Are the Public Health Responsibility Deal alcohol pledges likely to improve public health? An evidence synthesis
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Are the Public Health Responsibility Deal alcohol pledges likely to improve public health? An evidence synthesis.

Knai C., Petticrew M., Durand M.A. et al.
Addiction: 2015, 1000(8), p. 1232–1246.
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Even if fully implemented, pledges made by alcohol companies under the ‘Responsibility Deal’ for England would be unlikely to significantly affect consumption or health, judge the deal’s evaluators. Instead, other sources suggest they helped forestall a more effective measure – a minimum per unit price for alcohol.

Summary The Public Health Responsibility Deal in England was launched in 2011 by the Department of Health as a publicprivate partnership. Together with government, industry and other partners developed a set of commitments or ‘pledges’ including associated targets and actions which business, health, community and public organisations can commit to in order to improve health. The health topics addressed were food, alcohol, physical activity and health at work. The featured article from a university unit funded by the Department of Health to evaluate the Responsibility Deal analysed the pledges and proposed actions in the alcohol domain. Effectively it asked whether, if implemented, the evidence indicates that such actions would appreciably reduce consumption of alcohol or improve consumer awareness. To assess their potential impacts, the researchers relied on the 14 reviews of the evidence uncovered by a literature search which assessed the research evidence for similar initiatives.

Key points icon

Key points
From summary and commentary

The Public Health Responsibility Deal for alcohol in England offers a set of pledges which alcohol industry and other bodies can choose to commit to with a view to improving health.

Even if fully implemented, the pledges would be unlikely to significantly affect consumption or population health because generally they do not entail actions which would make alcohol less available or more expensive.

The Responsibility Deal seems to have helped forestall a more effective measure – setting a minimum per unit price for alcohol.

Each proposed action to implement the pledges was classified as belonging to a ‘rung’ on a ‘ladder’ of public health interventions formulated by the Nuffield Council on Bioethics. This ascends in eight rungs from doing nothing via information and (dis)incentives up to eliminating choice, progressing from the least to the most coercive or intrusive measures, the higher rungs being seen as requiring the strongest justifications.

Although at the time of the featured study there were eight alcohol pledges, the analysis focused on four key pledges: A1 – alcohol labelling; A4 – tackling underage alcohol sales; A6 – advertising and marketing alcohol; and A8 – alcohol unit reduction panel below. These were selected because they cover much of what was proposed in the remaining pledges.

A companion article from the same research team has analysed the actual plans made by alcohol industry organisations to fulfil the four key pledges, and progress on those plans reported in 2013 and 2014.

Main findings

Most of the 20 classifiable actions proposed to implement the eight pledges were assigned to the lowest (apart from the bottom do-nothing rung) two rungs of the intervention ladder, the least coercive and intrusive types of public health interventions. Providing consumer information was the basis for 60% of the measures and enabling choice for another 15%. Just 15% were assigned to the top two rungs which restrict or eliminate rather than merely influence consumer choices. Just two schemes to prevent illegal underage sales sought to eliminate choice. More typical were proposals to extend information on labels and change promotion and marketing strategies or priorities.

Four key pledges

As of 3 July 2015. See here for complete set of current pledges

A1. We will ensure that over 80% of products on shelf (by December 2013) will have labels with clear unit content, NHS guidelines and a warning about drinking when pregnant.

A4. We commit to ensuring effective action is taken in all premises to reduce and prevent under-age sales of alcohol (primarily through rigorous application of Challenge 21 and Challenge 25).

A6. We commit to further action on advertising and marketing, namely the development of a new sponsorship code requiring the promotion of responsible drinking, not putting alcohol adverts on outdoor poster sites within 100m of schools and adhering to the Drinkaware brand guidelines to ensure clear and consistent usage.

A8. (a) As part of action to reduce the number of people drinking above the guidelines, we have already signed up to a core commitment to “foster a culture of responsible drinking which will help people drink within guidelines”. To support this we will remove 1bn units of alcohol sold annually from the market by Dec 2015 principally through improving consumer choice of lower alcohol products. (b) To support our pledge to remove a billion units of alcohol sold annually from the market, we will carry out a review of the alcohol content and container sizes of all alcohol products in our portfolio. By December 2014 we will not produce or sell any carbonated product with more than (4) units of alcohol in a single-serve can.

The evidence reviews considered by the researchers generally agreed that effectively reducing consumption (and thereby harm) requires comprehensive policies which alter the market environment, including banning alcohol advertising and making alcohol more expensive and less available. Many of these most effective strategies were not consistently reflected in the proposed actions to implement the Responsibility Deal’s alcohol pledges. Most actions were of the type seen by the reviews as probably ineffective or backed by no, poor or inconclusive evidence. The exceptions were reducing the availability of alcohol to young people by enforcing a minimum purchasing age, and laws to restrict marketing of alcoholic beverages. More of the proposed actions were judged effective or probably effective in improving consumers’ knowledge and awareness, even if this did not mean they would reduce consumption.

The authors’ conclusions

Even if implemented fully the pledges are unlikely to affect consumption or have any significant positive impact on population health in England. Achieving these goals requires changing the market environment to make alcohol less available and more expensive, approaches generally not found among the Responsibility Deal’s alcohol pledges.

Most pledges favour information and communication interventions. Though they may improve consumers’ knowledge and awareness, research suggests these do not generally translate into positive behavioural change unless bolstered by interventions strengthening skills, resources and motivation. If implemented, the pledge to reduce the alcohol content of drinks could prove effective, but it will be important to account for any countervailing reactions. For example, rather than switching from higher-alcohol variants, consumers might add new or more heavily promoted low-alcohol products to their drinking repertoires. Evidence suggests that switching is more likely if promoted by incentives such as making lower-strength products relatively cheap and restricting the availability of higher-strength beverages.

The featured article may overstate the potential effectiveness of Responsibility Deal pledges, because it assumes the associated actions would be implemented to a standard similar to those evaluated in research. As shown in a companion article, this is unlikely to be the case.

Findings logo commentary The featured article argues that even if they were fully implemented, the Responsibility Deal pledges promoted by the Department of Health would be unlikely to significantly affect consumption or population health. A companion article from the same research team has analysed the plans made by alcohol industry organisations to fulfil the pledges they signed up to, plus progress on those plans as reported in 2013 and 2014. It concluded that even these relatively weak levers had generally not been activated by the Responsibility Deal, but had already been or were in the process of being activated regardless. Counteracting any possible benefits seems to be ( below) the major public health negative of helping to forestall a minimum unit price for alcohol in England. If the deal has helped substitute relatively ineffective pledges for more effective regulations, it cannot be considered a good deal in terms of population health in England.

Official commentaries on the alcohol Responsibility Deal have focused on the flagship pledge to remove a billion units of alcohol from the market. A Department of Health analysis has calculated that the target was exceeded, but the validity of their figure has been disputed, and even if valid, how far the deal was responsible is unclear below.

Has the deal has worked – to forestall regulation?

One of the most worrying findings of the featured analysis was the apparent impossibility of estimating the impact on consumption and health of actions taken to fulfil the pledges. When the deal was promised as part of the 2010–2015 Conservative-led government’s public health plans for England, it was presented as a light-touch voluntary arrangement which if it failed to improve health, might be bolstered by regulation forcing companies to comply. But it seems that given current data sources, it could not convincingly be demonstrated that the deal has or has not worked, meaning that the conditions for triggering an escalation to mandatory regulations cannot be met.

Forestalling regulation unwelcome to influential sectors of the alcohol industry has been seen as the prime function of the Responsibility Deal, one which would have a detrimental impact on public health because regulatory measures which increase price and decrease availability are the most powerful public health levers. At least in England, in this respect the deal seems to have been a success.

The Responsibility Deal for alcohol came about after the government had committed itself to a minimum per unit price policy for England. The move had been strongly resisted by sections of the alcohol industry, but made it into law in Scotland when the Scottish National Party – not one of the UK-wide parties the industry had been courting – took power. Famously, the commitment for England was reversed, seemingly a tribute at least partly to the industry’s successful long-term cultivation of relationships with UK political parties in order to position themselves as “key stakeholders in the policy process, who must be consulted on policy developments as a matter of course”.

In its formal announcements of the U-turn in July 2013 (1 2), government appealed to the Responsibility Deal as providing an alternative to minimum pricing, and the rejection of minimum pricing as offering the 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.”

For the British Medical Journal, industry influence meant the consultation which preceded the policy reversal had been a “sham”. The journal had discovered that 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, though it was not asked about in the consultation document.

Assuming the veracity of this report, their concerns can be read as a warning that the deal would be undermined if the administration went ahead with minimum pricing. That warning was also 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.” To 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 fact that alcohol industry figures used the deal to press for withdrawal of the minimum pricing policy seems clear, whether this influenced the reversal of that policy is not, but having to admit that a central and repeatedly trumpeted plank of their alcohol strategy had fallen through would have been a bitter pill for government to swallow. For public health academics and lobbyists, it was enough that the industry seemed to be bargaining a key public health initiative in the form of the Responsibility Deal against another, rather than supporting the deal process regardless as their contribution to reducing harm from their products.

Was the ‘1 billion fewer units’ target exceeded?

One of the pledges which the featured article saw as potentially effective if bolstered by other measures is the reduction in the strength of alcohol products. If effective, government estimated that the resultant removal of around 2% of alcohol from the market would in a decade “result in many hundreds fewer alcohol-related deaths; many thousands fewer hospital admissions and alcohol-related crimes, as well as substantial savings to health services and crime costs each year.” However, even this will not work in health improvement terms unless there are strong availability and price incentives to switch from higher strength products. Without this, lower strength products can simply add to net drinking. That can be counteracted by reducing the strength of the high-content products, but the featured report says actions taken to fulfil this pledge mainly appeared to involve launching and promoting new low-alcohol products rather than removing units from existing products, leaving consumers the option of continuing with undiluted higher-strength drinks, or adding lower-strength drinks to their repertoires rather than switching to them.

Reassurance that this had not happened came in 2014 when Department of Health analysts calculated that in 2012 and 2013, 1.9 billion fewer units of alcohol were distributed in the UK than would have been the case if sales of 52.1 billion units in 2011 had been repeated. Reductions in the average strength of alcoholic products (especially beer) accounted for 1.3 billion of the 1.9 billion drop, exceeding the Responsibility Deal target. These calculations imply that lower-strength products did not simply add to the total volume of alcohol consumed, but helped reduce it.

However, researchers from the Sheffield University unit entrusted by UK governments to model the effects of minimum pricing (1 2 3) say increasing underestimates of units sold as wine and cider between 2011 and 2013 could have accounted for the entire 1.3 billion units. They also highlight other possible influences on the calculations and trends in drinking patterns which make it unclear whether 1.3 billion units were removed from the market, and whether any changes in units distributed were due to the Responsibility Deal. Given available data, they concluded, “It is not clear whether a robust quantitative evaluation of the billion unit pledge is possible” – again, an indication that failure of the deal is not provable, meaning (if this is the criterion) that the case for replacing it with regulation will also remain unproven.

One clear example of an influence independent of the Responsibility Deal is that in October 2011, around the time the deal was launched, government raised duty on strong beers by 25% and halved duty on weak beers, creating a substantial extra price differential if these changes fed through to retail prices. Even before these changes, the structure of the duty tax meant reducing strength was one way to reduce costs per can of beer. For example, when brewing giant AB InBev announced in 2012 that it was cutting the alcohol content of some of the UK’s biggest selling lager brands from 5% to 4.8%, a report from an alcohol trade magazine did not mention the Responsibility Deal as the instigator. AB InBev’s line was that it was following “evolving UK category trends”, but the report highlighted the potential savings of many millions of pounds in duty costs, helping the company off-set rising costs and retain market share by keeping prices stable. Such influences might have generated strength reductions, even without the Responsibility Deal.

In March 2015 what they felt was inappropriate alcohol industry involvement in assessing whether the 1 billion unit pledge had been fulfilled was highlighted by the Institute for Alcohol Studies, which had contributed comments to a draft of Sheffield University’s critique of the Department of Health’s calculations. The institute had used the Freedom of Information Act to extract email correspondence from the department which showed that the alcohol producers’ health promotion organisation the Portman Group had asked for critical data “to be refined without informing the Chair and other public health members of the [Responsibility Deal monitoring and evaluation group], [and] that the Chair was not apparently included in crucial emails between the Department of Health and the Portman Group.” At the very least, said the institute, “the process was not transparent”. So concerned had been the group’s chair from the Centre for Public Health at Liverpool John Moores University that in July 2013 he resigned from the group, saying “transparency and trust in the process has been eroded by data being delivered inappropriately to the industry’s Portman Group who not only failed to inform me that they had the data but also unilaterally asked for it to be revisited at least twice.”

Last revised 15 July 2015. First uploaded 07 July 2015

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