Alcohol - Minimum Unit Pricing (MUP) - continuation and future pricing consultation: Scottish Government response

Response to feedback raised in public consultation

An additional financial burden created either by MUP or by a price increase / that it is unfair to moderate drinkers

Some individual respondents set out their view that continuing MUP and, in particular, an increase in the minimum price of alcohol would have a negative effect on low income households, or that the policy impacted on moderate drinkers (people who consume within the Chief Medical Officer guidelines of 14 units of alcohol a week).

A small number of respondents set out that MUP has not penalised moderate drinkers, stating their view that MUP has had little or no impact on the pricing of the alcohol products consumed by most moderate drinkers.

Increasing the unit price will have differing effects on people with different levels of consumption and whilst it is recognised that the wider cost of living crisis is having an impact on many households, and particularly those on low incomes, people consuming smaller quantities of alcohol will see a much smaller increase in spend than people purchasing higher quantities of alcohol. Whilst it is recognised the increase to 65ppu will see an increase in the cost of purchasing products currently priced under this, the increased costs will be greater for people consuming higher quantities of alcohol than for those with lower levels of consumption.

Evidence suggests that people in lower income groups who consume high levels of alcohol experience greater negative health effects than people in higher income groups with equivalent levels of consumption.^[3] The policy is therefore anticipated to have a broadly positive effect on health inequalities, in particular supporting Scottish Government action to address health inequalities.

The Scottish Government recognises the effect that the cost of living crisis is having on many people in Scotland. £3bn has been allocated to support policies which tackle poverty and protect people, as far as possible, from the ongoing impacts of this crisis.

MUP will not deter people with alcohol dependence

Another common theme across responses from individuals, and some organisations, was that increasing the minimum unit price would not reduce the amount of alcohol consumed by people with alcohol dependency. Closely linked to this, and another commonly raised theme, was the need for more targeted support for people with alcohol dependence.

There is limited evidence that MUP had a positive impact on people with alcohol dependency, and there is some evidence that it had a negative impact on some people who were alcohol dependent. The Scottish Government is aware that people with alcohol dependency are likely to require specialist treatment services to support them to reduce their alcohol consumption. Whilst people with alcohol dependency are within the hazardous and harmful category of drinkers, MUP was not designed to target them specifically.

The Scottish Government considered the evidence and the views provided in response to the consultation related to the affects on people with an alcohol dependency as part of reaching the decision, and continues to consider how it can provide support to people who are dependent on alcohol.

Feedback on the evidence base – comments both agreeing and disagreeing that the evidence base suggest MUP has been effective

Some respondents felt the available evidence showed that MUP has been effective. All these respondents, around three quarters of whom were organisations, felt the policy should continue, with the majority supporting an uplift in price.

Some respondents set out their view on the limitations of the evidence, including the PHS evaluation, on assessing the impact of MUP. Summarised these included:

• The validity of the methods used in the evaluation, including the theory-based approach to the evaluation and the modelling methods used in some of the individual studies;
• the fact that, of the 8 underlying studies in the evaluation which considered health harms, only 1 (on hospitalisation and deaths) indicated positive outcomes and is heavily relied on;
• the impact of the Covid-19 pandemic on the data collection around MUP and the findings of the evaluation;

PHS’s evaluation of MUP took a theory-based approach. The HM Treasury Magenta Book^[4] Central Government guidance on conducting evaluations and Medical Research Council guidance^[5] both highlight theory-based approaches as particularly suited for the evaluation of complex interventions or simple interventions in complex environments. In this case, MUP is a simple intervention in a complex environment and a theory-based approach allowed consideration of the numerous potential impacts and the range of external factors which could interact with the policy and/or influence delivery and outcomes.

Other approaches, such as a more traditional experimental evaluation, would not have been feasible as there was no way of controlling exposure to the policy which would be required for this type of methodology. Theory-based evaluations can use a range of methods, and the evaluation of MUP used quantitative methods to measure change and qualitative methods to provide more understanding and insight. The evaluation also used a natural experiment design, where it was able, to compare Scotland to an area (usually England) where MUP was not in place.

This evaluation methodology and practice has been supported by a range of internationally renowned medical and public health experts as demonstrated by their letter to the Lancet^[6], a world leading peer-reviewed medical journal, praising the appropriateness and robustness of the approach taken by PHS to evaluate MUP.

The evaluation concluded that the policy had a positive impact on health outcomes. Some stakeholders have raised concerns with this conclusion and highlighted that the final evaluation report draws upon eight studies which looked at health harms, but only one of these demonstrated positive outcomes.

This outcomes in this study were however key to most robustly demonstrating an impact of the policy. It measured alcohol-related deaths and hospitalisations, which are directly influenced by alcohol consumption and did show positive outcomes. The other studies considered other health harms or looked at specific populations, to provide a more complete picture of the evidence and to provide reassurance that MUP was not causing negative or unintended impacts. The other measures are less directly connected to the plausible chain of events and might be influenced by other factors such as recording practices, demand on services and decision to present at services, and as such provide more indirect evidence.

The evidence on compliance with MUP and reductions in alcohol consumption from the wider evaluation, demonstrated that the expected chain of outcomes followed the implementation of MUP, which increased confidence that MUP contributed to the relative reductions in alcohol-related deaths and hospitalisations. The evaluation also considered a range of alternative explanations for these outcomes and concluded most of these were unlikely. This finding is also consistent with previous evidence that increasing the cost of alcohol reduces harm.

Some respondents expressed a view that the the impact of Covid could have affected data collection around MUP, as well as potentially affecting the outcomes of interest.

PHS accounted for the impact of COVID within the evaluation with only a small number of studies including data collection during the COVID-19 period, and most using a geographical control which helped to account for COVID-19 restrictions. Importantly, there were very similar results achieved in the deaths and hospitalisations study when the post-intervention period was restricted to pre-pandemic only i.e. ended the study period in Feb 2020.

The PHS evaluation also considered COVID as a factor which may have impacted on the outcomes of interest and concluded that COVID was unlikely to be an important explanation. However, understanding of COVID-19 continues to grow and therefore cannot be fully ruled out as having had some contribution to the increase in alcohol related deaths.

It is clear that Covid-19 has had an impact on alcohol consumption trends and likely that this is translating across into increased health harms. The University of Sheffield analysis^[7] estimated that alcohol-related harms are likely to increase as a result of the pandemic, and this pattern may be sustained if increases in consumption among harmful and hazardous drinkers persist over time. The analysis suggests that it is likely had MUP not been in place health harms would have been even greater.

Whilst deaths increased after implementation of MUP, the PHS evaluation concluded that alcohol specific deaths were lower than would have been seen if MUP was not in effect. There are a range of factors that drive alcohol specific deaths, in addition to those a population level that drive levels of alcohol consumption, in addition to the effects of the Covid-19 pandemic which saw a change in levels of alcohol consumption both in groups that drink little to moderate amounts and groups that drink higher amounts.

Alcohol specific deaths increasing overall is not itself a key indicator of the efficacy of MUP and the evidence supports that, for the study period considered by the PHS evaluation it is likely that deaths would have been higher if MUP was not in effect.

On reaching a conclusion, Ministers have considered the available evidence including the limitations of available evidence base and concluded that on balance the evidence suggests that MUP has been an effective policy intervention that achieved its aims.

The need for more targeted action and support/ Support for a wide range of alcohol harm prevention measures, in some cases including MUP

As part of tackling alcohol harm in Scotland, in 2022/2023 the Scottish Government provided £106 million, which increased to £112 million in 2023/24 as part of the national mission on tackling drug-related deaths is being provided to Alcohol and Drug Partnerships across Scotland to support people facing problems because of both alcohol and drug use.

The Scottish Government will ensure it writes to all Alcohol and Drug Partnerships (ADPs) in advance of an increase in price taking effect so that services are prepared for any increase in engagement with their services from people with an alcohol dependency who are affected by the increase in price to 65ppu.