Examining recent attempts to address Scotland’s dysfunctional relationship with alcohol
They are on their way to the airport and on the table in front of them is an array of alcohol. I watch one boy unscrew a bottle of cheap rosé wine and begin to chug from the bottle. By the time the train is pulling into the next stop he has drained it and is choosing his next poison. His friend asks him if he wants a cider, proffering a bottle of blackcurrant juice and a plastic tumbler to mix it in; joking that all the fruit makes it the healthy option.
The boy turns it down and selects one of the alcopops instead, explaining that he is “trying to take it easy.”
This incident took place at eight in the morning. As the group continued to swap stories of recent drunken shenanigans my fellow commuters and I did nothing beyond exchanging synchronised tuts and eye rolls. Similarly, the conductor breezed straight past them, choosing to ignore their raucous behaviour. Nobody wanted to be the one to stick their head above the parapet and spoil the party by challenging their conduct.
But the party has been raging for too long and there is now a culture of alcohol misuse in Scotland. It has become part of our national identity despite the harm that we can’t help but be aware it causes. Some 3,000 deaths, 42,000 hospital stays, and 110,000 GP visits are linked to alcohol annually. These figures demonstrate that this is an issue that affects us all and is down to the behaviour of the many, not the few. So far, like those of us on the train, we have failed to recognise it as such and proved unwilling to accept our share of responsibility for the problem. Meanwhile, the cost of our silence continues to mount both socially and economically, with research by York University indicating that alcohol misuse may be costing the taxpayer between £2.4bn and £4.6bn each year.
Scotland’s Parliament has a key role to play in leading the charge towards real and lasting change. However, while the MSPs seem genuinely determined that we do not continue to let our destructive relationship with drink define who we are as a nation; currently it is the deterioration of their relationships within Holyrood that is stifling debate and halting Scotland’s progress.
The adversarial debate surrounding the Scottish Government’s Alcohol (Scotland) Bill – which proposes to ban irresponsible off-sales promotions, to allow local licensing boards to raise the age for off-sales to 21 and a power to introduce a social responsibility fee on some retailers to offset the costs of dealing with drink problems, in addition to the controversial minimum unit pricing proposal – clearly demonstrates the extent to which relations in the chamber have eroded.
For better or for worse, minimum pricing has dominated the debate surrounding the Alcohol Bill. The SNP Government feels somewhat maligned by the opposition to their proposal. Out with the Parliament, the roll call of those who support the minimum pricing policy includes: all four UK Chief Medical Officers; the British Medical Association; the Royal Colleges of Nursing, Physicians, Surgeons and GPs’ the Faculty of Public Health; British Liver Trust; the Association of Chief Police Officers in Scotland; Scotland’s Commissioner for Children and Young People; a consortium of children’s organisations that includes Children 1st and Barnardo’s Scotland; the Scottish Licensed Trade Association; Tennent’s; and NUS Scotland. And yet within Holyrood’s concrete walls – backed by a considerably smaller roll call of organisations that mainly consists of supermarkets and drinks manufacturers – Labour, the Conservatives and the Liberal Democrats have all spoken out against the policy and questioned everything, from its legality and morality, to the detrimental effect it could have on Scotland’s alcohol producers.
However, while it readily admits that minimum pricing is no silver bullet, the SNP nevertheless maintains that it is a step in the right direction and an important part of the Government’s strategy to tackle the availability of strong booze at pocket-money prices, “All the evidence suggests that price is the most effective area to target,” agrees Professor Anne Ludbrook, Health Economics Research Unit, University of Aberdeen, adding that there is a vast literature looking at the relationship between price and consumption.
“There are a number of fairly startling examples like Finland when they reduced their taxation so dramatically and consumption shot up,” she says.
“And it is not just consumption, there is also a strong relationship between price and alcohol-related harm so that you get the whole chain of evidence between price and consumption and the harm that it is causing coming through quite strongly.
“Really the only other fairly strong evidence we have about things that are effective are at the treatment end so frankly, people have already had the problem before you get to them then. So price is about doing things that are more upstream and preventing the problem from happening in the first place.”
The World Health Organisation, which is currently in the process of formulating a global strategy on harmful use of alcohol, has also stressed the strong linkage between affordability of alcohol, consumption and harm. The strategy is due to be discussed by the member states in May and minimum pricing is one of a number of policy options suggested for inclusion.
However, while the WHO continues to deliberate the policy, Ludbrook sets out why she believes minimum pricing is the right choice for Scotland.
“I think firstly you have to think about the context of Scotland and the powers that are available to the Scottish Parliament,” she says, “and there are restricted options available to the Scottish Parliament to do something about price.”
Another fairly distinctive aspect of the market for alcohol in the UK is the evidence that taxation is not always passed on in full to consumers, she says.
“So that does create a different perspective because the comparison obviously is do you go for minimum pricing or do you go for increasing the duty in a way that will impact on price? So increasing duty will impact on consumption because it increases price but the big question in the UK is does taxation increase price?”
Minimum pricing is also a more targeted approach than taxation, she argues, as it raises the price of the cheapest forms of alcohol and creates a floor. However, another strand of the debate is what that floor should be. 40p has been the most commonly mooted price, however, the Faculty of Public Health Scotland has stated that considerable public health impact would be achieved by setting a 60p per unit minimum price, arguing that it would prevent 866 alcohol-related deaths each year once the policy is in full effect. The Government has yet to reveal its own preference despite Health Secretary Nicola Sturgeon being pressed to “name her price” while giving evidence to the Health and Sport Committee as part of its scrutiny of the Bill.
For her part, Ludbrook argues that the 40- 50p price range is a reasonable starting place.
“There is a trade off because the higher you set it, the more impact you will have,” she says, “but the higher you set it you have got to consider the implications of lower income families. So there is a tail off there between those two things. I think the range that is being considered, 40-50p, is a reasonable place to be looking.”
However, the impact the policy could have on low-income families remains unclear. Scottish Labour’s shadow health secretary Jackie Baillie has branded the SNP’s proposals as “immoral”, arguing that they would take £90m from pensioners and ordinary families and put it in the pockets of the big supermarkets; while her colleague, shadow public health minister Dr Richard Simpson, has criticised the Government for declining the opportunity to commission research on the effect of the policy on lower income groups.
“We have a problem with hazardous drinking across every income group but the only group that will actually be significantly affected by minimum unit pricing is people in the lower income groups,” he argues.
“There are six or seven per cent who are harmfully drinking. I accept that it will affect them but I am not prepared to see people in lower income groups punished in order to tackle a problem that is about six or seven per cent of the population who drink harmfully. The health professionals have repeatedly said in correspondence to us that they think it is a price that the poorer people just have to pay.
“Well, I’m sorry, but I didn’t come into politics to disproportionately punish people because they had much lower incomes.”
Simpson contends that minimum pricing “will not do what it says on the tin” and says he would like to see greater discussion of alternative pricing mechanisms.
By way of example, he says: “I am happy to go in Scotland for unit pricing but not minimum unit pricing. That means if one unit of alcohol is being sold at x units, two units are sold at 2x. At the moment if you go to a restaurant and buy a 125ml glass of wine for, say, £2.50, if you order a 250ml glass you will probably get it not for £5 but around £4.50. So that encourages you to say, ‘Am I going to want two glasses? Well, I might so I’ll just order the larger glass now.’ So it encourages people to buy more alcohol than they perhaps would otherwise have done. So actually having unit pricing is acceptable.”
He also points to Labour’s recent calls to introduce a limit on the amount of caffeine you can have in alcoholic drinks, and UK Transport Minister Lord Adonis’ pledge to review the drink-driving level as other measures that he feels should be progressed.
In an attempt to move the debate on minimising alcohol harm away from minimum pricing, Labour has established a commission, which is chaired by Emeritus Professor of Education at the University of Stirling, Sally Brown.
“We probably don’t need more evidence on alcohol over consumption,” says Brown, “but we do need to think in new ways about the kinds of measures one might be able to take.”
The commission will publish an interim report in April, with its main report due at the end of summer. Its work will not be about the Alcohol Bill but there will inevitably be areas of overlap, says Brown, adding: “But really, we are trying to look ahead and see what different kinds of measures might be taken and what do people think of those measures.”
One such measure she says she is keen to follow through on is considering the impact of the 2005 Licensing Act.
“We are interested to know in general what evidence there is for these measures having had an impact and also something about the enforcement of them. We also want to know what people think about things like advertising and promotion of products. We want to know what they feel about how to improve the communication or referral among services, such as the courts and the police and primary healthcare teams. And then of course there is education, which is really rather difficult because so much of the evidence has suggested that school-based education doesn’t seem to do much good so we have to think in new ways about that.”
Labour initially announced that the commission would not consider the issue of minimum pricing. But with many of the evidence submissions focusing squarely on the proposal, was the elephant in the room impossible to ignore?
“We could avoid considering it,” says Brown. “We could just say that the Health and Sport Committee in the Parliament is doing that so we will just leave it to one side. I’m not suggesting we will do that because people have quite powerful views on it.”
Supporters of the policy tend to have a “gut feeling” that it will work in lieu of evidence to support their conviction, she argues.
“The thing about minimum unit pricing is it seems to be a rather simple minded straightforward thing and people either say, ‘ah yes, that will do it,’ but really, there are some quite complex arguments about why minimum pricing actually could be more trouble than it is worth. I’m not making a statement about minimum unit pricing here. I’m just saying it isn’t that easy.”
Scotland isn’t the only country grappling with how to address alcohol misuse, she says, but adds that, “we haven’t been prepared so far to take some of the really serious measures that perhaps some of the Scandinavian countries have,” giving the example of state monopoly shops for alcohol.
“One thing that quite a lot of people think would work quite well is if we had state monopoly shops for alcohol.
“This is based on nothing at all other than my guess, but my guess would be that political parties wouldn’t be too keen to be seen to be the ones to be introducing that. So you can sometimes think of things that could work but are unlikely to be taken up.”
Personally, Brown says she would be keen to see politicians taking a “fairly radical” approach to the alcohol issue. But would state monopolies be a proposal too far for Scotland’s parliamentarians?
“Well, that would be extremely radical,” says Simpson, “but I do think that if the supermarkets do not respond to the measures that will be proposed both in this Bill and what the Labour Party will propose when we get back into power in 2011 – we will have a list of additional proposals to put in if this government won’t do it – then if they do not respond we will have to seriously think about other potential solutions.”
As for the proposal currently under the spotlight, Simpson insists there is no evidence to support it and criticises the modelling study conducted on behalf of the Government by the University of Sheffield – which found that a 40p minimum price together with a promotions ban would result in a 5.4 per cent drop in total alcohol consumption across society that it said would be concentrated among hazardous and harmful drinkers – and in particular takes umbrage with Principal Investigator Dr Petra Meier’s comparison of the modelling used with weather forecasting.
“I’m sorry,” he says, “but I’m not going to adopt a policy that is a central plank of our attempts to control alcohol problems in Scotland on the basis of something that is no better than weather forecasting.”
However, Ludbrook makes the point that while there are similar policies that can be considered – such as social reference pricing in Canada – minimum pricing has yet to be tried and therefore the evidence has not been created.
“One of the problems that people have been struggling with is nobody else has done it so we can’t work out what the effects are likely to be,” she says.
“But if you have strong evidence of price working, some evidence that targeting lower cost products is more effective, and you have also got to take into account this issue about the heavier drinkers and it has always been the contention in the literature but the problem with general price increases with heavy drinkers is that the heavy drinker will always trade down to a cheaper product. By putting in a floor price, you take that argument out of the equation.”
She continues: “Now this is the kind of logical reasoning from what is in the evidence base that leads to the conclusion that this will work in the way that is being predicted. And if you never allowed people to do that kind of logical reasoning from the existing evidence base then you would never have any innovation in policy because everybody would be waiting for someone else to do it first.”
Ludbrook is keen for Scotland to grasp the thistle and see the policy not just for its potential health benefits, but also recognise the statement it makes about what Scotland, the nation, stands for.
“I think it has the potential to be a very effective policy,” she says. “Given the public health aspects of smokefree legislation, which I think were enormously beneficial to Scotland in terms of its whole ethos and image, and therefore the benefits can go beyond the immediate impact of the individual policy to project that, yes, we really are serious about being a healthier nation and taking the sometimes hard decisions that might be needed to get there.” To achieve this, she recognises that the elusive political consensus will be needed.
However, despite the stramash created by the policy, it is possible that cooler heads may yet prevail. While Labour and the Conservatives seem unyielding in their opposition to the policy, it is possible that the Liberal Democrats may yet be coaxed into supporting the measures. Despite initially voicing their staunch opposition to the policy, the party’s health spokesperson and vice convener of the Health and Sport Committee, Ross Finnie has now pledged to keep an open mind while considering the evidence before it. He stresses, however, that the party will require to see more evidence on the Scottish Government’s interpretation of European law, and clear and detailed analysis of how the minimum pricing scheme meets the necessity and material health benefit tests.
However, whether the Bill progresses or not it is important to stress that it should not be portrayed as a victory or failure for any particular party; our alcohol problem is too grave for political point scoring. It is, as First Minister Alex Salmond pointed out, about what is right, not whom, and the only one that stands to win or lose in this debate is Scotland.