Developing a social practice-based typology of British drinking culture in 2009-2011: Implications for alcohol policy analysis

Background and aims: The concept of national drinking culture is well-established in research and policy debate but rarely features in contemporary alcohol policy analysis. We aim to apply the alternative concept of social practices to quantitatively operationalise drinking culture. We discuss how a practice perspective addresses limitations in existing analytical approaches to health-related behaviour before demonstrating its empirical application by constructing a statistical typology of British drinking practices and examining sociodemographic variation in practice. Design: Cross-sectional latent class analysis of drinking occasions derived from one-week drinking diaries collected for market research. Occasions are periods of drinking with no more than two hours between drinks. Setting: Great Britain, 2009-2011. Cases: 187,878 occasions nested within 60,215 nationally-representative adults (18+). Measurements: Beverage type and quantity per occasion. Location, company and gender composition of company. Motivation and reason for occasion. Day, start-time and duration of occasion. Age, sex and social grade. Findings: Eight drinking practices are derived. Three of the four most common practices are low risk, brief, relaxed, home-drinking (46.0% of occasions). The most high risk practices had diverse characteristics and were observed across all sociodemographic groups. Two often-high risk practices identified are rarely acknowledged in policy debate: lengthy weekend domestic gatherings of friends and/or family (14.4% of occasions) and lengthy, typically weekend occasions encompassing both on-trade and off-trade locations (10.4% of occasions). Conclusions: A practice-based perspective offers potential for a step-change in alcohol policy analysis by enabling evaluation of how much and why drinking cultures change in response to public health interventions

Alcohol policy and gender : a modelling study estimating gender‐specific effects of alcohol pricing policies

Aims To describe gender differences in alcohol consumption, purchasing preferences and alcohol‐attributable harm. To model the effects of alcohol pricing policies on male and female consumption and hospitalizations. Design Epidemiological simulation using the Sheffield Alcohol Policy Model version 4. Setting and Participants Adults aged 18+ years, England. Interventions Three alcohol pricing policies: 10% duty increase and minimum unit prices (MUP) of £0.50 and £0.70 per UK unit. Measures Gender‐specific baseline and key outcomes data: annual beverage‐specific units of alcohol consumed and beverage‐specific alcohol expenditure (household surveys). Alcohol‐attributable hospital admissions (administrative data). Key model parameters: literature‐based own‐ and cross‐price elasticities for 10 beverage‐by‐location categories (e.g. off‐trade beer). Sensitivity analysis with new gender‐specific elasticities. Literature‐based risk functions linking consumption and harm, gender‐disaggregated where evidence was available. Population subgroups: 120 subgroups defined by gender (primary focus), age, deprivation quintile and baseline weekly consumption. Findings Women consumed 59.7% of their alcohol as off‐trade wine while men consumed 49.7% as beer. Women drinkers consumed fewer units annually than men (494 versus 895) and a smaller proportion of women were high‐risk drinkers (4.8 versus 7.2%). Moderate drinking women had lower hospital admission rates than men (44 versus 547 per 100 000), but rates were similar for high‐risk drinking women and men (14 294 versus 13 167 per 100 000). All three policies led to larger estimated reductions in consumption and admission rates among men than women. For example, a £0.50 MUP led to a 5.3% reduction in consumption and a 4.1% reduction in admissions for men but a 0.7% reduction in consumption and a 1.6% reduction in hospitalizations for women. Conclusion Alcohol consumption, purchasing preferences and harm show strong gender patterns among adult drinkers in England. Alcohol pricing policies are estimated to be more effective at reducing consumption and harm for men than women

Reporting the characteristics of the policy context for population-level alcohol interventions: A proposed 'Transparent Reporting of Alcohol Intervention ContExts' (TRAICE) checklist

Issues Effectiveness of alcohol policy interventions varies across times and places. The circumstances under which effective polices can be successfully transferred between contexts are typically unexplored with little attention given to developing reporting requirements that would facilitate systematic investigation. Approach Using purposive sampling and expert elicitation methods, we identified context-related factors impacting on the effectiveness of population-level alcohol policies. We then drew on previous characterisations of alcohol policy contexts and methodological-reporting checklists to design a new checklist for reporting contextual information in evaluation studies. Key Findings Six context factor domains were identified: (i) baseline alcohol consumption, norms and harm rates; (ii) baseline affordability and availability; (iii) social, microeconomic and demographic contexts; (iv) macroeconomic context; (v) market context; and (vi) wider policy, political and media context. The checklist specifies information, typically available in national or international reports, to be reported in each domain. Implications The checklist can facilitate evidence synthesis by providing: (i) a mechanism for systematic and more consistent reporting of contextual data for meta-regression and realist evaluations; (ii) information for policy-makers on differences between their context and contexts of evaluations; and (iii) an evidence base for adjusting prospective policy simulation models to account for policy context. Conclusions Our proposed checklist provides a tool for gaining better understanding of the influence of policy context on intervention effectiveness. Further work is required to rationalise and aggregate checklists across interventions types to make such checklists practical for use by journals and to improve reporting of important qualitative contextual data

Effects on alcohol consumption of announcing and implementing revised UK low-risk drinking guidelines : findings from an interrupted time series analysis

Background: In January 2016, the UK announced and began implementing revised guidelines for low-risk drinking of 14 units (112 g) per week for men and women. This was a reduction from the previous guidelines for men of 3–4 units (24–32 g) per day. There was no large-scale promotion of the revised guidelines beyond the initial media announcement. This paper evaluates the effect of announcing the revised guidelines on alcohol consumption among adults in England. Methods: Data come from a monthly repeat cross-sectional survey of approximately 1700 adults living in private households in England collected between March 2014 and October 2017. The primary outcomes are change in level and time trend of participants’ Alcohol Use Disorders Identification Test—Consumption (AUDIT-C) scores. Results: In December 2015, the modelled average AUDIT-C score was 2.719 out of 12 and was decreasing by 0.003 each month. After January 2016, AUDIT-C scores increased immediately but non-significantly to 2.720 (β=0.001, CI −0.079 to 0.099) and the trend changed significantly such that scores subsequently increased by 0.005 each month (β=0.008, CI 0.001 to 0.015), equivalent to 0.5% of the population increasing their AUDIT-C score by 1 point each month. Secondary analyses indicated the change in trend began 7 months before the guideline announcement and that AUDIT-C scores reduced significantly but temporarily for 4 months after the announcement (β=−0.087, CI −0.167 to 0.007). Conclusions: Announcing new UK drinking guidelines did not lead to a substantial or sustained reduction in drinking or a downturn in the long-term trend in alcohol consumption, but there was evidence of a temporary reduction in consumption

The impact of promoting revised UK low-risk drinking guidelines on alcohol consumption: interrupted time series analysis

Background The UK’s Chief Medical Officers revised the UK alcohol drinking guidelines in 2016 to ≤ 14 units per week (1 unit = 10 ml/8 g ethanol) for men and women. Previously, the guideline stated that men should not regularly consume more than 3–4 units per day and women should not regularly consume more than 2–3 units per day. Objective To evaluate the impact of promoting revised UK drinking guidelines on alcohol consumption. Design Interrupted time series analysis of observational data. Setting England, March 2014 to October 2017. Participants A total of 74,388 adults aged ≥ 16 years living in private households in England. Interventions Promotion of revised UK low-risk drinking guidelines. Main outcome measures Primary outcome – alcohol consumption measured by the Alcohol Use Disorders Identification Test – Consumption score. Secondary outcomes – average weekly consumption measured using graduated frequency, monthly alcohol consumption per capita adult (aged ≥ 16 years) derived from taxation data, monthly number of hospitalisations for alcohol poisoning (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision: T51.0, T51.1 and T51.9) and assault (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision: X85–Y09), and further measures of influences on behaviour change. Data sources The Alcohol Toolkit Study, a monthly cross-sectional survey and NHS Digital’s Hospital Episode Statistics. Results The revised drinking guidelines were not subject to large-scale promotion after the initial January 2016 announcement. An analysis of news reports found that mentions of the guidelines were mostly factual, and spiked during January 2016. In December 2015, the modelled average Alcohol Use Disorders Identification Test – Consumption score was 2.719 out of 12.000 and was decreasing by 0.003 each month. After the January 2016 announcement, Alcohol Use Disorders Identification Test – Consumption scores did not decrease significantly (β = 0.001, 95% confidence interval –0.079 to 0.099). However, the trend did change significantly such that scores subsequently increased by 0.005 each month (β = 0.008, 95% confidence interval 0.001 to 0.015). This change is equivalent to 0.5% of the population moving each month from drinking two or three times per week to drinking four or more times per week. Secondary analyses indicated that the change in trend began 6 months before the guideline announcement. The secondary outcome measures showed conflicting results, with no significant changes in consumption measures and no substantial changes in influences on behaviour change, but immediate reductions in hospitalisations of 7.3% for assaults and 15.4% for alcohol poisonings. Limitations The pre-intervention data collection period was only 2 months for influences on behaviour change and the graduated frequency measure. Our conclusions may be generalisable only to scenarios in which guidelines are announced but not promoted. Conclusions The announcement of revised UK low-risk drinking guidelines was not associated with clearly detectable changes in drinking behaviour. Observed reductions in alcohol-related hospitalisations are unlikely to be attributable to the revised guidelines. Promotion of the guidelines may have been prevented by opposition to the revised guidelines from the government's alcohol industry partners or because reduction in alcohol consumption was not a government priority or because practical obstacles prevented independent public health organisations from promoting the guidelines. Additional barriers to the effectiveness of guidelines may include low public understanding and a need for guidelines to engage more with how drinkers respond to and use them in practice. Trial registration Current Controlled Trials ISRCTN15189062. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 14. See the NIHR Journals Library website for further project information

Potential benefits of minimum unit pricing for alcohol versus a ban on below cost selling in England 2014: modelling study

Objective To evaluate the potential impact of two alcohol control policies under consideration in England: banning below cost selling of alcohol and minimum unit pricing. Design Modelling study using the Sheffield Alcohol Policy Model version 2.5. Setting England 2014-15. Population Adults and young people aged 16 or more, including subgroups of moderate, hazardous, and harmful drinkers. Interventions Policy to ban below cost selling, which means that the selling price to consumers could not be lower than tax payable on the product, compared with policies of minimum unit pricing at £0.40 (€0.57; $0.75), 45p, and 50p per unit (7.9 g/10 mL) of pure alcohol. Main outcome measures Changes in mean consumption in terms of units of alcohol, drinkers’ expenditure, and reductions in deaths, illnesses, admissions to hospital, and quality adjusted life years. Results The proportion of the market affected is a key driver of impact, with just 0.7% of all units estimated to be sold below the duty plus value added tax threshold implied by a ban on below cost selling, compared with 23.2% of units for a 45p minimum unit price. Below cost selling is estimated to reduce harmful drinkers’ mean annual consumption by just 0.08%, around 3 units per year, compared with 3.7% or 137 units per year for a 45p minimum unit price (an approximately 45 times greater effect). The ban on below cost selling has a small effect on population health—saving an estimated 14 deaths and 500 admissions to hospital per annum. In contrast, a 45p minimum unit price is estimated to save 624 deaths and 23 700 hospital admissions. Most of the harm reductions (for example, 89% of estimated deaths saved per annum) are estimated to occur in the 5.3% of people who are harmful drinkers. Conclusions The ban on below cost selling, implemented in the England in May 2014, is estimated to have small effects on consumption and health harm. The previously announced policy of a minimum unit price, if set at expected levels between 40p and 50p per unit, is estimated to have an approximately 40-50 times greater effect

Evaluating the effects of minimum unit pricing in Scotland on the prevalence of harmful drinking: a controlled interrupted time series analysis

Objectives In May 2018, the Scottish Government introduced a minimum unit price (MUP) for alcohol of £0.50 (1 UK unit = 8 g ethanol) to reduce alcohol consumption, particularly among people drinking at harmful levels. This study aimed to evaluate MUP's impact on the prevalence of harmful drinking among adults in Scotland. Study design This was a controlled interrupted monthly time series analysis of repeat cross-sectional data collected via 1-week drinking diaries from adult drinkers in Scotland (N = 38,674) and Northern England (N = 71,687) between January 2009 and February 2020. Methods The primary outcome was the proportion of drinkers consuming at harmful levels (>50 [men] or >35 [women] units in diary week). The secondary outcomes included the proportion of drinkers consuming at hazardous (≥14–50 [men] or ≥14–35 [women] units) and moderate (<14 units) levels and measures of beverage preferences and drinking patterns. Analyses also examined the prevalence of harmful drinking in key subgroups. Results There was no significant change in the proportion of drinkers consuming at harmful levels (β = +0.6 percentage points; 95% confidence interval [CI] = −1.1, +2.3) or moderate levels (β = +1.4 percentage points; 95% confidence interval = −1.1, +3.8) after the introduction of MUP. The proportion consuming at hazardous levels fell significantly by 3.5 percentage points (95% CI = −5.4, −1.7). There were no significant changes in other secondary outcomes or in the subgroup analyses after correction for multiple testing. Conclusions Introducing MUP in Scotland was not associated with reductions in the proportion of drinkers consuming at harmful levels but did reduce the prevalence of hazardous drinking. This adds to previous evidence that MUP reduced overall alcohol consumption in Scotland and consumption among those drinking above moderate levels

Potential effects of minimum unit pricing at local authority level on alcohol-attributed harms in North West and North East England: a modelling study

Background In 2018, Scotland implemented a 50p-per-unit minimum unit price for alcohol. Previous modelling estimated the impact of minimum unit pricing for England, Scotland, Wales and Northern Ireland. Decision-makers want to know the potential effects of minimum unit pricing for local authorities in England; the premise of this study is that estimated effects of minimum unit pricing would vary by locality. Objective The objective was to estimate the potential effects on mortality, hospitalisations and crime of the implementation of minimum unit pricing for alcohol at local authority level in England. Design This was an evidence synthesis, and used computer modelling using the Sheffield Alcohol Policy Model (local authority version 4.0). This study gathered evidence on local consumption of alcohol from the Health Survey for England, and gathered data on local prices paid from the Living Costs and Food Survey and from market research companies’ actual sales data. These data were linked with local harms in terms of both alcohol-attributable mortality (from the Office for National Statistics) and alcohol-attributable hospitalisations (from Hospital Episode Statistics) for 45 conditions defined by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. These data were examined for eight age–sex groups split by five Index of Multiple Deprivation quintiles. Alcohol-attributable crime data (Office for National Statistics police-recorded crimes and uplifts for unrecorded offences) were also analysed. Setting This study was set in 23 upper-tier local authorities in North West England, 12 upper-tier local authorities in the North East region and nine government office regions, and a national summary was conducted. Participants The participants were the population of England aged ≥ 18 years. Intervention The intervention was setting a local minimum unit price. The base case is 50p per unit of alcohol. Sensitivity analyses were undertaken using minimum unit prices of 30p, 40p, 60p and 70p per unit of alcohol. Main outcome measures The main outcome measures were changes in alcohol-attributable deaths, hospitalisations and crime. Savings in NHS costs, changes in alcohol purchasing and consumption, changes in revenue to off-trade and on-trade retailers and changes in the slope index of inequality between most and least deprived areas were also examined. Results The modelling has proved feasible at the upper-tier local authority level. The resulting estimates suggest that minimum unit pricing for alcohol at local authority level could be effective in reducing alcohol-attributable deaths, hospitalisations, NHS costs and crime. A 50p minimum unit price for alcohol at local authority level is estimated to reduce annual alcohol-related deaths in the North West region by 205, hospitalisations by 5956 (–5.5%) and crimes by 8528 (–2.5%). These estimated reductions are mostly due to the 5% of people drinking at high-risk levels (e.g. men drinking > 25 pints of beer or five bottles of wine per week, women drinking > 17 pints of beer or 3.5 bottles of wine per week, and who spend around £2500 per year currently on alcohol). Model estimates of impact are bigger in the North West and North East regions than nationally because, currently, more cheap alcohol is consumed in these regions and because there are more alcohol-related deaths and hospitalisations in these areas. A 30p minimum unit price has estimated effects that are ≈ 90% lower than those of a 50p minimum unit price, and a 40p minimum unit price has estimated effects that are ≈ 50% lower. Health inequalities are estimated to reduce with greater health gains in the deprived areas, where more cheap alcohol is purchased and where there are higher baseline harms. Limitations The approach requires synthesis of evidence from multiple sources on alcohol consumption; prices paid; and incidence of diseases, mortality and crime. Price elasticities used are from previous UK analysis of price responsiveness rather than specific to local areas. The study has not estimated ‘cross-border effects’, namely travelling to shops outside the region. Conclusions The modelling estimates suggest that minimum unit pricing for alcohol at local authority level would be an effective and well-targeted policy, reducing inequalities. Future work The Sheffield Alcohol Policy Model for Local Authorities framework could be further utilised to examine the local impact of national policies (e.g. tax changes) or local policies (e.g. licensing or identification and brief advice). As evidence emerges from the Scottish minimum unit price implementation, this will further inform estimates of impact in English localities. The methods used to estimate drinking and purchasing patterns in each local authority could also be used for other topics involving unhealthy products affecting public health, for example to estimate local smoking or high-fat, high-salt food consumption patterns. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information

Effects on alcohol consumption of announcing revised UK low-risk drinking guidelines : findings from a monthly cross-sectional survey

Background Health authorities publish alcohol consumption guidelines for low-risk drinking in most high-income countries but the effects of these guidelines on alcohol consumption are unclear. In January, 2016, the UK's Chief Medical Officers announced revised guidelines recommending that men and women should not regularly drink more than 14 units per week, a reduction to the previous guideline for men of 3–4 units per day. We aimed to evaluate the effect of announcing the revised guidelines on alcohol consumption. Methods Data were collected from March, 2014, to October, 2017, using the Alcohol Toolkit Survey, a monthly repeat cross-sectional survey of approximately 1800 adults (older than 16 years) resident in England. The survey uses a hybrid between random location sampling and quota sampling designed to generate a nationally representative sample, which selects random areas in England (about 300 households) from strata defined by area-level geographical and sociodemographic profiles. Participants provided verbal informed consent. The University College London ethics committee granted ethical approval for the Alcohol Toolkit Study and The University of Sheffield for the evaluation of the UK lower-risk drinking guidelines. The primary outcome is participants’ Alcohol Use Disorders Identification Test for Consumption (AUDIT-C) scores. Effects were estimated using segmented regression. Secondary analyses test for alternative breakpoints in the long-term trend and pulse effects. All analyses were preregistered in the ISRCTN registry, number ISRCTN15189062. Findings At baseline, 70·4% of the sample were drinkers and the mean AUDIT-C score was 2·8. The main analysis showed no significant step-change in AUDIT-C scores immediately following announcement of the guideline (β=0·001 [95% CI –0·079 to 0·099]; p=0·82) and the trend changed significantly such that scores increased by 0·005 each month (β=0·008 [0·001–0·015]; p=0·015). This finding was not robust as secondary analyses of alternative breakpoints suggested the change in behaviour began in June, before the new guidelines were announced. Secondary analyses also suggest that AUDIT-C scores reduced temporarily for 3 months (a pulse effect) after the announcement (β=–0·126 [–0·218 to –0·034]; p=0·007). Interpretation Announcing new UK drinking guidelines with no large-scale organised promotion did not lead to a substantial or sustained reduction in drinking or a downturn in long-term alcohol consumption behaviour. Well designed promotional campaigns might improve the effect of drinking guidelines on alcohol consumption. This study is limited by potential seasonal confounding—January is typically a light-drinking month, whereas December is a heavy-drinking month. We control for seasonal trends but this approach might be inadequate if seasonality varies substantially between years as our time series is relatively short

An integrated dual process simulation model of alcohol use behaviours in individuals, with application to US population-level consumption, 1984–2012

Introduction The Theory of Planned Behaviour (TPB) describes how attitudes, norms and perceived behavioural control guide health behaviour, including alcohol consumption. Dual Process Theories (DPT) suggest that alongside these reasoned pathways, behaviour is influenced by automatic processes that are determined by the frequency of engagement in the health behaviour in the past. We present a computational model integrating TPB and DPT to determine drinking decisions for simulated individuals. We explore whether this model can reproduce historical patterns in US population alcohol use and simulate a hypothetical scenario, “Dry January”, to demonstrate the utility of the model for appraising the impact of policy interventions on population alcohol use. Method Constructs from the TPB pathway were computed using equations from an existing individual-level dynamic simulation model of alcohol use. The DPT pathway was initialised by simulating individuals’ past drinking using data from a large US survey. Individuals in the model were from a US population microsimulation that accounts for births, deaths and migration (1984–2015). On each modelled day, for each individual, we calculated standard drinks consumed using the TPB or DPT pathway. In each year we computed total population alcohol use prevalence, frequency and quantity. The model was calibrated to alcohol use data from the Behavioral Risk Factor Surveillance System (1984–2004). Results The model was a good fit to prevalence and frequency but a poorer fit to quantity of alcohol consumption, particularly in males. Simulating Dry January in each year led to a small to moderate reduction in annual population drinking. Conclusion This study provides further evidence, at the whole population level, that a combination of reasoned and implicit processes are important for alcohol use. Alcohol misuse interventions should target both processes. The integrated TPB-DPT simulation model is a useful tool for estimating changes in alcohol consumption following hypothetical population interventions