Evaluating the impact of alcohol minimum unit pricing on deaths and hospitalisations in Scotland: a controlled interrupted time series study.

BACKGROUND: Since May 1, 2018, every alcoholic drink sold in Scotland has had minimum unit pricing (MUP) of £0·50 per unit. Previous studies have indicated that the introduction of this policy reduced alcohol sales by 3%. We aimed to assess whether this has led to reductions in alcohol-attributable deaths and hospitalisations. METHODS: Study outcomes, wholly attributable to alcohol consumption, were defined using routinely collected data on deaths and hospitalisations. Controlled interrupted time series regression was used to assess the legislation's impact in Scotland, and any effect modification across demographic and socioeconomic deprivation groups. The pre-intervention time series ran from Jan 1, 2012, to April 30, 2018, and for 32 months after the policy was implemented (until Dec 31, 2020). Data from England, a part of the UK where the intervention was not implemented, were used to form a control group. FINDINGS: MUP in Scotland was associated with a significant 13·4% reduction (95% CI -18·4 to -8·3; p=0·0004) in deaths wholly attributable to alcohol consumption. Hospitalisations wholly attributable to alcohol consumption decreased by 4·1% (-8·3 to 0·3; p=0·064). Effects were driven by significant improvements in chronic outcomes, particularly alcoholic liver disease. Furthermore, MUP legislation was associated with a reduction in deaths and hospitalisations wholly attributable to alcohol consumption in the four most socioeconomically deprived deciles in Scotland. INTERPRETATION: The implementation of MUP legislation was associated with significant reductions in deaths, and reductions in hospitalisations, wholly attributable to alcohol consumption. The greatest improvements were in the four most socioeconomically deprived deciles, indicating that the policy is positively tackling deprivation-based inequalities in alcohol-attributable health harm. FUNDING: Scottish Government.

Evaluating the impact of minimum unit pricing for alcohol in Scotland: a theory-based synthesis of the evidence.

BACKGROUND: In May 2018, the Scottish Government set a minimum unit price (MUP) of £0·50 per unit of alcohol sold in Scotland to reduce alcohol-related health harms. We synthesised evidence to establish the effects of MUP on alcohol-related health and social harms, at population level and within specific societal groups. METHODS: We did a theory-based synthesis of academic and grey research evidence about impacts of MUP in Scotland, including compliance, price, consumption, health outcomes, social outcomes, public attitudes, and the alcoholic drinks industry. We searched the Public Health Scotland's MUP evaluation portfolio and relevant grey and academic literature for studies published between Jan 1, 2018, and Jan 31, 2023. We conducted systematic searches and screening of bibliographic databases (Scopus, Public Health Database, EconLit, MEDLINE, ProQuest Public Health, Social Policy and Practice, NHS Scotland Knowledge Network Library Search, medRxiv, bioRxiv, SSRN, Idox Knowledge Exchange, Social Policy & Practice, and Google Search). Search terms were tailored to specific databases but included variants of the terms "minimum unit pricing", "alcohol", and "policy". Eligibility literature included English-language research into impacts of MUP on either the population of Scotland or a specific subpopulation. We excluded conference abstracts, literature reviews, articles that did not report research, and research based solely on data from before the introduction of MUP. FINDINGS: We included 40 reports in our analysis. On the balance of evidence, MUP improved population-level health outcomes, demonstrated most starkly by a 13·4% reduction in alcohol-attributable deaths in Scotland compared with England. There was no evidence of substantial negative effects on the alcoholic drinks industry or social harms at the population level. While population-level outcomes were predominantly positive, some qualitative evidence suggests that MUP might have exacerbated health and social harms for some individuals or groups, especially those with alcohol dependence who were financially vulnerable. INTERPRETATION: MUP in Scotland has been effective in reducing alcohol-related health harms, with little evidence of any effect on social harms. If MUP continues, policymakers should consider raising the £0·50 per unit threshold and supplementing the intervention with policies or services to address any unintended negative effects experienced by specific groups. The synthesis is persuasive due to the prospective, theory-based design of the evaluation portfolio and the quality and comprehensiveness of the evidence. FUNDING: Scottish Government.

Tracking Biases: An Update to the Validity and Reliability of Alcohol Retail Sales Data for Estimating Population Consumption in Scotland.

AIMS: To highlight the importance of monitoring biases when using retail sales data to estimate population alcohol consumption. METHODS: Previously, we identified and where possible quantified sources of bias that may lead to under- or overestimation of alcohol consumption in Scotland. Here, we update findings by using more recent data and by quantifying emergent biases. RESULTS: Underestimation resulting from the net effect of biases on population consumption in Scotland increased from -4% in 2010 to -7% in 2013. CONCLUSION: Biases that might impact on the validity and reliability of sales data when estimating population consumption should be routinely monitored and updated.

Evaluating the impact of minimum unit pricing (MUP) on alcohol sales after 3 years of implementation in Scotland: A controlled interrupted time-series study.

BACKGROUND AND AIMS: On 1 May 2018, Scotland introduced minimum unit pricing (MUP), a strength-based floor price below which alcohol cannot be sold, throughout all alcoholic beverages. The legislation necessitates an evaluation of its impact across a range of outcomes that will inform whether MUP will continue beyond its sixth year. We measured the impact of MUP on per-adult alcohol sales (as a proxy for consumption) after 3 years of implementation. DESIGN, SETTING AND PARTICIPANTS: Controlled interrupted time-series regression was used to assess the impact of MUP on alcohol sales in Scotland after 3 years of implementation, with England and Wales (EW) being the control group. In adjusted analyses, we included household disposable income, on-trade alcohol sales (in off-trade analyses) and substitution between drink categories (in drink category analyses) as covariates. MEASUREMENTS: Weekly data were assessed on the volume of pure alcohol sold in Scotland and EW between January 2013 and May 2021, expressed as litres of pure alcohol per adult. The impact of MUP on total (on- and off-trade combined), off-trade and on-trade alcohol sales was assessed separately. RESULTS: The introduction of MUP in Scotland was associated with a 3.0% (95% confidence interval = 1.8-4.2%) net reduction in total alcohol sales per adult after adjustment for the best available geographical control, disposable income and substitution. This reflects a 1.1% fall in Scotland in contrast to a 2.4% increase in EW. The reduction in total alcohol sales in Scotland was driven by reduced sales of beer, spirits, cider and perry. The reduction in total sales was due to reductions in sales of alcohol through the off-trade. There was no evidence of any change in on-trade alcohol sales. CONCLUSION: Minimum unit pricing has been effective in reducing population-level alcohol sales in Scotland in the 3 years since implementation.

A review of the validity and reliability of alcohol retail sales data for monitoring population levels of alcohol consumption: a Scottish perspective.

AIMS: To assess the validity and reliability of using alcohol retail sales data to measure and monitor population levels of alcohol consumption. METHODS: Potential sources of bias that could lead to under- or overestimation of population alcohol consumption based on alcohol retail sales data were identified and, where possible, quantified. This enabled an assessment of the potential impact of each bias on alcohol consumption estimates in Scotland. RESULTS: Overall, considering all the possible sources of overestimation and underestimation, and taking into account the potential for sampling variability to impact on the results, the range of uncertainty of consumption during 2010 was from an overestimate of 0.3 l to an underestimate of 2.4 l of pure alcohol per adult. This excludes the impacts of alcohol stockpiling and alcohol sold through outlets not included in the sampling frame. On balance, there is therefore far greater scope for alcohol retail sales data to be underestimating per adult alcohol consumption in Scotland than there is for overestimation. CONCLUSION: Alcohol retail sales data offer a robust source of data for monitoring per adult alcohol consumption in Scotland. Consideration of the sources of bias and a comprehensive understanding of data collection methods are essential for using sales data to monitor trends in alcohol consumption.

Evaluating the impact of minimum unit pricing (MUP) on off-trade alcohol sales in Scotland: an interrupted time-series study.

BACKGROUND AND AIMS: On 1 May 2018, Scotland became the first country in the world to introduce minimum unit pricing (MUP), a strength-based floor price below which alcohol cannot be sold, across all alcoholic beverages. The legislation contains a sunset clause meaning a comprehensive mixed-methods evaluation of its impact across a range of outcomes will inform whether it will continue beyond its sixth year. In this study, we assessed the impact of MUP on off-trade alcohol sales (as a proxy for consumption) after its first year. DESIGN, SETTING AND PARTICIPANTS: Controlled interrupted time-series regression was used to assess the impact of MUP on alcohol sales among off-trade retailers in Scotland in the year after it was introduced, with England and Wales (EW) being the control group. In adjusted analyses, we included household disposable income, on-trade alcohol sales and substitution between beverage categories as covariates. MEASUREMENTS: Weekly data on the volume of pure alcohol sold by off-trade retailers in Scotland and EW between January 2013 and May 2019, expressed as litres of pure alcohol per adult. FINDINGS: The introduction of MUP in Scotland was associated with a 3.5% [95% confidence interval (CI) = 2.2-4.9%] reduction in off-trade alcohol sales per adult after adjustment for the best available geographical control, disposable income and substitution. In unadjusted analysis, the introduction of MUP was associated with a 2.0% (95% CI = 0.4-3.6%) reduction in off-trade alcohol sales per adult in Scotland. In EW, there was a 2.4% (95% CI = 0.8-4.0%) increase during the same time-period. The reduction in off-trade alcohol sales in Scotland was driven by reduced sales of spirits, cider and perry beverage categories. CONCLUSION: The implementation of minimum unit pricing for alcohol in Scotland in 2018 appears to have been associated with a reduction in off-trade alcohol sales after its first year.

Evaluation of Minimum Unit Pricing of Alcohol: A Mixed Method Natural Experiment in Scotland.

In May 2018, Scotland became the first country in the world to implement minimum unit pricing (MUP) for all alcoholic drinks sold in licensed premises in Scotland. The use of a Sunset Clause in the MUP legislation was a factor in successfully resisting legal challenges by indicating that the final decision on a novel policy would depend on its impact. An overarching evaluation has been designed and the results will provide important evidence to inform the parliamentary vote on the future of MUP in Scotland. The evaluation uses a mixed methods portfolio of in-house, commissioned, and separately funded studies to assess the impact of MUP across multiple intended and unintended outcomes related to compliance, the alcoholic drinks industry, consumption, and health and social harms. Quantitative studies to measure impact use a suitable control where feasible. Qualitative studies assess impact and provide an understanding of the lived experience and mechanism of change for key sub-groups. As well as providing important evidence to inform the parliamentary vote, adding to the international evidence on impact and experience of alcohol pricing policy across a broad range of outcomes, this approach to evaluating novel policy interventions may provide guidance for future policy innovations.

Evaluating possible intended and unintended consequences of the implementation of alcohol minimum unit pricing (MUP) in Scotland: a natural experiment protocol.

INTRODUCTION: Scotland is the first country to carry out a national implementation of minimum unit pricing (MUP) for alcohol. MUP aims to reduce alcohol-related harms, which are high in Scotland compared with Western Europe, and to improve health equalities. MUP is a minimum retail price per unit of alcohol. That approach targets high-risk alcohol users. This work is key to a wider evaluation that will determine whether MUP continues. There are three study components. METHODS AND ANALYSIS: Component 1 sampled an estimated 2800 interviewees at a baseline and each of two follow-ups from four Emergency Departments in Scotland and Northern England. Research nurses administered a standardised survey to assess alcohol consumption and the proportion of attendances that were alcohol-related.Component 2 covered six Sexual Health Clinics with similar timings and country allocation. A self-completion survey gathered information on potential unintended effects of MUP on alcohol source and drug use.Using a natural experiment design and repeated cross-sectional audit, difference between Scotland (intervention) and North England (control) will be tested for outcomes using regression adjusting for differences at baseline. Differential impacts by age, gender and socioeconomic position will be investigated.Component 3 used focus groups with young people and heavy drinkers and interviews with stakeholders before and after MUP implementation. The focus groups will allow exploration of attitudes, experiences and behaviours and the potential mechanisms by which impacts arise. The interviews will help characterise the implementation process. ETHICS AND DISSEMINATION: Study components 1 and 2 have been ethically approved by the NHS, and component 3 by the University of Stirling. Dissemination plans include peer-reviewed journal articles, presentations, policy maker briefings and, in view of high public interest and the high political profile of this flagship policy, communication with the public via media engagement and plain language summaries. TRIAL REGISTRATION NUMBER: ISRCTN16039407; Pre-results.

The short-term impact of the alcohol act on alcohol-related deaths and hospital admissions in Scotland: a natural experiment.

BACKGROUND AND AIM: The introduction of the Alcohol Act in Scotland on 1 October 2011, which included a ban on multi-buy promotions, was probably associated with a fall in off-trade alcohol sales in the year after its implementation. The aim of this study was to test if the same legislation was associated with reduced levels of alcohol-related deaths and hospital admissions in the 3-year period after its introduction. DESIGN: A natural experiment design using time-series data to assess the impact of the Alcohol Act legislation in Scotland. Comparisons were made with unexposed populations in the rest of Great Britain. SETTING: Scotland with comparable data obtained for geographical control groups in other parts of Great Britain. PARTICIPANTS: For alcohol-related deaths, a total of 17 732 in Scotland and 88 001 in England and Wales throughout 169 4-week periods between January 2001 and December 2013 and for alcohol-related hospital admissions, a total of 121 314 in Scotland and 696 892 in England throughout 182 4-week periods between January 2001 and December 2014. MEASUREMENTS: Deaths and hospital admissions in Scotland and control groups that were wholly attributable to alcohol for consecutive 4-week periods between January 2001 and December 2014. Data were obtained by age, sex and area-based socio-economic position. FINDINGS: There was no evidence to suggest that the Alcohol Act was associated with changes in the overall rate of alcohol-related deaths [incidence rate ratio (IRR) = 0.99, 95% confidence interval (CI) = 0.91-1.07)] or hospital admissions (IRR = 0.98, 95% CI = 0.95-1.02) in Scotland. In control group analyses, the pseudo intervention variable was not associated with a change in alcohol-related death rates in England/Wales (IRR = 0.99, 95% CI = 0.95-1.02), but was associated with an increase in alcohol-related hospital admission rates in England (IRR = 1.05, 95% CI = 1.03-1.07). In combined models, the interaction analysis did not provide support for a 'net effect' of the legislation on alcohol-related deaths in Scotland compared with England/Wales (IRR 0.99, 95% CI = 0.95-1.04), but suggested a net reduction in hospital admissions for Scotland compared with England (IRR = 0.93, 95% CI = 0.87-0.98). CONCLUSION: The implementation of the Alcohol Act in Scotland has not been associated clearly with a reduction in alcohol-related deaths or hospital admissions in the 3-year period after it was implemented in October 2011.

Evaluating the impact of the alcohol act on off-trade alcohol sales: a natural experiment in Scotland.

BACKGROUND AND AIMS: A ban on multi-buy discounts of off-trade alcohol was introduced as part of the Alcohol Act in Scotland in October 2011. The aim of this study was to assess the impact of this legislation on alcohol sales, which provide the best indicator of population consumption. DESIGN, SETTING AND PARTICIPANTS: Interrupted time-series regression was used to assess the impact of the Alcohol Act on alcohol sales among off-trade retailers in Scotland. Models accounted for underlying seasonal and secular trends and were adjusted for disposable income, alcohol prices and substitution effects. Data for off-trade retailers in England and Wales combined (EW) provided a control group. MEASUREMENTS: Weekly data on the volume of pure alcohol sold by off-trade retailers in Scotland and EW between January 2009 and September 2012. FINDINGS: The introduction of the legislation was associated with a 2.6% (95% CI = -5.3 to 0.2%, P = 0.07) decrease in off-trade alcohol sales in Scotland, but not in EW (-0.5%, 95% CI = -4.6 to 3.9%, P = 0.83). A statistically significant reduction was observed in Scotland when EW sales were adjusted for in the analysis (-1.7%, 95% CI = -3.1 to -0.3%, P = 0.02). The decline in Scotland was driven by reduced off-trade sales of wine (-4.0%, 95% CI = -5.4 to -2.6%, P < 0.001) and pre-mixed beverages (-8.5%, 95% CI = -12.7 to -4.1%, P < 0.001). There were no associated changes in other drink types in Scotland, or in sales of any drink type in EW. CONCLUSIONS: The introduction of the Alcohol Act in Scotland in 2011 was associated with a decrease in total off-trade alcohol sales in Scotland, largely driven by reduced off-trade wine sales.