Title: Change in alcohol and tobacco availability, population health and the lived experience
Funder: Economic and Social Research Council

Abstract: The overarching ambitions of this project are to explore neighbourhood level supply of alcohol and tobacco over time and to improve our understanding of the impact of availability on the health and wellbeing of residents. We will interrogate existing quantitative datasets, supplemented with updated availability data and a qualitative work package. In order to achieve these ambitions this project aims to: 1. Explore whether the changing availability of alcohol and tobacco in neighbourhoods is related to consumption and health-related harm. 2. Improve our understanding of the potential pathways between supply and harm through an exploration of the lived experience in areas of contrasting supply. 3. Engage with stakeholders to explore potential supply side policy scenarios. In seeking to realise these aims the project will: a. Develop small area measures of tobacco and alcohol outlet availability through time in Scotland. For both alcohol and tobacco we have collected data on the location of every outlet in Scotland for 2012 and 2016. We will collect further data on every outlet in the country for 2019/20. For alcohol we also have data on every outlet in the four major cities for 2008. Using Kernel Density Estimation and this data we will create availability measure for every postcode in Scotland at each time point. We will do this for tobacco outlets and alcohol outlets separately and in combination. In addition we will create separate measures for on-sales alcohol outlets and off-sales alcohol outlets. b. Employ an innovative method, Trajectory Modelling, to group neighbourhoods with similar levels of change in alcohol (on-sales and off-sales and total sales), tobacco and alcohol and tobacco combined. The temporal trajectory method will not only detect the relative change in outlet density over time, but also the progress and direction of change over the period. c. Identify neighbourhood characteristics that explain and predict trajectories of change. Such characteristics will be identified from the literature, but may include the domains of the Scottish Index of Multiple Deprivation, age profiles, population change, economic indicators and urban/rural status. d. Employ innovative supply-demand models to identify neighbourhoods with higher or lower than expected smoking and alcohol-related behaviours given area level characteristics. e. Construct indicators of alcohol and tobacco related harm (morbidity and mortality) using secondary administrative data from the National Records of Scotland (NRS) and NHS Information Services Division (ISD). These data, coupled with the availability data and trajectories of change, will allow us to examine the association between outlet density and alcohol and tobacco-related health behaviours, mortality and morbidity. We will explore both cross-sectional relationships at each time point and using the trajectories we will examine change in outlet availability and any corresponding change in related harms. f. Employ qualitative techniques, including focus groups, to understand the experiences of people living in different alcohol and tobacco environments and seek to identify the likely causal pathways through which outlet density may influence both tobacco and alcohol consumption. g. Examine public and stakeholder views, through semi-structured interviews, on the efficacy and acceptability of policy interventions that could reduce both alcohol and tobacco outlet density. h. Work closely with non-academic partners, Alcohol Focus Scotland and Action on Smoking and Health Scotland, to deliver robust and relevant empirical evidence that can be used by a range of stakeholders both within and beyond academia. Such evidence can be used to make concrete recommendations on availability that will inform policy decision-making.

Lay abstract: This research project will measure change in the availability of alcohol and tobacco in Scottish neighbourhoods over time. We will explore how this change relates to health outcomes and how residents experience the availability of alcohol and tobacco in their neighbourhoods. The findings will be important because smoking and alcohol consumption are leading causes of illness and death. In Scotland smoking causes one in every 5 deaths and one in 20 deaths is related to alcohol. This harm is not equally shared; those on the lowest incomes suffer the greatest harm. These illnesses and deaths are preventable. The World Health Organisation recommends that nations prioritise interventions that reduce the supply of alcohol and tobacco. Why might neighbourhood supply of alcohol and tobacco matter? Research suggests that when there are a lot of outlets in a neighbourhood this impacts upon consumption in three ways. 1. The outlets may be more competitive and drive prices down to attract customers. 2. Oversupply may normalise the products when they are sold alongside everyday commodities, such as bread and milk. 3. Tobacco and alcohol may simply be easier to buy in areas where there are more outlets. In order to explore the relationship between supply, behaviour and harm we need data on the location of every outlet in Scotland selling tobacco and/or alcohol. Ideally, to be able to say something about whether the relationship may be causal, we need this data over time. We have already collected data on the specific location of every outlet selling tobacco and licensed to sell alcohol over multiple time periods (2012 and 2016 (nationwide alcohol and tobacco) and 2008 (alcohol in four cities)). As part of this project we will collect updated data for 2019/20. This will allow us to measure this change over time. Using an approach called trajectory modelling we will group neighbourhoods that have had a similar degree of change; some neighbourhoods may have lost, or gained, local shops or pubs, whereas some may not have changed at all. We will then identify features of these neighbourhoods that may be driving this change, for example the age profile of the population or poverty levels. This will help policy makers understand the drivers of change in our neighbourhoods. To measure the relationship between changing supply and harm we will link these trajectories, and our measures of availability at each time point, to alcohol and tobacco health outcomes (behaviour, illness and death). We will use statistical models to see whether areas experiencing an increase or decrease in outlets have seen a corresponding increase or decrease in these outcomes. This will allow us to get a better understanding of whether an over supply of alcohol and tobacco is related to smoking and alcohol consumption and harm. These findings will provide important evidence related to the provision of such commodities in our neighbourhoods. Although these statistics are important to report we also need to understand why an oversupply of alcohol and tobacco may influence behaviour and harm. Whilst the literature suggests the pathways listed above, we know little about the experiences of individuals living in neighbourhoods with contrasting availability. We don't understand the individual experience of these pathways. We will meet with groups of individuals, in neighbourhoods of contrasting trajectories, to talk to them about the supply of alcohol and tobacco. We will explore their experiences of neighbourhood and assess how their perceived notions of their neighbourhood availability contrast with our statistical measures. Finally, we will meet with residents, retailers and policy stake-holders to explore potential interventions related to supply. Policies at this level require public, retailer and political support. We will discuss the priorities held by various groups, present our empirical results and gauge attitudes towards potential interventions.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;ORAL AND GASTROINTESTINAL;RESPIRATORY;STROKE