Minimum unit pricing for alcohol comes into effect in Wales

Professor Ian Gilmore and Dr Ruth Alcolado give their insights on the effects MUP will have on alcohol misuse in Wales.

Professor Sir Ian Gilmore

During his time as RCP president he made several public statements on alcohol misuse in the United Kingdom, and under his leadership the college initiated the AHA in 2007, which he still chairs. He was knighted in the 2010 Queen's Birthday Honours.

'As people all over Wales will have spent yesterday celebrating St David’s Day, it is an opportune moment to reflect on society’s alcohol consumption.

Drinking too much alcohol especially on a regular basis can lead to long term health risks. Regular drinkers risk a future hampered by illnesses such as cancer, liver cirrhosis and heart disease.

Frequent alcohol consumption might also turn into alcohol dependence, which can itself cause the breakdown of relationships, domestic violence and lead to poverty.

For society, the costs of the harmful use of alcohol includes both the direct costs to public services and the substantial impact of alcohol-related harm on productivity and earnings.

This issue is of particular relevance in Wales, where one in five people admit to drinking more than the recommended weekly limit and around one in ten people in hospitals is dependent on alcohol.

It is well documented that those living in the poorest areas are disproportionately affected by the damaging effects of cheap alcohol and in Wales there is a higher than average level of deprivation.

Alcohol harm places a huge burden on the NHS, the police and the wider community. Of all alcohol sold, it is the very cheap products, such as large bottles of strong cider, that play the biggest part in alcohol-related harm.

The simplest way to reduce demand for alcohol is to raise its price and we know that the introduction of MUP for alcohol is an effective and evidence-based way to tackle health inequalities.'

So why do we think MUP will reduce alcohol related problems?

Evidence shows that heavy drinkers favour the cheapest options, therefore targeting the heaviest drinkers is the most effective way to reduce alcohol consumption.

The relationship between alcohol price, consumption and harms is well established. UK alcohol is 74% more affordable today than it was in 1987. As alcohol became more affordable, alcohol-related harms sky-rocketed; alcohol-related hospital admissions doubled, admissions for alcoholic liver disease increased and there was a 94% increase in alcohol poisoning admissions.

For those that argue that MUP penalises moderate drinkers, evidence shows that MUP will have more effect on the alcohol consumption of heavy drinkers than moderate drinkers right across the socioeconomic groups. A MUP of 50p would reduce consumption by harmful drinkers by 5.4% compared with 1% for moderate drinkers.

My professional career specialising in gastroenterology, specifically liver disease has allowed me to see first-hand the damage caused by alcohol misuse.

During my time as RCP president I made several public statements on the harmful use of alcohol and worked to initiate the Alcohol Health Alliance (AHA) UK in 2007 which I currently chair.

One of the AHA’s key recommendations is that the most effective way to reduce the harm from alcohol is to reduce its affordability, availability and marketing. Of these, affordability is the most effective and that is why the introduction of MUP in Wales is so welcome.'

You can find out more about MUP in Wales by clicking here.

Dr Ruth Alcolado 

Dr Ruth Alcolado is a Cardiff based physician who specialises in gastroenterology. She has worked with RCP Cymru on policy and service issues since 2014 and is the RCP lead for Physicians Associates implementation in Wales. For the last 3 years she has chaired the All Wales Steering group and also serves as deputy medical director for Cwm Taf Morgannwg.

The Welsh Governments Minimum Unit Pricing (MUP) Act comes into force on Monday March 2nd 2020. It supports the ground-breaking ‘Future Generation and Wellbeing Act in Wales’. Why do you think this is a necessary step in Wales?

'The introduction of MUP in Wales will lead to immediate improvements in health outcomes, a reduction in alcohol related deaths and long-term health problems. There is good evidence that price and availability are two significant factors in alcohol consumption and that cheap alcohol is a key driver for many regular heavy drinkers.

MUP will also lead to a reduction in societal problems attributed to alcohol misuse, such as physical and or emotional abuse, divorce, domestic violence, as well as imprisonment.

The children of alcohol dependant parents also face a higher risk of mental health issues, alcohol dependency and an increased risk of several physical illnesses. MUP will have a positive impact on this group.

We should also look at the results from countries where MUP and other alcohol controls have been put in place. Where these countries are reporting to seeing a reduction in alcohol consumption as a result of these measures.'

It is well documented that deprived populations are disproportionately affected by the permissive effects of cheap alcohol and in Wales we have higher than average levels of deprivation. Why do you think deprived areas have higher rates of alcohol dependence?

'Interestingly, there is an indication that on a population basis, people with a more affluent background drink more than adults from more deprived backgrounds. There is however robust evidence to show that those from a more deprived background suffer a disproportionate burden of the negative consequences of high alcohol consumption, this is known as the alcohol harm paradox.

Some of this can be explained by higher levels of non-drinkers in the more deprived populations and that those who do drink in these populations tend to drink more.

The reasons for the alcohol harm paradox may well lie in the complex inter-relationships between diet, smoking, exercise, inherited genetic traits, environment, and background risk of mental health issues.

It should also be noted that areas of high outlet density i.e. more shops selling alcohol are often located in deprived populations. In Edinburgh this correlation was seen with shops selling cheap alcohol.

Studies have demonstrated that heavy drinking associated with poor diet and smoking amplify the risk of alcohol related damage but even accounting for this, people from a poorer background still suffer more harm than those from a more affluent background.

There is also research from Glasgow which suggests that higher levels of alcohol dependency was due to higher levels of psychosocial stress in those of a less affluent background.

Work on adverse childhood experiences also sheds a light on the association between alcohol related harm and high levels of deprivation.'

Harmful use of alcohol places a huge burden on the NHS, the police and the wider community. Almost one in five adults in Wales drink more than the weekly recommended limit. Can you describe these burdens a bit further?

'The RCP document: Alcohol, can the NHS afford it?  published almost 2 decades ago is still relevant today and outlined much of the harm that can result from high levels of alcohol consumption.

Alcohol related health harm is traditionally thought to centre on liver disease but whilst the liver is one of the more susceptible organs, we also know that alcohol plays a part in increased risk of cardiovascular diseases including high blood pressure, heart attacks and strokes. Alcohol related brain injury is another devastating outcome of alcohol excess, causing a dementia type illness in a young population.

There are clear links between alcohol consumption and some cancers including breast, bowel, oesophagus and mouth cancers. Alcohol can cause direct cell damage, increases tobacco related damage, affects hormones linked to development of breast cancer and affects the breakdown of other cancer-causing chemicals.

Alcohol misuse also impacts societal areas for example, accidents at home and on the roads are increased in people who drink more. There is a link between domestic violence and alcohol and this in turn leads to intergenerational effects through adverse childhood experiences. Costs to local policing requirements of city and town centres where alcohol consumption is high can be seen in every police force in the country as well as the burdens placed on A&E services.'

Of all alcohol sold, it is the very cheap products, such as large bottles of strong cider, that play the biggest part in alcohol-related harm. What would you say to people who say that MUP discriminates against the poorest in society from having a well-earned drink after working all week in a low wage job?

'The effect of the MUP on most alcohol sales is minimal. MUP has been set at a level where it affects the types of high strength alcohol known to be used disproportionately by problem drinkers.

There are already more non-drinkers in the poorest in society therefore those who only have a drink at the end of a week will see very little change.

Alcohol that is consumed in licenced premises will not be affected as it is already above the MUP, so those going out with friends, family or colleagues for a drink at the end of a busy week will not see any change.'

The simplest way to reduce demand for alcohol is to raise its price and we know that the introduction of a minimum unit price (MUP) for alcohol is an effective and evidence-based way to tackle health inequalities and reduce consumption. How do you think we should measure this impact?

'Scotland implemented MUP in 2018 and have taken a four-strand approach to measuring the impact that MUP is having. The four strands are:

• Monitoring implementation and compliance with MUP
• Economic assessments of the market
• Consumption levels
• Health and Social outcomes

I should mention that it is too early to draw any conclusive results of MUP’s impact in Scotland, but it is an area to keep an eye on.

In Wales, our main aim is to improve health and social outcomes and we can do this by monitoring the data that is collected routinely. Data which measures hospital admission statistics, alcohol attributable death rates, levels of alcohol consumption in young people and crime statistics should be monitored for changes in trajectory as MUP takes effect.

We should also factor in new studies into the impact that MUP is having on children. By exploring both their experience of living with family members affected by alcohol dependency and on their own drinking related behaviours.

Finally, it is also important to note that in due course assessment of the public view of the impact and acceptability of the policy should be considered.'