Beyond minimum unit pricing: Did it work – and what's next?

Between 2018 and 2022, the number of people dying in Scotland from causes wholly attributable to alcohol misuse climbed from 1,136 to 1,276.

The death rate - adjusted to account for Scotland's growing and ageing population - went up by 10%.

Yet analysis published in the Lancet in March 2023 - the most comprehensive evaluation of the policy to date - concluded that it had prevented 156 alcohol deaths per year, particularly among men and people living in the most deprived areas.

The 50 pence rate for MUP was set in 2012, but came into effect in April 2018. The 65p rate is expected to be introduced on September 30 2024 (Image: Newsquest)

Updated modelling by the University of Sheffield Alcohol Research Group anticipates that the new 65p rate will save 60 additional lives per year.

If this seems counterintuitive, it is partly because what the scientists are counting are deaths which never happened.

In this sense then, it is possible for MUP to work and for deaths to increase; what matters is whether the outcome would have been even worse without it.

To assess that, researchers compared what happened in Scotland to a "control" population - north-east England - where almost everything, from demographics and deprivation to alcohol duties, consumption, availability, and marketing, are virtually identical.

The only substantive difference was MUP.

When they did so, they found that alcohol-specific mortality rates in the region went up by 38% over the same four year period. In England as a whole, they increased 36%.

This is particularly striking because, historically, it is almost unheard of for alcohol death rates to rise faster south of the border than in Scotland.

Scotland's alcohol death rate remains higher than England's following a 10 per cent increase, but the mortality rate rose three times faster in England between 2018 and 2022 (Image: IAS)

Jim Lewsey, a professor of medical statistics at Glasgow University and a co-author on the Lancet paper, said: "I can understand why it is confusing to people, but what we’re trying to do in these evaluations is something that is actually impossible: to imagine what would have happened had MUP never been in place.

"Basically, to go back in time and re-run history.

"We can’t do that, of course, but what we can do is to use a control group which is pretty similar to the intervention group – Scotland – in terms of sharing other factors which influence alcohol consumption and harms, but which didn’t have the intervention in place.

"That’s quite powerful because it allowed not only for us to compare Scotland before and after MUP, but across that same period to compare Scotland to a control group without MUP."

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Another recurring criticism is that MUP did not cut consumption among "dependent" drinkers - those with alcoholism - and, more worryingly, led some to cut down on food and heating as the cost of alcohol rose.

Experts caution that dependent drinkers are a very small percentage of Scotland's "harmful" drinkers - women routinely consuming over 35 units a week, and more than 50 for men - and that it is misleading to conflate the two.

Jem Roberts, from the Institute of Alcohol Studies, said: "You could drink 40, 50, 70 units a week, and not be physically dependent on alcohol.

"Those people were at very high risk of harm, and purchasing among those households did decrease. That's why the policy has worked.

"For dependent drinkers, a change in the price of alcohol is not necessarily going to change their habits.

"For many of these people, their life is centred around accessing and consuming alcohol.

"What minimum unit pricing can do and will have done, however, is prevent people from becoming dependent in the first place."

Dr Alastair MacGilchrist, a consultant liver specialist and chair of Scottish Health Action on Alcohol Problems (SHAAP), says that the estimated 156 deaths-a-year avoided as a result of MUP will mainly have occurred among this group of harmful, non-dependent, drinkers.

He said: "There are lots of folk out there with cirrhosis who are just coping, but that one extra binge - that bit more alcohol - would tip them over the edge.

"That's the theory why alcohol deaths are so responsive to price: as soon as you put the price up, alcohol deaths fall; as soon as you put the price down alcohol deaths rise again.

"The people who are not dying are people with liver disease, and that's one reason why we can be very confident that MUP must be having an effect on people who are drinking heavily.

"People don't get liver disease unless they're drinking very heavily. It's not the person drinking 14 units a week who gets cirrhosis, it's the person drinking 50 units a week."

Experts are clear that the benefits of MUP must be balanced against the risks to dependent drinkers.

In January 2022, Ireland implemented MUP at €1 per unit - equivalent to 85 pence - but ministers in Scotland have opted to set the new rate just above inflation.

In real terms, alcohol sold in the UK - especially in the off-trade - has become steadily more affordable since 1987, due to duty freezes and increases in disposable income (Image: Institute of Alcohol Studies)

Had the 50 pence rate - set in 2012 - risen in line with inflation it would be worth around 61 pence now.

Laura Mahon, deputy chief executive at Alcohol Focus Scotland said 65p was the "minimum increase" necessary.

Liam Mehigan, operations director at residential rehab provider, Abbeycare, said he would like to see the additional money raised by the MUP uplift "ring-fenced to help support extra treatment services".

Overall, there is a consensus among those working in the alcohol field that minimum pricing must be one strand in a much broader package of measures designed to reduce alcohol consumption and harm.

A recent report by Fraser of Allander estimated that £57 million a year could be raised for alcohol treatment services if retailers selling alcohol were required to pay a public health levy, based on the non-domestic rates for their premises. This would mainly affect large supermarket chains.

Alcohol problems are estimated to cost the Scotland's NHS and social care services £700m a year, while Fraser of Allander estimates that MUP has boosted alcohol revenue for shops and supermarkets by £30m a year despite a 3.5% drop in sales.

In several US states, including New York, grocery stores are forbidden from stocking any alcohol except beer (Image: Getty)

There are also concerns that duty on alcohol - set by the UK Government - has failed to keep pace with inflation.

By 2021, alcohol sold in the UK was 78% more affordable in real-terms than it had been in 1987, due to a combination of rising disposable income, soaring off-trade sales, and successive cuts or freezes in duty - including in almost every Budget from 2012 to 2022.

Dr Peter Rice, an addictions psychiatrist, said: "It’s a political battle every year. If alcohol duties go up with inflation that’s a cruel and unusual punishment – industry ‘hammered again’ and so forth.

"Australia automatically uprates their alcohol duty with inflation, but they’re one of very few countries who do that.

"Politicians like to have the flexibility, but I think that makes for bad health policy. Health usually loses out."

Beyond price, the next frontiers for campaigners are availability and marketing.

In Norway, a blanket ban on alcohol marketing has been in place since 1975, and alcohol over 4.8% strength is only sold through Vinmonopolet, the state-owned liquor stores.

Annual alcohol consumption, in litres per capita, in selected European nations - 2021 (Image: Statista)

The restrictions have been credited with "de-normalising" drinking in the Nordic country where consumption levels are now among the lowest in Europe.

In 2018, Ireland also passed legislation which means that supermarkets can only display alcohol in an area distanced from checkouts and other groceries, and hidden behind swing door barriers.

Compared to countries such as New Zealand and the United States, the UK is unusual in stocking "hard liquor" - vodka, gin, and other spirits - in supermarkets.

In New Zealand, grocery stores can sell only beer and wine, while New York State permits only beer.

"Alcohol's integration with the rest of the grocery market has been a big driver behind increased consumption," said Dr Rice.

"I remember when it was sold in an aisle tucked away from everything else. I can remember my Dad buying alcohol through a grille at the back of the shop. People get very used to the norm."

In Scotland, there is also evidence that pubs and off-licences cluster at much higher levels in areas of the highest deprivation, where alcohol death rates are four times higher than the most affluent areas.

Alcohol Focus Scotland backs a ban on alcohol adverts on billboards and other public spaces, including sports sponsorship (Image: PA)

Much of this boils down to the peculiarities our local licensing system. 

Ms Mahon said: "In terms of controlling availability, there's nothing [Licensing Boards] can do to reduce availability.

"They can't revoke existing licences unless someone is caught, for example, selling to under-18s.

"The very most they can do is prevent increases, but even that's tricky.

"If a Licensing Board doesn't receive any objections, unless they have a particular policy position where they've said 'we're not going to grant anymore off-licences in this particular area'  - which they could do - they will have to grant the licence."

The Scottish Government is due to unveil a revised consultation on alcohol marketing later this year.

Ms Mahon said she hopes it will be "more focused", with a particular emphasis on sports and event sponsorship, retail environments, and displays on billboards, bus stops, and other areas where children's exposure is highest. 

She added: "We've seen huge opposition to that from the alcohol industry though, so it's probably going to be fairly contentious."