The zombie policies of public health

Is minimum pricing too big to fail? The brilliant wheeze of putting a 50p floor price under a unit of alcohol has failed in predictable ways for predictable reasons, but do governments have too much invested in a policy that was once described as a “game-changer” and is still described (by the Scottish government) as “world-leading” to accept reality and pack up their tent?

It would appear so. After the Scottish government introduced minimum unit pricing (MUP) in May 2018, it commissioned a thorough evaluation which produced report after report showing that the policy had been a flop. It “did not lead to a decline in the proportion of adult drinkers consuming alcohol at harmful levels” and there was “no clear evidence that MUP led to an overall reduction in alcohol consumption among people drinking at harmful levels”. Unsurprisingly, therefore, it had no effect on A & E admissions, ambulance call-outs or crime. 

It was later discovered that deaths from alcohol abuse in Scotland had reached a 15 year high but by that time a modelling study had come to the rescue by claiming that things would have been even worse if minimum pricing had not been introduced and that if you use your imagination and take a Humpty Dumpty approach to the meaning of words, the policy led to “a 13.4% reduction in deaths”. Orwell would have been proud.

No one talks much about Wales where exactly the same policy was introduced in 2020. If there is any ambiguity about the Scottish experiment, Wales is the ideal place to get a second opinion. 

And it was a flop there too. Between 2018 and 2022, the number of “increasing or higher risk drinkers” rose from 33 per cent to 45 per cent of the adult population. More people were binge-drinking, fewer people were abstaining, and twice as many people were binge-drinking every day. The number of alcohol-specific deaths fell the year before MUP was introduced but has gone up every year since.

It requires something approaching heroism to put lipstick on this pig, but the Welsh government has tried its best. Its evaluation has been a more modest affair than Scotland’s, mostly confined to chatting to a few retailers, ‘public health experts’ and drinkers in focus groups. What they heard back was not encouraging, especially from the heavy drinkers whom the policy was supposed to most benefit. For example: 

As soon as I saw a news article saying that they were going to put… a minimum pricing on units of alcohol, I thought at the time all that is going to do is lead to more shoplifting by people who are alcoholics, and that’s exactly what I’ve seen. 

You tend not to pay certain bills, where really now it’s put me in a position where I’m being supported by Citizens Advice with a potential debt relief order because of financial hardship and not having the regular income to pay my way. It’s just – it’s all sort of escalated fairly quickly to be quite frank. Yeah, so, yeah we do skip things, skip food, skip paying bills.

I think my drug use went up as well, because it was to that point where drinking wasn’t the cheapest way of getting out… So, I wasn’t drinking as much alcohol because alcohol was expensive, but then I became dependent on drugs. I was doing more drugs, but that was just a spiral of addiction with drugs I think as well.

To be fair, not every dependent drinker switched to drugs. Some of them just drank more, as the authors of one report explain. 

Others, however, report no longer being able to afford illicit drugs, leading to an increase in alcohol intake.

Contrary to the policy’s goal of reducing drinking amongst hazardous and harmful drinkers, many respondents reported no change or even an increase in their intake, as stronger drinks are often the most economical.

[Minimum pricing] is considered by most service user respondents to have particularly pushed dependent drinkers toward stronger alcoholic beverages, especially vodkas. Some have continued to maintain or even to increase their consumption despite the policy, which was intended to reduce consumption.

I could quote much more of this, but you get the picture. When the final report was published last week, it found that “service users” (i.e. alcoholics) had suffered “increased financial pressure” as a result of MUP and that many of them had switched from cider to spirits. It did not explicitly admit that the heaviest drinkers had failed to reduce their consumption but it did say that the evidence from Wales “broadly resounds with that reported by Holmes et al with a similar cohort for the Scottish MUP evaluation”. This is a reference to a study which found “no clear evidence” of an overall decline in consumption among “harmful drinkers” in Scotland.

The report also acknowledged that minimum pricing in Wales “appears to have had little impact on the drinking patterns” of the “wider population” and that “some people engaged in cross border shopping activity”. 

To cap it off, the report published the hard data: 

Alcohol specific death data for Wales highlights that the three-year rolling average increased by 9.2 per cent in 2020-22 compared to 2019-21, with rates highest among those aged 50-70. 

In 2021-2022 alcohol related hospital admissions increased by 5.5% compared to 2019-20.

Recent increases in drink driving related deaths have also been recorded, and since 2010 in Wales, the proportion of casualties that occur in drink-drive collisions has been higher than in England or Scotland.

It should be noted that drink-related deaths have gone up all over Britain since the pandemic, with a large spike in 2020. This tells you something about what the real drivers of heavy drinking are (hint: it’s not price). Wales happened to introduce minimum pricing a week after the first lockdown began. As the report acknowledges, this makes evaluating the policy more awkward, but the obvious test is to see whether there was a smaller spike in alcohol-specific deaths in Wales than in England. The authors choose not to do this, but we can see from ONS data that there was essentially no difference in outcomes between the two nations.

By 2022, Wales was seeing an extra 3.5 alcohol-specific deaths per 100,000 people compared to the pre-pandemic and pre-MUP year of 2019. In England, there were an extra 3.7 deaths per 100,000 people — a statistically insignificant difference. England and Wales track each other almost exactly over the Covid period, as you can see in the graph above. In Scotland, where minimum pricing has been in place the longest, there were an extra 4.1 deaths per 100,000. I’ll say it one more time: minimum pricing doesn’t work. 

There is a sunset clause for minimum pricing in Wales, as there was in Scotland. If it isn’t renewed by the Welsh government it will automatically cease in April 2026. It has obviously been an expensive failure and so you won’t be surprised to hear that the government’s official evaluation concludes that… [drum roll] … it should be renewed and the minimum price should go up to 65p. 

Never mind the drinkers and service users. The final report contains the results from the only focus group that really matters, a group of eight “key stakeholders”, defined as “those with leading/national roles in advocacy, evaluation, modelling, policy and service provision responsibilities”. In other words, the “public health” blob. And guess what? 

There was unanimous support for continuing with the policy …

“Overall,” concludes the final report, “the implementation of the policy has been successful, with some specific observable impacts, general agreeability, and limited evidence of widespread harms.”

The authors reach this Comical Ali conclusion by noting that retailers complied with the law, there was broad public awareness of it, and people can no longer buy alcohol for less than 50p a unit. Every indicator may have gone in the wrong direction and there have been copious unintended consequences, but the policy is supported by “modelling, academic literature, and evaluations in other jurisdictions [i.e. Scotland]”  so it must have worked in Wales. And if you are still not convinced, they remind us that the incompetent and corrupt World Health Organisation describes minimum pricing as a “best buy”. 

The final report refers to “some cross border shopping taking place, but not in any significant volume”, despite 20 of the 36 drinkers in the “wider population” focus group telling them that they are “now buying alcohol in England”. It says that Wales “has not seen any of the initially perceived fears of adverse harm materialise in any significant manner”, despite the evaluation providing evidence for every negative consequence predicted by the policy’s critics. Shoplifting, cutting down on food and switching to hard liquor as a result of minimum pricing is dismissed as people “adjusting [their] lifestyle”. And while it admits that the policy has led to more drug use, it assures us that this has probably only involved “those with prior experience of drug use”, so that’s alright.  

The lesson here is that modern “public health” doctrine is unfalsifiable and academics will turn cartwheels to perpetuate the myth of its infallibility. There is no amount of evidence that will convince the “public health” lobby that their policies have failed. They are in the business of politics, not science, and politicians make political decisions, not evidence-based decisions. As one of the “key stakeholders” says in the final report: “I believe that if we drop it, it has bigger consequences than just the pricing. I think it will be a sort of — it will be a step back.” 

The ratchet only turns one way.