- Email: [email protected]
Alcohol minimum unit pricing and socioeconomic status
Comment
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Dartnall E, Jewkes R. Sexual violence against women: the scope of the problem. Best Pract Res Clin Obstet Gynaecol 2013; 27: 3–13. Vanwesenbeeck I. Sexual violence and the MDGs. Int J Sex Health 2008; 20: 25–49. García-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts C. WHO multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. Geneva: WHO, 2005. Abrahams N, Devries K, Watts C, et al. Worldwide prevalence of nonpartner sexual violence: a systematic review. Lancet 2014; published online Feb 12. http://dx.doi.org/10.1016/S0140-6736(13)62243-6. Lawry L, Reis C, Kisielewski M, Asher J. Problems in reporting sexual violence prevalence. Am J Public Health 2011; 101: 2004–05. Johnson K, Scott J, Rughita B, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo. JAMA 2010; 304: 553–62.
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Watts CH, Foss AM, Hossain M, Zimmerman C, von Simson R, Klot J. Sexual violence and conflict in Africa: prevalence and potential impact on HIV incidence. Sex Transm Infect 2010; 86 (suppl 3): iii93–99. Peterman A, Palermo T, Bredenkamp PC. Peterman et al respond. Am J Public Health 2011; 101: 2005. The Lancet. Sexual violence: a global awakening, from India. Lancet 2013; 318: 2. García-Moreno C, Stöckl H. Protection of sexual and reproductive health rights: addressing violence against women. Int J Gynaecol Obstet 2009; 106: 144–47. Yount KM, VanderEnde K, Zureick-Brown S, Minh TH, Schuler SR, Hoang TA. Measuring attitudes about women’s recourse after exposure to intimate partner violence: The ATT-RECOURSE scale. J Interpers Violence 2013; published online Dec 24. DOI:10.1177/0886260513511536.
Britt Chudleigh/Mint Images/Corbis
Alcohol minimum unit pricing and socioeconomic status
Published Online February 10, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60154-9 See Articles page 1655
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Floor prices for alcohol, beneath which alcohol cannot be sold, are in place in Moldova, Russia, Ukraine, Uzbekistan, some US states (eg, Connecticut), and eight of the ten Canadian provinces. In 2012, Scotland legislated alcohol minimum unit pricing—a lowest price per unit of alcohol—the introduction of which is pending legal challenge. In the UK, minimum unit pricing is the subject of substantial political and policy debate. UK alcohol prices in the off-trade, particularly supermarkets, have risen more slowly than have taxes on alcohol.1 Harmful drinkers favour cheap off-trade alcohol,2 which is targeted by minimum unit pricing. Drinkers on low income also favour cheap alcohol.3 The UK Government reneged on its plans to introduce a minimum unit price of £0·45, citing concerns that responsible drinkers on a low income might be disadvantaged.4 However, the burden of minimum unit pricing on people from lowincome groups would be small, at worst.5,6 People from low socioeconomic status backgrounds have fewer resources to protect themselves from the ill effects of drinking, and have high levels of alcohol-related mortality and hospital admission at all levels of drinking compared with people from higher socioeconomic status backgrounds.7 In The Lancet, John Holmes and colleagues8 report their assessment of the effect of the proposed £0·45 minimum unit price in England as a function of income and socioeconomic status, based on their Sheffield Alcohol Policy Model. This model combines an econometric model, which relates changes in the price of alcohol to changes in alcohol consumption, and an epidemiological model, which translates alcohol
consumption to mortality and morbidity. In response to the minimum unit price, the study predicts that harmful drinkers in the lowest income quintile would reduce their annual alcohol consumption by 7·6% (about 4 weeks’ worth of alcohol) and spend less on alcohol overall, whereas harmful drinkers in the highest quintile would only reduce their consumption by 1%. Responsible drinkers in the lowest quintile would reduce consumption by 1·6% and also spend less on alcohol. Public health outcomes were predicted by occupation or socioeconomic status. In Holmes and colleagues’ study8 the lowest socioeconomic groups made up about 41% of the population, but were estimated to account for 59% of the alcoholassociated health costs. 10 years after introduction of minimum unit pricing, annual alcohol-related health costs for this group were reduced by 4·7%; this reduction accounting for 88% of population-wide savings. The study assumed that retailers would only increase prices to the minimum threshold, providing a conservative estimate of the effect of minimum unit pricing. Canada’s experience is that retailers also increase the price of more expensive forms of alcohol to maintain relative price structures.9 The Sheffield Alcohol Policy Model would ideally be built on a dataset including people’s alcohol purchases, consumption, location of purchase, and price. No such dataset exists, so the model links the 2009 General Lifestyle Survey (containing information on mean weekly and highest daily alcohol consumption by beverage types) and the UK Living Costs and Food Survey (containing information on alcoholic beverages www.thelancet.com Vol 383 May 10, 2014
Comment
purchased off-trade and on-trade and prices paid). Government and other funders of research should prioritise collection of such data to inform evidencebased policy decisions. The econometric model centres on estimates of people’s responsiveness to changes in the price of alcohol. In the absence of data that follow individuals over time, the Sheffield Alcohol Policy Model uses a pseudo-panel built from repeated cross-sectional data (the UK Living Costs and Food Survey), and estimates a set of measures of price responsiveness for on-trade and off-trade beverages, controlling for age, sex, and birth year of the purchaser. To predict effects of minimum unit pricing on alcohol consumption, the model assumes that drinkers with a preference for packaged beer from supermarkets, for example, respond in the same way, irrespective of their income and pattern of alcohol consumption. No data exist to support or refute this assumption. A methodological limitation of the analysis is that changes in the highest daily consumption were based on changes in average consumption, despite some evidence that risky single-occasion drinking is less responsive to price changes than is average consumption.10 The model translates estimated changes in alcohol consumption to mortality and disease prevalence for 47 chronic and acute conditions based on the published literature, with the same risk curves for mortality and morbidity. The authors acknowledge that recent meta-analyses have found different risks of mortality and morbidity for some illnesses.11 Holmes and colleagues’ study follows a well-accepted approach for dealing with uncertainty in modelling, and undertakes sensitivity analysis. For example, when combining the consumption and purchase datasets it considers the possibility that people buy alcohol for others, and it also considers the possibility of under-reporting of alcohol consumption in the General Lifestyle Survey. Stakeholders in the UK minimum unit pricing policy debate regard the predictions made by the Sheffield Alcohol Policy Model that are specific to the UK as more relevant than assessments of floor prices in other jurisdictions.12 This study provides persuasive evidence that the proposed £0·45 minimum unit price will have little effect on what low-income moderate drinkers drink and spend on alcohol. Rather, it targets individuals www.thelancet.com Vol 383 May 10, 2014
least able to protect themselves from the ill effects of harmful drinking. Of further benefit, families containing harmful drinkers stand to gain from the decreased likelihood of loss of income through the drinker’s death, injury, or illness and reduced risk of domestic violence.13 Furthermore, the potential reduction in government spending on health care could result in lower taxes and charges and expanded government services. Holmes and colleagues’ findings8 should assuage the UK Government’s concerns and provide further support for proponents of minimum unit pricing in this hotly argued debate. Jenny Chalmers Drug Policy Modelling Program, National Drug and Alcohol Research Centre, University of New South Wales Australia, Sydney, NSW 2052, Australia [email protected] I declare that I have no competing interests. Copyright © Chalmers. Open Access article distributed under the terms of CC BY-NC-ND. 1 2
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HM Treasury. Review of alcohol taxation. London: HM Treasury, 2010. Crawford MJ, Parry AMH, Weston ARW, et al. Relationship between price paid for off-trade alcohol, alcohol consumption and income in England: a cross-sectional survey. Alcohol Alcohol 2012; 47: 738–42. Forsyth AJ, Ellaway A, Davidson N. How might the alcohol minimum unit pricing (MUP) impact upon local off-sales shops and the communities which they serve? Alcohol Alcohol 2014; 49: 96–102. Gilmore I, Daube M. How a minimum unit price for alcohol was scuppered. BMJ 2014; published online Jan 8. DOI:10.1136/bmj.g23. Griffith R, Leicester A, O’Connell M. Price-based measures to reduce alcohol consumption. IFS Briefing Note BN138. London: Institute for Fiscal Studies, 2013. Ludbrook A, Petrie D, McKenzie L, Farrar S. Tackling alcohol misuse: purchasing patterns affected by minimum pricing for alcohol. Appl Health Econ Health Policy 2012; 10: 51–63. Mäkelä P, Paljärvi T. Do consequences of a given pattern of drinking vary by socioeconomic status? A mortality and hospitalisation follow-up for alcohol-related causes of the Finnish Drinking Habits Survey. J Epidemiol Community Health 2008; 62: 728–33. Holmes J, Meng Y, Meier PS, et al. Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study. Lancet 2014; published online Feb 10. http://dx.doi.org/10.1016/S01406736(13)62417-4. Robson K. Alcohol (Minimum Pricing) (Scotland) Bill, 2012. SPICe Briefing 12/01. Edinburgh: Scottish Government, 2012. Byrnes J, Shakeshaft A, Petrie D, Doran C. Can harms associated with high-intensity drinking be reduced by increasing the price of alcohol? Drug Alcohol Rev 2013; 32: 27–30. Rehm J, Taylor B, Mohapatra S, et al. Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis. Drug Alcohol Rev 2010; 29: 437–45. Katikireddi SV, Bond L, Hilton S. Perspectives on econometric modelling to inform policy: a UK qualitative case study of minimum unit pricing of alcohol. Eur J Public Health 2013; published online Dec 23. DOI:10.1093/ eurpub/ckt206. Stockwell T, Thomas G. Is alcohol too cheap in the UK? The case for setting a minimum unit price for alcohol. April, 2013. London: Institute of Alcohol Studies, 2013. http://www.ias.org.uk/uploads/pdf/News%20 stories/iasreport-thomas-stockwell-april2013.pdf (accessed Jan 10, 2014).
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Dartnall E, Jewkes R. Sexual violence against women: the scope of the problem. Best Pract Res Clin Obstet Gynaecol 2013; 27: 3–13. Vanwesenbeeck I. Sexual violence and the MDGs. Int J Sex Health 2008; 20: 25–49. García-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts C. WHO multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. Geneva: WHO, 2005. Abrahams N, Devries K, Watts C, et al. Worldwide prevalence of nonpartner sexual violence: a systematic review. Lancet 2014; published online Feb 12. http://dx.doi.org/10.1016/S0140-6736(13)62243-6. Lawry L, Reis C, Kisielewski M, Asher J. Problems in reporting sexual violence prevalence. Am J Public Health 2011; 101: 2004–05. Johnson K, Scott J, Rughita B, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo. JAMA 2010; 304: 553–62.
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8 9 10
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Watts CH, Foss AM, Hossain M, Zimmerman C, von Simson R, Klot J. Sexual violence and conflict in Africa: prevalence and potential impact on HIV incidence. Sex Transm Infect 2010; 86 (suppl 3): iii93–99. Peterman A, Palermo T, Bredenkamp PC. Peterman et al respond. Am J Public Health 2011; 101: 2005. The Lancet. Sexual violence: a global awakening, from India. Lancet 2013; 318: 2. García-Moreno C, Stöckl H. Protection of sexual and reproductive health rights: addressing violence against women. Int J Gynaecol Obstet 2009; 106: 144–47. Yount KM, VanderEnde K, Zureick-Brown S, Minh TH, Schuler SR, Hoang TA. Measuring attitudes about women’s recourse after exposure to intimate partner violence: The ATT-RECOURSE scale. J Interpers Violence 2013; published online Dec 24. DOI:10.1177/0886260513511536.
Britt Chudleigh/Mint Images/Corbis
Alcohol minimum unit pricing and socioeconomic status
Published Online February 10, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60154-9 See Articles page 1655
1616
Floor prices for alcohol, beneath which alcohol cannot be sold, are in place in Moldova, Russia, Ukraine, Uzbekistan, some US states (eg, Connecticut), and eight of the ten Canadian provinces. In 2012, Scotland legislated alcohol minimum unit pricing—a lowest price per unit of alcohol—the introduction of which is pending legal challenge. In the UK, minimum unit pricing is the subject of substantial political and policy debate. UK alcohol prices in the off-trade, particularly supermarkets, have risen more slowly than have taxes on alcohol.1 Harmful drinkers favour cheap off-trade alcohol,2 which is targeted by minimum unit pricing. Drinkers on low income also favour cheap alcohol.3 The UK Government reneged on its plans to introduce a minimum unit price of £0·45, citing concerns that responsible drinkers on a low income might be disadvantaged.4 However, the burden of minimum unit pricing on people from lowincome groups would be small, at worst.5,6 People from low socioeconomic status backgrounds have fewer resources to protect themselves from the ill effects of drinking, and have high levels of alcohol-related mortality and hospital admission at all levels of drinking compared with people from higher socioeconomic status backgrounds.7 In The Lancet, John Holmes and colleagues8 report their assessment of the effect of the proposed £0·45 minimum unit price in England as a function of income and socioeconomic status, based on their Sheffield Alcohol Policy Model. This model combines an econometric model, which relates changes in the price of alcohol to changes in alcohol consumption, and an epidemiological model, which translates alcohol
consumption to mortality and morbidity. In response to the minimum unit price, the study predicts that harmful drinkers in the lowest income quintile would reduce their annual alcohol consumption by 7·6% (about 4 weeks’ worth of alcohol) and spend less on alcohol overall, whereas harmful drinkers in the highest quintile would only reduce their consumption by 1%. Responsible drinkers in the lowest quintile would reduce consumption by 1·6% and also spend less on alcohol. Public health outcomes were predicted by occupation or socioeconomic status. In Holmes and colleagues’ study8 the lowest socioeconomic groups made up about 41% of the population, but were estimated to account for 59% of the alcoholassociated health costs. 10 years after introduction of minimum unit pricing, annual alcohol-related health costs for this group were reduced by 4·7%; this reduction accounting for 88% of population-wide savings. The study assumed that retailers would only increase prices to the minimum threshold, providing a conservative estimate of the effect of minimum unit pricing. Canada’s experience is that retailers also increase the price of more expensive forms of alcohol to maintain relative price structures.9 The Sheffield Alcohol Policy Model would ideally be built on a dataset including people’s alcohol purchases, consumption, location of purchase, and price. No such dataset exists, so the model links the 2009 General Lifestyle Survey (containing information on mean weekly and highest daily alcohol consumption by beverage types) and the UK Living Costs and Food Survey (containing information on alcoholic beverages www.thelancet.com Vol 383 May 10, 2014
Comment
purchased off-trade and on-trade and prices paid). Government and other funders of research should prioritise collection of such data to inform evidencebased policy decisions. The econometric model centres on estimates of people’s responsiveness to changes in the price of alcohol. In the absence of data that follow individuals over time, the Sheffield Alcohol Policy Model uses a pseudo-panel built from repeated cross-sectional data (the UK Living Costs and Food Survey), and estimates a set of measures of price responsiveness for on-trade and off-trade beverages, controlling for age, sex, and birth year of the purchaser. To predict effects of minimum unit pricing on alcohol consumption, the model assumes that drinkers with a preference for packaged beer from supermarkets, for example, respond in the same way, irrespective of their income and pattern of alcohol consumption. No data exist to support or refute this assumption. A methodological limitation of the analysis is that changes in the highest daily consumption were based on changes in average consumption, despite some evidence that risky single-occasion drinking is less responsive to price changes than is average consumption.10 The model translates estimated changes in alcohol consumption to mortality and disease prevalence for 47 chronic and acute conditions based on the published literature, with the same risk curves for mortality and morbidity. The authors acknowledge that recent meta-analyses have found different risks of mortality and morbidity for some illnesses.11 Holmes and colleagues’ study follows a well-accepted approach for dealing with uncertainty in modelling, and undertakes sensitivity analysis. For example, when combining the consumption and purchase datasets it considers the possibility that people buy alcohol for others, and it also considers the possibility of under-reporting of alcohol consumption in the General Lifestyle Survey. Stakeholders in the UK minimum unit pricing policy debate regard the predictions made by the Sheffield Alcohol Policy Model that are specific to the UK as more relevant than assessments of floor prices in other jurisdictions.12 This study provides persuasive evidence that the proposed £0·45 minimum unit price will have little effect on what low-income moderate drinkers drink and spend on alcohol. Rather, it targets individuals www.thelancet.com Vol 383 May 10, 2014
least able to protect themselves from the ill effects of harmful drinking. Of further benefit, families containing harmful drinkers stand to gain from the decreased likelihood of loss of income through the drinker’s death, injury, or illness and reduced risk of domestic violence.13 Furthermore, the potential reduction in government spending on health care could result in lower taxes and charges and expanded government services. Holmes and colleagues’ findings8 should assuage the UK Government’s concerns and provide further support for proponents of minimum unit pricing in this hotly argued debate. Jenny Chalmers Drug Policy Modelling Program, National Drug and Alcohol Research Centre, University of New South Wales Australia, Sydney, NSW 2052, Australia [email protected] I declare that I have no competing interests. Copyright © Chalmers. Open Access article distributed under the terms of CC BY-NC-ND. 1 2
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HM Treasury. Review of alcohol taxation. London: HM Treasury, 2010. Crawford MJ, Parry AMH, Weston ARW, et al. Relationship between price paid for off-trade alcohol, alcohol consumption and income in England: a cross-sectional survey. Alcohol Alcohol 2012; 47: 738–42. Forsyth AJ, Ellaway A, Davidson N. How might the alcohol minimum unit pricing (MUP) impact upon local off-sales shops and the communities which they serve? Alcohol Alcohol 2014; 49: 96–102. Gilmore I, Daube M. How a minimum unit price for alcohol was scuppered. BMJ 2014; published online Jan 8. DOI:10.1136/bmj.g23. Griffith R, Leicester A, O’Connell M. Price-based measures to reduce alcohol consumption. IFS Briefing Note BN138. London: Institute for Fiscal Studies, 2013. Ludbrook A, Petrie D, McKenzie L, Farrar S. Tackling alcohol misuse: purchasing patterns affected by minimum pricing for alcohol. Appl Health Econ Health Policy 2012; 10: 51–63. Mäkelä P, Paljärvi T. Do consequences of a given pattern of drinking vary by socioeconomic status? A mortality and hospitalisation follow-up for alcohol-related causes of the Finnish Drinking Habits Survey. J Epidemiol Community Health 2008; 62: 728–33. Holmes J, Meng Y, Meier PS, et al. Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study. Lancet 2014; published online Feb 10. http://dx.doi.org/10.1016/S01406736(13)62417-4. Robson K. Alcohol (Minimum Pricing) (Scotland) Bill, 2012. SPICe Briefing 12/01. Edinburgh: Scottish Government, 2012. Byrnes J, Shakeshaft A, Petrie D, Doran C. Can harms associated with high-intensity drinking be reduced by increasing the price of alcohol? Drug Alcohol Rev 2013; 32: 27–30. Rehm J, Taylor B, Mohapatra S, et al. Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis. Drug Alcohol Rev 2010; 29: 437–45. Katikireddi SV, Bond L, Hilton S. Perspectives on econometric modelling to inform policy: a UK qualitative case study of minimum unit pricing of alcohol. Eur J Public Health 2013; published online Dec 23. DOI:10.1093/ eurpub/ckt206. Stockwell T, Thomas G. Is alcohol too cheap in the UK? The case for setting a minimum unit price for alcohol. April, 2013. London: Institute of Alcohol Studies, 2013. http://www.ias.org.uk/uploads/pdf/News%20 stories/iasreport-thomas-stockwell-april2013.pdf (accessed Jan 10, 2014).
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