19 pandemic for many people. This study quantified how these changes in drinking varied across the population and their potential longer-term impact on health and health inequalities. METHODS: We analyzed data from the Alcohol Toolkit Study to estimate how alcohol consumption changed during the pandemic (April 2020-November 2021) and how these changes varied with age, sex, drinking level and socioeconomic position. We combined these estimates with a range of alternative scenarios of future alcohol consumption and used the Sheffield Alcohol Policy Model to assess the long-term health and health inequality impacts of these changes. RESULTS: Alcohol consumption in 2020-21 increased in heavier drinkers but fell in moderate drinkers. If alcohol consumption returns to pre-pandemic levels in 2022, we estimate a total of 42 677 additional hospital admissions and 1830 deaths over 20 years because of these changes. If consumption remains at 2021 levels in the long-term these figures rise to 355 832 and 12 849, respectively. In all scenarios, the biggest increase in harm occurs in the most deprived 20% of the population. CONCLUSIONS: Pandemic-era changes in alcohol consumption are likely to have a significant negative impact on public health and health inequalities, even under optimistic assumptions about future drinking.

Brief interventions for smoking and alcohol associated with the COVID-19 pandemic: a population survey in England.

BACKGROUND: Following the onset of the COVID-19 pandemic, in March 2020 health care delivery underwent considerable changes. It is unclear how this may have affected the delivery of Brief Interventions (BIs) for smoking and alcohol. We examined the impact of the COVID-19 pandemic on the receipt of BIs for smoking and alcohol in primary care in England and whether certain priority groups (e.g., less advantaged socioeconomic positions, or a history of a mental health condition) were differentially affected. METHODS: We used nationally representative data from a monthly cross-sectional survey in England between 03/2014 and 06/2022. Monthly trends in the receipt of BIs for smoking and alcohol were examined using generalised additive models among adults who smoked in the past-year (weighted N = 31,390) and those using alcohol at increasing and higher risk levels (AUDIT score 38, weighted N = 22,386), respectively. Interactions were tested between social grade and the change in slope after the onset of the COVID-19 pandemic, and results reported stratified by social grade. Further logistic regression models assessed whether changes in the of receipt of BIs for smoking and alcohol, respectively, from 12/2016 to 01/2017 and 10/2020 to 06/2022 (or 03/2022 in the case of BIs for alcohol), depended on history of a mental health condition. RESULTS: The receipt of smoking BIs declined from an average prevalence of 31.8% (95%CI 29.4-35.0) pre-March 2020 to 24.4% (95%CI 23.5-25.4) post-March 2020. The best-fitting model found that after March 2020 there was a 12-month decline before stabilising by June 2022 in social grade ABC1 at a lower level (~ 20%) and rebounding among social grade C2DE (~ 27%). Receipt of BIs for alcohol was low (overall: 4.1%, 95%CI 3.9-4.4) and the prevalence was similar pre- and post-March 2020. CONCLUSIONS: The receipt of BIs for smoking declined following March 2020 but rebounded among priority socioeconomic groups of people who smoked. BIs for alcohol among those who use alcohol at increasing and higher risk levels were low and there was no appreciable change over time. Maintaining higher BI delivery among socioeconomic and mental health priority groups of smokers and increasing and higher risk alcohol users is important to support reductions in smoking and alcohol related inequalities.

Evaluating the Acceptability of the Drink Less App and the National Health Service Alcohol Advice Web Page: Qualitative Interview Process Evaluation.

BACKGROUND: The extent to which interventions are perceived as acceptable to users impacts engagement and efficacy. OBJECTIVE: In this study, we evaluated the acceptability of (1) the smartphone app Drink Less (intervention) and (2) the National Health Service (NHS) alcohol advice web page (usual digital care and comparator) among adult drinkers in the United Kingdom participating in a randomized controlled trial evaluating the effectiveness of the Drink Less app. METHODS: A subsample of 26 increasing- and higher-risk drinkers (Alcohol Use Disorders Identification Test score≥8) assigned to the intervention group (Drink Less; n=14, 54%; female: n=10, 71%; age: 22-72 years; White: n=9, 64%) or usual digital care group (NHS alcohol advice web page; n=12, 46%; female: n=5, 42%; age: 23-68 years: White: n=9, 75%) took part in semistructured interviews. The interview questions were mapped on to the 7 facets of acceptability according to the Theoretical Framework of Acceptability: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy. Alongside these constructs, we also included a question on perceived personal relevance, which previous research has linked to acceptability and engagement. Framework and thematic analysis of data was undertaken. RESULTS: The Drink Less app was perceived as being ethical, easy, user-friendly, and effective for the period the app was used. Participants reported particularly liking the tracking and feedback sections of the app, which they reported increased personal relevance and which resulted in positive affect when achieving their goals. They reported no opportunity cost. Factors such as negative affect when not meeting goals and boredom led to disengagement in the longer term for some participants. The NHS alcohol advice web page was rated as being easy and user-friendly with no opportunity costs. However, the information presented was not perceived as being personally relevant or effective in changing drinking behavior. Most participants reported neutral or negative affect, most participants thought the alcohol advice web page was accessible, and some participants reported ethical concerns around the availability of suggested resources. Some participants reported that it had acted as a starting point or a signpost to other resources. Participants in both groups discussed motivation to change and contextual factors such as COVID-19 lockdowns, which influenced their perceived self-efficacy regardless of their assigned intervention. CONCLUSIONS: Drink Less appears to be an acceptable digital intervention among the recruited sample. The NHS alcohol advice web page was generally considered unacceptable as a stand-alone intervention among the recruited sample, although it may signpost and help people access other resources and interventions.

The clustering of physical health conditions and associations with co-occurring mental health problems and problematic alcohol use: a cross-sectional study.

BACKGROUND: There is strong evidence for the co-occurrence of mental health conditions and alcohol problems, yet physical health outcomes among this group are not well characterised. This study aimed to identify clusters of physical health conditions and their associations with mental health and problematic alcohol use in England's general population. METHODS: Cross-sectional analysis of the 2014 Adult Psychiatric Morbidity Survey (N = 7546) was conducted. The survey used standardised measures of problematic alcohol use and mental health conditions, including the Alcohol Use Disorders Identification Test (AUDIT) and the Clinical Interview Schedule-Revised. Participants self-reported any lifetime physical health conditions. Latent class analysis considered 12 common physical illnesses to identify clusters of multimorbidity. Multinomial logistic regression (adjusting for age, gender, ethnicity, education, and occupational grade) was used to explore associations between mental health, hazardous drinking (AUDIT 8 +), and co-occurring physical illnesses. RESULTS: Five clusters were identified with statistically distinct and clinically meaningful disease patterns: 'Physically Healthy' (76.62%), 'Emerging Multimorbidity' (3.12%), 'Hypertension & Arthritis' (14.28%), 'Digestive & Bowel Problems'' (3.17%), and 'Complex Multimorbidity' (2.8%). Having a mental health problem was associated with increased odds of 'Digestive & Bowel Problems' (adjusted multinomial odds ratio (AMOR) = 1.58; 95% CI [1.15-2.17]) and 'Complex Multimorbidity' (AMOR = 2.02; 95% CI [1.49-2.74]). Individuals with co-occurring mental health conditions and problematic alcohol use also had higher odds of 'Digestive & Bowel Problems' (AMOR = 2.64; 95% CI [1.68-4.15]) and 'Complex Multimorbidity' (AMOR = 2.62; 95% CI [1.61-4.23]). CONCLUSIONS: Individuals with a mental health condition concurrent with problematic alcohol use experience a greater burden of physical illnesses, highlighting the need for timely treatment which is likely to include better integration of alcohol and mental health services.

Quantile regression of tobacco tax pass-through in the UK 2013-2019. How have manufacturers passed through tax changes for different tobacco products?

BACKGROUND: The effectiveness of tax increases relies heavily on the tobacco industry passing on such increases to smokers (also referred to as 'pass-through'). Previous research has found heterogeneous levels of tax pass-through across the market segments of tobacco products available to smokers. This study uses retail sales data to assess the extent to which recent tax changes have been passed on to smokers and whether this varies across the price distribution. METHODS: We use panel data quantile regression analysis on Nielsen commercial data of tobacco price and sales in the UK from January 2013 to March 2019 combined with official UK tax rates and inflation to calculate the rate of tax pass-through for factory made (FM) cigarettes and roll your own (RYO) tobacco. RESULTS: Following increases in the specific tax payable on tobacco, we find evidence of overshifting across the price distribution for both FM and RYO. The rate of the overshift in tax increased the more expensive the products were. This was consistent for FM and RYO. Additionally, our findings suggest that the introduction of standardised packaging was not followed by changes in how the tobacco industry responded to tax increases. CONCLUSIONS: Following the repeated introduction of increases in specific tobacco tax as well as standardised packaging, we show that the tobacco industry applies techniques to keep the cheapest tobacco cheaper relative to the more expensive products when passing on tax increases to smokers.

Reweighting national survey data for small area behaviour estimates: modelling alcohol consumption in Local Authorities in England.

BACKGROUND: There are likely to be differences in alcohol consumption levels and patterns across local areas within a country, yet survey data is often collected at the national or sub-national/regional level and is not representative for small geographic areas. METHODS: This paper presents a method for reweighting national survey data-the Health Survey for England-by combining survey and routine data to produce simulated locally representative survey data and provide statistics of alcohol consumption for each Local Authority in England. RESULTS: We find a 2-fold difference in estimated mean alcohol consumption between the lightest and heaviest drinking Local Authorities, a 4.5-fold difference in abstention rates, and a 3.5-fold difference in harmful drinking. The method compares well to direct estimates from the data at regional level. CONCLUSIONS: The results have important policy implications in itself, but the reweighted data can also be used to model local policy effects. This method can also be used for other public health small area estimation where locally representative data are not available.

Cost-effectiveness of strategies to improve delivery of brief interventions for heavy drinking in primary care: results from the ODHIN trial.

BACKGROUND: Screening and brief interventions (SBIs) for heavy drinking are an effective and cost-effective approach to reducing alcohol-related harm, yet delivery rates remain low. This study uses trial data to estimate the cost-effectiveness of alternative strategies to increase SBI delivery. METHODS: Data from a large cluster-randomized trial were combined with the Sheffield Alcohol Policy Model, a policy appraisal tool, to estimate the cost-effectiveness of eight strategies to increase SBI delivery in primary care in England, Poland and the Netherlands: care as usual (control), training and support (TS), financial reimbursement (FR), referral of patients to an online brief intervention (eBI) and all combinations of TS, FR and eBI. cost-effectiveness was assessed from a healthcare perspective by comparing health benefits (measured in Quality-Adjusted Life Years) with total implementation costs and downstream healthcare savings for each strategy over a 30-year horizon and calculating Incremental cost-effectiveness ratios (ICERs). RESULTS: All trialled strategies were cost-effective compared to control. TS combined with FR was the most cost-effective approach in England (more effective and less costly than control) and Poland (ICER €4632 vs. next-best strategy). This combination is not cost-effective in the Netherlands, where TS alone is the most cost-effective approach (ICER €3386 vs. next-best strategy). CONCLUSIONS: Structured TS, financial incentives and access to online interventions are all estimated to be cost-effective methods of improving delivery of alcohol brief interventions. TS and FR together may be the most cost-effective approach, however this is sensitive to country characteristics and alternative BI effect assumptions. TRIAL REGISTRATION: ClinicalTrials.gov trial identifier: NCT01501552.

Exploring the impact of public health teams on alcohol premises licensing in England and Scotland (ExILEnS): procotol for a mixed methods natural experiment evaluation.

BACKGROUND: Recent regulatory changes in the system by which premises are licensed to sell alcohol, have given health representatives a formal role in the process in England and Scotland. The degree to which local public health teams engage with this process varies by locality in both nations, which have different licensing regimes. This study aims to critically assess the impact on alcohol-related harms - and mechanisms - of public health stakeholders' engagement in alcohol premises licensing from 2012 to 2018, comparing local areas with differing types and intensities of engagement, and examining practice in Scotland and England. METHODS: The study will recruit 20 local authority areas where public health stakeholders have actively engaged with the alcohol premises licensing system (the 'intervention') and match them to a group of 20 lower activity areas using genetic matching. Four work packages are included: (1) Structured interviews and documentary analysis will examine the type and level of intervention activity from 2012 to 2018, creating a novel composite measure of the intensity of such activity and will assess the local licensing system and potential confounding activities over the same period. In-depth interviews with public health, licensing, police and others will explore perceived mechanisms of change, acceptability, and impact. (2) Using longitudinal growth models and time series analyses, the study will evaluate the impact of high and low levels of activity on alcohol-related harms using routine data from baseline 2009 to 2018. (3) Intervention costs, estimated National Health Service cost savings and health gains will be evaluated using the Sheffield Alcohol Policy Model to estimate impact on alcohol consumption and health inequalities. (4) The study will engage public health teams to create a new theory of change for public health involvement in the licensing process using our data. We will share findings with local, national and international stakeholders. DISCUSSION: This interdisciplinary study examines, for the first time, whether and how public health stakeholders' involvement in alcohol licensing impacts on alcohol harms. Using mixed methods and drawing on complex systems thinking, it will make an important contribution to an expanding literature evaluating interventions not suited to traditional epidemiological research.

Alcohol Screening and Brief Intervention in Police Custody Suites: Pilot Cluster Randomised Controlled Trial (AcCePT).

AIMS: There is a clear association between alcohol use and offending behaviour and significant police time is spent on alcohol-related incidents. This study aimed to test the feasibility of a trial of screening and brief intervention in police custody suites to reduce heavy drinking and re-offending behaviour. SHORT SUMMARY: We achieved target recruitment and high brief intervention delivery if this occurred immediately after screening. Low rates of return for counselling and retention at follow-up were challenges for a definitive trial. Conversely, high consent rates for access to police data suggested at least some outcomes could be measured remotely. METHODS: A three-armed pilot Cluster Randomised Controlled Trial with an embedded qualitative interview-based process evaluation to explore acceptability issues in six police custody suites (north east and south west of the UK). Interventions included: 1. Screening only (Controls), 2. 10 min Brief Advice 3. Brief Advice plus 20 min of brief Counselling. RESULTS: Of 3330 arrestees approached: 2228 were eligible for screening (67%) and 720 consented (32%); 386 (54%) scored 8+ on AUDIT; and 205 (53%) were enroled (79 controls, 65 brief advice and 61 brief counselling). Follow-up rates at 6 and 12 months were 29% and 26%, respectively. However, routinely collected re-offending data were obtained for 193 (94%) participants. Indices of deprivation data were calculated for 184 (90%) participants; 37.6% of these resided in the 20% most deprived areas of UK. Qualitative data showed that all arrestees reported awareness that participation was voluntary, that the trial was separate from police work, and the majority said trial procedures were acceptable. CONCLUSION: Despite hitting target recruitment and same-day brief intervention delivery, a future trial of alcohol screening and brief intervention in a police custody setting would only be feasible if routinely collected re-offending and health data were used for outcome measurement. TRIAL REGISTRATION: ISRCTN number: 89291046.

Estimating the public health impact of disbanding a government alcohol monopoly: application of new methods to the case of Sweden.

BACKGROUND: Government alcohol monopolies were created in North America and Scandinavia to limit health and social problems. The Swedish monopoly, Systembolaget, reports to a health ministry and controls the sale of all alcoholic beverages with > 3.5% alcohol/volume for off-premise consumption, within a public health mandate. Elsewhere, alcohol monopolies are being dismantled with evidence of increased consumption and harms. We describe innovative modelling techniques to estimate health outcomes in scenarios involving Systembolaget being replaced by 1) privately owned liquor stores, or 2) alcohol sales in grocery stores. The methods employed can be applied in other jurisdictions and for other policy changes. METHODS: Impacts of the privatisation scenarios on pricing, outlet density, trading hours, advertising and marketing were estimated based on Swedish expert opinion and published evidence. Systematic reviews were conducted to estimate impacts on alcohol consumption in each scenario. Two methods were applied to estimate harm impacts: (i) alcohol attributable morbidity and mortality were estimated utilising the International Model of Alcohol Harms and Policies (InterMAHP); (ii) ARIMA methods to estimate the relationship between per capita alcohol consumption and specific types of alcohol-related mortality and crime. RESULTS: Replacing government stores with private liquor stores (Scenario 1) led to a 20.0% (95% CI, 15.3-24.7) increase in per capita consumption. Replacement with grocery stores (Scenario 2) led to a 31.2% (25.1-37.3%) increase. With InterMAHP there were 763 or + 47% (35-59%) and 1234 or + 76% (60-92%) more deaths per year, for Scenarios 1 and 2 respectively. With ARIMA, there were 850 (334-1444) more deaths per year in Scenario 1 and 1418 more in Scenario 2 (543-2505). InterMAHP also estimated 10,859 or + 29% (22-34%) and 16,118 or + 42% (35-49%) additional hospital stays per year respectively. CONCLUSIONS: There would be substantial adverse consequences for public health and safety were Systembolaget to be privatised. We demonstrate a new combined approach for estimating the impact of alcohol policies on consumption and, using two alternative methods, alcohol-attributable harm. This approach could be readily adapted to other policies and settings. We note the limitation that some significant sources of uncertainty in the estimates of harm impacts were not modelled.

Estimating the cost-effectiveness of brief interventions for heavy drinking in primary health care across Europe.

Background: Screening and Brief Interventions for alcohol are an effective public health measure to tackle alcohol-related harm, however relatively few countries across the European Union (EU) have implemented them widely. This may be due to a lack of understanding of the specific financial implications of such policies within each country. Methods: A novel 'meta-modelling' approach was developed based on previous SBI cost-effectiveness models for four EU countries. Data were collected on the key factors which drive cost-effectiveness for all 28 EU countries (mean per capita alcohol consumption, proportion of the population to be screened over a 10-year SBI programme; per capita alcohol-attributable mortality; per capita alcohol-attributable morbidity; mean cost of an alcohol-related hospitalisation and mean SBI-delivery staff cost). Regression analysis was used to fit two meta-models estimating net programme costs and Quality-Adjusted Life Years (QALYs) gained, to calculate cost-effectiveness estimates specific to each EU country. Results: Costs are dependent upon the proportion of the population covered by the screening programme, the country-specific per capita mortality and morbidity rate and the country-specific costs of GP care and hospitalisation. QALYs depend on the proportion of the population screened and per capita alcohol consumption. Despite large inter-country variability in factor values, SBI programmes are likely to be cost-effective in 24 out of 28 EU countries and cost-saving in 50% of countries. Conclusion: Implementing national programmes of SBI in primary health care would be a cost-effective means of reducing alcohol-attributable morbidity and deaths in almost all countries of the EU.

Estimated Effects of Different Alcohol Taxation and Price Policies on Health Inequalities: A Mathematical Modelling Study.

INTRODUCTION: While evidence that alcohol pricing policies reduce alcohol-related health harm is robust, and alcohol taxation increases are a WHO "best buy" intervention, there is a lack of research comparing the scale and distribution across society of health impacts arising from alternative tax and price policy options. The aim of this study is to test whether four common alcohol taxation and pricing strategies differ in their impact on health inequalities. METHODS AND FINDINGS: An econometric epidemiological model was built with England 2014/2015 as the setting. Four pricing strategies implemented on top of the current tax were equalised to give the same 4.3% population-wide reduction in total alcohol-related mortality: current tax increase, a 13.4% all-product duty increase under the current UK system; a value-based tax, a 4.0% ad valorem tax based on product price; a strength-based tax, a volumetric tax of £0.22 per UK alcohol unit (= 8 g of ethanol); and minimum unit pricing, a minimum price threshold of £0.50 per unit, below which alcohol cannot be sold. Model inputs were calculated by combining data from representative household surveys on alcohol purchasing and consumption, administrative and healthcare data on 43 alcohol-attributable diseases, and published price elasticities and relative risk functions. Outcomes were annual per capita consumption, consumer spending, and alcohol-related deaths. Uncertainty was assessed via partial probabilistic sensitivity analysis (PSA) and scenario analysis. The pricing strategies differ as to how effects are distributed across the population, and, from a public health perspective, heavy drinkers in routine/manual occupations are a key group as they are at greatest risk of health harm from their drinking. Strength-based taxation and minimum unit pricing would have greater effects on mortality among drinkers in routine/manual occupations (particularly for heavy drinkers, where the estimated policy effects on mortality rates are as follows: current tax increase, -3.2%; value-based tax, -2.9%; strength-based tax, -6.1%; minimum unit pricing, -7.8%) and lesser impacts among drinkers in professional/managerial occupations (for heavy drinkers: current tax increase, -1.3%; value-based tax, -1.4%; strength-based tax, +0.2%; minimum unit pricing, +0.8%). Results from the PSA give slightly greater mean effects for both the routine/manual (current tax increase, -3.6% [95% uncertainty interval (UI) -6.1%, -0.6%]; value-based tax, -3.3% [UI -5.1%, -1.7%]; strength-based tax, -7.5% [UI -13.7%, -3.9%]; minimum unit pricing, -10.3% [UI -10.3%, -7.0%]) and professional/managerial occupation groups (current tax increase, -1.8% [UI -4.7%, +1.6%]; value-based tax, -1.9% [UI -3.6%, +0.4%]; strength-based tax, -0.8% [UI -6.9%, +4.0%]; minimum unit pricing, -0.7% [UI -5.6%, +3.6%]). Impacts of price changes on moderate drinkers were small regardless of income or socioeconomic group. Analysis of uncertainty shows that the relative effectiveness of the four policies is fairly stable, although uncertainty in the absolute scale of effects exists. Volumetric taxation and minimum unit pricing consistently outperform increasing the current tax or adding an ad valorem tax in terms of reducing mortality among the heaviest drinkers and reducing alcohol-related health inequalities (e.g., in the routine/manual occupation group, volumetric taxation reduces deaths more than increasing the current tax in 26 out of 30 probabilistic runs, minimum unit pricing reduces deaths more than volumetric tax in 21 out of 30 runs, and minimum unit pricing reduces deaths more than increasing the current tax in 30 out of 30 runs). Study limitations include reducing model complexity by not considering a largely ineffective ban on below-tax alcohol sales, special duty rates covering only small shares of the market, and the impact of tax fraud or retailer non-compliance with minimum unit prices. CONCLUSIONS: Our model estimates that, compared to tax increases under the current system or introducing taxation based on product value, alcohol-content-based taxation or minimum unit pricing would lead to larger reductions in health inequalities across income groups. We also estimate that alcohol-content-based taxation and minimum unit pricing would have the largest impact on harmful drinking, with minimal effects on those drinking in moderation.

Temporal patterns of alcohol consumption and attempts to reduce alcohol intake in England.

BACKGROUND: The Alcohol Toolkit Study (ATS) is a monthly survey of approximately 1700 adults per month aged 16 years of age or more in England. We aimed to explore patterns of alcohol consumption and motivation to reduce alcohol use in England throughout the year. METHODS: Data from 38,372 participants who answered questions about alcohol consumption (March 2014 to January 2016) were analysed using weighted regression using the R survey package. Questions assessed alcohol consumption (AUDIT-C) and attempts to reduce consumption. RESULTS: Sixty-seven percent of participants reported using alcohol, with a small negative trend of about 2 % reduction over 12 months in the studied period (P < 0.01). These include ~25 % higher risk drinkers and ~10 % regular binge drinkers. About 20 % of higher risk drinkers indicated they were attempting to reduce their alcohol consumption. Attempts were lowest in December (-20 %; 95 % CI 0-35 %), but increases significantly in January (+41 %; 95 % CI 16-73 %) compared with other months (P < 0.001), indicating a small net gain; at least in attempts to reduce. However, there was no evidence that the increased motivation in January was accompanied by a reported decrease in consumption or binge drinking events. This could be an artefact of the use of AUDIT questions, but could also reflect a disconnect between attempting to reduce alcohol consumption and subsequent change; maybe as a result of lack of continuing support. CONCLUSIONS: January is associated with moderate increased attempts to reduce alcohol consumption. However, we find little evidence of a change in alcohol consumption. In part, this may be due to temporal insensitivity of the AUDIT questions.

Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study.

BACKGROUND: Several countries are considering a minimum price policy for alcohol, but concerns exist about the potential effects on drinkers with low incomes. We aimed to assess the effect of a £0·45 minimum unit price (1 unit is 8 g/10 mL ethanol) in England across the income and socioeconomic distributions. METHODS: We used the Sheffield Alcohol Policy Model (SAPM) version 2.6, a causal, deterministic, epidemiological model, to assess effects of a minimum unit price policy. SAPM accounts for alcohol purchasing and consumption preferences for population subgroups including income and socioeconomic groups. Purchasing preferences are regarded as the types and volumes of alcohol beverages, prices paid, and the balance between on-trade (eg, bars) and off-trade (eg, shops). We estimated price elasticities from 9 years of survey data and did sensitivity analyses with alternative elasticities. We assessed effects of the policy on moderate, hazardous, and harmful drinkers, split into three socioeconomic groups (living in routine or manual households, intermediate households, and managerial or professional households). We examined policy effects on alcohol consumption, spending, rates of alcohol-related health harm, and opportunity costs associated with that harm. Rates of harm and costs were estimated for a 10 year period after policy implementation. We adjusted baseline rates of mortality and morbidity to account for differential risk between socioeconomic groups. FINDINGS: Overall, a minimum unit price of £0.45 led to an immediate reduction in consumption of 1.6% (-11.7 units per drinker per year) in our model. Moderate drinkers were least affected in terms of consumption (-3.8 units per drinker per year for the lowest income quintile vs 0.8 units increase for the highest income quintile) and spending (increase in spending of £0.04 vs £1.86 per year). The greatest behavioural changes occurred in harmful drinkers (change in consumption of -3.7% or -138.2 units per drinker per year, with a decrease in spending of £4.01), especially in the lowest income quintile (-7.6% or -299.8 units per drinker per year, with a decrease in spending of £34.63) compared with the highest income quintile (-1.0% or -34.3 units, with an increase in spending of £16.35). Estimated health benefits from the policy were also unequally distributed. Individuals in the lowest socioeconomic group (living in routine or manual worker households and comprising 41.7% of the sample population) would accrue 81.8% of reductions in premature deaths and 87.1% of gains in terms of quality-adjusted life-years. INTERPRETATION: Irrespective of income, moderate drinkers were little affected by a minimum unit price of £0.45 in our model, with the greatest effects noted for harmful drinkers. Because harmful drinkers on low incomes purchase more alcohol at less than the minimum unit price threshold compared with other groups, they would be affected most by this policy. Large reductions in consumption in this group would however coincide with substantial health gains in terms of morbidity and mortality related to reduced alcohol consumption. FUNDING: UK Medical Research Council and Economic and Social Research Council (grant G1000043).

The Sheffield Alcohol Policy Model - A Mathematical Description.

This methodology paper sets out a mathematical description of the Sheffield Alcohol Policy Model version 2.0, a model to evaluate public health strategies for alcohol harm reduction in the UK. Policies that can be appraised include a minimum price per unit of alcohol, restrictions on price discounting, and broader public health measures. The model estimates the impact on consumers, health services, crime, employers, retailers and government tax revenues. The synthesis of public and commercial data sources to inform the model structure is described. A detailed algebraic description of the model is provided. This involves quantifying baseline levels of alcohol purchasing and consumption by age and gender subgroups, estimating the impact of policies on consumption, for example, using evidence on price elasticities of demand for alcohol, quantification of risk functions relating alcohol consumption to harms including 47 health conditions, crimes, absenteeism and unemployment, and finally monetary valuation of the consequences. The results framework, shown for a minimum price per unit of alcohol, has been used to provide policy appraisals for the UK government policy-makers. In discussion and online appendix, we explore issues around valuation and scope, limitations of evidence/data, how the framework can be adapted to other countries and decisions, and ongoing plans for further development. © 2014 The Authors. Health Economics published by John Wiley & Sons Ltd.

Cost-effectiveness of a programme of screening and brief interventions for alcohol in primary care in Italy.

BACKGROUND: As alcohol-related health problems continue to rise, the attention of policy-makers is increasingly turning to Screening and Brief Intervention (SBI) programmes. The effectiveness of such programmes in primary healthcare is well evidenced, but very few cost-effectiveness analyses have been conducted and none which specifically consider the Italian context. METHODS: The Sheffield Alcohol Policy Model has been used to model the cost-effectiveness of government pricing and public health policies in several countries including England. This study adapts the model using Italian data to evaluate a programme of screening and brief interventions in Italy. Results are reported as Incremental Cost-Effectiveness Ratios (ICERs) of SBI programmes versus a 'do-nothing' scenario. RESULTS: Model results show such programmes to be highly cost-effective, with estimated ICERs of €550/Quality Adjusted Life Year (QALY) gained for a programme of SBI at next GP registration and €590/QALY for SBI at next GP consultation. A range of sensitivity analyses suggest these results are robust under all but the most pessimistic assumptions. CONCLUSIONS: This study provides strong support for the promotion of a policy of screening and brief interventions throughout Italy, although policy makers should be aware of the resource implications of different implementation options.