Colin Angus

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

Summary 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).

Modelling the Cost-Effectiveness of Alcohol Screening and Brief Interventions in Primary Care in England

AIMS To estimate the cost-effectiveness and resourcing implications of universal alcohol screening and brief intervention (SBI) programmes in primary care in England. METHODS This was a health economic model, combining evidence of the effectiveness and health care resource requirements of SBI activities with existing epidemiological modelling of the relationship between alcohol consumption and health harms. RESULTS Screening patients on registration with a family doctor would steadily capture ~40% of the population over a 10-year programme; screening patients at next primary care consultation would capture 96% of the population over the same period, but with high resourcing needs in the first year. The registration approach, delivered by a practice nurse, provides modest cost savings to the health care system of £120 m over 30 years. Health gains over the same period amount to 32,000 quality-adjusted life years (QALYs). This SBI programme still appears cost-effective (at £6900 per QALY gained) compared with no programme, under pessimistic effectiveness assumptions. Switching to a consultation approach, delivered by a doctor, would incur an incremental net cost of £108 m, with incremental health gains equivalent to 92,000 QALYs, giving an incremental cost-effectiveness ratio of £1175 per QALY gained compared with current practice. CONCLUSION A universal programme of alcohol SBI in primary care is estimated to be cost-effective, under all but the most pessimistic assumptions for programme costs and effectiveness. Policymakers should ensure that SBI programmes are routinely evaluated and followed up, given the substantial uncertainty over the effects of many of the implementation details.

Estimation of own and cross price elasticities of alcohol demand in the UK—A pseudo-panel approach using the Living Costs and Food Survey 2001–2009

Highlights • A pseudo-panel approach is used to estimate own- and cross-price elasticities of off- and on-trade alcoholic beverages.• Estimated own-price elasticities are all negative, with off-trade cider and beer being most elastic and off-trade spirits and on-trade ready-to-drinks least elastic.• Estimated cross-price elasticities are smaller in magnitude with a mix of positive and negative signs.• The results could be used for appraising the estimated impact of price-based interventions such as minimum unit pricing and taxation in the UK.

Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England

Background Brief interventions have a modest but meaningful effect on promoting smoking cessation and reducing excessive alcohol consumption. Guidelines recommend offering such advice opportunistically and regularly but incentives vary between the two behaviours. Aim To use representative data from the perspective of patients to compare the prevalence and characteristics of people who smoke or drink excessively and who receive a brief intervention. Design and setting Data was from a representative sample of 15 252 adults from household surveys in England. Method Recall of brief interventions on smoking and alcohol use, sociodemographic information, and smoking and alcohol consumption patterns were assessed among smokers and those who drink excessively (AUDIT score of ≥8), who visited their GP surgery in the previous year. Results Of 1775 smokers, 50.4% recalled receiving brief advice on smoking in the previous year. Smokers receiving advice compared with those who did not were more likely to be older (odds ratio [OR] 17-year increments 1.19, 95% confidence interval [CI] =1.06 to 1.34), female (OR 1.35, 95% CI =1.10 to 1.65), have a disability (OR 1.44, 95% CI = 1.11 to 1.88), have made more quit attempts in the previous year (compared with no attempts: one attempt, OR 1.65, 95% CI = 1.32 to 2.08; ≥2 attempts, OR 2.02, 95% CI =1.49 to 2.74), and have greater nicotine dependence (OR 1.17, 95% CI =1.05 to 1.31) but were less likely to have no post-16 qualifications (OR 0.81, 95% CI = 0.66 to 1.00). Of 1110 people drinking excessively, 6.5% recalled receiving advice in their GP surgery on their alcohol consumption in the previous year. Those receiving advice compared with those who did not had higher AUDIT scores (OR 1.17, 95% CI =1.12 to 1.23) and were less likely to be female (OR 0.44, 95% CI = 0.23 to 0.87). Conclusion Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, <10% of those who drink excessively report having received advice on their alcohol consumption.

What are the Implications for Policy Makers? A Systematic Review of the Cost-Effectiveness of Screening and Brief Interventions for Alcohol Misuse in Primary Care

Introduction: The efficacy of screening and brief interventions (SBIs) for excessive alcohol use in primary care is well established; however, evidence on their cost-effectiveness is limited. A small number of previous reviews have concluded that SBI programs are likely to be cost-effective but these results are equivocal and important questions around the cost-effectiveness implications of key policy decisions such as staffing choices for delivery of SBIs and the intervention duration remain unanswered. Methods: Studies reporting both the costs and a measure of health outcomes of programs combining SBIs in primary care were identified by searching MEDLINE, EMBASE, Econlit, the Cochrane Library Database (including NHS EED), CINAHL, PsycINFO, Assia and the Social Science Citation Index, and Science Citation Index via Web of Knowledge. Included studies have been stratified both by delivery staff and intervention duration and assessed for quality using the Drummond checklist for economic evaluations. Results: The search yielded a total of 23 papers reporting the results of 22 distinct studies. There was significant heterogeneity in methods and outcome measures between studies; however, almost all studies reported SBI programs to be cost-effective. There was no clear evidence that either the duration of the intervention or the delivery staff used had a substantial impact on this result. Conclusion: This review provides strong evidence that SBI programs in primary care are a cost-effective option for tackling alcohol misuse.

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.

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

BackgroundAs 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.MethodsThe 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.ResultsModel 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.ConclusionsThis 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.

Measurable effects of local alcohol licensing policies on population health in England

Background English alcohol policy is implemented at local government level, leading to variations in how it is put into practice. We evaluated whether differences in the presence or absence of cumulative impact zones and the ‘intensity’ of licensing enforcement—both aimed at regulating the availability of alcohol and modifying the drinking environment—were associated with harm as measured by alcohol-related hospital admissions. Methods Premises licensing data were obtained at lower tier local authority (LTLA) level from the Home Office Alcohol and Late Night Refreshment Licensing data for 2007–2012, and LTLAs were coded as ‘passive’, low, medium or highly active based on whether they made use of cumulative impact areas and/or whether any licences for new premises were declined. These data were linked to 2009–2015 alcohol-related hospital admission and alcohol-related crime rates obtained from the Local Alcohol Profiles for England. Population size and deprivation data were obtained from the Office of National Statistics. Changes in directly age-standardised rates of people admitted to hospital with alcohol-related conditions were analysed using hierarchical growth modelling. Results Stronger reductions in alcohol-related admission rates were observed in areas with more intense alcohol licensing policies, indicating an ‘exposure–response’ association, in the 2007–2015 period. Local areas with the most intensive licensing policies had an additional 5% reduction (p=0.006) in 2015 compared with what would have been expected had these local areas had no active licensing policy in place. Conclusions Local licensing policies appear to be associated with a reduction in alcohol-related hospital admissions in areas with more intense licensing policies.

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.

UK alcohol industry’s “billion units pledge”: interim evaluation flawed

Flaws in the Department of Health’s interim evaluation of an alcohol industry pledge to remove one billion alcohol units from the market raise questions about the claimed success argue John Holmes and colleagues. They say that the report should be withdrawn and revised targets set