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

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          Abstract

          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.

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          Most cited references44

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          Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

          Mohammad Forouzanfar, Ashkan Afshin, Lily T Alexander … (2017)
          Summary Background The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. Methods We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). Findings Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. Interpretation Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Funding Bill & Melinda Gates Foundation.
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            Alcohol and public health.

            Robin Room, Thomas Babor, Jürgen Rehm (2005)
            Alcoholic beverages, and the problems they engender, have been familiar fixtures in human societies since the beginning of recorded history. We review advances in alcohol science in terms of three topics: the epidemiology of alcohol's role in health and illness; the treatment of alcohol use disorders in a public health perspective; and policy research and options. Research has contributed substantially to our understanding of the relation of drinking to specific disorders, and has shown that the relation between alcohol consumption and health outcomes is complex and multidimensional. Alcohol is causally related to more than 60 different medical conditions. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco and hypertension. Treatment research shows that early intervention in primary care is feasible and effective, and a variety of behavioural and pharmacological interventions are available to treat alcohol dependence. This evidence suggests that treatment of alcohol-related problems should be incorporated into a public health response to alcohol problems. Additionally, evidence-based preventive measures are available at both the individual and population levels, with alcohol taxes, restrictions on alcohol availability, and drinking-driving countermeasures among the most effective policy options. Despite the scientific advances, alcohol problems continue to present a major challenge to medicine and public health, in part because population-based public health approaches have been neglected in favour of approaches oriented to the individual that tend to be more palliative than preventative.
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              Effects of alcohol tax and price policies on morbidity and mortality: a systematic review.

              Kelli Komro, Alexander C Wagenaar, Amy Tobler (2010)
              We systematically reviewed the effects of alcohol taxes and prices on alcohol-related morbidity and mortality to assess their public health impact. We searched 12 databases, along with articles' reference lists, for studies providing estimates of the relationship between alcohol taxes and prices and measures of risky behavior or morbidity and mortality, then coded for effect sizes and numerous population and study characteristics. We combined independent estimates in random-effects models to obtain aggregate effect estimates. We identified 50 articles, containing 340 estimates. Meta-estimates were r = -0.347 for alcohol-related disease and injury outcomes, -0.022 for violence, -0.048 for suicide, -0.112 for traffic crash outcomes, -0.055 for sexually transmitted diseases, -0.022 for other drug use, and -0.014 for crime and other misbehavior measures. All except suicide were statistically significant. Public policies affecting the price of alcoholic beverages have significant effects on alcohol-related disease and injury rates. Our results suggest that doubling the alcohol tax would reduce alcohol-related mortality by an average of 35%, traffic crash deaths by 11%, sexually transmitted disease by 6%, violence by 2%, and crime by 1.4%.
              Article 0 comments Cited 147 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2019
                Publication date (Electronic): 20 June 2019
                Volume: 9
                Issue: 6
                Electronic Location Identifier: e028482
                Affiliations
                [1 ] departmentMRC/CSO Social & Public Health Sciences Unit , University of Glasgow School of Life Sciences , Glasgow, UK
                [2 ] departmentScottish Public Health Observatory , NHS Health Scotland , Glasgow, UK
                [3 ] departmentAddictions , King’s College London , London, UK
                [4 ] departmentInstitute of Psychiatry , Kings College London , London, UK
                [5 ] departmentSchool of Health Sciences , Institute for Social Marketing , Stirling, UK
                [6 ] ISD Scotland , Edinburgh, UK
                [7 ] departmentHealth Economics Research Unit , University of Aberdeen , Aberdeen, UK
                [8 ] departmentFaculty of Health Sciences Institute for Clinical and Applied Health Research (ICAHR) , University of Hull , Hull, UK
                [9 ] departmentInstitute for Social Marketing , University of Stirling and the Open University , Stirling, UK
                [10 ] departmentInstitute for Social Marketing , University of Stirling , Stirling, UK
                [11 ] departmentAustralian Health Policy Collaboration , Victoria University , Victoria, Australia
                Author notes
                [Correspondence to ] Dr Andrew Millard; Andrew.millard@ 123456glasgow.ac.uk
                Author information
                http://orcid.org/0000-0003-3824-7458
                http://orcid.org/0000-0003-0633-8152
                http://orcid.org/0000-0001-8020-4510
                Article
                Publisher ID: bmjopen-2018-028482
                DOI: 10.1136/bmjopen-2018-028482
                PMC ID: 6596978
                PubMed ID: 31221890
                SO-VID: a319dd37-bf34-4140-beea-7486a7f43df5
                Copyright © © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 10 December 2018
                Date revision received : 27 March 2019
                Date accepted : 30 May 2019
                Funding
                Funded by: NIHR Public Health Research Programme;
                Funded by: FundRef http://dx.doi.org/10.13039/501100000265, Medical Research Council;
                Funded by: NRS Senior Clinical Fellowship (for SVK);
                Funded by: Scottish Government Chief Scientist Office;
                Categories
                Subject: Addiction
                Subject: Protocol
                Subject: 1506
                Subject: 1681
                Custom metadata
                special-feature unlocked

                ScienceOpen disciplines: Medicine
                Keywords: alcohol,pricing,policy,evaluation
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: alcohol, pricing, policy, evaluation

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