Title: EXILENS – EXploring the Impact of alcohol Licensing in ENgland and Scotland: A mixed-method, natural experiment evaluation of public health engagement in alcohol premises licensing and impact on alcohol-related harms
Funder: Chief Scientist Office, Scotland

Abstract: BACKGROUND: In England & Scotland, LOCAL COUNCIL LICENSING AUTHORITIES regulate the sale of alcohol through the licensing system. The statutory objectives of the alcohol premises licensing system are to prevent crime and disorder, to prevent public nuisance, to promote public safety, to protect children from harm and in Scotland only, to protect and improve public health. Since 2011 (England) and 2009 (Scotland), local PUBLIC HEALTH TEAMS (PHTs, including Alcohol and Drug Partnerships in Scotland) are designated as ‘Responsible Authorities’ for licensing. Subsequently, many, but not all, PHTs have become proactive in engaging with alcohol licensing, e.g. collating and using local data on availability and harms to: - help councils decide if the number of premises in a specific area is causing problems - make representations against licence applications - help develop licensing conditions for individual premises - involve local communities in licensing issues Both PHTs ENGAGEMENT IN ALCOHOL LICENSING, and LICENSING AUTHORITIES’ activities commensurate with public health goals, vary between local authorities by both ‘intensity’ and type (1-3). It is not known if, or how, these activities have an influence on licensing outcomes, health outcomes or crime rates. Systematic reviews have identified control of the availability of alcohol as a key approach for reducing alcohol-related harm (4,5), but a review of 160 studies found that the relationship between public health activities, specific local licensing controls, indicators and types of availability and alcohol-related harms is not clear or consistently examined in the literature (6). Relevant recent studies conducted in England; and others finding significant associations between the intensity of local licensing and reductions in alcohol-related hospital admissions and crimes (7,8). We aim to build on these, virtually eliminating exposure measurement error, by capturing in detail the nature of all intervention activities, licensing activity, and confounding activity. This study will also examine the impact on A&E attendances. AIM: To critically assess the impact and mechanisms of impact of PUBLIC HEALTH TEAM ENGAGEMENT on ALCOHOL LICENSING and ALCOHOL-RELATED HARMS in England and Scotland from 2012 to 2018 by comparing areas with differing types and intensities of engagement SETTINGS & CONTROLS: 20 high activity intervention areas and 20 low/no activity matched control areas, 12 of each in England; 8 of each in Scotland. PRIMARY OUTCOMES: Alcohol-related hospital admissions; A&E attendances; Cost-effectiveness, theory of change, and acceptability to public health and licensing teams. SECONDARY OUTCOMES: Crime rates; Alcohol-related mortality; Health inequalities; Local licensing policies and decisions. RESEARCH QUESTIONS: PRIMARY: 1. Does intensive PUBLIC ENGAGEMENT IN ALCOHOL LICENSING reduce alcohol-related harms, in local authorities where such activity exists, compared with authorities with low levels of, or no, such activity? SECONDARY: 2. What are the costs and cost-savings, mechanisms of action (including contribution to impact of specific aspects of licensing regimes), and impact on health inequalities of PUBLIC HEALTH ENGAGEMENT IN LICENSING? 3. How do engagement, processes, acceptability, and outcomes vary between Scotland (where a public health objective for licensing exists) and England; and from PHTs and licensing perspectives? DESIGN: Mixed methods natural experiment with four Work Packages (WPs) delivered between April 2017 and March 2020. WP1 INTERVENTION SCOPING & PROCESS EVALUATION: Documentary analysis, scoping and in-depth interviews with 40 PHTs (20 intervention & 20 control) to examine local PHT activity and intensity, the local licensing regime, mechanisms of change, acceptability and processes involved. WP2 ALCOHOL HARMS EVALUATION: Use longitudinal growth models and time series analyses to evaluate the impact of high & low levels of activity on alcohol-related harms using routine data from baseline 2009 to 2018. WP3 WIDER IMPACT, COSTS, & DISTRIBUTION OF EFFECTS: Evaluate intervention costs, estimated NHS cost savings, and health gains using Sheffield Alcohol Policy Model. Estimate impact on alcohol consumption, and health inequalities (gender/socioeconomic). WP4 IMPACT: Refine & revise hypothesised theory of change. Organise stakeholder workshop with PHTs to discuss interim findings, final theory of change, and dissemination strategy. Synthesise all findings and recommendations. Chief Investigator: Niamh Fitzgerald, Lecturer in Alcohol Studies, Institute for Social Marketing, UK Centre for Tobacco & Alcohol Studies, Faculty of Health Sciences & Sport, Stirling University Co-Investigators: Frank de Vocht, Bristol; Colin Angus, Sheffield; James Nicholls, Alcohol Research UK; Matt Egan, LSHTM; Niamh Shortt, Edinburgh; Tim Nicols (formerly Brighton) and Linda Bauld, Stirling. Independent Advisory Group: Prof. Eileen Kaner (Newcastle University, Chair); Maria Smolar (Public Health England); Jon Foster (Institute for Alcohol Studies); Alison Douglas (Alcohol Focus Scotland); Colin Sumpter (NHS Forth Valley, formerly of Islington Council); Dr. Vittal Katikireddi (Glasgow University); Prof. Kypros Kypri (Newcastle University, Australia); Prof. Jamie Pearce (Edinburgh University); other advisors to be confirmed. References: 1. Fitzgerald N, Nicholls J, Winterbottom Jo and Katikireddi S.V. Implementing a public health objective for alcohol premises licensing in Scotland: A qualitative study of strategies, values and perceptions of evidence. Int. J. Environ. Res. Public Health, 2017, 14(3), 221. 2. Mahon L, Nicholls J. Using licensing to protect public health From evidence to practice. London; 2014. 3. Egan M, Brennan A, Buykx P, DeVocht F, et al. Local policies to tackle a national problem: Comparative qualitative case studies of an English local authority alcohol availability intervention. Health & Place 2016, 41, 11-18. 4. Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: No Ordinary Commodity: Research and Public Policy. 2nd ed. OUP Oxford; 2010. 5. Martineau, F.; Tyner, E.; Lorenc, T.; Petticrew, M.; Lock, K. Population-level interventions to reduce alcohol-related harm: An overview of systematic reviewsp. Prev. Med. 2013, 57, 278–296. 6. Holmes J, Guo Y, Maheswaran R, Nicholls J, Meier PS, Brennan A. The impact of spatial and temporal availability of alcohol on its consumption and related harms: a critical review in the context of UK licensing policies. Drug Alcohol Rev. 2014 Sep;33(5):515–25. 7. De Vocht F, Heron J, Angus C, Brennan A, Mooney J, Lock K, et al. Measurable effects of local alcohol licensing policies on population health in England. J Epidemiol Community Health. 2015 Nov 10;70(3):231–7. 8. De Vocht F, Heron J, Campbell R, Egan M, Mooney JD, Angus C, et al. Testing the impact of local alcohol licencing policies on reported crime rates in England. J Epidemiol Community Health. BMJ Publishing Group Ltd; 2016 Aug 11;jech – 2016–207753

Lay abstract: In England and Scotland, local councils have power over alcohol licensing – that is the system by which certain premises are allowed to sell alcohol. In recent years, professionals who work on ways to improve health across the population (‘PUBLIC HEALTH TEAMS’ or ‘PHT’s) have been trying to influence this licensing system. They do this by getting involved in licensing processes and encouraging licensing authorities and licence-holders to act in ways they hope will ultimately improve the health of the local population. Our AIM is to find out what PHTs have been doing and whether their actions have had any impact on these alcohol-related harms, and if this activity is worth the cost and effort. OUR PLAN OF WORK: To answer these questions we will divide our work into four packages: 1) CURRENT ACTIVITY: Identify and engage the most active PHTs by speaking to national organisations who help them – these are ‘intervention areas’. a) Gather a wide range of information about what PHTs are doing (or not doing) to engage with alcohol licensing authorities, as well as records of licences applied for, granted, refused etc. from 2012 to 2018. b) Ask public health and licensing practitioners about how acceptable these activities are, how they make a difference, what are the challenges? (By visiting, interviewing them and looking at paperwork) 2) CHANGES IN HARMS: Match intervention areas with teams from similar areas where nothing or very little has been done in relation to these activities – these are ‘comparison’ areas. Gather existing information on alcohol-related harms and crime rates from 2009 to 2018 in both the ‘intervention’ and ‘comparison’ areas. Analyse whether any changes in harms or crime rates are related to the level of activity of PHTs, specific aspects of the local licensing system, and any differences between Scotland and England. 3) COSTS & BENEFITS: Estimate the value of this kind of PHT activity by comparing the costs of the activities with the savings from any health harms or crimes avoided, and the impact on inequalities between different groups in society. Estimate whether or not this kind of activity may have other impacts, such as on alcohol consumption or deaths in the longer term. 4) IMPACT: Pull together all the information, in consultation with local areas, to examine the ways in which the PHT’s licensing activity might have an effect, and to make recommendations about future activity, policy, and research on this topic. OUR TEAM & EXPERTISE Our team includes researchers from 6 institutions and a former senior licensing professional. Together we have experience of researching alcohol licensing using a variety of methods, an in-depth understanding of the licensing system in Scotland and England, excellent links with local PHTs and extensive experience of conducting similar research with local authorities. We also have colleagues from national organisations (Public Health England; Alcohol Focus Scotland; Institute for Alcohol Studies), senior academics, and a public health practitioner on an independent advisory group, chaired by Prof. Eileen Kaner, who will help guide the study. Two members of the public will sit on the advisory group, one each from public involvement groups on alcohol research already established at Stirling and LSHTM. The Stirling group have already given a lay perspective on this study and supported the development of this summary.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;ORAL AND GASTROINTESTINAL;STROKE