Alcohol, health, and healthcare
In England and Ireland, alcohol harms contribute significantly to the burden on healthcare. In England, alcohol accounted for 7.2% of all days that patients spent in hospital in 2009 – 2010, and in Ireland this figure was 8.7% in 2000 – 2004. The estimated annual healthcare cost of the alcohol-related burden on the NHS in 2009 was £3.5bn (or 2.3% of the healthcare budget) and in Ireland in 2010 was €1.5bn (or 7% of the healthcare budget).
Alcohol represents the 7th leading risk factor for early death and loss of healthy years worldwide. In the UK, the highest number of alcohol-specific deaths on record was in 2021 (9,641 deaths), and 78% (7,518 deaths) of these were due to alcohol-related liver disease (ARLD). This increase in ARLD deaths reflects the increasing trend of hospital admissions for ARLD in England, which peaked in 2020/21 (24,544 admissions, or 45.5 per 100,000 admissions). In Ireland, ARLD discharge rates also showed a constant increase over 2 decades up to 2017 (102.3 per 100,000 discharges).
Alcohol is a modifiable risk factor; meaning that the harms from alcohol misuse can be addressed by a reduction in alcohol consumption. Unfortunately, cheap alcohol is easily available, and alcohol today is 74% more affordable than 3 decades ago in England.
A promising public health approach which has been studied is Minimum Unit Pricing (MUP) which sets a legally required floor price per measure of alcohol (£0.50 per unit in Scotland, and €1.00 per standard drink in Ireland) below which alcohol cannot be sold.
MUP is not a tax, and works differently to general alcohol taxation, which can be undermined by retailers selling alcohol at below cost price or transferring profit margins to non-alcoholic products to absorb the tax. This is not possible with MUP as there is a legally fixed floor price of alcohol, removing cheap alcohol from the market.
What we did and what we found
We conducted a Systematic Review of 600 studies to understand whether MUP reduces the burden of hospital admissions due to alcohol. 22 studies met the requirements to be included.
The studies were from 8 countries: Canada, England, Scotland, Wales, Northern Ireland, Republic of Ireland, Australia and South Africa. 16 studies were modelling studies (studies that aim to predict the impact of MUP in countries where MUP is not introduced) and 6 were “real-world” studies (studies that measured the impact of MUP in countries where MUP is introduced).
- When we compared both types of studies we found that all “real-world” studies were consistent with the predictions of modelling studies.
- Modelling studies predicted that MUP could reduce alcohol-related hospitalisations by 3% – 10% annually and “real-world” studies confirmed that MUP did reduce alcohol-related admissions by 2% – 9% for acute conditions (immediately), and by 4% – 9% for chronic conditions (with benefits delayed by 2 – 3 years).
- The greatest benefits were targeted amongst those from the lowest income group.
- Modelling studies consistently highlighted that MUP outperformed general alcohol taxation in reducing alcohol-related hospitalisations.
- One real-world study in Scotland led by Professor Ewan Forrest and his team at the Glasgow Royal Infirmary found that MUP also reduced alcohol-related liver disease (ARLD) hospital discharges, especially amongst patients who were actively drinking. These findings were consistent with the predictions from modelling studies and previous related studies on ARLD and alcohol consumption.
What does this mean?
Our review was the first to collectively evaluate MUP and whether it could reduce alcohol-related hospital burden. We found significant and consistent findings from several countries that MUP would reduce alcohol-related hospital burden, and we were able to conclude this with a “moderate-to-strong” level of certainty.
Various patterns and degrees of alcohol consumption collectively contribute to the burden of alcohol harms presenting to hospitals; such as injuries due to intoxication, long-term diseases such as alcohol-related liver disease (ARLD), or cancers as a result of years of alcohol use. Therefore, it would be expected that with a reduction in alcohol consumption in the population (for example, with Minimum Unit Pricing), a reduction in collective harms would follow.
Our study also highlights the ability of MUP to target those at greatest risk of alcohol harms who are typically the heaviest alcohol consumers, who tend to drink the cheapest alcohol, and are often (but not always) from the lowest income group. An example of this inequality can be seen in the early deaths (<75 years) due to ARLD, which was 4·8 times higher in the most deprived areas of England than the most affluent.
MUP could have targeted benefit in this high risk group as individuals would be the most likely to change to less strong beverages or to reduce consumption as a result of increases in price, potentially reducing health inequalities where there are disproportionately high rates of alcohol-related harm and early death compared to individuals from higher income groups.
At a time when our hospital services are under significant pressure and overcrowding, these findings are timely and informative in understanding ways to reduce the alcohol-related burden in hospitals. However the evaluation of MUP and harm reduction is still ongoing and its benefit to specific groups such as those with Alcohol Use Disorder (AUD) warrants further study. Other approaches such as dedicated “Alcohol Care Teams (ACTs)” in the UK; which are specialist-led, multidisciplinary, integrated services with strong links between acute hospitals and community care; have been shown to be cost-effective at reducing hospitalisations, readmissions, and death due to alcohol.
MUP should not be viewed as the panacea to addressing all alcohol issues. Alcohol use and resultant harms remain a public health emergency and there is an urgent need for increased public health initiatives, especially public awareness of the extent of alcohol harms in society. It is only with the public’s understanding, engagement, and support that we can move forward in addressing this epidemic of alcohol harms.
Written by Dr Tobias Maharaj, Royal College of Surgeons in Ireland, and Beaumont Hospital Dublin, Ireland.
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.
The Institute of Public Health (IPH) and the Health Service Executive (HSE) in Ireland provided salary funding for a Clinical Research Fellowship for Tobias Maharaj which made this work possible.
Conflict of interest
Study author Prof John D Ryan has received consulting fees from Kyowa Kirin separate to this study. No other conflicts of interests to declare for other authors involved in this study.