Minimum Unit Pricing (MUP) Continuation and future pricing: Stage 2: Child Rights and Wellbeing Impact Assessment

1. What evidence have you used to inform your assessment? What does it tell you about the impact on children's rights?

Background

MUP forms part of the Scottish Government's wider whole population approach to alcohol harm prevention, which is set out in the Alcohol Framework 2018^[1] and contains 20 actions to reduce alcohol-related harm.

Alcohol-related harm continues to be a key public health challenge in Scotland. In 2021, the latest year for which data is available, Scots bought enough alcohol for everyone aged over 16 to drink 18.1 units of alcohol every week (9.4 litres)^[2]. 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.

The high levels of consumption in Scotland cause a range of harms. High levels of alcohol consumption causes significant harm both at the individual and the population level. 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^[3]. 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.^[4] 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.^[5]

MUP is subject to a 'sunset clause' that means that policy will expire at the end of 30 April 2024 unless Parliament agrees to extend its effects. Ministers were under a duty to lay a report before Parliament setting out their assessment of MUP over its period of operation. This report was laid before Parliament on 20^th September 2023^[6].

To support their assessment of MUP, the Scottish Government commissioned Public Health Scotland to undertake an extensive evaluation of the policy, the conclusions of which were published in 2023. The PHS evaluation considered the evidence of the effects and effectiveness of MUP over a number of years, including the impacts on a range of groups some of whom are have, or are likely to have, a protected characteristic.

Broadly, the evaluation concluded that there was evidence that MUP had reduced alcohol specific deaths and likely to have reduced hospitalisations wholly attributable to alcohol during the periods relevant studies considered. There was evidence that MUP has contributed to a population level reduction in alcohol consumption of around 3% in the period considered.

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, among those who drink at hazardous and harmful 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.

The PHS evaluation noted that there was limited evidence to suggest that MUP was effective in reducing consumption for people with alcohol dependence (at a population level, this is estimated to represent around 1% of adults, based on Scottish Health Survey 'AUDIT' scores of 16+ which indicate drinking at harmful and possibly dependent levels^[7]).

People 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 2023/24, the Scottish Government made £112.9 million available to Alcohol and Drugs Partnerships to support local and national treatment initiatives. The Scottish Government has been involved in a UK-wide group on reviewing and updating clinical guidance for alcohol treatment, which has been consulted on. Evidence around Managed Alcohol Programmes is also being explored.

To compile this CRWIA, A variety of information sources were used, including -

• Public Health Scotland's, Evaluating the impact of minimum unit pricing for alcohol in Scotland: Final report: A synthesis of the evidence, which was published on 27 June 2023.
• Engagement with stakeholders in summer 2022 and summer 2023 as part of our report on minimum unit pricing (MUP).
• Meeting with internal policy colleagues
• Health Behaviour in School-Aged Children (HBSC): 2022 Survey in Scotland

Evidence from research

The Scottish Government commissioned Public Health Scotland (PHS) to lead a wide-ranging, comprehensive, five-year review of MUP. The evaluation sought to answer two overarching questions:

1. To what extent has implementing MUP in Scotland contributed to reducing alcohol-related health and social harms?

2. Are some people and businesses more affected (positively or negatively) than others?

The evaluation comprised a portfolio of quantitative and qualitative studies across a number of areas including price and product range; alcohol sales and consumption; alcohol related harm; and economic impact on the alcoholic drinks industry.

The findings from each of these studies have been published on the PHS website. Two of these related specifically to the impact of MUP on children and young people: Minimum Unit Pricing in Scotland: A qualitative study of children and young people's own drinking and related behaviour (published November 2019) and Minimum Unit Pricing (MUP) for alcohol evaluation The impact of MUP on protecting children and young people from parents' and carers' harmful alcohol consumption: A study of practitioners' views (published 12 May 2020)

The first of these studies was a qualitative project with children and young people under the age of 18 who consumed alcohol to gather their views and experiences of drinking and related behaviour following the introduction of MUP. 50 children and young people between the ages of 13 and 17 participated in the research, and a further 21 staff and volunteers who worked with children and young people were interviewed, including support workers, youth workers, school guidance staff, and service managers. The study concluded:

Among the young people who took part in the study, the introduction of Minimum Unit Pricing had limited impact on alcohol use and no reported impact on related behaviour. The price of many drinks popular among young people did not change following MUP's introduction. The price of alcohol was not a significant factor in the young people's alcohol use as they tended to have the financial means to purchase the alcohol they wanted, including when the price of their favoured drink increased, sometimes by prioritising it over other purchases. However, some young people did switch to alternative alcohol products, and a small number of young people reduced their drinking when the price of their favoured drink rose. There were no reported negative impacts on children and young people from the introduction of MUP.

Overall, this research highlighted that alcohol use among children and young people is a complex issue influenced by a range of factors which can change as they get older and their experiences and perceptions change.

It should be noted that the research only considered children and young people who consumed alcohol before and after the introduction of MUP in May 2018, and as such the views and experiences of the children and young people who took part are not representative to the general population of children and young people in Scotland.

The second study considered the potential impact of MUP in protecting children and young people from harm from the harmful alcohol use of their parent or carers. Eight focus groups and one interview were held with a total of 42 practitioners with specialist expertise in alcohol-related services. The study concluded:

The aim of the study was to contribute to an understanding of the potential role of MUP in protecting children and young people from harm from parent or carer harmful alcohol use. Through in-depth discussions with practitioners with specialist expertise in alcohol-related services the study powerfully illustrates the harms that children and young people may experience as a result of parent/carer alcohol use within some families. The participants in this study were experienced practitioners that understand the complexity of the lives of the families they work with, the pressures they face from challenges relating to financial hardship, and the multitude of factors that influence alcohol consumption and related harms to children. This complexity, together with the comparatively recent implementation of MUP made it difficult for participants to identify specifically how MUP had changed children and young people's experience of harm from parents'/carers' drinking.

Participants did feel that MUP may support some of those who were drinking at hazardous and harmful levels to reflect on and possibly reduce their consumption. There were some examples of this happening, with the potential for beneficial effects for children and young people. Participants felt that MUP may have a limited positive impact on those living with a possible dependence on alcohol. The study suggests that, in addition to MUP, in order to address alcohol consumption and related behaviours and to help mitigate the risk of harms to children and young people, interventions are needed that support individuals to address their underlying reasons for harmful drinking. It will be important to consider whether such interventions for individuals living with a possible dependence on alcohol may be different to those for individuals who are considered to be drinking at harmful and hazardous levels, but not living with a possible dependence. In a context of pervasive poverty, including child poverty, the study also suggests a need for greater understanding of, and actions to address, the interactions between poverty, welfare reform and substance use.

In producing the final report on the impact of MUP, PHS conducted a comprehensive evidence synthesis which pulls together the findings of the PHS evaluation in addition to work on the impact of MUP conducted by others, primarily academic institutions. Following a quality appraisal process, 40 research publications were identified and rated as of sufficient quality for inclusion in the evidence synthesis. PHS published their final report, Evaluating the impact of minimum unit pricing for alcohol in Scotland: Final report: A synthesis of the evidence, on 27 June 2023.

The overall conclusion by PHS on the impact of MUP is:

Overall, the evidence supports that MUP has had a positive impact on health outcomes, namely a reduction in alcohol-attributable deaths and hospital admissions, particularly in men and those living in the most deprived areas, and therefore contributes to addressing alcohol-related health inequalities. There was no clear evidence of substantial negative impacts on the alcoholic drinks industry, or of social harms at the population level.

In relation to children and young people, the evaluation included three papers, each of which was assigned a strong quality appraisal rating, and contributed qualitative evidence about the effects of MUP on families and children. This included the two papers described above. Looking at the evidence from these three studies, PHS wrote:

Practitioners working with families affected by alcohol expressed concerns about the ability of those with probable alcohol dependence to absorb the price increase without affecting the family budget, but recognised MUP was just one of many factors at play in the complex lives of these families^[8]. Overall, they felt unable to determine if MUP had positive or negative impact on the lives of children and young people affected by other people's drinking^[9]. Holmes and colleagues^[10] also provided insights into the impact of MUP on children and families. In structured interviews with those with probable alcohol dependence there was no evidence of change in any parenting outcomes after the introduction of MUP. Qualitative interviews with the families of people who drink at harmful levels provided some accounts of concerns about impacts on household budgets and the potential for increased domestic violence^[11]. Analysis of survey data suggested that sharing a home with a partner or children had no impact on the consumption of people who drink at harmful levels^[12]. Interviews with drinkers under 18 years old did not indicate any increase in social harms for this group linked to MUP^[13].

In summary, there were some qualitative insights that suggest that for some drinkers, especially those with probable alcohol dependence and particularly the financially vulnerable, existing social harms, particularly those related to financial pressures, may have been exacerbated, but there is no evidence of those experiences being prevalent or typical.

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.

The Scottish Government recognises that people with alcohol dependence need timely and evidence-based treatment and wider support that addresses the root cause of their dependence. In 2023/24, the Scottish Government made £112.9 million available to Alcohol and Drugs Partnerships to support local and national treatment initiatives. The Scottish Government has been involved in a UK-wide group on reviewing and updating clinical guidance for alcohol treatment, which has been consulted on. Evidence around Managed Alcohol Programmes is also being explored.

It is not possible to say whether children and young people in families affected by alcohol use were positively or negatively affected.