Learning from 25 years of preventative interventions in Scotland

10. Minimum Unit Pricing of Alcohol (MUP)

Minimum Unit Pricing of Alcohol: reducing harm by reducing consumption

Minimum Unit Pricing (MUP) sets a floor price below which alcohol cannot be sold. The Scottish Government introduced a MUP of 50p per unit in 2018, which led to changes in alcohol consumption and was estimated to have contributed to reductions in alcohol-related deaths and hospital admissions for alcohol-related causes, particularly among men and those living in the most deprived areas.

Introduction

Minimum Unit Pricing (MUP) is a primary preventative intervention that aims to reduce health harms caused by alcohol consumption by setting a floor price below which alcohol cannot be sold. It targets a reduction in consumption of alcohol that is considered cheap, relative to its strength, among those who drink at hazardous and harmful levels. MUP is also intended to address alcohol-related health inequalities, given the greater harms people in lower socio-economic groups experience in relation to alcohol. It may also offer a means to reduce indirect harms associated with excessive alcohol consumption such as violence or accidents.

Context

Scotland has a high rate of hazardous and harmful drinking. In 2012, people in Scotland consumed 21.0 units of pure alcohol per adult per week compared with 17.6 units per adult per week in England and Wales;^[220] 25% of men and 18% of women in Scotland were drinking at hazardous or harmful levels^[221], a decline since 2003 but still a cause for concern. Rates of alcohol-related harms were also higher than in other countries, such as deaths from chronic liver disease.^[222] In 2012-13, 36,222 hospital admissions in Scotland were alcohol-related and 62% of violent crimes took place under the influence of alcohol.^[223] 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 effects of multiple drivers of health inequality.^[224]

The societal costs of such consumption are substantial. In 2007 the Scottish Government commissioned research estimated these at £3.6bn per year, comprising expenditure associated with health services (7.5%) and social work services (6.5%), crime (20.4%) and costs to productive capacity (24.3%) as well as wider social costs (41.2%).^[225] In 2012, academic researchers produced a higher estimate of £7.5bn that also accounted for morbidity (where alcohol related illness does not result in death), with 40.41% of that figure arising from the 20% most deprived areas.^[226]

The low cost at which alcohol could be purchased was understood to be a driver of these trends. In 2009, alcohol was 70% more affordable in Scotland than it had been in 1980. ^[227] In 2017, just under half of all off-trade alcohol (sold for consumption off the premises) was estimated to have been sold under the £0.50 per unit floor proposed in the MUP legislation, and the average price was £0.54 per unit. In contrast, the average price in the on-trade was £1.08 per unit.

Response

The Scottish Government’s 2009 Framework for Action recognised the need for a new approach to alcohol misuse that claimed twice as many lives in Scotland as it had 15 years previously and hit the poorest communities the hardest.⁸ It proposed the introduction of a minimum price per unit as a mandatory condition of Premises Licences and Occasional Licences granted under the Licensing (Scotland) Act 2005.

The Alcohol (Minimum Pricing) (Scotland) Act 2012 (“the 2012 Act”) was the Scottish Parliament's second attempt to legislate for the policy of setting a minimum price for a unit of alcohol sold. [228] An almost identical measure was included as section 1 of the Alcohol etc. (Scotland) Bill 2009 as introduced, but was left out by amendment during that Bill’s Parliamentary passage.^[229] The case for MUP was underpinned by modelling from the University of Sheffield. This estimated that a 50p unit price would result in a 5.7% reduction in consumption, 60 fewer deaths and 1,600 fewer hospital admissions per year. ^[230]

During scrutiny of the Bill which became the 2012 Act, there were opposing views about how targeted the policy impacts would be.^[231] Those in favour believed it to be a targeted intervention as it would only affect low-price, high-strength products favoured by more harmful drinkers. Those opposed claimed MUP was a blunt tool that would have no effect on the heaviest drinkers, while punishing moderate drinkers and those on low incomes.

The legislation was subject to a lengthy legal challenge by alcohol producers. This concluded in the UK Supreme Court which issued a judgment in November 2017 finding that the 2012 Act was a proportionate means of targeting the use and abuse of cheap alcohol in Scotland. Following a vote in the Scottish Parliament to approve the original SSI setting the minimum unit price at 50ppu,^[232] MUP was introduced on 1 May 2018 in a form that had not been implemented elsewhere. A sunset clause was included in the 2012 Act, stipulating that the legislation would expire on 30 April 2024 unless the Scottish Parliament voted for it to continue, to ensure that Parliament could consider its effectiveness as a novel policy intervention before confirming it as a permanent intervention.

Intervention

A minimum unit price of 50p was introduced in Scotland on the basis of strong evidence from other jurisdictions that raising the price of alcohol, and doing so through a minimum price specifically (rather than via alcohol duties or taxation) reduces harms.^{[233],[234],[235],[236]} The modelling from Sheffield Addictions Research University also informed consideration of price level and impacts.¹¹

A theory of change was developed for how this measure would influence behaviour and therefore health and other outcomes (Figure 1). Potential factors affecting this process included external influences on population-level alcohol consumption, impacts on the alcoholic drinks industry, and adverse consequences such as potential substitution of alcohol with other harmful substances.

Source: Protocol for the evaluation of Minimum Unit Pricing for alcohol

A diagram of the 'Theory of Change' for minimum unit pricing (MUP) of alcohol. The theory of change shows the main expected chain of outcomes whereby compliance with MUP results in a price change, reduced alcohol purchasing, reduced population consumption and safer patterns of drinking, and reduced health and social harms. There is a bidirectional relationship between these factors listed and product and marketing changes and changes in social norms and attitudes to MUP and alcohol.

There may be other changes, such as the economic impact on the alcohol industry; displacement of spending; substitution to non-beverage alcohol or other drugs; and impact on demand for services.

The diagram also shows how the effects of MUP will be influenced by its interaction with factors external to MUP, such as factors that influence the price of alcohol and/or disposable income, other alcohol policy and other factors that affect availability, access to treatment etc.

Monitoring and Evaluation

MUP was the focus of an extensive multi-component evaluation coordinated by Public Health Scotland (PHS).^[237] This work was commissioned to support the review of MUP and duty on Scottish Ministers to lay a report before Parliament on their assessment of the effects of MUP in advance of the sunset clause expiring. The work began with a feasibility study^[238] which concluded that a mixed method approach would be needed.

Twelve studies were carried out, or commissioned, by PHS with funding provided by the Scottish Government to provide robust evidence on the steps set out in the Theory of Change, as well as the impact of MUP on protecting and improving public health, preventing crime, disorder and public nuisance, securing public safety, protecting children and young persons from harm, and on alcohol producers and licence holders. Seven additional studies that were separately funded also examined its effect, including through qualitative research, a natural experiment, a daily survey and analysis of administrative data. Where possible, studies compared any change with other parts of the UK. Qualitative evidence was used to help explain findings and understand the lived experience of different key groups including homeless individuals, children and young people and those drinking at harmful levels.

A final report was published in 2023^[239] that synthesised findings from 40 publications, following a published protocol for synthesis.^[240] This report was used as the basis for the production of a Scottish Government report on the operation and effect of MUP, a requirement of the sunset clause in the 2012 Act.^[241]

Key Findings

There were two main questions for the evaluation and key findings relating to each of these are set out below.

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

• Following implementation, sales of alcohol below £0.50 per unit largely disappeared, with a net reduction of 3% in total per-adult sales of pure alcohol in the next three years. Reductions in alcohol purchases were greatest among households that were previously buying the most alcohol.
• There was strong evidence that MUP reduced deaths wholly attributable to alcohol consumption by an estimated 13.4%, equating to 156 deaths per year up to the end of 2020, compared to what would have happened had MUP not been in place.
• The benefits to society valued in monetary terms arising from partially attributable deaths prevented by MUP were estimated at approximately £215.5 million, ranging from approximately £3.6m to £428m.
• There was strong evidence that MUP reduced wholly attributable hospital admissions due to chronic causes.^[242] Overall, it was likely that MUP had reduced wholly attributable hospital admissions in Scotland compared to what would have happened in the absence of MUP.
• The estimated averted costs for admissions for causes wholly attributable to alcohol were approximately £407,000 per year, and for admissions partially attributable to alcohol the estimated costs averted were £483,000 per year.
• There was no consistent evidence that MUP affected other alcohol-related health outcomes such as ambulance callouts, emergency department attendances and prescribing of medication for alcohol dependence.
• There was also no consistent evidence that the policy led to any widespread health or wider harms, or significant costs to the alcohol industry or that it had positive or negative impacts on social outcomes. Quantitative studies on crime (including drug crime), switching to non-beverage alcohol, spend on food and the nutritional value of food all found no positive or negative effects, and quantitative evidence on the impact on road traffic accidents was mixed.

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

• The greatest reduction in deaths wholly attributable to alcohol was seen amongst men and those living in the 40% most socio-economically deprived areas in Scotland, indicating a strong potential to address health inequality.
• Qualitative evidence from those working with families affected by alcohol suggested that MUP helped reduce consumption in those drinking at hazardous or harmful levels but not in those with alcohol dependence

Some people, particularly those with established alcohol dependence with limited financial or social support (a group with specific needs) may have experienced harm, such as reduced expenditure on food

Taken together, the research found that MUP had a positive impact on health outcomes, and was estimated to have reduced alcohol-attributable deaths and likely to have reduced hospital admissions. This was particularly so for men and those living in the most deprived areas, contributing to tackling alcohol-related health inequalities. The main PHS evaluation determined it was not possible to undertake a full cost benefit analysis due to both technical and resource constraints). However, the final report suggested that the balance of costs and benefits were favourable.

While the natural experiment approach employed for many of the studies was considered gold standard given that individuals could not be randomised to purchase alcohol at different prices, the evaluation report notes as a limitation that theory-based consideration was relied on to determine whether external factors or differences between areas might have contributed to outcomes.

Learning and Next Steps

Because MUP for all alcoholic drinks represented a novel policy that had not been implemented in the same way in other countries, the legislation had contained a sunset clause that the provision would expire on 30 April 2024 unless the Scottish Parliament voted for it to continue. While consultation in 2023 on the continuation of the policy returned mixed views^[243] there was strong support from all public health and local government organisations. In addition, a 2023 survey of a nationally representative sample of 1,029 adults in Scotland found that more people were in favour of MUP (43%) than against (38%).^[244]

Research commissioned by the Scottish Government from University of Sheffield suggested the real-terms value of MUP had been reduced by high inflation from the original 50p price to a 2023 equivalent of 41p, and that the threshold would need to have increased to 61p/unit to maintain its real-terms value.^[245] The researchers modelled that adjusting the MUP threshold in 2023 to account for deflation in its level since 2018 and then adjusting its level in line with inflation in future years could lead to around 1,200 fewer deaths, 15,000 fewer hospital admissions, 38,000 fewer years of life lost and a £17million reduction in NHS costs due to alcohol over 20 years compared to retaining a MUP of 50p/unit.

The Scottish Parliament agreed in 2023 to continue the effect of the MUP legislation beyond 30 April 2024 and to raise the level it is set at. From 30^th September 2024 the minimum unit price rose to 65p per unit.

The evaluation has been influential, with the approach commended in an article in The Lancet^[246] and calls in response from experts for the introduction of MUP in other jurisdictions^[247]. The WHO included minimum pricing (as a complement to taxation) among its priorities for action on alcohol in 2022^[248], noting in response to the 2023 evaluation report that other European countries were following Scotland’s example. It stated that: “learning from Scotland's experience, countries can work towards creating safer communities and improving public health outcomes for all.”^[249] The Public Health Association Australia described MUP in Scotland as one of the most thoroughly evaluated public health policies in decades.^[250]

In 2020 Wales became the second nation in the UK to introduce an MUP of 50p per unit for all alcohol. This has since been found to be associated with reduced alcohol purchases, notably among drinkers under 28 favouring cheap high-strength alcohol.^[251]

The potential of MUP has been demonstrated in relation to primary (rather than secondary or tertiary) prevention, to the extent that it appears less likely to affect positive outcomes for dependent drinkers, who are already experiencing harms and have distinct and complex needs. In 2024, Audit Scotland recommended that the Scottish Government should identify ways of developing more preventative approaches to tackling Scotland’s long history of alcohol problems, to target people at risk of harm before problems with alcohol use develop.^[252]