Minimum Unit Pricing (MUP) Continuation and future pricing: Fairer Scotland Duty Assessment

Minimum Unit Pricing of Alcohol – Continuation and Future Pricing: Fairer Scotland Duty Assessment

Summary

The policy aim of MUP is to reduce health harms caused by alcohol consumption by setting a floor price below which alcohol cannot be sold. In particular, it targets a reduction in consumption of alcohol that is considered cheap, relative to its strength. It aims to reduce both the consumption of alcohol at population level and, in particular, those who drink at hazardous^[1] and harmful^[2] levels. In doing so, it aims to reduce alcohol related health harms among hazardous and harmful drinkers, and contribute to reducing harm at a whole population level.

People who drink at hazardous and harmful levels in lower socio-economic groups suffer greater harms than those who drink at these levels in higher socio-economic groups due to the impact of multiple drivers of health inequality. MUP is also intended to address alcohol related health inequalities by reducing consumption and therefore harm among hazardous and harmful drinkers as a whole, having a positive effect on health inequalities given the greater harms people in lower socio-economic groups experience in relation to alcohol.

The policy was implemented on 1 May 2018 at a level of 50 pence per unit (ppu) of alcohol^[3]. The legislation, the Alcohol (Minimum Pricing) (Scotland) Act 2012^[4], contains a ‘sunset clause’ which means further legislation is required to continue the policy, as well as setting the level going forward.

The Scottish Government set out, in a statement to Parliament on 8 February given by the Deputy First Minister, that it would lay secondary legislation seeking the agreement of Parliament to continue Minimum Unit Pricing and to set the price at 65 pence per unit, to take effect from 30 September 2024.

In 2021, the latest year for which data are available, Scots bought enough alcohol for everyone aged over 16 to drink 18.1 units of alcohol every week (9.4 litres)^[5]. This is equivalent to around 36 bottles of spirits, or around 90 bottles of wine, per adult each year. This is nearly 30% more than the lower-risk UK Chief Medical Officers’ guidelines of 14 units per week. Alcohol increases the risk for developing liver disease, a range of cancers as well as for heart disease and stroke.

For example, the most recent figures published by National Records for Scotland showed that there were 1,276 alcohol-specific deaths in Scotland in 2022^[6], a 2% increase on 2021 figures. Whilst recognised as a problem across the UK, the evidence shows that alcohol-related harm through alcohol misuse is greater in Scotland, with rates of alcohol-specific deaths highest in Scotland for 2021.^[7] Mortality rates for chronic liver disease, of which alcohol consumption is one of the most common causes, are also markedly higher in Scotland compared to the UK as a whole and other Western European countries.^[8]

Furthermore, it is important to recognise the range of effects the COVID-19 pandemic has had on the health on the population of Scotland, particularly the impacts on alcohol-related harms and alcohol treatment services. There is much evidence that drinking at hazardous and harmful levels increased for some groups, including heavier drinkers^[9], during the pandemic, despite consumption reducing at a population level.

The impact is expected to be greatest on hazardous and harmful drinkers as they drink the most alcohol and so suffer the most harms. There is a significant social gradient to alcohol harms: alcohol-specific death rates in the most deprived areas were 4.3 times^[10] more than those in the least, and those in the most deprived areas were 6 times^[11] more likely to be admitted to general acute hospitals for an alcohol-related condition than those in the least deprived areas.

MUP targets hazardous and harmful drinkers in the most deprived areas who, as the above statistics demonstrate, are more likely to be detrimentally impacted by alcohol harms. The evaluation also found that the greatest estimated reductions in deaths and hospital admissions as a result of MUP were observed in the four most deprived deciles in Scotland.^[12] The Scottish Government’s assessment is that continuing MUP and increasing the unit price to 65ppu is likely to increase these public health benefits.

The Scottish Health Survey 2022 (SHeS 2022^[13]) found that, prevalence of hazardous or harmful drinking levels was higher among those living in the least deprived areas (28% in SIMD quintile 5) than among those living elsewhere (19-24%). The survey also found that there continued to be an association between area deprivation and non-drinking prevalence in 2021, with the highest proportion of non-drinkers living in the most deprived areas (25%) and lowest proportion living in the least deprived areas (12%).

However despite lower levels of hazardous or harmful drinking, those in the most deprived areas are still experiencing higher levels of alcohol harm compared to those living in the least deprived areas. This is known in the public health literature as the alcohol harm paradox, and the reasons for this are not fully understood but there are a number of possibilities. For example, drinking combined with other health risk behaviours, such as smoking or having a poor diet, has been found to multiply your risk of developing conditions like alcoholic liver disease and some cancers, compared to doing them separately or not at all.

Those living in the most deprived areas are more likely to have multiple risk factors, compared with those in the least deprived areas.^[14] Another explanation could be that people living in the most deprived areas drink alcohol in more harmful ways, for example, binge drinking. Additionally, those living in the most deprived areas can find it more challenging to access health services for and may be less likely to seek help for alcohol-related conditions.^[15]

Summary of evidence:

This Fairer Scotland Duty Assessment has been developed to assess the socio-economic impacts MUP has had since its introduction, as well as understand how it has affected those living in deprived areas in Scotland. This evidence is relied up in the assessment as to the impact which is likely to be seen going forward, as minimum unit pricing is continued at an increased price of 65ppu.

Continuation of MUP

PHS evaluation of MUP

Since MUP at 50ppu was introduced in 2018, it has been extensively evaluated with Public Health Scotland leading the independent evaluation. The PHS final evaluation report^[16] is a synthesis of all the evidence considered in the evaluation which consisted of quantitative and qualitative studies. Forty research publications were identified and rated as of sufficient quality for inclusion in the evidence synthesis. Details of all the studies can be found on the PHS website.

The final PHS evaluation report concluded that “overall, the evidence supports that MUP has had a positive impact on health outcomes, particularly for those living in the most deprived areas, with no clear evidence of substantial negative impacts on the alcoholic drinks industry or social harms at the population level.”

The individual evaluation report by PHS (which is included in the final report) on the impact of MUP on alcohol harms, Evaluating the impact of alcohol minimum unit pricing (MUP) on alcohol-attributable deaths and hospital admissions in Scotland^[17] found that the estimated reductions in deaths and hospital admissions over the first 32 months following implementation, compared to what would have happened in the absence of MUP, were largest among men and those living in the 40% most deprived areas in Scotland.

For men, wholly attributable deaths were associated with an estimated 14.8% reduction, while the estimated reduction for women was 12.0%. For hospital admissions for conditions wholly attributable to alcohol consumption, the estimated reduction for men was 6.2% compared to a non-significant 3.1% estimated increase for women. This study estimated a significant 21.6% reduction in deaths wholly attributable to alcohol consumption for the most deprived decile. It also found that MUP was associated with significant estimated decreases in deaths from alcoholic liver disease in the three most deprived deciles.

Hospital admissions for conditions wholly attributable to alcohol consumption were estimated to have reduced across the four most deprived deciles following the implementation of MUP (although the reduction for decile 2 was non-significant). In the most deprived decile, total hospital admissions for conditions wholly attributable to alcohol consumption significantly reduced by 6.8%. For the other deprivation deciles, changes were smaller, with the exception of decile 5 where an uncertain increase of 11.9% was estimated instead.

The PHS final evaluation report found that there is strong and consistent quantitative evidence of a reduction in alcohol consumption, as measured by alcohol sales or purchasing data, in Scotland relative to other areas in Great Britain. The overall reduction in consumption was driven by a reduction in consumption of alcohol sold through the off-trade. The evidence consistently shows that the greatest reductions were seen for cider and spirits with mixed evidence of the impact on beer and wine.

Purchasing data considered as part of the evaluation suggest that the reduction in consumption was driven by the heaviest purchasing households, and the majority of households were not affected, meaning MUP was well targeted. However, analysis by Rehm and colleagues^[18] did suggest that the size of the associated drop in consumption for men became smaller with increasing deprivation, with men living in the most deprived areas having no associated decrease in consumption. For women, this trend was less pronounced.

The fact that MUP resulted in a decrease in alcohol-attributable deaths and hospital admissions related to chronic conditions also suggests that MUP reduced consumption in those that drink at hazardous and harmful levels. Attempting to draw out distinctions between impacts on consumption rates for hazardous versus harmful drinkers is difficult. Data on alcohol consumption is self-reported, and these kind of surveys may be subject to biases as a result of sampling, incorrect recall or social desirability, and reaching the heaviest drinkers to take part in surveys may be particularly challenging. One national population level survey on self-reported consumption found decreased consumption levels for harmful drinking but little evidence of impact for hazardous levels. On the other hand, a study using Kantar Alcovision data found a reduction in alcohol consumption at hazardous levels but did not find a change for the prevalence of drinking at harmful levels.^[19] Studies reviewed as part of the MUP evaluation suggested some hazardous or harmful drinkers had reduced their alcohol consumption, while others reported no change to their drinking.

There was evidence that some people with alcohol dependence had been unable to reduce their consumption. One evaluation study found no significant change in the proportion of drinkers consuming at harmful levels amongst those in the lowest social grade.^[20] For those drinking underage, there appeared to be other more important drivers of beverage choice than price, although a small number of young people with limited incomes did report reducing their alcohol consumption as a result of a MUP price rise of their favoured drink. Others, especially those with alcohol dependence who were also financially vulnerable, reported needing to use pre-existing harmful strategies more often, such as reducing spending on food and, for those who were also homeless, begging or stealing to cope with the price increase. Substituting illicit drugs appeared to be uncommon and confined to those who already used such substances.

Those with alcohol dependence are a particular subgroup of those who drink at harmful levels and have specific needs. People with alcohol dependence need timely and evidence-based treatment, and wider support that addresses the root cause of their dependence. In 2021, just 1% of all adults had an AUDIT score of 16+, indicating harmful or possibly dependent consumption levels. Levels of dependent drinking (AUDIT score of 20+) have generally been relatively stable between 2012-2019, usually at 1% for all deprivation areas apart from the most deprived quintile, which has tended to be between 2-3%. In 2021, levels had decreased across all quintiles, with 1% (down from 3% in 2019) of people in the most deprived areas having an AUDIT score of 20+, and 0% across the other SIMD quintiles. In 2019, 6% of men in the most deprived areas were consuming alcohol at a level indicating dependence, and this was down to 1% in 2021.

We are working in partnership with key stakeholders, including voices of lived experience, to review the treatment and support services available for those with problem alcohol use.

Scottish Government report on MUP

In accordance with section 3 of the 2012 Act, the Scottish Ministers compiled a report on the operation and effect of MUP over that period^[21]. The findings from the PHS final report fed into this report.

In compiling this report, the Scottish Government carried out two rounds of consultation (in summer 2022 and summer 2023), both of which focused on targeted stakeholder engagement where MUP would potentially impact on their business/organisation/community. The two consultations took various forms including:

• Targeted stakeholder roundtable events.
• Individual meetings (either instead of the roundtable events or as well as).
• Written responses.
• An online survey to capture views on the level was provided separately in order to feed into the price review.

Various organisations representing those with lived experience of poverty were invited to attend the targeted stakeholder roundtable events (summer 2022 and summer 2023). Apart from one organisation, we received no response to this call for evidence. Organisations were also invited to give anonymous feedback to a survey.

One organisation representing those with lived experience of poverty attended a roundtable in 2022. During this roundtable stakeholders noted that they hadn’t noticed a difference with the people they work with, even in peer groups, following the introduction of MUP and they believed that alcohol was still relatively cheap and available. They were not aware of any known negative impacts on those that they represent because of MUP but they believed that the removal of MUP would be a “massive step back”.

This Scottish Government report considered evidence on the operation and effect of MUP over the five years between its implementation in May 2018 up to end April 2023. It contains detail on the extent to which the policy has, to date, met its intended aim of reducing alcohol related harm. This information is drawn from the evaluation of the policy led by Public Health Scotland and from the findings of a call for evidence which included Ministerial roundtable events, and engagement with relevant stakeholders and expert groups including public health and business sectors.

University of Sheffield modelling results for the removal of MUP

To support decision making about a future price, the Scottish Government commissioned updated modelling^[22] from the University of Sheffield’s School of Health and Related Research (ScHARR) which is a world-leading centre for research on alcohol harms. Their work was used to inform the development of MUP in Scotland, and has since been used for the development of the policy in Wales and the Republic of Ireland. Their research also supported the development of the UK government’s alcohol strategy, and they were the lead authors in the 2022 World Health Organisation report on the potential value of Minimum Unit Pricing^[23].

The modelling results show that the removal of MUP is estimated to increase alcohol consumption and hence alcohol harms, which is not consistent with our policy aim of reducing alcohol-related harm. This is also likely to further entrench health inequalities, given the evidence that, even if consumption levels are equal, people from areas of deprivation are more likely to experience alcohol harm than people from higher income households.

The details of the modelling results are set out in the interim Business and Regulatory Impact Assessment (BRIA).^[24]

World Health Organisation

The World Health Organisation report, No place for cheap alcohol (published 20 June 2022) found that drinkers from lower socio-economic groups are most likely to benefit from MUP with a reduction in health inequalities overall being likely as well^[25].

Increased unit price

The Scottish Government’s Business and Regulatory Impact Assessment contains the detailed consideration of increasing the minimum unit price to 65ppu. Having considered all relevant factors, Ministers consider that 65ppu strikes the right balance between achieving their public health aims and any potential effects on the alcoholic drinks industry.

In relation to people experiencing economic disadvantage, it is expected that should Parliament agree to increase the unit price to 65ppu there will be a broadly positive effect on this group of people in relation to reducing health harms, and therefore reducing health inequalities.

The PHS evaluation reports some evidence of impacts on people with alcohol dependency as a result of the increase in the price of alcohol. For example, this included negative impacts, such as increased financial strain, and concern about switching from weaker to stronger alcohol drinks, and positive impacts, such as deciding to seek treatment.

As a whole population policy (rather than a clinical intervention) MUP alone is not specifically designed to reduce consumption in people with alcohol dependency. People dependent on alcohol require specialist treatment and support services – such as those provided by Alcohol and Drug Partnerships (ADPs) that the Scottish Government has allocated £112m of funding to in the financial year 2023/2024.

Impact of Covid-19 on alcohol sales and harms

Public Health Scotland published a summary of evidence on the impact of the COVID-19 pandemic on alcohol consumption and harm in Scotland and England. This found that, overall, alcohol consumption decreased following the start of the COVID-19 pandemic. However, changes in drinking behaviours were polarised with some increasing their alcohol consumption and others decreasing^[26]. This was associated with drinking behaviour before the pandemic: those who increased their alcohol consumption tended to drink more before the pandemic, and those who decreased consumption tended to drink less.

Since the COVID-19 pandemic, increases in alcohol-specific mortality have been observed across many countries including all 4 nations of the UK,^[27] other European countries^[28], the US^[29] and Canada^[30]. It is widely observed, including by The Office for National Statistics, that these rises are likely in part to be the result of increased alcohol consumption during the Covid-19 pandemic.^[31]

Ministers considered evidence on the effects of Covid-19 on drinking behaviour in reaching a decision to propose that Parliament increase the unit price to 65ppu.

Cost crisis

Alcohol affordability is also impacted by disposable income, which has fallen over the last year. The highest 12-month inflation rate (CPI and CPIH) was recorded among the bottom three income deciles in October 2022 and the gap of 1.4 percentage points between low- and high- income household inflation rates is the largest since March 2009.^[32]

As everyone buys different things, inflation in reality is felt differently by different individuals and different groups of the population. The ONS estimate that CPIH annual inflation was 10.5% for low-income households in the UK compared to 9.1% for high-income households, in the year to October 2022^[33]. This is down to rising energy and food costs having more bearing on the inflation rate experienced by lower income households who spend a greater share of their expenditure on these.^[34]

Not all people drink alcohol and those in the most deprived areas have higher rates of non-drinkers and moderate drinkers than the least deprived areas. So the increased minimum unit price will not impact on all people in the most deprived areas. As with the impact of a MUP at 50ppu, hazardous and harmful drinkers in the most deprived groups are likely to see a greater reduction in alcohol harms at a sub-group level.

Public attitudes research from July 2023^[35] commissioned by the Scottish Government found that the lowest income households (less than £26,000 per annum) were least likely to be against MUP and most likely to be strongly in favour of MUP compared to other income groups, but were slightly less likely to be in favour of MUP overall than average (41% compared to 43%). However, respondents from the most deprived areas were least likely to be in favour of MUP (35%) and most likely to be against MUP (41%) compared to respondents from other SIMD areas. However, respondents from the least deprived areas were second most likely to be against MUP.

Ultimately, MUP is a targeted policy in that people with the highest levels of consumption, and in particular those consuming more than the CMO guidelines and who are therefore more likely to experience health harms, will experience the greater financial impact of the increase. This is the mechanism of the policy that delivers effect by reducing the affordability of alcohol that is cheap relative to strength.

Summary of assessment findings:

From the evidence gathered, and the comprehensive independent evaluation of MUP, the Scottish Government has concluded that MUP has had a positive impact on reducing alcohol harm for hazardous and harmful drinkers, and specifically those drinkers within the more deprived areas. In particular, the evidence suggests that MUP has acted to reduce inequalities in alcohol-attributable deaths in Scotland, and modelling suggests that these gains could be reversed if MUP were to be removed.

Having considered all relevant factors, as set out in the BRIA a minimum unit price of 65ppu is intended to balance reducing alcohol harms with the impact on the alcoholic drinks market.

At a MUP of 50ppu, estimated reductions of deaths wholly attributable to alcohol consumption, compared to what would have happened in the absence of MUP, were greatest among the four most socio-economically deprived area-based deciles. The Scottish Government has concluded that an increased price of 65ppu will likely have an even greater positive impact on this group.