Potential smoke-free dividend across local areas in England: a cross-sectional analysis.

BACKGROUND: The value that might be added to local economies each year through the money that people who smoke tobacco would save if everyone quit smoking is called the 'smoke-free dividend'. This study aimed to estimate the value of the smoke-free dividend across local areas in England, and how it relates to the average income in those areas. METHODS: The study was a cross-sectional descriptive analysis of tobacco expenditure from the Smoking Toolkit Study (STS) matched to income and smoking prevalence data for English local authorities. The STS sample was from 2014 to 2020 and comprised 18 721 adults who smoke cigarettes. Self-reported expenditure estimates from the STS were adjusted for under-reporting. This adjustment aimed to align the total expenditure estimate with figures derived from government tax receipts and national estimates of illicit tobacco use. The smoke-free dividend is calculated as 93% of spending on legal tobacco, which is the percentage estimated to leave the local economy, plus 100% of spending on illicit tobacco. RESULTS: The total dividend in England is estimated to be £10.9 billion each year, which equates to £1776 per person who smokes or £246 per adult regardless of smoking status. The estimated dividend is greater in areas with lower average income, with a correlation coefficient of -0.521 (95% CI -0.629, -0.392) between the average income of local areas and the dividend per adult. CONCLUSIONS: This study has estimated that local economies could gain a substantial dividend if everybody stopped smoking, which is larger in lower income areas, meaning that geographical economic inequalities could be reduced.

Reintroducing face-to-face support alongside remote support to form a hybrid stop smoking service in England: a formative mixed methods evaluation.

BACKGROUND: During the COVID-19 pandemic, United Kingdom (UK) stop smoking services had to shift to remote delivery models due to social distancing regulations, later reintroducing face-to-face provision. The "Living Well Smokefree" service in North Yorkshire County Council adopted a hybrid model offering face-to-face, remote, or a mix of both. This evaluation aimed to assess the hybrid approach's strengths and weaknesses and explore potential improvements. METHODS: Conducted from September 2022 to February 2023, the evaluation consisted of three components. First, qualitative interviews involved 11 staff and 16 service users, analysed thematically. Second, quantitative data from the QuitManager system that monitored the numbers and proportions of individuals selecting and successfully completing a 4-week quit via each service option. Third, face-to-face service expenses data was used to estimate the value for money of additional face-to-face provision. The qualitative findings were used to give context to the quantitative data via an "expansion" approach and complementary analysis. RESULTS: Overall, a hybrid model was seen to provide convenience and flexible options for support. In the evaluation, 733 individuals accessed the service, with 91.3% selecting remote support, 6.1% face-to-face, and 2.6% mixed provision. Remote support was valued by service users and staff for promoting openness, privacy, and reducing stigma, and was noted as removing access barriers and improving service availability. However, the absence of carbon monoxide monitoring in remote support raised accountability concerns. The trade-off in "quantity vs. quality" of quits was debated, as remote support reached more users but produced fewer carbon monoxide-validated quits. Primarily offering remote support could lead to substantial workloads, as staff often extend their roles to include social/mental health support, which was sometimes emotionally challenging. Offering service users a choice of support options was considered more important than the "cost-per-quit". Improved dissemination of information to support service users in understanding their options for support was suggested. CONCLUSIONS: The hybrid approach allows smoking cessation services to evaluate which groups benefit from remote, face-to-face, or mixed options and allocate resources accordingly. Providing choice, flexible provision, non-judgmental support, and clear information about available options could improve engagement and match support to individual needs, enhancing outcomes.

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.

Estimation of integrated price elasticities for alcohol and tobacco in the United Kingdom using the living costs and food survey 2006-2017.

INTRODUCTION: Evidence shows that price is an important policy lever in reducing consumption of alcohol and tobacco. However, there is little evidence of the cross-price effect between alcohol and tobacco. METHODS: This paper uses an econometric model which estimates participation and consumption elasticities, on data from the UK Living Costs and Food Survey 2006-2017 and extends the literature by, for the first time, estimating joint price elasticities for disaggregated alcohol and tobacco products. This paper presents new price elasticities and compares them to the existing literature. RESULTS: The own-price elasticity estimates are all negative for both participation and consumption. There is no pattern to the estimates of cross-price elasticities. The elasticity estimates, when used in the Sheffield Tobacco and Alcohol Policy Model, produce bigger changes in consumption for the same change in price compared to other elasticity estimates in the existing literature. DISCUSSION AND CONCLUSIONS: Consumption of alcohol and tobacco are affected by the prices of one another. Policymakers should bear this in mind when devising alcohol or tobacco pricing policies.

Mapping alcohol and tobacco tax policy interventions to inform health and economic impact analyses: A United Kingdom based qualitative framework analysis.

BACKGROUND: Alcohol and tobacco have different policy regimes and there is little understanding of how changes to policy on each commodity might combine to affect the same outcomes or to affect people who both drink and smoke. The aim of this study was to deepen understanding of the policy objectives of UK alcohol and tobacco tax options being considered at the time of the interviews with a set of UK policy participants in 2018, and the factors affecting the implementation and outcomes of the policy options discussed. METHODS: Ten tax policy experts were recruited from government arms-length organisations and advocacy groups in England and Scotland (4 alcohol, 4 tobacco, 2 alcohol and tobacco). Alcohol and tobacco experts were interviewed together in pairs and asked to discuss alcohol and tobacco tax policy objectives, options, and the mechanisms of effect. Interviews were semi-structured, supported by a briefing document and topic guide, audio-recorded, transcribed and then analysed deductively using framework analysis. RESULTS: Alcohol and tobacco tax policy share objectives of health improvement and there is a common set of policy options: increasing duty rates, duty escalators, multi-rate tax structures, industry levies and the hypothecation of tax revenue for investment in societal benefits. However, participants agreed that the harms caused by alcohol and tobacco and their industries are viewed differently, and that this influences the impacts that are prioritised in tax policymaking. Working-out how alcohol and tobacco taxes could work synergistically to reduce health inequalities was seen as desirable. Participants also highlighted the importance of avoiding the combined effects of price increases on alcohol and tobacco widening economic inequalities. CONCLUSIONS: Impact analyses should consider the combined effects of alcohol and tobacco tax policies on health and economic inequalities, and how the effects of changes to the tax on each commodity might trade-off.

Options for modifying UK alcohol and tobacco tax: A rapid scoping review of the evidence over the period 1997-2018.

Background: Increased taxation is recognised worldwide as one of the most effective interventions for decreasing tobacco and harmful alcohol use, with many variations of policy options available. This rapid scoping review was part of a NIHR-funded project ('SYNTAX' 16/105/26) and was undertaken during 2018 to inform interviews to be conducted with UK public health stakeholders with expertise in alcohol and tobacco pricing policy. Methods: Objectives: To synthesise evidence and debates on current and potential alcohol and tobacco taxation options for the UK, and report on the underlying objectives, evidence of effects and mediating factors.Eligibility criteria: Peer-reviewed and grey literature; published 1997-2018; English language; UK-focused; include taxation interventions for alcohol, tobacco, or both. Sources of evidence: PubMed, Scopus, Cochrane Library, Google, stakeholder and colleague recommendations.Charting methods: Excel spreadsheet structured using PICO framework, recording source characteristics and content. Results: Ninety-one sources qualified for inclusion: 49 alcohol, 36 tobacco, 6 both. Analysis identified four policy themes: changes to excise duty within existing tax structures, structural reforms, industry measures, and hypothecation of tax revenue for public benefits. For alcohol, policy options focused on raising the price of cheap, high-strength alcohol. For tobacco, policy options focused on raising the price of all tobacco products, especially the cheapest products, which are hand-rolling tobacco. For alcohol and tobacco, there were options such as levies that take money from the industries to help reduce the societal costs of their products. Due to the perceived social and economic importance of alcohol in contrast to tobacco, policy options also discussed supporting pubs and small breweries. Conclusions: This review has identified a set of tax policy options for tobacco and alcohol, their objectives, evidence of effects and related mediating factors. The differences between alcohol and tobacco tax policy options and debates suggest an opportunity for cross-substance policy learning.

Why we did it: Alcohol and tobacco cause many diseases and deaths. People who drink heavily are more likely to be smokers. People who smoke and drink heavily are more likely to get ill and die sooner. Increasing alcohol and tobacco taxes has been shown to reduce their consumption. Research was needed to understand how and why alcohol and tobacco tax might be changed. This rapid scoping review was undertaken during 2018 as part of a National Institute for Health and Care Research funded project called 'SYNTAX' (16/105/26). Its main purpose was to inform interviews to be conducted with UK public health stakeholders with expertise in alcohol and tobacco pricing policy. Why we did it: We looked at academic papers and policy reports published between 1997 and 2018 that discussed or estimated the effects of changes to tax on alcohol and tobacco. What we found: The results of the review summarise the options for changing alcohol and tobacco taxes that were being considered in the UK, and why. What this means: Some options for changing tax were the same for alcohol and tobacco, but there were also differences between alcohol and tobacco, which reflected differences in how alcohol and tobacco are viewed in society. We used the findings of the review to prepare to speak to alcohol and tobacco tax experts about the options for changing tax on alcohol and tobacco, which we did in 2018.

Covariates of success in quitting smoking: a systematic review of studies from 2008 to 2021 conducted to inform the statistical analyses of quitting outcomes of a hospital-based tobacco dependence treatment service in the United Kingdom.

Background: Smoking cessation interventions are being introduced into routine secondary care in the United Kingdom (UK), but there are person and setting-related factors that could moderate their success in quitting smoking. This review was conducted as part of an evaluation of the QUIT hospital-based tobacco dependence treatment service ( https://sybics-quit.co.uk). The aim of the review was to identify a comprehensive set of variables associated with quitting success among tobacco smokers contacting secondary healthcare services in the UK who are offered support to quit smoking and subsequently set a quit date. The results would then be used to inform the development of a statistical analysis plan to investigate quitting outcomes. Methods: Systematic literature review of five electronic databases. Studies eligible for inclusion investigated quitting success in one of three contexts: (a) the general population in the UK; (b) people with a mental health condition; (c) quit attempts initiated within a secondary care setting. The outcome measures were parameters from statistical analysis showing the effects of covariates on quitting success with a statistically significant (i.e., p-value <0.05) association. Results: The review identified 29 relevant studies and 14 covariates of quitting success, which we grouped into four categories: demographics (age; sex; ethnicity; socio-economic conditions; relationship status, cohabitation and social network), individual health status and healthcare setting (physical health, mental health), tobacco smoking variables (current tobacco consumption, smoking history, nicotine dependence; motivation to quit; quitting history), and intervention characteristics (reduction in amount smoked prior to quitting, the nature of behavioural support, tobacco dependence treatment duration, pharmacological aids). Conclusions: In total, 14 data fields were identified that should be considered for inclusion in datasets and statistical analysis plans for evaluating the quitting outcomes of smoking cessation interventions initiated in secondary care contexts in the UK. PROSPERO registration: CRD42021254551 (13/05/2021).

Stop smoking interventions are being incorporated as a systematic and opt-out component of secondary care services in the UK's National Health Service (NHS), driven by the NHS's Long Term Plan. This review was conducted as part of an evaluation of the QUIT hospital-based tobacco dependence treatment service ( https://sybics-quit.co.uk). To support the development of statistical analyses to find out what affects smokers' success in quitting smoking after contacting the service, research was needed to identify what characteristics of the individual smokers and the healthcare setting might be important for success in quitting. The main purpose of the review was to support the development of a statistical analysis plan of quitting outcomes. We looked at academic papers published between 2008 and 2021 that estimated the influence of different factors on success in quitting smoking. The results of the review summarise the list of factors that previous studies have found to have an influence on quitting outcomes. The list of factors was used to inform discussions with the service about what data fields it would be important for the service to collect because that data could be important for helping the service to understand variation in quitting outcomes.

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.

Understanding long-term trends in smoking in England, 1972-2019: an age-period-cohort approach.

BACKGROUND AND AIMS: Smoking prevalence has been falling in England for more than 50 years, but remains a prevalent and major public health problem. This study used an age-period-cohort (APC) approach to measure lifecycle, historical and generational patterns of individual smoking behaviour. DESIGN: APC analysis of repeated cross-sectional smoking prevalence data obtained from three nationally representative surveys. SETTING: England (1972-2019). PARTICIPANTS: Individuals aged 18-90 years. MEASUREMENTS: We studied relative odds of current smoking in relation to age in single years from 18 to 90, 24 groups of 2-year survey periods (1972-73 to 2018-19) and 20 groups of 5-year birth cohorts (1907-11 to 1997-2001). Age and period rates were studied for two groups of birth cohorts: those aged 18-25 years and those aged over 25 years. FINDINGS: Relative to age 18, the odds of current smoking increased with age until approximately age 25 [odds ratio (OR) = 1.48, 95% confidence interval (CI) = 1.41-1.56] and then decreased progressively to age 90 (OR = 0.06, 95% CI = 0.04-0.08). They also decreased almost linearly with period relative to 1972-73 (for 2018-19: OR = 0.30, 95% CI = 0.26-0.34) and with birth cohort relative to 1902-06, with the largest decreased observed for birth cohort 1992-96 (OR = 0.44, 95% CI = 0.35-0.46) and 1997-2001 (OR = 0.35, 95% CI = 0.74-0.88). Smoking declined in the 18-25 age group by an average of 7% over successive 2-year periods and by an average of 5% in those aged over 25. CONCLUSIONS: Smoking in England appears to have declined over recent decades mainly as a result of reduced smoking uptake before age 25, and to a lesser extent to smoking cessation after age 25.

The SPECTRUM Consortium: a new UK Prevention Research Partnership consortium focussed on the commercial determinants of health, the prevention of non-communicable diseases, and the reduction of health inequalities.

The main causes of non-communicable diseases (NCDs), health inequalities and health inequity include consumption of unhealthy commodities such as tobacco, alcohol and/or foods high in fat, salt and/or sugar. These exposures are preventable, but the commodities involved are highly profitable. The economic interests of 'Unhealthy Commodity Producers' (UCPs) often conflict with health goals but their role in determining health has received insufficient attention. In order to address this gap, a new research consortium has been established. This open letter introduces the SPECTRUM ( S haping  Public h Ealth poli Cies  To  Reduce ineq Ualities and har M)Consortium: a multi-disciplinary group comprising researchers from 10 United Kingdom (UK) universities and overseas, and partner organisations including three national public health agencies in Great Britain (GB), five multi-agency alliances and two companies providing data and analytic support. Through eight integrated work packages, the Consortium seeks to provide an understanding of the nature of the complex systems underlying the consumption of unhealthy commodities, the role of UCPs in shaping these systems and influencing health and policy, the role of systems-level interventions, and the effectiveness of existing and emerging policies. Co-production is central to the Consortium's approach to advance research and achieve meaningful impact and we will involve the public in the design and delivery of our research. We will also establish and sustain mutually beneficial relationships with policy makers, alongside our partners, to increase the visibility, credibility and impact of our evidence. The Consortium's ultimate aim is to achieve meaningful health benefits for the UK population by reducing harm and inequalities from the consumption of unhealthy commodities over the next five years and beyond.

Do dual purchasers behave differently? An analysis of purchasing data for households that buy both alcohol and tobacco in the United Kingdom.

BACKGROUND AND AIMS: Dual purchasers of alcohol and tobacco are at increased health risk from the interacting health impacts of alcohol and tobacco use. They are also at financial risk from exposure to the dual financial cost of policies that increase alcohol and tobacco prices. Understanding whose alcohol and tobacco use exposes them to these health and financial risks is important for understanding the inequality impacts of control policies. This study explores the extent to which household spending on alcohol and tobacco combined varies between socio-economic groups and compares this with results for households which purchase only one of the commodities. DESIGN: Cross-sectional analysis of household-level alcohol and tobacco purchasing data. SETTING: United Kingdom, 2012-17. PARTICIPANTS/CASES: A total of 26 021 households. MEASUREMENTS: We analysed transaction-level data from individual 14-day spending diaries in the Living Cost and Food Survey (LCFS). We used this to calculate expenditure, volumes of alcohol and tobacco purchased, and the price paid per unit of alcohol (1 unit = 8 g) and per stick of tobacco. This was compared with equivalized total expenditure and quintiles of equivalized household income. Prices were calibrated and pack sizes were imputed using empirical sales data from Nielsen/CGA to correct for reporting bias. FINDINGS: Dual purchasing households spent [95% confidence interval] more on alcohol and more on tobacco than their single-purchasing counterparts. In general, lower-income households spent less on both alcohol and tobacco than higher-income households. Furthermore, dual purchasing households in the lowest income group were most exposed to potential increases in price than were other income groups, with (CI = 12.41-13.15%) of their total household budget spent on alcohol and tobacco. CONCLUSIONS: Dual purchasers of alcohol and tobacco in the United Kingdom appear to be concentrated evenly among income groups. However, dual purchasers may experience particularly large effects from pricing policies, as they spend a substantially higher proportion of their overall household expenditure on alcohol and tobacco than do households that purchase only one of the commodities.

The effect of alcohol tax changes on retail prices: how do on-trade alcohol retailers pass through tax changes to consumers?

The effectiveness of alcohol duty increases relies on alcohol retailers passing the tax increase on to consumers. This study uses sales data from a market research company to investigate tax pass-through over 11 years for on-premise retailers in England and whether this varies across the price distribution, for different beverage categories and outlet types. Panel data quantile regression analysis is used to estimate the impact of 12 excise duty changes and 3 sales tax changes between 2007 and 2017 on prices. We use product-level quarterly panel data from for 777 alcoholic products. We undertake the regression at all outlets level separating products are analysed in seven broad beverage categories (Beer, Cider, RTDs, Spirits, Wine, Sparkling Wine, and Fortified Wine). We further test sensitivity by disaggregating outlets into seven outlet types. For all seven broad beverage categories, we find that there exists significant differences in tax pass-through across the price distribution. Retailers appear to "undershift" cheaper beverages (prices rise by less than the tax increase) and subsidise this loss in revenue with an "overshift" in the relatively more expensive products. Future modelling of tax change impacts on population subgroups could incorporate this evidence, and this is important because different socio-economic and drinker groups purchase alcohol at different points on the price distribution and hence are affected differently by tax changes. Governments could also potentially incorporate this evidence into future impact assessments.

Conceptualising changes to tobacco and alcohol policy as affecting a single interlinked system.

BACKGROUND: To support a move towards a coordinated non-communicable disease approach in public health policy, it is important to conceptualise changes to policy on tobacco and alcohol as affecting a single interlinked system. For health economic models to effectively inform policy, the first step in their development should be to develop a conceptual understanding of the system complexity that is likely to affect the outcomes of policy change. Our aim in this study was to support the development and interpretation of health economic models of the effects of changes to tobacco and alcohol policies by developing a conceptual understanding of the main components and mechanisms in the system that links policy change to outcomes. METHODS: Our study was based on a workshop from which we captured data on participant discussions on the joint tobacco-alcohol policy system. To inform these discussions, we prepared with a literature review and a survey of participants. Participants were academics and policy professionals who work in the United Kingdom. Data were analysed thematically to produce a description of the main components and mechanisms within the system. RESULTS: Of the people invited, 24 completed the survey (18 academic, 6 policy); 21 attended the workshop (16 academic, 5 policy). Our analysis identified eleven mechanisms through which individuals might modify the effects of a policy change, which include mechanisms that might lead to linked effects of policy change on tobacco and alcohol consumption. We identified ten mechanisms by which the tobacco and alcohol industries might modify the effects of policy changes, grouped into two categories: Reducing policy effectiveness; Enacting counter-measures. Finally, we identified eighteen research questions that indicate potential avenues for further work to understand the potential outcomes of policy change. CONCLUSIONS: Model development should carefully consider the ways in which individuals and the tobacco and alcohol industries might modify the effects of policy change, and the extent to which this results in an unequal societal distribution of outcomes. Modelled evidence should then be interpreted in the light of the conceptual understanding of the system that the modelling necessarily simplifies in order to predict the outcomes of policy change.

Developing logic models to inform public health policy outcome evaluation: an example from tobacco control.

BACKGROUND: The evaluation of large-scale public health policy interventions often relies on observational designs where attributing causality is challenging. Logic models-visual representations of an intervention's anticipated causal pathway-facilitate the analysis of the most relevant outcomes. We aimed to develop a set of logic models that could be widely used in tobacco policy evaluation. METHODS: We developed an overarching logic model that reflected the broad categories of outcomes that would be expected following the implementation of tobacco control policies. We subsequently reviewed policy documents to identify the outcomes expected to result from the implementation of each policy and conducted a literature review of existing evaluations to identify further outcomes. The models were revised according to feedbacks from a range of stakeholders. RESULTS: The final models represented expected causal pathways for each policy. The models included short-term outcomes (such as policy awareness, compliance and social cognitive outcomes), intermediate outcomes (such as changes in smoking behaviour) and long-term outcomes (such as mortality, morbidity and health service usage). CONCLUSIONS: The use of logic models enables transparent and theory-based planning of evaluation analyses and should be encouraged in the evaluation of tobacco control policy, as well as other areas of public health.

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.

Impact of Socioeconomic Differences on Distributional Cost-effectiveness Analysis.

Public health decision makers value interventions for their effects on overall health and health inequality. Distributional cost-effectiveness analysis (DCEA) incorporates health inequality concerns into economic evaluation by accounting for how parameters, such as effectiveness, differ across population groups. A good understanding of how and when accounting for socioeconomic differences between groups affects the assessment of intervention impacts on overall health and health inequality could inform decision makers where DCEA would add most value. We interrogated 2 DCEA models of smoking and alcohol policies using first national level and then local authority level information on various socioeconomic differences in health and intervention use. Through a series of scenario analyses, we explored the impact of altering these differences on the DCEA results. When all available evidence on socioeconomic differences was incorporated, provision of a smoking cessation service was estimated to increase overall health and increase health inequality, while the screening and brief intervention for alcohol misuse was estimated to increase overall health and reduce inequality. Ignoring all or some socioeconomic differences resulted in minimal change to the estimated impact on overall health in both models; however, there were larger effects on the estimated impact on health inequality. Across the models, there were no clear patterns in how the extent and direction of socioeconomic differences in the inputs translated into the estimated impact on health inequality. Modifying use or coverage of either intervention so that each population group matched the highest level improved the impacts to a greater degree than modifying intervention effectiveness. When local level socioeconomic differences were considered, the magnitude of the impacts was altered; in some cases, the direction of impact on inequality was also altered.

Assessing the contribution of alcohol-specific causes to socio-economic inequalities in mortality in England and Wales 2001-16.

BACKGROUND AND AIMS: When measuring inequalities in health, public health and addiction research has tended to focus on differences in average life-span between socio-economic groups. This does not account for the extent to which age of death varies between individuals within socio-economic groups or whether this variation differs between groups. This study assesses (1) socio-economic inequalities in both average life-span and variation in age at death, (2) the extent to which these inequalities can be attributed to alcohol-specific causes (i.e. those attributable only to alcohol) and (3) how this contribution has changed over time. DESIGN: Cause-deleted life table analysis of national mortality records. SETTING: England and Wales, 2001-16. CASES: All-cause and alcohol-specific deaths for all adults aged 18+, stratified by sex, age and quintiles of the index of multiple deprivation (IMD). MEASUREMENTS: Life expectancy at age 18 yearss and standard deviation in age at death within IMD quintiles and the contribution of alcohol to overall differences in both measures between the highest and lowest IMD quintiles by comparing observed and cause-deleted inequality 'gaps'. FINDINGS: In 2016, alcohol-specific causes reduced life expectancy for men and women by 0.26 and 0.14 years, respectively, and increased the standard deviation in age at death. These causes also increased the inequality gap in life expectancy by 0.33 years for men and 0.17 years for women, and variation in age at death by 0.14 years and 0.13 years, respectively. For both measures, the contribution of alcohol to mortality inequalities rose after 2001 and subsequently fell back. For women, alcohol accounted for 3.6% of inequality in age at death and 6.0% of life-span uncertainty, suggesting that using only the former may underestimate alcohol-induced inequalities. There was no comparable difference for men. CONCLUSIONS: Deaths from alcohol-specific causes increase inequalities in both life expectancy and variation in age of death between socio-economic groups. Using both measures can provide a fuller picture of overall inequalities in health.

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.

Socioeconomic inequalities in the delivery of brief interventions for smoking and excessive drinking: findings from a cross-sectional household survey in England.

OBJECTIVES: Brief interventions (BI) for smoking and risky drinking are effective and cost-effective policy approaches to reducing alcohol harm currently used in primary care in England; however, little is known about their contribution to health inequalities. This paper aims to investigate whether self-reported receipt of BI is associated with socioeconomic position (SEP) and whether this differs for smoking or alcohol. DESIGN: Population survey of 8978 smokers or risky drinkers in England aged 16+ taking part in the Alcohol and Smoking Toolkit Studies. MEASURES: Survey participants answered questions regarding whether they had received advice and support to cut down their drinking or smoking from a primary healthcare professional in the past 12 months as well as their SEP, demographic details, whether they smoke and their motivation to cut down their smoking and/or drinking. Respondents also completed the Alcohol Use Disorders Identification Test (AUDIT). Smokers were defined as those reporting any smoking in the past year. Risky drinkers were defined as those scoring eight or more on the AUDIT. RESULTS: After adjusting for demographic factors and patterns in smoking and drinking, BI delivery was highest in lower socioeconomic groups. Smokers in the lowest social grade had 30% (95% CI 5% to 61%) greater odds of reporting receipt of a BI than those in the highest grade. The relationship for risky drinking appeared stronger, with those in the lowest social grade having 111% (95% CI 27% to 252%) greater odds of reporting BI receipt than the highest grade. Rates of BI delivery were eight times greater among smokers than risky drinkers (48.3% vs 6.1%). CONCLUSIONS: Current delivery of BI for smoking and drinking in primary care in England may be contributing to a reduction in socioeconomic inequalities in health. This effect could be increased if intervention rates, particularly for drinking, were raised.

Understanding the alcohol harm paradox: an analysis of sex- and condition-specific hospital admissions by socio-economic group for alcohol-associated conditions in England.

BACKGROUND AND AIMS: In many countries, conflicting gradients in alcohol consumption and alcohol-associated mortality have been observed. To understand this 'alcohol harm paradox' we analysed the socio-economic gradient in alcohol-associated hospital admissions to test whether it was greater in conditions which were: (1) chronic (associated with long-term drinking) and partially alcohol-attributable, (2) chronic and wholly alcohol-attributable, (3) acute (associated with intoxication) and partially alcohol-attributable and (4) acute and wholly alcohol-attributable. Our aim was to clarify how (1) drinking patterns (e.g. intoxication linked to acute admissions or dependence linked to chronic conditions) and (2) non-alcohol causes (e.g. smoking and poor diet which are risks for partially alcohol-attributable conditions) contribute to the paradox. DESIGN: Regression analysis testing the modifying effects of condition-group (1-4 above) and sex on the relationship between area-based deprivation and admissions. SETTING: England, April 2010-March 2013. PARTICIPANTS: A total of 9 239 629 English hospital admissions where a primary or secondary cause was one of 36 alcohol-associated conditions. MEASUREMENTS: Admissions by condition and deciles of Index of Multiple Deprivation (IMD). Socio-economic gradient measured as the relative index of inequality (RII, the slope of a linear regression of IMD on admissions adjusted for overall admission rate). Conditions were categorized by ICD-10 code. FINDINGS: A socio-economic gradient in hospitalizations was seen for all conditions, except partially attributable chronic conditions. The gradient was significantly steeper for conditions which were wholly attributable to alcohol and for acute conditions than for conditions partially alcohol-attributable and for chronic conditions. Gradients were steeper for men than for women in cases of wholly alcohol attributable conditions. CONCLUSIONS: There is a socio-economic gradient in English hospital admission for most alcohol-associated conditions. The greatest inequalities are in conditions associated with alcohol dependence, such as liver disease and mental and behavioural conditions, and in acute conditions, such as alcohol poisoning and assault. Socio-economic differences in harmful drinking patterns (dependence and intoxication) may contribute to the 'alcohol harm paradox'.