Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study

Background: Several countries are considering a minimum price policy for alcohol, but concerns exist about the potential effects on drinkers with low incomes. We aimed to assess the effect of a £0·45 minimum unit price (1 unit is 8 g/10 mL ethanol) in England across the income and socioeconomic distributions. Methods: We used the Sheffield Alcohol Policy Model (SAPM) version 2.6, a causal, deterministic, epidemiological model, to assess effects of a minimum unit price policy. SAPM accounts for alcohol purchasing and consumption preferences for population subgroups including income and socioeconomic groups. Purchasing preferences are regarded as the types and volumes of alcohol beverages, prices paid, and the balance between on-trade (eg, bars) and off-trade (eg, shops). We estimated price elasticities from 9 years of survey data and did sensitivity analyses with alternative elasticities. We assessed effects of the policy on moderate, hazardous, and harmful drinkers, split into three socioeconomic groups (living in routine or manual households, intermediate households, and managerial or professional households). We examined policy effects on alcohol consumption, spending, rates of alcohol-related health harm, and opportunity costs associated with that harm. Rates of harm and costs were estimated for a 10 year period after policy implementation. We adjusted baseline rates of mortality and morbidity to account for differential risk between socioeconomic groups. Findings: Overall, a minimum unit price of £0·45 led to an immediate reduction in consumption of 1·6% (−11·7 units per drinker per year) in our model. Moderate drinkers were least affected in terms of consumption (−3·8 units per drinker per year for the lowest income quintile vs 0·8 units increase for the highest income quintile) and spending (increase in spending of £0·04 vs £1·86 per year). The greatest behavioural changes occurred in harmful drinkers (change in consumption of −3·7% or −138·2 units per drinker per year, with a decrease in spending of £4·01), especially in the lowest income quintile (−7·6% or −299·8 units per drinker per year, with a decrease in spending of £34·63) compared with the highest income quintile (−1·0% or −34·3 units, with an increase in spending of £16·35). Estimated health benefits from the policy were also unequally distributed. Individuals in the lowest socioeconomic group (living in routine or manual worker households and comprising 41·7% of the sample population) would accrue 81·8% of reductions in premature deaths and 87·1% of gains in terms of quality-adjusted life-years. Interpretation: Irrespective of income, moderate drinkers were little affected by a minimum unit price of £0·45 in our model, with the greatest effects noted for harmful drinkers. Because harmful drinkers on low incomes purchase more alcohol at less than the minimum unit price threshold compared with other groups, they would be affected most by this policy. Large reductions in consumption in this group would however coincide with substantial health gains in terms of morbidity and mortality related to reduced alcohol consumption. Funding: UK Medical Research Council and Economic and Social Research Council (grant G1000043)

Anxiety after stroke: prevalence, intervention effectiveness, and illness representations

Stroke is a life changing event that can result in significant negative consequences. As such psychological disturbances may arise. In the general population anxiety is the most prevalent mental health condition, yet it remains under-researched and under-recognised within stroke survivors. Anxiety, is associated with decreased quality of life, increased healthcare utilisation, and increased severity of depression. The aims of the programme of research organised in this thesis were to establish a quantitative estimate of the prevalence of anxiety after stroke, to determine if there were any interventions that were effective in treating it and to uncover psychological factors that may have attributed to the manifestation of anxiety after stroke. Three studies were conducted. The first was a systematic review and meta-analysis of observational studies that assessed the prevalence of anxiety after stroke. The second study was a Cochrane systematic review of randomised control trials to examine if any interventions were effective in treating anxiety after stroke. The third study was a longitudinal cohort study that used the common-sense model of illness representations (Leventhal, Meyer and Nerenz 1980) to uncover the illness beliefs held by stroke survivors, and to evaluate whether these beliefs were associated with anxiety after stroke. Approximately 20% of stroke survivors were found to have an anxiety disorder, and 25% experienced significant levels of anxiety symptoms. Currently, there is insufficient evidence from randomised control trials to guide treatment of anxiety after stroke. Illness representations were relatively stable over time. Only higher illness identity (e.g. attributing a higher symptom burden to stroke), and having a more emotional response to ones stroke were associated with anxiety in stroke survivors. Several limitations in all three studies may restrict the generalisability and validity of the findings and there are many questions that remain unanswered. However this work has contributed substantially to the investigation into the phenomenon of anxiety after stroke and can inform clinical guideline development, post-stroke psychological service provision and future intervention studies

Minimum unit pricing for alcohol: policy appraisal modelling of income and socioeconomic group-specific effects on consumption, spending, and health harms

Background UK legislatures are at different stages in the policy process for introducing a minimum price for alcohol. Although there is evidence about the effectiveness of such policies, political and public concern exists about the potential effects on low-income drinkers. We present appraisals of the effects of a £0·45 minimum unit price (MUP; 1 unit=8g/10mL ethanol) policy in England in 2014–15 across the income and socioeconomic distributions. Methods We undertook policy appraisals using the Sheffield Alcohol Policy Model (SAPM version 2.6), a causal, deterministic, epidemiological model. SAPM accounts for differential alcohol purchasing and consumption preferences for population subgroups defined, using self-reported survey data, by age, sex, consumption level, and income or socioeconomic group. We derived volumes purchased and prices paid for ten alcoholic beverage categories (beer, cider, wine, spirits, and ready-to-drink beverages [RTDs], purchased in the on trade [eg, bars] or off trade [eg, shops]) from household-level 2-week spending diaries. A 10 × 10 price elasticity matrix was estimated to describe the relation between price changes and purchasing changes (assumed to represent consumption changes). After a policy change, the elasticity matrix was used to adjust individual-level survey data on self-reported mean weekly and peak daily alcohol consumption. We modelled resulting effects on mortality and disease prevalence using functions relating consumption measures to risk of having 47 chronic or acute disorders wholly or partly attributable to alcohol. Baseline mortality and morbidity rates were those reported for England and Wales in 2005 by the North West Public Health Observatory. These rates are adjusted to account for socioeconomic variability in mortality and morbidity risk with Office for National Statistics socioeconomic group-specific alcohol-related mortality data for 2001–03. Findings On average, moderate drinkers purchase 36 below-MUP units per year whereas harmful drinkers in the lowest and highest income groups purchase 1610 and 712 units, respectively. The policy is estimated to have small effects on moderate drinkers' alcohol consumption (–1·6 units per drinker per year) and spending (£0·78 per year). Bigger behavioural changes are estimated to occur among harmful drinkers and these are largest in the lowest income quintile (–300 units, –£34·63) compared with the highest (–34 units, £16·35). The same pattern of results was noted in sensitivity analyses using (a) alternative elasticity matrices, and (b) population subgroups defined by socioeconomic status rather than income. A list of published sensitivity analyses undertaken with SAPM is provided in the appendix. Health benefits from the policy are also unequally distributed due to differential baseline harm risks and purchasing patterns. Lower socioeconomic groups that make up 41·7% of the population would accrue 81·8% of the reduction in deaths and 87·1% of the reduction in quality-adjusted life-years lost. Interpretation Moderate drinkers, regardless of income, are only marginally affected by the policy because it chiefly targets harmful drinkers. Because they purchase more below-MUP alcohol, low-income harmful drinkers would be affected more than those with higher incomes. Policymakers must balance low-income harmful drinkers' larger consumption reductions against their greater health gains from reduced alcohol-related morbidity and mortality. Limitations of the model include supply-side responses not being considered (eg, retailers increasing prices above the MUP threshold) and the data used for adjusting baseline health risks for socioeconomic groups only relating to mortality and not being condition specific

Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study.

Several countries are considering a minimum price policy for alcohol, but concerns exist about the potential effects on drinkers with low incomes. We aimed to assess the effect of a £0·45 minimum unit price (1 unit is 8 g/10 mL ethanol) in England across the income and socioeconomic distributions