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Artillery Row

Minimum pricing, miserable results

Minimum pricing has not succeeded even on its own terms

When minimum pricing for alcohol was introduced in Scotland in May 2018, it came with a sunset clause. If the policy couldn’t be shown to have worked after five years, it would be repealed twelve months later.

And so it was politically awkward when Public Health Scotland’s official evaluation kept showing that it was not having the desired effect. The people who were commissioned to look at minimum pricing’s impact on crime found “no changes in the trend direction or statistically significant changes in the level of all alcohol-related crime and disorder” except in one local authority where alcohol-related crime went up.

A thorough study of minimum pricing’s impact on alcohol-related A & E attendance found no decline after the policy was introduced and even suggested that “minimum unit pricing was associated with 258 more alcohol-related emergency department visits.” Another study found no impact on alcohol-related ambulance call-outs.

A study of the heaviest drinkers — who were the primary targets of the policy — found “no clear evidence that MUP led to an overall reduction in alcohol consumption” although it did lead to “increased financial strain for a substantial minority of those with alcohol dependence”. This was echoed by a study published this month which admitted that “the lack of evidence for a decline in the prevalence of harmful drinking arising from MUP is contrary to model-based evidence that informed the introduction of the policy.”

It was also echoed by a study published independently of the official evaluation which found that minimum pricing was associated with a small decline in overall alcohol consumption, amounting to less than one unit per drinker per week, but that this was not driven by heavy drinkers cutting down. On the contrary, the heaviest drinking men drank more under minimum pricing. To the disappointment of the pub trade, the study also found that young men responded to the policy by drinking more at home and less in the pub.

Researchers have also found various unwelcome, unintended and not wholly unpredictable consequences, such as drinkers spending less on fruit and vegetables and more on crisps and snacks, as well as “increased intoxication after they switched to consuming spirits rather than cider” and “concerns about increased violence”. As of 2021, Scotland had its highest rate of alcohol-specific deaths in over a decade. So does the rest of the UK, to be fair, but the rate in Scotland is much, much higher than England’s.

It seems inconceivable that anyone could claim that minimum pricing was a success, but never underestimate the determination of the public health lobby. Public Health Scotland has today declared that the policy “had a positive impact on health outcomes” and claimed that it “reduced deaths directly caused by alcohol consumption by 13.4 per cent and hospital admissions by 4.1 per cent”. These estimates come straight out of a study published in March which has become a life raft for supporters of minimum pricing to cling to.

The authors of that study compared Scottish data between 2018 to 2020 to a counterfactual of what they thought would have happened if minimum pricing had not been introduced. The counterfactual was largely based on trends in England, which does not have minimum pricing. Both countries saw a large rise in alcohol-related deaths in 2020, presumably due to the stress of the pandemic, but Scotland saw a decline in 2019 whereas England saw a slight rise. It is this contrast that forms the basis of the claim that minimum pricing saved lives.

Can the pre-pandemic dip in alcohol-specific mortality confidently be attributed to minimum pricing? Correlation does not equal causation, and trends in England and Wales have often gone in different directions in the past. The number of alcohol-related deaths fell by a third in Scotland between 2006 and 2012 for no obvious reason. The decline in 2019 was a blip by comparison. 

Public Health Scotland doesn’t mention it but the 4.1 per cent decline in hospital admissions reported in the same study was not statistically significant and was, again, only an estimate compared to a hypothetical counterfactual; alcohol-related hospital admissions did not fall in 2018 or 2019. Similarly, the 13.4 per cent decline in mortality compared to a counterfactual does not mean that the number of deaths actually declined. On the contrary, Scotland’s alcohol-specific death rate rose from 20.5 per 100,000 people in 2017 to 21.5 per 100,000 people in 2020.

We might take the claim about minimum pricing’s effect on mortality more seriously if it was supported by other evidence from the evaluation but, as we have seen, it isn’t. The claim from Public Health Scotland that the largest reductions in alcohol-related harm were seen “in men and those living in the 40 per cent most deprived areas” is the exact opposite of what a study published last year found. The authors of that research wrote:

When the Minister for Public Health, Sport and Wellbeing introduced the 2018 alcohol policy framework, he emphasised that the implementation of the MUP was strongly motivated by an interest in decreasing health inequalities through a reduction in alcohol consumption among the heaviest and most vulnerable drinkers. Our results indicate that this goal may not be fully realised: first, we found that women, who are less heavy drinkers in our data and in almost all surveys worldwide to date, reduced their consumption more than men; second, the 5% of heaviest drinking men had an increase in consumption associated with MUP; and, third, younger men and men living in more deprived areas had no decrease in consumption associated with MUP.

That study was not part of the official evaluation, but none of the official studies give much support to Public Health Scotland’s claim either. Of the five studies looking at health outcomes in today’s report, only one found a positive impact from minimum pricing and that is the study that made the claim of a 13.4 per cent decline. A further twelve studies looked at “wider health and social outcomes” but they all either found no evidence of an impact or limited and inconsistent evidence. In short, the claim that minimum pricing “worked” rests almost exclusively on a single study which is an outlier in many respects, which cannot come close to proving causation, and whose findings are highly dependent on the assumptions of its authors. 

Minimum pricing is a flagship policy for the Scottish Government

It was perhaps inevitable that a government-funded public health agency would find in minimum pricing’s favour. Minimum pricing is a flagship policy for the Scottish Government and the public health lobby is keen for it to be rolled out to other countries (Wales already has it, and it didn’t work there either). But it is a shabby end to an evaluation process that has cost a great deal of money and has been impressive in its breadth and depth. Taken together, the reports give a good impression of what has happened in Scotland under minimum pricing. Most of it is rigorous and impartial. Much of it supports the common sense criticisms of the policy made by sceptics before it was introduced. To make the case for minimum pricing, you would have to pretend that most of it doesn’t exist, and so that’s what Public Health Scotland has done.

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