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Letter from Glasgow
Harpreet S Kohli
Honorary Clinical Senior Lecturer, Institute of Health and Wellbeing – Public Health, University of Glasgow, 11 Branklyn Crescent, Glasgow G13 1GJ, Scotland
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Kohli HS. Letter from Glasgow. Natl Med J India 2017;30:354-355
Minimum Unit Pricing (MUP) for Alcohol in Scotland
Readers of the ‘Letter from Glasgow’ will be aware that every now and then I write about alcohol and its use in Scotland. It has been quite a while since I got on my hobby horse, so it is time to do so again.
Scotland has a long and chequered relationship with its favourite drug, alcohol. The alcohol industry, particularly but not exclusively, the whisky industry, is important to the Scottish and UK economies for the employment it creates and the revenues it generates from excise duty and value added tax (VAT, a tax on sales and services), and from exports. The industry is quick to point out the role alcohol plays in social life but it comes with a cost for individuals and society in Scotland.
The cost of harm from alcohol in monetary terms for Scotland has been estimated to be £3.6 billion (US$5.15 billion, €4.17 billion) per annum—£900 (US$1288, €1041) per adult each year. The health-related damage caused by alcohol is huge with over 60 diseases and conditions in which alcohol is a causal factor including:
- alcohol-related liver damage including a 5-fold increase in cirrhosis in 35–55-year-old people in Scotland over the past 10 years
- psychiatric illnesses and dual diagnosis
- cancers such as of the mouth, upper throat, larynx, oesophagus, breast, liver and bowel
- gastrointestinal illnesses
- neurological illnesses
- accidents—at home, and on the road affecting pedestrians, cyclists and drivers
- alcohol-related violence—among men, gender-based violence, sexual harassment, and violence to children.
In a population of over 5 million people in Scotland, 20 people die each week because of alcohol. And the alcohol-related harm extends beyond health and, in varying ways, damages children, families, women, men, communities and society as a whole.
I am not so naive to think that abstention as a policy is possible or desirable. As public health physicians we need to decrease the amount of alcohol we drink in Scotland right across the board. This is not a problem of young drinkers or old drinkers, or men or women (although men still drink much more than women), but if you do drink, you need to drink less than you are currently. As a member of the Scottish Health Action on Alcohol Problems (SHAAP, available at www.shaap.org.uk/; accessed on 17 Dec 2017), an organization created by the Scottish Medical Royal Colleges to help reduce alcohol-related harm in Scotland, I am particularly aware of the harms that alcohol causes. Countering that harm requires a broad strategy including: having effective governmental policies; ensuring effective prevention and treatment of alcohol problems; reducing the availability of alcohol; increasing the price of alcohol; and controlling the marketing of alcohol.
With regard to the element of increasing the price of alcohol, anoraks interested in the governance of the UK will know that the levying of excise duty on alcohol is undertaken by the UK government in Westminster (London) and that the Scottish government in Holyrood (Edinburgh) has no authority over excise duty. However, the Scottish government can make price changes through minimum unit pricing (MUP) for alcohol. MUP sets a ‘floor price’ of alcohol below which retailers of alcohol cannot sell alcohol. As Brennan et al. state in their paper ‘Under a minimum unit price policy, the minimum selling price increases in proportion to the alcohol units contained in the drink (1 unit=7.9 g/10 ml of pure ethanol)’. The intention of MUP is to base the price of alcohol on the number of units in the bottle per container so that alcoholic drinks which are sold relatively cheaply must raise their price. So the effect in Scotland of a MUP of £0.50 ($0.72, €0.58) per unit would be to raise the price of cheap white cider—the drink of choice to get the biggest bang for the buck— and of cheaper spirits. It would not affect the price of the vast majority of alcohol drinks that already sell for more than this, including in bars and restaurants.
In May 2012, the Scottish Parliament passed legislation to introduce MUP for alcohol. This was done not as an isolated policy on alcohol but as part of a broader strategy including brief interventions for alcohol, restrictions on marketing, training of bar staff, and better public and professional education. The price was set at £0.50 ($0.72, €0.58) per unit. This, though, was only the start of the struggle to implement the legislation in Scotland.
Fearful that this would set a precedent, the legislation was challenged by the Scotch Whisky Association (SWA), Spirits Europe, and the Comité Européen des Enterprises Vins (CEEV). It will not be lost on readers to know that the vast majority of the sales of the three alcohol industry organizations would not be affected by MUP. What the alcohol industry was worried about was any challenge to its power to sell—and profit from—alcohol.
The challenge by the alcohol industry was taken through the courts in Scotland, the UK and Europe. After a review by the European Court, MUP was ruled to be legal as an effective, evidence-based measure to reduce alcohol-related harm in October 2016 by the Scottish Court of Session. The SWA and its partners choose to appeal this decision. The UK Court of Appeal heard the case in July 2017 and issued its judgment in November 2017 that MUP in Scotland was legal. Following a brief consultation on the level of price of MUP (which confirmed the £0.50 per unit price), the Scottish government will implement the legislation from 1 May 2018.
The Scottish government states that the benefits estimated of MUP in Scotland are that 120 lives would be saved and 2000 hospital admissions avoided every year by the policy when the full effects of it are realized. Furthermore, the projected benefits are greater for harmful drinkers and poorer people. The effects of the legislation will be evaluated with a ‘sunset’ clause on the legislation to withdraw it if it is not working.
Reducing alcohol-related harm requires a coordinated and consistent approach and there are neither magic bullets nor any easy solutions. We must use the evidence available to us in the context of different societies in which we live and work to roll back the damage inflicted by alcohol. Winston Churchill said of the fight against Nazi Germany in the Second World War that ‘I have nothing to offer but blood, toil, tears and sweat’. The fight for MUP in Scotland shows that perhaps blood, toil, tears and sweat are also needed in the struggle against the alcohol industry.
Kohli HS. Scotland and alcohol: The gathering storm. Natl Med J India 2006;19:227.[Google Scholar]
Alcohol Focus Scotland (AFS). Changing Scotland's relationship with alcohol— Recommendations for further action. Glasgow:Alcohol Focus Scotland; 2017. Available at www.alcohol-focus-scotland.org.uk/media/222528/Alcohol-strategy-recommendations-Report.pdf (accessed on 17 Dec 2017).[Google Scholar]
Brennan A, Meng Y, Holmes J, Hill-McManus D, Meier PS. Potential benefits of minimum unit pricing for alcohol versus a ban on below cost selling in England 2014: Modelling study. BMJ 2014;349:g5452. Available at https://doi.org/10.1136/bmj.g5452 (accessed on 17 Dec 2017).[Google Scholar]
Scottish Government. Minimum Unit Pricing. Available at www.gov.scot/Topics/Health/Services/Alcohol/minimum-pricing (accessed 17 Apr 2017).[Google Scholar]
SHAAP Media Release. Scottish health professions celebrate final legal victory, clearing the way for implementation of Alcohol Minimum Unit Pricing (MUP) legislation. Edinburgh:SHAAP (Scottish Health Action on Alcohol Problems); 15 November 2017. Available at www.shaap.org.uk/media-releases.html (accessed on 17 Dec 2017).[Google Scholar]