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A minimum price for drink?

Setting a high minimum price per UK unit (about 8g) of alcohol promises the greatest feasible health gains per policy £, but also risks the greatest political losses. The effect would be to eliminate legal supply of the strong but cheap drink favoured by heavy drinkers, but also to raise the floor price of all alcoholic beverages, inviting a backlash from drinking voters and sections of the alcohol industry for doing it, or one from health lobbyists for not. Its profound implications have transformed this simple policy option into a touchstone – on one side, of whether our government is serious about protecting our health, and on the other, of whether they are serious about free markets and loosening the grip of the ‘killjoy nanny’ state.

Evidence is clearly not all there is to this debate, but it has played a substantial part, mainly in the form of simulations predicting what would happen should the policy be implemented. The uncertainty inherent in these calculations has left the field open to contesting views from non-scientific sources, not just on priorities and values, but on the validity of the science itself. A recurring bone of contention has been whether, as the simulations predict, the heaviest drinkers really would cut back, or instead divert money from other uses to sustain their ‘addiction’. Another implicit in complaints that the policy would ‘punish’ drinkers is that research has focused on the avoidance of the bad consequences of drinking, while neglecting why most people drink in the first place: for pleasure, relaxation, stress-relief, companionship, relationship-building, and indeed, for de-rigidifying intoxication.

Even were it cut and dried, science can only tell us whether with such a policy there will be more of ‘x’ and less of ‘y’. Beyond that, it can ask us how much we value x and y, but cannot scientifically determine what those values should be. Which matters most is a matter of opinion – whether gaining 10 of x while losing 5 of y is on balance worthwhile. When not just x and y, but enough variables to exhaust the alphabet are in play, each variously weighted with cultural, economic, welfare and moral value by strongly vested but opposing interests, the resultant balance is likely to be unstable. Critical re-balancings include the sudden reversal of minimum pricing by the UK government with direct responsibility for England, and before that, its rejection and then adoption by the devolved administration in Scotland, where the fallout from heavy drinking is most apparent. Spearheaded by Scotland, all the nations of the UK except England are planning to make progress on implementing or consulting on minimum pricing, but their plans may be derailed by legal challenges.

England pulls back

For England and Wales the 2012 UK alcohol strategy seemed a turning point in alcohol politics; acceptance that action to counter population-level drink-related harm must affect the majority of the population, even if this means bigger alcohol-related holes in middle-England’s pockets, and even if it threatened votes. In opposition, Conservative party plans had focused on ‘binge’-drinking youngsters, probably a net vote-winning target; in 2012 they grasped a nettle which might alienate most adult voters.

The nettle was to set a uniform minimum price per unit (about 8g) of alcohol across all drinks, substantially raising the cost of cheaper and stronger products. Not just grasped, it was held firmly and without equivocation. According to the prime minister, “We are going to introduce a new minimum unit price. For the first time it will be illegal for shops to sell alcohol for less than this set price per unit” (emphasis added).

By the following year the nettle had been dropped onto a shelf marked ‘Awaiting Evidence’. A consultation on what the price should be and how it should be regulated turned in to a trial of the evidence for setting a price in the first place. There remained no doubt in the government’s mind that a minimum price of around £0.45 would improve health and reduce crime, but no longer were they of a mind to accept it would do so “without penalising all those who drink responsibly”. Rather than new evidence, it was the “absence” of “empirical” and “conclusive” evidence which persuaded the Home Secretary “it would be a mistake” to implement minimum pricing at this stage – evidence no more absent in 2013 than it had been in 2012, and which could never be ‘conclusive’ and ‘empirical’ until the policy had been tried and evaluated.

About who and what matters most

The flip-flopping on setting a minimum price exemplifies that the adequacy of scientific evidence is a matter of judgement, one subject to influences from outside the scientific sphere. What one year may be judged a sufficiently robust platform for radical action may the next be pronounced too flimsy. Even whether the evidence needs to be conclusive – or whether uncertainty can be tolerated – is a judgement which too can change.

Underlying the reversal in both the policy and the assessment of the evidence was a complex and often competing network of possible losses and gains, and of losers and gainers, whose weighting in the decision-making was dependent on what and who was valued most. The reversals were not simply a case of ‘wrongly’ reading the ‘true’ cost-benefit balance, but of making an alternative cost-benefit calculation based on different values and priorities. Events have been most exhaustively catalogued for the British Medical Journal by journalist Jonathan Gornall. As he saw it, “In a time of austerity ... the short termism of jobs, votes, and the perceived political importance of the price of ‘a pint of beer at the end of a hard day’s work’ led to the government making a cynical cost-benefit analysis.”

His account described how in the early 2000s alcohol industry interests capitalised on the then Labour government’s reluctance to be seen to “restrict the responsible consumption of the majority due to the actions of a small, problematic minority”, the latter usually identified with young ‘bingers’. It was a perspective which suited the industry, promising to leave untouched the vast bulk of drinking and risky drinking alike, and implying a hands-off approach to mainstream pricing and marketing. In this, alcohol industry interests were continuing a longstanding strategy of seeking to contain the policy struggle to territory which lent itself to their weapons and disarmed those of public health opponents – safeguarding personal freedom for the moderate majority, and instead focusing restrictions on the narrow problem of youth disorder. Pulling the other way, public health advocates sought to shift the ground towards protecting health across a whole population. Which perspective wins the ear of decision-makers is the key proximal determinant of policy over population-wide measures like minimum pricing.

For its producers and sellers, it was critical that alcohol avoid being daubed as an inherently dangerous product like tobacco. They sought to ensure that only its injudicious use would be attacked, the responsibility for which lay with irresponsible consumers, not the alcohol industry. This stance may also have been more comfortable for policymakers and policy influencers in the media, who could distance the ‘problem’ to people ‘not like us’, exempting the less spectacular but nevertheless damaging drinking they too might share in. The alternative view that alcohol-related harm was related to overall consumption, and that most was generated by the majority of non-dependent, non-binge drinkers, was tabled in policy discussions but rejected by the previous Labour government, and at first too by the 2010 coalition government led by the Conservative Party. Acceptance of that view in the coalition’s 2012 national alcohol strategy was what led to minimum pricing being placed at the centre of the strategy.

What tipped the balance?

Accounts of what in 2013 precipitated the policy’s relegation to the ‘awaiting evidence’ back-burners include concerns about the electoral impact, crystallised by the Conservative Party’s new election campaign manager’s insistence on scraping away non-core and possibly damaging policy diversions. Energetic lobbying by the alcohol industry bolstered political misgivings. Among the tactics was to attack the simulation exercises which provided much of the scientific support for a minimum price and ( below) to hint at possible withdrawal of cooperation with the government’s flagship Responsibility Deal agreements with industry players. Also weighing in were some major supermarket chains, perhaps concerned that minimum pricing would impede their ability to undercut other shops and attract custom through cheap drink. Another credible possibility was the ‘UKIP factor’ – the threatening ascendancy of ‘beer and fag’ populism represented by a political party attracting former Conservative voters. Pushing through a huge hike in the price of alcohol would have been to gift UKIP the anti-nanny state mantle coveted by the Conservative Party.

Opposition within cabinet was lent force by the powerful position of the Treasury, said to have been concerned over loss of revenue due to decreased sales; a small loss had been predicted in a Home Office impact assessment. According to the Independent newspaper, a significant consideration was the cost to business as alcohol sales fell in response to higher prices. Related to this was the prime minister’s pledge to reduce the ‘red-tape’ burden of regulation on industry. Whether the promise has been kept is judged in terms of financial costs, not the number of regulations. A minimum-price law would effectively raise costs due to lost sales, threatening to break the promise. On three influential counts – tax and business revenues and the regulatory burden on industry – the consumption-reducing effects lauded by public health advocates were seen as a negative impact.

Among alcohol industry interests, leading the charge against minimum pricing was brewing giant SABMiller armed by think-tank reports it commissioned which lent credibility to its focus on the influence of parenting on alcohol consumption, and which slated minimum pricing as inadequately researched. Resulting recommendations largely kicked tackling unhealthy drinking into the inter-generational long grass, locating its genesis and solution in parent-child relationships not directly amenable to government action. The reports’ perspectives were promoted to parliamentary and political players at launch events at the House of Commons and at all three major party conferences.

The access SABMiller and other alcohol industry bodies had to leading political figures was not the result of a sudden mobilisation over minimum pricing, but the fruit of decades of nuzzling up to people with the power to affect their business interests, itself made possible by the centrality of alcohol in British society. Whilst having a cigarette branded with your name might be embarrassing, the Treasury’s political leader George Osborne (also gifted the title “Beer Drinker of the Year”) and his economic secretary and chief secretary all received the accolade of having beers named in their honour. Being seen to be on the side of the beer drinker and whisky aficionado was and remains a positive political asset.

Punishing the many for the few?

Policy reversals mirrored the precarious balance between minimum pricing improving health and bolstering the Conservative Party’s ‘tough on crime’ image, versus the risk of being hoist on its own petards of deriding the ‘nanny state’, championing free markets, and its repeated insistence that the majority drinking public should not be ‘punished’ for the antics of the binge-drinking minority.

That minimum pricing would unfairly hit ‘responsible’ drinkers and disproportionately affect low-income drinkers were perhaps the key arguments made by critics, claims which repeatedly attracted media coverage. The arguments had some – but limited – merit. Low-income drinkers would be affected more than their better-off counterparts, but if they were virtuous to begin with (that is, at worst moderate drinkers), the punishment would be slight. Only the heavy consumers among low-income drinkers would find themselves having to make hard choices, because typically they buy large quantities of the cheapest drink per unit of alcohol, products which would no longer be available at bottom-end prices.

Official impact assessments for both Scotland and England acknowledged that those hit hardest in the pocket would be poor regular drinkers, though they also stood to gain most in health terms if (as predicted) they responded by cutting back on their drinking. Graphic evidence of how much they might gain came from studies of liver unit patients at an English hospital. Alcohol-related liver disease is strongly associated with poverty, and the rising trend in this condition has been a prime motivator of political concern over drinking. Sufferers at the hospital had compromised their livers by regularly drinking prodigious amounts of alcohol, which the heavier drinkers at the unit managed by finding the cheapest sources. Sustaining this consumption at a £0.50 minimum per unit price would cost an extra 13% of their average incomes – the kind of financial pressure which, fed into Sheffield University’s simulations, meant low-income heavy drinkers were predicted to gain most in health terms by being forced to cut back. They would also, of course, at the same time be the greatest losers in terms of having to forgo the benefits they felt themselves to get from their pre-minimum price drinking.

At the government’s request, how drinkers in different income bands would be affected was specifically addressed by the University of Sheffield team whose simulation studies were influential in promoting minimum pricing. In contrast to government assessments based on their earlier work, they calculated that drinkers among the roughly one-fifth of the population in the poorest households would cut back so much they would actually spend less on drink if the minimum price was set at £0.45. By far the greatest savers would be the heaviest of drinkers among the poor, who would find hunting out cheap drink no longer a viable strategy for maintaining consumption.

Later a similar analysis from the same research team instead divided the population equally into five household income levels. It too predicted that faced with a £0.45 minimum price, drinkers among the poorest fifth would cut back and switch to other products, resulting in them each spending on average £1.89 less per year on drink. The small minority who drank over 50 units a week for men or 35 units for women would save nearly £35 a year. The next poorest fifth would also save nearly £9 a year. At all income levels, the spending of the majority of the population who drink below weekly safer drinking guidelines would barely be affected Though the stable door had been closed by the 2013 reversal on minimum pricing, the report’s authors offered this comment on a key justification for the reversal: “This mixture of effects provides no support for the UK Government’s concerns about the effect of a minimum unit price on responsible drinkers and suggests that claims of the policy being regressive [adversely affecting the poorest] need substantial qualification.”

So surprising are these estimates that they warrant closer examination. Compared to the research team’s earlier reports, they were based on an improved method and more years of data from which to calculate the critical factor – how much each population subgroup would cut back on their drinking of each beverage type in response to a price increase. The data they fed into the calculations derived from the shopping diaries of a sample of UK households, who constituted generally only about half of those asked to join the surveys in the years 2001 to 2009. Depending on how it is measured, over this period the affordability of alcohol in the UK either substantially increased or remained about the same. At no time was there anything near the substantial dip in affordability which those reliant on strong but cheap drink would face from a high minimum price. As Professor John Beath warned the Scottish parliament’s health and sports committee, how drinkers respond when alcohol prices are in relative terms stable or falling may not predict how they would respond to a sudden increase. Alcohol devotees may, he suggested, take advantage of increased affordability by drinking more, and then find it difficult to cut back when prices go up.

Their latest predictions also seem at odds with the Sheffield team’s initial conclusions based on the international literature. In respect of low-income drinkers, this led them to believe that “A tax increase sufficient to reduce physical and other consequences of drinking ... will also reduce the economic wellbeing of drinkers who continue to regularly consume alcohol, since ... alcohol has considerable price inelasticity” – ‘inelasticity’ meaning drinkers cut back relatively little in response to price rises.

Whether in reality the poorer of the UK’s heavier drinkers would respond to a high per unit price by switching from favoured products and cutting their drinking so much that they actually spend less, or maintain their drinking and cut back on other spending, will remain unclear until we can actually observe what happens. Either way, the evidence is converging on them (and their families) being most affected by such a policy, standing to gain most in health terms, and to lose most either in income available for other purposes or by having to cut back on their drinking.

And not punishing the few

On one critical issue, minimum pricing’s opponents and the University of Sheffield team who generated much of the supportive science agreed: that the policy would have little impact on the type of drinking of greatest political and public concern – the visible drunkenness of young people at nightlife venues and in town centres associated with violence, crime and a high load on emergency services. Because this group tend to drink episodically and in pubs and clubs, in 2010 a University of Sheffield analysis calculated that even a high minimum price of £0.50 per unit would lead them to drink on average just 3% less a year, meaning that proportionately they would be slightly less affected than the more politically favoured general population of moderate drinkers.

Even if concerns about the responsible majority’s wallets might be misplaced, concerns that minimum pricing would leave city-centre binging relatively untouched seem valid, and were a key weakness in the argument for its introduction. It allowed opponents to argue that the policy would hit the majority without adequately tackling the kind of drinking which caused them most concern.

Alternatives less effective

As minimum pricing was abandoned for England, the government sought to reassure by introducing other measures. One of these was an alternative pricing regulation – banning of the sale of alcohol ‘below cost’. The ban came into force in England and Wales on 28 May 2014, accompanied by Home Office guidance which clarified that ‘below cost’ meant below the cost of duty plus VAT, the absolute minimum the sale of alcohol would cost a retailer even if the product itself had cost them nothing. The guidance gave examples of what these minimums would be. Rough calculations show how much lower they are than those based on a £0.50 minimum per unit price: a can of beer which under the below-cost ban must be sold for at least £0.40 would at a £0.50 minimum rise to at least £0.90, a minimum £8.89 bottle of spirits to at least £13, and a minimum £2.41 bottle of wine to £4.70.

A study conducted in Newcastle upon Tyne in 2010 and 2011 suggested that a below-cost ban would affect only a handful of price-based promotions. On this basis, it can also be expected to have a very small impact on consumption and on related harms. This too was the conclusion of a study conducted for the UK Home Office, which said that though there would be an impact, it would probably be relatively small compared with broader restrictions on discounts and promotions, and would also fall well short of the impacts of some minimum price or tax increase measures.

Most decisively, the UK government asked the University of Sheffield unit responsible for the major reports on pricing policies to assess the effect of a ‘duty plus VAT’ below-cost ban. Their analysis estimated that by the time it had fully impacted, it would result in tiny average drinking reductions and just 14 fewer deaths a year, compared to 624 fewer from a £0.45 minimum per unit price. The Home Office had this analysis before the decision was made, yet still preferred a below-cost ban to minimum pricing. Though it was available to government, nobody else could use the analysis to try to sway their decision. At the government’s request, public release was delayed until after the announcement of the policy reversal. The argument was that prior publication would have signalled that a below-cost ban was now the favoured policy, pre-empting the announcement; the effect was to deprive minimum-price lobbyists both of the knowledge that they needed to argue against a below-cost ban, and also of important data supporting that argument.

Like minimum pricing, a proposed ban on off-licence promotions offering discounts contingent on buying several drinks at once also fell victim to the lack of “convincing evidence” that it would significantly reduce consumption. Ironically, just a couple of months before the government’s statement to the Commons in July 2013 rejecting this policy, seemingly convincing evidence had come from Scotland. There NHS Health Scotland estimated that a similar policy had been followed by a 2.6% decrease in off-trade alcohol sales, due mainly to reduced sales of wine. A statistically significant 1.7% extra reduction was estimated for Scotland after trends in England and Wales had been adjusted for.

Based on the volume of alcohol sold by off-trade retailers, NHS Health Scotland’s assessment seemed contradicted by a second assessment, but this was based on the less complete accounting derived from records submitted by a sample of households. In trying to account for its figures, the second study pointed out that the ban on ‘buy one get one free’ promotions was being undermined by shops instead simply offering price discounts, a get-out which would be curtailed by a minimum unit price. Another analysis found that in major UK supermarket chains, tax increases in the form of excise duty and VAT tended not to be fully passed on to consumers of cheaper sources of alcohol, undermining impacts on the heaviest drinkers who rely most on these products. Both studies illustrate what for health campaigners is a great advantage of minimum per unit pricing – its narrowing of the wiggle room for producers and retailers to work round the restriction and therefore also to counter its health benefits.

Was the Responsibility Deal used to head off minimum pricing?

Another initiative offered by government to fill the gap left by the reversal on minimum pricing was the alcohol strand of the Public Health Responsibility Deal launched in 2011 by the Department of Health. The initiative asks alcohol and retail industry bodies to sign up to ‘pledges’ to implement guidelines or meet targets on issues such as under-age sales, responsible marketing, and labelling. But rather than being prompted by the Deal, studies found the measures industry bodies agreed to were usually already completed or underway, and even if implemented, were unlikely to significantly improve health.

The Responsibility Deal is critical because this seemingly largely ineffective measure was presented (1 2) as a key rationale for the abandonment of minimum pricing. For the government, rejecting minimum pricing was a way of offering the alcohol industry “an opportunity to demonstrate what more it can do to reduce harms associated with problem drinking ... building on what has already been achieved through the Public Health Responsibility Deal”. Abandoning minimum pricing may also have been a concession the government had to make to secure continued cooperation with the Deal. As a British Medical Journal investigation put it, even if the Responsibility Deal failed to reduce alcohol-related harm, it had successfully played its part as “one of the tactical bricks in the wall of social responsibility the industry had built to protect itself from the threat of regulatory interference”.

According to the British Medical Journal, shortly before the minimum pricing reversal, in February 2013 public health minister Anna Soubry had met seven industry representatives who voiced their “deep concern” that minimum pricing would damage Responsibility Deal agreements with the industry and hit Treasury revenues. Soubry was told they would prefer a ban on below-cost sales, an ineffectual measure which was in fact implemented instead of minimum pricing above. Elevation of a below-cost ban into law was puzzling because government had not even posed it as an option in the consultation which preceded the announcements, also meaning it had not formally tested opinion on the measure.

Industry concerns can be read as a warning that continued cooperation with the Deal would be threatened if the administration went ahead with minimum pricing. That warning was apparent to the chair of the Responsibility Deal monitoring and evaluation group. In his July 2013 resignation letter he recalled that, “At the last meeting an industry representative even made it clear that their continued contributions to the Deal were dependent on a minimum unit price not being implemented.” For Professor Bellis this was not the only example of the Deal being “turned by industry into a tool to avoid actions that would improve people’s health”.

Though the implication that some alcohol industry interests used the Deal to press for withdrawal of minimum pricing seems well founded, whether this influenced the reversal is unclear – but having to admit that a central and repeatedly trumpeted plank of their alcohol strategy had fallen apart would have been a bitter pill for government to swallow. For public health academics and lobbyists, as a credible process the Deal fell apart anyhow, and they were the ones who withdrew participation. Commitment of the industry to reducing harm from their products was for them revealed as a sham by their bargaining one public health initiative in the form of the Responsibility Deal against another in the form of minimum pricing, rather than supporting the Deal regardless.

Scotland leads

Like the UK government, the Scottish too had flip-flopped, but ended up with a different decision. As in England, there too a critical factor was the shift from seeing alcohol-related harm as a matter of individual responsibility to seeing it a population-wide problem to be addressed by population-wide measures. The shift happened when in 2007 the Scottish National Party (SNP) took power with a manifesto which proclaimed it was “not acceptable that a bottle of water can be more expensive than alcohol”.

What led Scotland to embrace a radical and risky policy while England pulled back has been the subject of both study and comment. Accession of the SNP to power had wrong-footed (1 2) alcohol industry lobbyists, who had spent little of their political capital on cultivating a non-UK wide minority party. Even more so than the rest of the UK, Scotland had reason to see drinking as causing severe health problems requiring radical responses which went beyond the binge-drinking minority. With a population more accepting of government intervention than in the more free-market England, an administration freed of the obligation to match policies north and south of the border, and one keen to see its country move from the bottom of the UK public health league, the scene was set for a policy breakthrough.

Well before the rest of the UK, in 2009 the Scottish national alcohol strategy had committed the Scottish government to a minimum price per unit of alcohol, following a consultation which had explicitly advanced reducing overall alcohol consumption as an objective. At first the Scottish parliament rejected the proposal, but after the 2011 election surprisingly gifted the SNP an outright majority, another attempt was made. By June 2012 the policy had become law in the form of the Alcohol (Minimum Pricing) Scotland Act.

The law enables government to issue regulations setting a minimum price. Originally it was to be £0.50, but by the time (legal challenges allowing) the law is implemented, this may need to be increased. In 2012, 60% of the volume of alcohol sold in Scotland in the off-trade was sold at below £0.50 per unit; at the time of the alcohol strategy in 2009, the proportion was 77%, highlighting how alcohol prices change over time, and demonstrating that a minimum price must be reviewed over time in order to retain its impact.

But first the law has to survive determined legal challenges on the basis that minimum pricing contravenes UK devolution and/or European Union free trade laws. In May 2013 a legal challenge from the Scotch Whisky Association and two European organisations representing the wine sector and spirits producers failed in a Scottish court, but an appeal continues to delay implementation. At European Union (EU) level the detailed opinion of the European Commission on the Scottish proposals suggested they may constitute a disproportionate restriction on free trade and competition, and could counter-productively increase the incentive to market the affected products due to higher profit margins gifted by a high minimum price. That profit margins and industry revenue will increase is acknowledged by impact assessments for Scotland and England, though how much extra profit will remain after costs, and which sector of the industry will benefit most, is unclear. Also, minimum pricing does not preclude tax increases to claw back some of the extra profits.

At the time of writing, the latest chapter in the case is a ‘pre-trial’ assessment from a senior lawyer in the EU’s Court of Justice. Their opinion – which may or may not be indicative of how the court will decide – was that minimum pricing did constitute a restriction on trade contrary to the EU Treaty, because it impeded price competition at the lower end of the market. However, what would otherwise be contraventions can be justified on public health grounds – as long as no feasible and less restrictive measure would achieve the same objectives without disproportionate adverse effects elsewhere. In the lawyer’s judgement, there could well be such a measure: a general increase in alcohol duty which would affect all products, not just those below a minimum price threshold. In turn this begs the question of what is the objective of Scotland’s minimum price law: to reduce the drinking only of hazardous drinkers, or to reduce drinking across all risk levels?

The lawyer’s argument has some foundation. In 2008 the Sheffield team’s first simulation for England compared a £0.40 minimum per unit price to a 10% general price increase. It was by no means clear that one was preferable to the other, either generally or in respect of harmful drinkers. Some key figures were: for a 10% price rise, overall consumption down by 4.4% versus 2.6% for the minimum price policy; harmful drinkers cutting back by 3.17 units per week versus 3.15 units; 1681 fewer deaths over 10 years versus 1381; and 65,000 fewer offences versus 16,000. These and other impacts were estimated to sum to £7.8 billion social cost savings versus £5.4 billion for the minimum price policy. Such comparisons are however dependent on the levels at which the policies are introduced. A £0.40 minimum per unit price is at the bottom of what has been contemplated by government, while forcing a 10% price rise would require very large and extensive tax increases.

If the EU court’s final decision forces UK nations to abandon minimum pricing and instead consider substantially raising alcohol taxes in order to increase prices, the result may well be to stymie any effective price policy initiative at all. Discourse to date suggests that an across-the board price rise would be harder for UK politicians and public to accept, because the politically favoured moderate drinkers would be harder hit. According to Sheffield’s 2008 report, on average each would have to spend an extra £25.75 per year to maintain current drinking versus just £5.50 at a £0.40 minimum per unit price.

What happens with Scotland’s EU case is certain to affect a draft law for Wales under consultation until 11 December 2015 which would set a £0.50 minimum unit price. In December 2014 Northern Ireland’s health minister also announced the administration’s plan to consult on a minimum price. Mirroring arguments elsewhere in the UK, Northern Ireland’s retailers opposed the move on the grounds that it would be “unfair to responsible consumers and the wrong approach to tackling excessive consumption”.

Alcohol-related illness reduced but what of health in general?

Minimum pricing’s rationale rests on reducing the social costs of drinking, and in particular on anticipated health gains. Unless these stack up, there is nothing to convincingly justify such a radical measure. The problem is that minimum pricing has rarely been implemented, leaving the predictions to be informed largely by responses to other policies.

Britain has substantially contributed to this evidence base with simulation exercises based on data from England, Scotland and Wales, which on public health grounds supported setting a relatively high minimum price per unit of alcohol. With some of these analyses available to them, the UK’s National Institute for Health and Care Excellence (NICE) argued that price rises and licensing changes to reduce the number of outlets were the key public health levers.

As evidence for minimum pricing, simulation exercises are all we have for the UK, predictions which have been likened to weather forecasting. The tone of the comparison was disparaging, though weather forecasts are highly scientific and in the short term generally accurate. However, policymakers know simulations constitute weaker support than studies of what has actually happened, especially since the data underlying the predictions seems relatively thin compared to that available to meteorologists.

More persuasive are real-world studies of minimum pricing in action, for which some Canadian provinces have been the prime source. Extrapolating from the actual figures, the most relevant study on consumption estimated that these were equivalent to a 10% rise in the minimum price leading to an 8% reduction in consumption. It seemed too that consumption impacts had improved health. For British Columbia it was estimated that the relationship was equivalent to a 10% increase in the average minimum price leading to a 9% decrease in hospital admissions due to drink. In the same province over the same 2002–09 period, deaths due to drinking also fell as minimum prices rose. Presumed to be due to price changes most affecting the heaviest drinkers, the effect was magnified: proportionately, the death rate changed more steeply than the change in prices.

Suggestive as they are, these Canadian studies had no corresponding data from other provinces against which to benchmark changes in the focal provinces, and unlike in the UK, the provincial governments concerned had a direct influence on the alcohol market via government alcohol distribution monopolies. Also, health-impact results differed depending on whether the focus was on deaths or illness wholly attributable to alcohol, versus the much larger number at least partly alcohol-related. The report on deaths placed most weight on wholly alcohol-related incidents, which in the hospital admissions study were not significantly related to price changes. At no time was there a uniform per unit price across all drinks, just different minimum prices for different types of drinks, which compared to other jurisdictions came relatively close to a uniform price, but still left substantial variations. Also the studies do not assess the sudden introduction of a minimum price, but of variations in and extensions of minimum pricing.

Setting a minimum price is one way to change the price of drink, and on the effects of price itself, and of price changes consequent on tax changes, there is substantial direct evidence which has been widely accepted. Scientific and expert support for price increases includes guidance from the World Health Organisation (WHO). In regions with a high prevalence of heavy drinkers such as Europe and North America, the guidance highlighted tax increases as the most effective and cost-effective way to reduce the burden of alcohol-related harm. The possible impact of WHO’s recommendations has been modelled for Australia. That exercise confirmed that in countries such as the UK where hazardous drinking is common, raising price by raising alcohol taxes has the greatest yet least resource-intensive impact on public health of the range of policy options assessed.

But in one important way, even the data on price and tax changes is very limited: it focuses on illness directly caused by drinking, not broader health impacts. A comprehensive review widely relied on found just one study which – unlike the Canadian studies – could assess net health harm/benefit, because it related tax to overall mortality, whatever the cause. In this study US state alcohol taxes were weakly related to fewer deaths overall, but not with sufficient strength or consistency to eliminate the possibility that the relationship was due to chance rather than to a real link with tax levels. Published two years later, another review was similarly conclusive about the impact of price on alcohol-related harm, but could not pronounce on net harm because none of the studies it found seemed to have assessed this. Even if these are real, it is highly unlikely that any direct positive effects of moderate drinking on health will counterbalance the direct negative effects, but there remain possible indirect health benefits from the employment the alcohol industry provides and the opportunities drinking and associated events and venues offer to form and cement life- and health-enhancing social relationships.

Health is not all there is to drinking

A large fly in the ointment rarely highlighted in public health studies is that health – the basis of most research-based policy recommendations – has little to do with why most Britons drink. The ‘benefits’ drinkers themselves feel they get are rarely valued in to cost-benefit calculations. In the recent past, at least one UK government analysis has argued that drinking produces social and business benefits for society as a whole due to “alcohol’s capacity to act as a catalyst in social interactions and leisure experiences ... promoting social cohesion,” but then as now there is no study on which estimates of these benefits could be based, so they are omitted from the calculations.

Neglect of benefits from drinking was one of the criticisms made by a prominent alcohol expert of attempts to establish a total cost (or cost reduction due to policy changes) to society of alcohol-related harm. He argued that though the constituents such as lives saved, crimes not committed, and illnesses avoided, may in themselves be good enough reasons to curtail the availability of alcohol, amalgamating these ‘apples and pears’ and attaching a monetary value to them is such a value-laden and imprecise exercise that it is of propaganda value only in determining policy. The British exercises in particular were dominated by productivity gains due to less drink-related unemployment, yet in the absence of full employment, vacancies left by drinkers will usually be filled by someone else, ending perhaps via a chain of job changes to someone currently unemployed gaining a job.

When the Home Office itself valued the costs and benefits of minimum per unit pricing, it accepted that “The costs of lost productivity due to alcohol misuse are substantial,” but excluded these from their calculations while consulting to see if more secure estimates can be made. Partly for this reason, the resulting estimate of the net benefit to society of a £0.45 unit price was £352 million over ten years, just £35 million a year, much less than in UK modelling exercises which included productivity gains.

Looking at the issue from the point of view of the drinker, the Home Office accepted they will experience a diminution in welfare as the ‘consumer surplus’ gap between what they are willing to pay and what they have to pay narrows, and that some will choose not to purchase alcohol at the higher prices or not as often as before, diminishing whatever benefits they see themselves as having got from drinking. In so far as they do pay more, there will be some countervailing financial gains for the alcohol and/or retail sectors, but the result would, it was said, be a “decrease in net social welfare”. This loss was not quantified, and needs to be set alongside the health gains for the same consumers and broader social gains.

Loss of consumer surplus due to many of the 80% of Australians who drink being forced to curtail their enjoyment or pay more for it weighed so heavily with the Australian National Preventive Health Agency that, despite the health benefits, on overall public interest grounds it rejected minimum pricing. The report included a careful consideration of the profound effect value judgements can have on what costs and benefits are placed in the balance and how they are weighted. Some analyses treat alcohol as an inherently pernicious drug which can confer no consumer benefits, others acknowledge moderate drinking confers consumer benefits but assume drinking ‘excessively’ confers no further benefits, and others that the self-perceived benefits heavy drinkers are prepared to pay for must be treated as real.

Huge trees, dark forest

Despite the uncertainties, when experts have looked at the evidence, they have become convinced that minimum pricing is the main way the UK can tackle alcohol-related harm, and by extension, the single most important feasible way to reduce harm related to psychoactive substance use. The possible prize is huge, but harm is not all there is to drinking. If it was, opposition to minimum pricing, no matter how well orchestrated by alcohol’s producers and retailers, would not resonate as it does with public and politicians. On harm reduction itself, nearly everything hinges on how much faith one has in the forecasts made by simulation exercises. Extraordinarily careful as these are, they are not based on reactions to the real introduction of a minimum price of the kind being considered in the UK. Countering that, it can be said that they are the best indications we can have without actually implementing the policy. Whether in England that will be enough to persuade government to give it a try is unclear, and whether other UK nations will be allowed to give it a try seems to rest in the hands of the European Union’s judges.

We have constructed two searches on this truly ‘hot’ topic: the first selects documents relevant to the impact of alcohol prices in general, the second narrows in on minimum pricing in particular.

Thanks for their comments on this entry to John Holmes of the University of Sheffield in England and Paul Skehan of spiritsEUROPE based in Belgium. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 05 November 2015. First uploaded 01 July 2010

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