Title: Evaluating possible intended and unintended consequences of the implementation of Minimum Unit Pricing of Alcohol in Scotland: a natural experiment
Funder: Chief Scientist Office, Scotland

Abstract: This is a mixed method study with three components: Component 1 is a repeat cross-sectional study of alcohol-related attendances to Emergency Departments (EDs) in 2 Scottish hospitals and 2 North England geographical control EDs at 3 time points. The study methods and tools are based on a previous study by one of the investigators (Drummond) and the experience of the Scottish Emergency Department Alcohol Audit. Baseline data collection will occur as soon as possible if funding is secured. Waves 2 and 3 will take place 6 and 12 months post-intervention. If implementation takes place more than 12 months post baseline, wave 2 will become a 2nd baseline. Patients aged 16 yrs and over (exclusion criteria in project detail) attending EDs will be asked by research staff to complete a short face-to-face interview. An ED attendance database will be maintained during data collection periods to monitor patient recruitment. The interview will include: basic demographic information; amount of alcohol consumed in the past 24 hours; whether the patient has been a victim of violence, problematic alcohol use in the past year (assessed by FAST). A note will be made of the hospital unique identifier for the attendance. Research staff will retrieve additional demographic characteristics, other attendance details, and diagnoses at discharge (ICD-10) from patient records. Based on previous study by CD, we have assumed 50% recruitment of eligible ED attendees. We anticipate from the 4 sites (2 Scotland, 2 England) 940 recruits per week. Recruiting over 3 weeks pre- and post-intervention would provide a total sample size of 5640 (940*6) giving us the power (>80%) to detect a decrease in the proportion of alcohol-related attendances from 30% to 25% with 95% significance. For subgroup analyses by age and deprivation, we would have good power (>80%) to detect changes on the FAST score Component 2 is a repeat cross-sectional questionnaire for patients attending sexual health services to determine changes in drinking patterns, other substance use and source of alcohol. All patients attending 3 sexual health services in Scotland and 3 in North England as geographical controls will be invited to complete a 5 minute anonymous questionnaire by a trained research support worker. Participants will be recruited over the times periods similar to the ED study. The following will be sought from respondents: where alcohol is procured, other substances used, views on alcohol control, FAST score (to quantify problematic drinkers), and basic characteristics (age band, sex, highest educational level). Assuming conservative recruitment of 50% of attendees at SH clinics at 6 sites (3 Scotland, 3 England) we will have about 10,000 recruits over two 3 week periods (an average of 288 per clinic per week). This would give us power of> 80% to detect an increase in the proportion of people using drugs from 30% to 34%. Component 3 is a repeat cross-sectional qualitative study of young binge drinkers aged 18-25 and older heavy drinkers aged 30+ living in disadvantaged circumstances, who evidence suggests are more sensitive to price changes. Focus groups will be conducted approximately 5-6 months prior to and 5-6 months post-implementation in urban-affluent, urban-deprived and rural-deprived communities within the catchment areas of the 2 hospitals in Scotland recruited for component 1. Discussions will focus on: changes in drinking patterns and purchasing habits, alcohol displacement behaviours; social norms and attitudes. A total of 12 single-sex focus groups will be recruited at each wave enabling comparisons between types of drinker and socio-economic status. Purposive sampling will be used to recruit individuals from the two population groups of interest.via licensed premises (off- and on-trade) with the permission of local licensees and via street intercepts. In addition we will undertake 15 -18 semi-structured interviews at each wave with key stakeholders from professional groups who are well positioned to observe impact and the challenges MUP creates within each study community. Data from the interviews will be triangulated with the findings with other components to provide a more vivid and rounded picture of community expectations, the implementation process and the legislation’s short term impact.

Lay abstract: As part of the strategy to reduce the high levels of alcohol-related harm, the Scottish Parliament has passed legislation to introduce a minimum unit price (MUP) for alcohol. Implementation is planned for April 2013 although legal challenges may delay this. MUP will be introduced at 50 pence per unit (ppu) with the level to be reviewed every two years. The policy aims to increase the price of the cheapest and/or strongest alcohol, thus reducing its affordability. There is evidence that reducing affordability of alcohol reduces consumption and reduces harm. However, there has been little evaluation of MUP previously and a number of possible adverse consequences have been identified. Once implemented, policy in Scotland is likely to differ from that in England for a period of time, presenting the opportunity to study the direct impact of introducing MUP. The findings will be of interest to policy makers and the public in Scotland, the UK and internationally. It is expected that alcohol-related attendances at emergency departments will reduce. However drinkers may avoid paying the increased price if they start buying alcohol not subject to MUP such as via the internet or across the border. There may be some adverse consequences if drinkers switch to illicit alcohol or other drugs. All impacts may be differentially patterned, affecting some groups such as young people or those with a low income more. This study aims to determine the impacts (including whether this differs by age or deprivation) of alcohol minimum unit pricing on selected acute health harms and to monitor what if any, unintended consequences occur. It has three components. The first will assess changes in alcohol-related attendances, and changes in the extent of hazardous and harmful drinking, in emergency departments in Scotland compared to North England. This will help establish whether MUP achieves its stated aim of reducing health harms. The second will use sexual health clinics in Scotland and North England as a setting for a survey to detect whether MUP results in displacement (change of source of alcohol) or substitution (with other drugs) as well as how it changes drinking patterns, particularly for young adults. This setting has been chosen as it allows the study of young people at particularly high risk. The fourth will collect qualitative data from young people and heavy drinkers in 3 contrasting communities in Scotland. It will explore whether MUP results in displacement (change of source of alcohol) or substitution (with other substances) as well as whether it changes drinking patterns. It aims to understand the experience of MUP and explore the potential mechanisms that may result in unanticipated benefits and harms and how these may differ between groups. All components will analyse data by age, sex and a measure of deprivation to determine differential impacts. To undertake this study we have gathered a team that brings expertise in evaluation, health research and alcohol epidemiology from six institutions including academia and the NHS.

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