This Tuesday, Shona Robison, the Scottish Cabinet Secretary for Health and Sport, announced that a Minimum Unit Price for alcohol (MUP) will be implemented in Scotland from 1st May 2018. This policy has been widely hailed by public health bodies as an innovative approach to reducing alcohol-related harm, however not everyone is convinced. Several commentators, particularly those of a libertarian bent, have accused the policy of being ‘a tax on the poor’. So, is it?
There is no question that there are substantial inequalities in health between the most and least deprived in our society. The age-standardised death rate in the most deprived decile of the Scottish population is double that in the least deprived. A man living in one of the 15% most deprived council areas in Scotland can expect to live an average of 7.2 years less than the rest of the population. If we concentrate on the harms caused by alcohol then these inequalities are even more acute with numerous studies (one example here, another example here) finding a three- to five-fold difference in alcohol-attributable mortality rates between the highest and lowest socioeconomic groups.
It is an almost inevitable consequence of this gulf that if you want to improve the health of the nation as a whole, you should seek to improve the health of the worst off in society. If you target health policy at the most affluent in society, you can only expect to achieve limited gains, as this group are already in much better health. In contrast, targeting health policy at the most deprived groups is likely to see large effects, as there is far more for them to gain. This means that even if you have no specific interest in reducing inequalities in health, you should be in favour of policies which target more deprived segments of the population, as such policies are likely to be more efficient at improving health overall.
There is only one scenario where this may not be true – where a policy is less effective at improving health in more deprived groups. This may happen because more deprived groups might experience the policy to a lesser degree, might be less likely to change their behaviour in response to the policy, or that those changes in behaviour may be less likely to translate to changes in health. For example, there is some evidence that patients living in more deprived areas are less likely to take up an invitation to an NHS Health Check. The critical question, therefore, is whether MUP satisfies these criteria or not.
In order to answer that question, we must first understand the relationship between drinking, socioeconomic status and alcohol-related harm. In Scotland, people living below the poverty line are almost twice as likely as the rest of the population to abstain from drinking entirely, and 75% of those in poverty who do drink, drink at moderate levels. However, a small proportion, around 5%, of people in poverty, drink at harmful levels, and they consume significantly more alcohol on average than harmful drinkers who are not in poverty: 4,500 units per year (equivalent to around 170 bottles of vodka), compared to 3,350. As a result of this we estimate that hazardous and harmful drinkers in poverty, who represent just 2.6% of the adult population, experience 23% of all deaths caused by alcohol. To understand the impact of MUP, we also need to understand differences in the prices that people pay for their alcohol. Whilst moderate drinkers across all socioeconomic groups buy a relatively small proportion of their alcohol for below 50p per unit, a substantial proportion of harmful drinkers’ purchases are below this level: 62% in the case of harmful drinkers in poverty.
Who drinks the cheap stuff? Average unit consumption of alcohol split by moderate, hazardous and harmful drinkers in and not in poverty in Scotland
Now let’s consider the implications of these socioeconomic gradients in alcohol consumption, prices paid and alcohol-attributable harm for the impact of MUP. Drinkers in poverty buy cheaper alcohol, particularly heavy drinkers. This cheaper alcohol will be more affected by MUP, so drinkers in more deprived groups will face a greater change in price as a result of the policy. Drinkers in lower socioeconomic groups also suffer greater harm for every unit of alcohol that they drink – through a combination of drinking in more harmful patterns and also the interaction of alcohol with other factors such as smoking, poor diet and general poor health. The consequence of this is that drinkers, particularly heavier drinkers, in poverty see a bigger gain in health (or a bigger reduction in the risk of negative health consequences) for each additional unit that they cut down by. To summarise, drinkers in poverty suffer more harm as a consequence of their drinking, will see a bigger impact of MUP on the prices they typically pay, and stand to gain more in terms of health as a result of reductions in drinking. The cumulative effect of this is that we estimate that the 2.6% of the population who are in poverty and drinking at hazardous and harmful levels experience 46% of the total reduction in alcohol-attributable deaths resulting from MUP.
MUP will save lives: proportion of deaths caused by alcohol versus those that will averted by 50p MUP, split by moderate, hazardous and harmful drinkers in and not in poverty in Scotland
These figures show that a Minimum Unit Price is likely to make a substantial dent in alcohol-attributable inequalities in health, whilst simultaneously reducing the total health burden that alcohol places on society. Some people may advance arguments of civil liberties, saying that it is unfair to deny people a fundamental ‘right’ to buy cheap alcohol. This may be a perfectly valid ideological position, but it is one which is essentially incompatible with a desire to reduce alcohol-related harm. Any policy which attempts to reduce this harm without addressing heavy drinking in lower socioeconomic groups is ultimately likely to have only limited success.
Whether you think that the impact of MUP is felt ‘disproportionately’ by the poor, depends on what you think it should be proportionate to. If you think that the benefits of a policy should be proportionate to need, then all the evidence points to MUP achieving that aim.
Written by Colin Angus, Research Fellow at the Sheffield Alcohol Research Group within The School of Health and Related Research.
All IAS Blogposts are published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Institute of Alcohol Studies.