Figure 1: Working years of life lost in England 2015 broken down by alcohol-related harms and other attributable harms (000’s) (2)
Written Evidence from Public Health England
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Contents
1. The scale of alcohol-related harm
2. PHE’s evidence review and the UK Supreme Court ruling
3. Price as a lever for behaviour change
4. Evidence to support a minimum unit price for alcohol
1. The scale of alcohol-related harm
1.1 A substantial number of people experience harm from alcohol, either as a result of their own consumption, or other people’s (1). Of over one million hospital admissions in 2014/15 where an alcohol-related condition was a feature, 47% occurred in the lowest three socioeconomic deciles (2).
1.2 In 2016, for people aged 15 to 49 years, alcohol was the second biggest risk factor for ill-health, disability and early death, and for all ages it is the fourth biggest risk factor (3). In 2016 there were 16,000 alcohol-specific deaths (4), many of which occurred in the young; the average age of those dying from an alcohol-related death is 54 years, 23 years premature compared to the general population (1).
1.3 As young and middle aged people die as a result of alcohol misuse, more working years were lost to alcohol in England in 2015 than the ten most frequent cancer types combined; there were an estimated 167,000 working years lost due to alcohol (16% of all working years lost) (Figure 1) (2).
1.4 As was outlined in PHE’s recent evidence review, alcohol plays a key role in a range of crimes (1). Alcohol intoxication is associated with aggression and violence, including glassing injuries, which rises with an increase in the amount of alcohol consumed. Alcohol consumption is also associated with an increased likelihood of carrying out homicide, physical assault, intimate partner violence, sexual assault, robbery, and burglary, with risks rising with increased alcohol consumption. Areas with a high density of licensed premises are also areas with high-levels of alcohol-related crime, particularly violence and public disorder. Finally, alcohol use disorder and dependence is highly prevalent among the prison population, with a large number of prisoners being identified as potentially dependent, some of whom are receiving treatment (1).
1.5 The UK government estimates place the economic burden of alcohol misuse at over £21 billion in 2012 (5), amounting to 1.3% of GDP. Estimates from the published literature suggest the gross economic costs could be as high as £52 billion (2.7% of GDP) (1) in 2016, and it is likely that the actual figure remains somewhere in between.
1.6 Combined data from the Health Survey for England shows that a small number of the heaviest drinkers consume a disproportionate amount of alcohol – 4.4% of the heaviest drinkers consume 30.3% of all self-reported alcohol (Figure 2) (2). This is equivalent to around two million drinkers. Additionally, Health Survey for England data shows that the heaviest drinkers are those who are least likely to report reducing their consumption compared to people who report drinking within low-risk levels.
1.7 There are substantial socioeconomic variations in alcohol-related mortality, with the inequalities being greater for women than for men. In a study by the Office for National Statistics (ONS), the mortality rate of men in the ‘routine class’ was 3.5 times those of men in ‘higher and managerial occupations’, while for women the corresponding figure was 5.7 times (6). These deaths occur most frequently in middle aged patients and have a devastating impact on their families (7).
1.8 In Scotland in 2011, data from patients with serious alcohol problems reports that they paid 43p per unit of alcohol on average (8). This was much lower than the Scottish population as a whole who paid, on average, 71p per unit. Of units consumed, 83% were consumed below the 50p per unit proposed by the Scottish legislation. The lower the price paid the more units a patient consumed.
2. PHE’s evidence review and the UK Supreme Court ruling
1.9 PHE recently reviewed the evidence of alcohol-related harm and the potential measures to reduce this (2). This review was subjected to national and international peer-review and published in the Lancet (Appendix 1) (1).
1.10 The review concluded: “An extensive number of policies seek to mitigate the health, social, and economic harms caused by alcohol. While these policies vary in their effectiveness and cost-effectiveness, evidence supports those that reduce the affordability of alcohol as the most effective and cost-effective approach to prevention and health improvement” (1).
1.11 As part of the PHE review, the quality of evidence to support each alcohol policy was evaluated using an adapted version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (9). GRADE is used by the National Institute for Health and Care Excellence (NICE), among others, and is an internationally recognised tool for rating the quality of a given evidence base. Evidence is rated from ‘very low quality’ (meaning any estimate of effect is very uncertain); through to ‘high quality’ (meaning further research is unlikely to change the estimate of effect).
1.12 Most alcohol policies cannot be directly manipulated and subjected to experimental methods such as a randomised controlled trial, so their evaluation has to rely on other research methods, namely natural experiments. Where natural experiments cannot be done, or for predicting long-term outcomes, modelling studies can be used. On these occasions, natural experiments should be considered the highest level of evidence followed by modelling studies.
1.13 PHE’s evidence review rated the quality of evidence for taxation for reducing alcohol-related harm as the highest, recognising that the evidence is strong and consistent, and future evidence is unlikely to change the estimate of effect (1). For minimum prices, the quality of evidence was rated as ‘moderate’, recognising that estimates of effects from modelling studies were consistent with the experience in Canada. The experience in Canada also suggested that the modelling studies produced conservative estimates
1.14 Mechanisms to make alcohol less affordable include increasing excise duty or the setting of a minimum price per unit of alcohol. The contrasting merits of these two approaches have been evaluated by the UK Supreme Court, which concluded that: “Minimum pricing targets the health hazards of cheap alcohol and the groups most affected in a way that an increase in excise or value added tax [VAT] does not. The latter would be felt across the board in relation to the whole category of goods to which it applied and unnecessarily affect groups which are not the focus of the legislation. Second, in agreement with the Lord Ordinary, minimum pricing is easier to understand and simpler to enforce. It would not be open to absorption (e.g. by selling alcohol below cost in order to attract other business onto their premises)” (10).
1.15 The Supreme Court also noted “that minimum pricing will involve a market distortion, including of EU trade and competition, is accepted. However, I find it impossible, even if it is appropriate to undertake the exercise at all in this context, to conclude that this can or should be regarded as outweighing the health benefits which are intended by minimum pricing” (10).
3. Price as a lever for behaviour change
1.16 The affordability of alcohol is an important determinant of alcohol consumption (11) and alcohol-related harm (12), so taxation or price regulation represent a crucial element of national alcohol policy.
1.17 The price of a product is an important lever for changing the behaviour of consumers and increasing revenue for the treasury. This has long been recognised in the field of tobacco, where there is an annual duty escalator, and has been more recently acknowledged in the field of obesity with the advent of the sugary drinks levy expected to be implemented from April this year.
1.18 Alcohol is now substantially more affordable than it was in 1980 (1). The alcohol duty escalator, which was introduced in 2008 to increase alcohol duties by 2% above inflation each year, had an almost immediate impact on mortality (Figure 3). The duty escalator was successively repealed for some beverage types, with further freezes and/or cuts to beverage duty since, and mortality returned to an upward trend. According to the UK Treasury, the cuts in alcohol duty since 2013 are projected to cost taxpayers a total of £4,695 billion (2).
1.19 The majority of alcohol-related deaths are from alcohol dependency and alcohol-related liver disease; as such, the changes in deaths during the period of the alcohol duty escalator show changes in drinking behaviour of very heavy and extreme drinkers in response to changes in affordability. This group drink simultaneously cheap, strong alcohol, and are more likely to be of low socioeconomic status and thus spending a high proportion of income on alcohol (6, 13, 14).
4. Evidence to support a minimum unit price for alcohol
1.20 MUP is a highly targeted price increase which affects the simultaneously cheap high-strength alcohol purchased by those drinking at harmful and extreme levels.
1.21 MUP has an advantage that the price increases of alcohol are passed on to the consumer at the point-of-sale ensuring price can be used in a way that benefits public health(15).
1.22 A range of scenarios have been modelled for a MUP in England ranging from 45-60p; the most recent estimates use a 60p over a cumulative five-year period, and older estimates predict the impact of a 50p MUP over 10 and 20 years. MUP as currently modelled, will not affect the price of alcohol in pubs and bars, and will have a minimal impact on people drinking within the Chief Medical Officers low risk guidelines (14 units/week). For example, in response to a 60p MUP moderate drinkers are estimated to spend an additional £7 per year (16).
1.23 The potential impact of MUP has been modelled in England (17-19), Scotland (20), Wales (21), Ireland (22), and Australia (23, 24). A very important conclusion from these studies is that because MUP only affects strong cheap alcohol, it will substantially reduce health inequality. For a 50p MUP high-risk drinkers in the lowest socioeconomic group are estimated to experience almost double the gains in terms of reduced mortality and hospital admissions, of any other population sub-group (19). Crucially, moderate drinkers, irrespective of socioeconomic status, are minimally affected even by a 60 pence MUP, with estimates of increases in monthly spending of 61 pence.
1.24 The findings of modelling studies have been corroborated by natural experiments in Canada (25-28). As predicted, the measured health response to a change in price was rapid and occurred within nine months in Canada (28), a 10% increase in MUP resulted in a 30% decrease in directly attributable mortality. The beneficial health impact of the policy was still present at two years.
1.25 The most recent data for England models a 60p MUP and estimates that the cumulative effect of a 60p MUP at five years would prevent (16):
1.26 Table 1 presents the estimated cumulative savings (in £ million) to the NHS and wider society five years after the introduction of a 60p MUP (16). These are substantial, and would enable increased sustainability of the NHS alongside increased economic development and competitiveness.
1.27 On the case brought against the Scottish Government, the European Court recommended that tax may be a better mechanism to reduce health harm from alcohol (10). However, modelling for England estimates taxation would need to increase by 28% to achieve the reductions in alcohol-related deaths estimated with a 50p MUP (20).
Figure 1: Working years of life lost in England 2015 broken down by alcohol-related harms and other attributable harms (000’s) (2)
Figure 2: Alcohol consumption recorded in the 2012-2014 Health Survey for England (2)
Figure 3: Trends in the affordability of alcohol, disposable income, and alcohol-related mortality; data indexed to 1980 (adapted from (1))
Table 1: Estimated cumulative savings (£ million) to the NHS and wider society five years after the introduction of a 60p MUP (16)
Healthcare costs
| QALY valuation a | Crime costs | Work absence costs | Total |
-£465.7
| -£1,201.5 | -£1,387.9 | -£136.1 | -£3,191.3 |
a A year of life lived in perfect health is worth one QALY (Quality Adjusted Life Year)
January 2018
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