Esther Curnock

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.

The impact on health of employment and welfare transitions for those receiving out-of-work disability benefits in the UK.

Employment status has a dynamic relationship with health and disability. There has been a striking increase in the working age population receiving out-of-work disability benefits in many countries, including the UK. In response, recent UK welfare reforms have tightened eligibility criteria and introduced new conditions for benefit receipt linked to participation in return-to-work activities. Positive and negative impacts have been suggested but there is a lack of high quality evidence of the health impact when those receiving disability benefits move towards labour market participation. Using four waves of the UK’s Understanding Society panel survey (2009–2013) three different types of employment and welfare transition were analysed in order to identify their impact on health. A difference-in-difference approach was used to compare change between treatment and control groups in mental and physical health using the SF-12. To strengthen causal inference, sensitivity checks for common trends used pre-baseline data and propensity score matching. Transitions from disability benefits to employment (n = 124) were associated on average with an improvement in the SF12 mental health score of 5.94 points (95% CI = 3.52–8.36), and an improvement in the physical health score of 2.83 points (95% CI = 0.85–4.81) compared with those remaining on disability benefits (n = 1545). Transitions to unemployed status (n = 153) were associated with a significant improvement in mental health (3.14, 95% CI = 1.17–5.11) but not physical health. No health differences were detected for those who moved on to the new out-of-work disability benefit. It remains rare for disability benefit recipients to return to the labour market, but our results indicate that for those that do, such transitions may improve health, particularly mental health. Understanding the mechanisms behind this relationship will be important for informing policies to ensure both work and welfare are ‘good for health’ for this group.

Investigation of the effect of a multi-buy discount ban on off-trade alcohol sales: a natural experiment in Scotland.

Abstract Background The Alcohol etc (Scotland) Act 2010 was implemented in Scotland on Oct 1, 2011, and included a ban on multi-buy discounts of alcohol in Scotlands supermarkets and off licences (ie, off trade). The main aim of the legislation was to remove the price incentive for consumers to purchase more alcohol than they may otherwise have intended and, in turn, to reduce population levels of alcohol consumption. Alcohol sales data provide the best estimate of population alcohol consumption. We have investigated the effect of the introduction of the Alcohol Act on off-trade alcohol sales in Scotland. Methods We obtained data for the volume of pure alcohol sold off trade in Scotland and in England and Wales from market research specialists Nielsen (Oxford, UK) for individual weeks between January, 2009, and September, 2012 (appendix). Sales estimates were produced from electronic sales records from most large multiple retailers and a weighted stratified random sample of smaller retailers. We have previously shown that alcohol retail sales data offer a robust source of data for measurement and monitoring of alcohol consumption in Scotland and England and Wales. We used interrupted autoregressive integrated moving average time-series models to test for any change in off-trade alcohol sales (all alcohol and by drink type) after the introduction of the Alcohol Act in Scotland. Models accounted for underlying seasonal and secular trends and were adjusted for changes in other potential confounding factors including disposable income, alcohol prices, and on-trade alcohol sales. Data for these covariates were obtained from the Scottish Government and Office for National Statistics; Nielsen and Office for National Statistics; and CGA Strategy (Stockport, UK), respectively. To provide a concurrent control group, we did the same analyses using data for England and Wales, where the Alcohol Act does not apply. Findings The introduction of the Alcohol Act was associated with a 2·6% decrease in per-adult off-trade alcohol sales in Scotland (95% CI −5·3 to 0·2). This decline was driven by changes in off-trade wine sales, which decreased by 4·0% after the Act was introduced (95% CI −5·4 to −2·6). The Act was also associated with reduced sales of pre-mixed alcohol beverages (–8·5%, 95% CI −12·7 to −4·1), although these account for a very small proportion of total off-trade sales (1%). The Act was not associated with changes in sales of spirits, beer, or cider or perry in Scotland. There was no evidence to support an association between off-trade alcohol sales and the dummy Alcohol Act variable in England and Wales. Interpretation The introduction of the Alcohol Act was associated with reduced off-trade alcohol sales in Scotland, largely attributable to a decline in wine sales. Key strengths of our study include the use of objective data for alcohol sales rather than subjective data on self-reported consumption, and the adjustment of our time-series models for underlying trends and potential confounders. Limitations include the exclusion of alcohol sales by certain retailers, the inability to disaggregate population sales estimates by different subgroups, and the short period after implementation of the Act. However, similar changes were not noted in England and Wales, where the Act does not apply, which lends weight to the hypothesis that the changes witnessed in Scotland were as a result of the Act rather than other unmeasured factors or biases. Thus, legislation to ban alcohol discounting seems an important policy in the mix to reduce population alcohol consumption levels. Funding Purchase of the sales data was funded by the Scottish Government as part of the wider Monitoring and Evaluating Scotlands Alcohol Strategy portfolio of studies.

What would it take to eradicate health inequalities? A cross-sectional study using routine administrative data

Abstract Background Phelan and Link argue that socioeconomic status is a fundamental cause of mortality inequalities, hypothesising that any fundamental cause (other candidates include racism and stigma) will have three essential features: (1) will be associated with many disease outcomes; (2) will affect outcomes through a range of intervening mediators; and (3) will persistently display health gradients despite substitution of new for old mediators, such as persistent gradient in all-cause mortality despite change from infectious to non-communicable disease risk factors. They further propose that fundamental causes probably operate via differential access to many resources, which can be variously used to protect and improve health, and that there should therefore be no or lesser health gradients when deployment of resources for health advantage cannot be consciously used; for example, in cases in which we know little or nothing about how to prevent or treat a fatal disease. In view of the already substantial evidence that socioeconomic status meets the first and second essential feature of a fundamental cause as defined by Phelan and Link, we set out to assess whether there is evidence of substitution in a Scottish population sample and investigate whether socioeconomic inequalities in mortality increase with increasing preventability in Scotland. Methods Using death certification data and census population data from 1961, 1981, 1991, and 2001, we described trends in absolute and relative inequalities for 46 causes of death for men and women across Carstairs index of deprivation deciles between 1983 and 1999 and for men aged 20–64 years across social classes for the period 1976–1999 to assess whether substitution of specific causes of mortality had occurred. Additionally, we described mortality rates within Carstairs deciles and social classes for: (1) avoidable mortality and a sample of causes of death not classified as avoidable by the Office of National Statistics and (2) four categories of death grouped according to a pre-existing, expert-established, preventability typology. The slope index of inequality (SII), which gives a single measure of the absolute difference across socioeconomic groups while accounting for the size of each socioeconomic group, was used to describe absolute inequalities trends. The relative index of inequality was calculated by dividing the SII by the mean mortality rate and was used to describe trends in relative inequalities. Findings Although socioeconomic inequalities in mortality decreased in both absolute and relative terms for certain causes of death (eg, tuberculosis and rheumatic heart disease for women), they increased over the same time period for others (eg, alcohol-related mortality and suicide). New socioeconomic gradients also emerged for many specific causes of death (eg, malignant melanoma, mortality associated with perinatal complications, and colorectal cancer). There was a clear socioeconomic gradient for avoidable mortality but not for non-avoidable mortality. Relative inequalities seemed to be directly proportional to preventability (appendix). Interpretation Socioeconomic status exhibits Phelan and Links proposed features of a fundamental cause of disease in Scotland, being associated with several causes of death mediated by a range of intermediate mechanisms and with evidence of substitution during the observation period. Weaknesses of this work include the small numbers of deaths for some specific causes; the inclusion of a small number of non-avoidable causes of death; the use of the 1991 Carstairs index throughout; and possible numerator and denominator mismatch for social class estimates. The first of these potentially limits the reliability of some findings, and the remainder introduce potential bias. This study suggests that continuing to focus on controlling individual intermediate mediators such as tobacco will ultimately fail to eradicate health inequalities and that sustained reduction and prevention will only be achieved by addressing underlying inequalities in income, wealth, and power. Funding None.

Do regional labour market conditions affect transitions into employment from health-related inactivity? Multilevel analysis of longitudinal UK Labour Force Survey data

Abstract Background Long-term worklessness (unemployment or economic inactivity) is associated with adverse health outcomes and inequalities. Recent UK welfare reforms, alongside other return-to-work policies, have aimed to increase employment rates for people who have been out of the labour market because of sickness and disability. However, sickness benefit claimant counts vary substantially by geographical area and are highest in the post-industrial regions with the weakest economies. The aim of this study was to investigate whether local labour market conditions affect transitions from health-related inactivity into employment and compare them with transitions from unemployment to work. Methods Longitudinal Labour Force Survey datasets were used to follow working age individuals resident in Great Britain over five consecutive quarters. Datasets from 1999–2013 were pooled (quarter 1 health-related inactivity group n=29 130, unemployed group n=14 873). Multilevel logistic regression models (region at level 3, year-within-region at level 2) were constructed with employment at quarter 5 (Q5) as the main outcome measure. Annual male regional employment rates were used as a proxy for local labour market conditions. Findings Transitions into employment for the health-related inactivity group were rare (1057/29 130 [3·6%] at Q5) compared with the unemployed group (6255/14 873 [42·1%]). Regional variance was significant at baseline (p=0·03), and adding local employment rates as a fixed effect eliminated all observed area-level variability. A 1% increase in local employment rates was associated with an unadjusted odds ratio (OR) of transition to employment for the health-related inactivity group of 1·08 (95% CI 1·05–1·10) and for the unemployed group 1·08 (1·06–1·10). Adjustment for sex, age, education, and long-term health status had little effect (health-related inactivity group adjusted OR 1·07, 1·05–1·10). Interpretation Local labour market conditions fully account for regional differences in transition rates from health-related inactivity into employment. Higher regional employment rates are associated with increased rates of return to employment, and this association is similar to that for unemployed groups; however, overall rates of transition were low compared with unemployed groups. One limitation of our study is loss to follow-up. Local labour market improvement could potentially increase return-to-work rates for the sick and disabled. Public health advocacy and collaborative action with policy makers in local and national government is needed to address this issue. Funding EC receives funding from the Chief Scientist Office of the Scottish Government Health Directorates (SPHSU1) as part of the Evaluating the Health Effects of Social Interventions programme at the Medical Research Council/Chief Scientist Office (MRC/CSO) Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. AHL receives core funding from the UK Medical Research Council (MC_UU_12017/5) and the Chief Scientist Office of the Scottish Government Health Directorates (SPHSU2) as part of the Measuring Health programme at the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. FP receives core funding from the UK Medical Research Council (MC_UU_12017/7) as part of the Social Patterning of Health over the Lifecourse Programme at the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.