Double or Quits?

More than a decade ago, we first posted on public health interventions proposed or implemented by the Scottish Government. A key focus area from those initiatives, alcohol mortality, has recently reported status, and the news does not seem encouraging. Despite the introduction of a minimum unit price (MUP) for alcohol in 2018, Scottish alcohol deaths reached a new high in 2024. So, does this mean the policy has failed and should be scrapped? Or, should we double-down, as Scotland has done, with it's 30% increase from a MUP of 50 pence to 65 pence? That question, like most that arise in public policy, is far from straightforward.

Complexity arises from the fact that no public health intervention exists in a vacuum, so it is seldom easy to distinguish cause from effect. In the case of alcohol consumption, following introduction of the MUP, something else fairly major took place. The Covid-19 pandemic brought lockdown measures beginning in March 2020, and with them, previously unthinkable changes in social behaviour. Since the impacts of Covid-19 upon alcohol consumption have surely been felt throughout the UK, some clarity might be found by examining the recent experience of England, where minimum unit pricing has not played any role. In a statistical commentary from earlier this year, the UK Government states:

[I]n 2022, there were 7,912 alcohol-specific deaths (wholly due to alcohol) in England which was an increase of 56.7% from 5,050 deaths in 2006 and a 4.7% increase since 2021. The trends in alcohol-related deaths (deaths wholly or partly due to alcohol) and deaths from chronic liver disease are similar 

[A]ll 3 mortality rates updated were fairly stable between 2006 and 2019 before increasing sharply in 2020

Alcohol Profiles for England (2024)

The suggestion that Covid-19 brought notable increases to previously stable alcohol mortality rates in England transformed last month into concrete news. The change in England's alcohol-related mortality prompted a letter to the UK Health Secretary from the Alcohol Health Alliance. The letter makes an explicit statement:

Evidence from Scotland has clearly demonstrated how policies such as minimum unit pricing (MUP) have saved lives, while inaction across the border has led English deaths to spiral.

A Letter to The Health Secretary - Alcohol Health Alliance (December 2024)

Looking north to Scotland, therefore, the unwelcome climb in death counts is unlikely to result from policy failure. Instead, it seems that determining the scale of success or failure of a MUP policy will be more of a marathon than a sprint.

Some public health efforts might be expected to tail off with time.  For example, mass human vaccination for a new pathogen can drive population immunity towards better outcomes in initial waves of infection. However, once the human immune system is less naive to a pathogen, high levels of vaccination may gradually reduce. Indeed, this behaviour has now emerged post-Covid-19, as countries such as the UK more tightly focus vaccination regimes upon at-risk groups. In contrast, other health measures are more of an ongoing commitment, and once started require a regime of monitoring and adjustment. The implementation of a minimum unit price for alcohol requires just such a regime, which is likely part of the reason the approach was adopted only two of the UK's four nations so far (Scotland was followed by Wales in 2020). 

Research arriving in September 2023 from the University of Sheffield, largely predicted recent policy actions in Scotland when it made two main observations:

1. In Scotland, Covid-19 increased alcohol consumption amongst a crucial subgroup: those already drinking above Government guidelines. This elevated the very alcohol-related harms the MUP policy sought to counter, and

2. High rates of inflation had blunted the impact of the MUP by 9 pence per unit, meaning it would have to rise simply to maintain its previously modelled impacts on mortality

So, like any game of double or quits, you make your play and await results. Here's hoping Scotland has a better year than last...