Title: Integrated evidence synthesis for joint appraisal of tobacco and alcohol tax interventions for harm reduction in the UK
Funder: Department of Health and Social Care

Abstract: Background == Tobacco and alcohol are major risk factors for cancers, respiratory and cardiovascular disease, causing substantial hospital admissions and mortality and around £6 billion per year of National Health Service (NHS) costs in England. Taxation is one of the most effective interventions for reducing consumption, but UK impact assessments for tax interventions do not currently examine the effect of tax changes on tobacco and alcohol in an integrated way. The reason for investigating tobacco and alcohol together is that they are correlated behaviours that together generate multiplicatively increased risks e.g. for head, neck and esophageal cancers, and therefore the evidence on the effects of changes to the tax on tobacco and alcohol would be incomplete – especially on differential social impacts - if considered singly. Aim == To provide evidence and tools to inform the potential scale of effects of taxation across tobacco and alcohol as an intervention to improve public health and reduce health inequalities in the UK. We will produce evidence on effectiveness and inequality of effects that integrates qualitative research on stakeholder views with quantitative research on health and economic outcomes. Methods == Work package 1. Qualitative research to define and understand relevant tax interventions -- The reason for our qualitative research in workpackage 1 is to ensure that we model relevant tax interventions across tobacco and alcohol, that we understand the rationale of different stakeholders for these interventions and in doing so explore the challenges for tax as a tool to improve health. We will take a structured approach that involves conducting expert UK stakeholder interviews, informed by a rapid review. WP1 aims to define a set of 'candidate' alcohol and tobacco tax interventions relevant to the UK context that will be modelled, and to provide a grounded understanding of the policy effects valued by stakeholders, of mediating factors they perceive as affecting deliberation and implementation, and evidence gaps in relation to both separate and joint tobacco and alcohol taxation intervention options. These interviews will enable the project team to gain a rich understanding of the complex policy space in which tobacco and alcohol taxation changes take place, co-exist and interact. Work package 2. Analysis of social patterns in spending on tobacco and alcohol -- WP2 aims to describe the socio-demographic variation in patterns of spending (product type and price) across the spectrum of tobacco and alcohol products. We will combine consumer spending data on tobacco and alcohol from the Living Costs and Food Survey (LCFS) with market research data on retail prices. We will conduct descriptive and statistical analyses of how spending varies by demographic (age, sex, family status) and socio-economic group (education, social class, employment status, income, index of multiple deprivation), and we will assess this expenditure in the context of household budgets. Work package 3. Analysis of industry and consumer responses to tax changes -- WP3 aims to estimate the responses of industry and consumers to changes in taxation. We will develop evidence to investigate tax pass-through (how taxes are passed-through to the prices faced by consumers) across the product and price spectrum for tobacco and alcohol products (using a consistent approach for tobacco and alcohol). We will also harmonise estimates of the price elasticities of demand across tobacco and alcohol in terms of how retail price changes affect participation in tobacco use, participation in alcohol use, quantity of tobacco products purchased and quantity of alcohol products purchased including the interactions between these behaviours. We will look to develop new price elasticity of demand estimates based on the LCFS to quantify effects of price changes on demand for different sub-types of tobacco and alcohol products including participation elasticities and purchase volume elasticities. We will consider how uncertainty in elasticities should be accounted for in WP4. Work package 4. Population modelling to appraise the health and economic outcomes of tax interventions -- WP4 aims to conduct a prospective long-term health economic assessment of the taxation interventions for tobacco and alcohol. We will build on prior modelling for alcohol and combine workpackage outputs to model the effects of tax interventions defined as relevant by stakeholders in WP1. Outcomes will be the overall and social differentials of effects on: i) hospitalisations and deaths; ii) NHS treatment costs; iii) tax revenue; iv) work absence; v) consumer spending. We will forecast 30 years from our baseline year. Our comparator will be the estimated effects of continuing the current tax regime. We will estimate uncertainty through sensitivity analysis, particularly in terms of uncertainty around industry modification of tax pass-through and consumer price elasticities of demand. Outputs == Use of evidence to support decisions -- Our outputs will provide an objective comparison of alternative tax changes across tobacco and alcohol. We are aiming for our outputs to inform decisions about changes to tax on tobacco and alcohol e.g. through submission to government consultations and a continuation of the research team's engagement with decision-makers. Scientific understanding of tax as a public health intervention -- Our technical contribution will be in developing methods that allow the fair comparison of interventions and outcomes across risk factors. Our outputs in conferences and peer-reviewed papers will cover the qualitative comparison of stakeholder perspectives (WP1), the use of national-level data on consumer behaviour (WP2), the behavioural economics of industry and consumer responses to tax change (WP3), and the synthesis of evidence using mathematical modelling to provide evidence that is effects at decision-support (WP4). Informing public debate -- In producing media we will look to partner with stakeholders and consumers from our public involvement panels to present and explain our findings in an engaging accessible way and with a consumer focus.

Lay abstract: Aim We aim to investigate how tobacco and alcohol taxation can be changed to improve health for all. We will talk with consumers, policymakers and experts and use survey and sales data to look at how tobacco and alcohol tax can work together: to change consumer behaviour and health; to benefit disadvantaged communities; and reduce NHS costs at a time of limited budgets. Background One in five adults in the UK smokes and one in five adults drinks alcohol in hazardous or harmful ways. These 'lifestyle factors' are leading causes of preventable illness and death, including from heart disease and cancers. Over 80,000 people a year die earlier than they should from diseases caused by drinking or smoking. For those who smoke and drink alcohol, the risk of developing these preventable diseases is even greater. This preventable human loss is compounded by an annual cost to the NHS of over £6 billion. There is evidence that people buy fewer cigarettes and alcoholic drinks when the price increases. Health advocates are therefore calling for higher taxes and changes to tax structures on alcohol and tobacco products to encourage people to quit smoking and reduce their drinking. However, it is not clear what effect this would have on tax revenues and the wider economy e.g. on time off sick from work due to smoking related illness, and there is uncertainty about the effects of tax increases on smokers and drinkers who are on a low income or unemployed. Consumers might also change what they buy to avoid price rises due to higher tax (for example, by switching to cheaper or smuggled products). Yet more uncertainty in the effects of tax changes on smoking and drinking arises because tobacco and alcohol companies and retailers might alter prices to ensure some products stay affordable despite tax increases. The planned research will address these areas of complexity. Design and methods The project will involve: 1) A review of relevant options for tobacco and alcohol tax change in the UK considering the history of tax changes and debate from 1997, followed by interviews with representatives of organisations that have an influence over and expertise in tobacco and/or alcohol taxation. We want to know how these organisations understand and prioritise options for tobacco and alcohol taxes. 2) Analysis of social patterns in spending on tobacco and alcohol products using data from the nationally representative Living Costs and Food Survey (approximately 6,000 responding households in the UK per year). 3) Analysis of how industry and consumers are likely to respond to tax changes using several years of data on retail prices and consumer spending. 4) A population forecast to estimate how tax options might differ in their effects on consumer spending, health and health inequalities, costs of ill-health to the NHS and the tax revenue to government. Public involvement To maintain a consumer focus we will discuss research plans and findings with three public involvement panels that have already been recruited and who are experienced in being involved in research projects: a panel of smokers, of general drinkers, and of people recovering from addiction or their families. We will also invite members of these panels to be part of our project management group to help direct our research. Dissemination We will communicate our findings directly to public health charities and governmental organisations. Before discussions, we will present our project and findings in an accessible way e.g. through a presentation, a short written briefing and online materials with a short explanatory video. We will also produce a technical report that we will publish on our website [https://www.shef.ac.uk/scharr/sections/ph/research/alpol], and a government focused briefing in readiness for responding to government consultations on tax change. To reach the widest scientific audience we will present our research at international conferences that specialise in either alcohol or tobacco and national conferences on public health and social science. We will also make presentations to the public e.g. at science festivals, and have a strong record of attracting news media coverage of our work which helps both the public and policymakers to hear about it.

Research activity codes: 3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;ORAL AND GASTROINTESTINAL;RESPIRATORY;STROKE