A minimum price for alcohol
What you should know and why you should care
Medical students and junior doctors are familiar with alcohol and its consequences, both on and off the wards. By day, patients present with conditions related to alcohol use in almost all specialties, not just gastroenterology. By night, medical students are known for drinking, a habit that continues into their careers as doctors.
The data on the harms of alcohol paint a similarly ubiquitous picture as an estimated 4.6% of ill health and mortality worldwide (in terms of disability adjusted life years) or 3.8% of deaths can be attributed to alcohol use. In 2009 in England alone there were 6584 deaths directly related to alcohol use, mostly from alcoholic liver disease. While liver disease is one harm that can be directly linked to alcohol, consumption is also linked to a whole host of other illnesses, including increased rates of breast cancer.
The harm caused by alcohol is not limited to harm to ourselves and our own organs; it is also associated with harms to society, such as those caused by drink-driving, crime, and job and family problems. Recent crime figures for England and Wales implicated alcohol in 47% of all violent crimes, and the children’s commissioner has identified that alcohol is a key factor in child protection issues and in social work cases involving children and families. In a controversial paper, David Nutt has argued that if you include the harm to society, alcohol is the most dangerous drug available.
In most countries many drugs that are known to cause harm to their users are illegal. Not all dangerous drugs, however, are illegal; tobacco has been known to cause lung cancer for several decades. While it is legal, there are near constant public health campaigns to encourage people to stop smoking, with support available through the NHS in both inpatient and outpatient settings. In addition, there is public health policy aimed at reducing tobacco use—such as health warnings with graphic pictures of smoking associated disease on cigarette packets. The biggest contributor to reductions in smoking levels in recent years, however, has been the steady increase in price.
A minimum price for alcohol?
There is no policy to establish a minimum price based on a unit of alcohol, despite the recent pledge to ban extreme discounting of alcohol to loss leading sale prices in England and Wales, a measure that Eric Appleby of Alcohol Concern describes as “laughable . . . confusing and close to impossible to implement.” Minimum unit pricing differs from the banning of below cost sales in that the minimum cost paid by the consumer per unit of alcohol would be unrelated to the cost paid by retailers. This might raise the cost of only the cheapest alcohol, as the cost to the retailer includes alcohol duty. Though minimum pricing was at one point “under consideration” by the UK government, with David Cameron himself giving support to the policy, it now seems unlikely to happen because of a lack of “concrete evidence.” Randomised controlled trials to test minimum unit pricing are impossible to conduct as these would be impractical and unworkable. There is, however, overwhelming evidence from over 100 other types of studies. These studies indicate that an appropriate minimum price per unit of alcohol would cut deaths and physical and social harms from alcohol in a way that educational campaigns simply will not. This is not the first time that a government has opted for an alcohol policy that is not in line with the evidence base or has opted for high cost-low impact interventions over low cost-high impact interventions such as a minimum unit price. Highly effective alcohol policies are those that increase the price of alcohol or reduce its availability.
Evidence for a minimum unit price comes from those countries or states that have introduced this policy, such as British Columbia in Canada. In British Columbia, a longitudinal observational study in 2002-09 found that a 10% increase in the price of alcohol was accompanied by a nearly 9% decrease in alcohol attributable hospital admissions and a 9.2% decrease in alcohol attributable admissions from chronic disease two years later. Alcohol attributable deaths also decreased by 32% after the introduction of a minimum unit price. The argument that a similar policy in the UK might achieve similar results is supported by the fact that 45% of all the alcohol consumed in the UK is consumed by the heaviest 10% of drinkers. Given that there were 1 057 000 alcohol related admissions in England in the year 2009-10, and this figure seems to be increasing, a small increase in unit price could reduce both harm to people and the burden of alcohol related disease on the NHS. Even though the UK government is unwilling to act on the evidence in England, the Scottish government’s recognition of the harms caused by cheap alcohol prompted the passing of a bill requiring a minimum unit price of 50p per 8 g unit of alcohol in 2012. The Scottish Government Alcohol Industry Partnership, founded in 2009, did not prevent the government from acting to take this important public health measure. Such is the power of the alcohol industry in Scotland, however, that the bill has yet to take effect. The legislation is currently on hold because of the Scottish Whisky Association’s appeal after they lost their earlier legal challenge.
Pros and cons for minimum pricing
Not everyone is in favour of a minimum price; some critics argue that it penalises people who drink in moderation. This argument does not stack up when the evidence is considered. Modelling estimates of a 50p per unit minimum suggest that moderate drinkers would be less than £10 worse off a year, compared with harmful drinkers, who would be nearly £200 worse off a year if they continued to drink the same amount. One other notable criticism is that a minimum price unfairly targets those on low incomes and will have little effect on “middle class alcoholism.” Those on low incomes are the very people who are most at risk of alcohol related harms and who tend to have worse outcomes per unit consumed than patients with higher incomes.
Low cost alcohol has been shown to be implicated in health harms in other ways. In Scotland again, a study showed that hospital inpatients or outpatients who were being treated for alcohol related problems bought their alcohol for an average of 43p per unit, compared with a Scottish average of 71p per unit in 2008. In addition, the lower the average unit cost, the more a patient consumed. Of units consumed by patients being treated for alcohol related morbidity, 83% cost below the soon to be introduced 50p per unit minimum price. This suggests that an increase in the price might reduce alcohol consumption in the heaviest drinkers, whose alcohol intake is known to be harming their health. David Nutt has also previously argued in favour of a minimum unit price, as it targets those who drink the most.
Until 2013, there was UK government support for minimum pricing in England, with Prime Minister David Cameron saying, “When beer is cheaper than water, it’s just too easy for people to get drunk on cheap alcohol at home before they even set foot in the pub. So we are going to introduce a new minimum unit price—so for the first time it will be illegal for shops to sell alcohol for less than this set price per unit.” It seems, however, that political pressure had more of an impact than evidence on policy, as with previous governments; after consultation, it was decided that evidence was lacking, as stated by Minister of State for Crime Prevention Jeremy Browne: “There has been much speculation about the government’s plans in relation to minimum unit pricing. . . We do not yet have enough concrete evidence that its introduction would be effective in reducing harms associated with problem drinking—this is a crucial point—without penalising people who drink responsibly.”
There are various reasons why a government might choose not to introduce a unit price. These could include pressure from the alcohol industry and a concern that such a measure might be unpopular with many voters. In an Australian study, the main impediments to the introduction of a minimum unit price were public opinion, the lobbying power of the alcohol industry, and that such a price required legislative change to introduce. A recent investigation published in the BMJ stated, “The government consultation into introducing a minimum unit price for alcohol in England and Wales was a sham and politicians ignored the strong health evidence in favour of protecting the interests of industry.” This investigation contains a chilling description of a government more concerned with its relationships with business than with the health of its citizens.
The scrapping of this policy had previously been condemned by various parties. Alastair Campbell, who has written about his experiences as an alcoholic in his autobiography, is working with Alcohol Concern to press for minimum pricing, “No politician wants to be a killjoy. But alcohol abuse is no longer the exception, it has become a norm. At the party conferences I will be supporting Alcohol Concern’s call for a minimum 50p unit price.”
The harms caused by alcohol are widespread and increasing. Many other interventions—such as school based interventions—have had limited efficacy in reducing alcohol related harm. The introduction of a minimum alcohol price has been opposed on several fronts, with critics arguing that it could prompt a flight to illicit alcohol and drugs. In a natural experiment in Gorbachev’s Russia in 1985-88, the Russian government increased prices for alcohol in response to high rates of alcohol related mortality, and there was indeed increased production of a home brewed alcohol called samogon. The samogon produced, however, was “not nearly enough to offset the reduction in state supply [of alcohol],” which dropped by around two thirds, and death rates from alcohol related causes in Russia plummeted during this period. The Russian experience adds to the overwhelmingly compelling evidence that an appropriate minimum unit price would reduce harm.
The Scottish government seems to have made a balanced consideration of the available evidence and, even in the face of legal challenges, still intends to implement a minimum unit price (once the present court cases have been resolved). The rest of the UK could see similar benefits to those seen in Canada and Australia if it followed suit with a minimum unit price. While it might not be a popular move with constituents in the short term, the long term health benefits for the population are clear.
Direct and indirect alcohol related harms
According to the ICD-10 (international classification of disease, 10th revision), there are more than 200 different diseases that can be directly or indirectly caused by alcohol. These include (but are not limited to):
- Cirrhosis of the liver
- Liver cancer
- Cancer of the mouth, oropharynx, oesophagus, colon, and rectum
- Breast cancer
- Hypertensive and ischaemic heart disease
- Ischaemic and haemorrhagic stroke
- Low birth weight and disorders arising in the perinatal period
- Road traffic incidents
- Falls, poisonings, and other unintentional injury
- Violence and intentional or self inflicted injury
- Alcohol use disorders and unipolar depression
What is a unit in the UK?
- A unit contains 8 g alcohol, which equates to around 10 mL, depending on temperature
- A small glass of wine has 1.6 units, a standard glass has 2.1
- A pint of standard lager has roughly 2 units, a pint (568 mL) of strong lager has 3.
- A single 25mL shot of 40% ABV spirits is 1 unit
- An average “alcopop” contains 1.5 units
1Balliol College, University of Oxford, Oxford OX1 3BJ, UK, 2Institute of Psychiatry, King’s College London, London SE5 8BB, UK
Correspondence to: firstname.lastname@example.org
Competing interests: SM’s postdoctoral work is funded by Alcohol Research UK, and her recently completed PhD studies were funded by Alcohol Research UK, the Society for the Study of Addiction, and King’s College London.
Provenance and peer review: Not commissioned; externally peer reviewed.
- Rourke E. Work hard, play hard. Student BMJ. 2012;20:e5326.
- Anderson P, Chisholm D, Fuhr D. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009;373:2234-46.
- Health and Social Care Information Centre. Statistics on alcohol: England, 2011. 2011:8.
- Chen WY, Rosner B, Hankinson SE, Colditz GA, Willett WC. Moderate alcohol consumption during adult life, drinking patterns, and breast cancer risk. JAMA 2011;306:1884-90.
- Office for National Statistics. www.ons.gov.uk/ons/dcp171778_298904.pdf,p 20.
- Adamson J, Templeton L. Silent voices. Supporting children and young people affected by parental alcohol misuse. Children’s Commissioner, 2012. www.childrenscommissioner.gov.uk/content/publications/content_619 Voices.
- Nutt DJ, King LA, Phillips LD; Independent Scientific Committee on Drugs. Drug harms in the UK: a multicriteria decision analysis. Lancet 2010;376:1558-65.
- Aspect Consortium. Tobacco or health in the European Union. Past, present and future. Office for Official Publications of the European Communities, 2004.
- BBC News. Alcohol floor price announced for England and Wales. 4 February 2014. www.bbc.co.uk/news/uk-26040550.
- Browne J. Statement to Parliament on 17 July 2013. www.gov.uk/government/speeches/governments-response-to-the-alcohol-strategy-consultation.
- Drummond DC. An alcohol strategy for England: the good, the bad, and the ugly. Alcohol Alcohol 2004;39:377-9.
- Zhao J, Stockwell T, Martin G, Macdonald S, Vallance K, Treno A, et al. The relationship between minimum alcohol prices, outlet densities and alcohol-attributable deaths in British Columbia, 2002-09. Addiction 2013;108:1059-69.
- Meier P, Brennan A, Purshouse P. Policy options for alcohol price regulation: the importance of modelling population heterogeneity. Addiction 2010;105:383-93.
- Alcohol (Minimum Pricing) (Scotland) Bill. 2012. www.scottish.parliament.uk/parliamentarybusiness/Bills/43354.aspx.
- BBC News. Minimum pricing: challenge to Scottish alcohol legislation fails. 3 May 2013. www.bbc.co.uk/news/uk-scotland-scotland-politics-22394438.
- Purshouse RC, Meier PS, Brennan A, Taylor KB, Rafia R. Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model. Lancet 2010;375:1355-64.
- Johnston MC, Ludbrook A, Jaffray MA. Inequalities in the distribution of the costs of alcohol misuse in Scotland: a cost of illness study. Alcohol Alcohol 2012;47:725-31.
- Black H, Gill J, Chick J. The price of a drink: levels of consumption and price paid per unit of alcohol by Edinburgh’s ill drinkers with a comparison to wider alcohol sales in Scotland. Addiction 2011;106:729-36.
- Nutt D. The price of super-strength lagers should reflect their content. Guardian 2011 January 17.
- Prime Minister’s Office. Minimum alcohol pricing. www.gov.uk/government/news/minimum-alcohol-pricing.
- Chalmers J, Carragher N, Davoren S, O’Brien P. Real or perceived impediments to minimum pricing of alcohol in Australia: Public opinion, the industry and the law. Int J Drug Policy 2013;24:517-23.
- Gornall J. Under the influence. BMJ 2014;348:f7646.
- Campbell A. Cameron, Clegg, and Miliband should listen to police and doctors re costs of booze. www.alastaircampbell.org/blog/2013/09/15/britain-has-a-drink-problem-needs-to-admit-it-then-get-help/.
- Craven B, Marlow M, Shiers A. The economics of minimum pricing for alcohol. Economic Affairs 2013;33:174-89.
- Bhattacharya J, Gathmann C, Miller G. The Gorbachev anti-alcohol campaign and Russia’s mortality crisis. Am Econ J Appl Econ 2013;5:232-60.
- Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009;373:2223-33.
- NHS Choices. Alcohol units. www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx.
Cite this as: Student BMJ 2014;22:g1473