Transcript Two cities - Alcohol Research UK

Alcohol and British
Society
12th March 2013
A tale of two cities
Jonathan Chick and Jan Gill
Queen Margaret
University
Edinburgh
Outline
• Policy/legislation background
• Our study: alcohol purchasing by ill heavy
drinkers
• Rationale and design
• Some preliminary findings.
Framework for Action- Addressing
Scotland’s Relationship with Alcohol
2009 onwards
Education and awareness, additional
investment for treatment and care services,
Alcohol and Drug Partnerships
ABIs (primary care brief interventions)
delivered with funding !
Licensing (Scotland) Act 2005
• Implemented 2009
(Test purchasing, mandatory training for staff,
ban on irresponsible promotions in the ontrade, restriction on place of display in offtrade etc).
Alcohol etc (Scotland) Act 2010 – Implemented
Oct 2011
• Ban on quantity discounts in off-sales
• Restrictions on alcohol display and promotions in off
sales.
• Mandatory Challenge 25 age verification policy.
• Health Boards to be notified of premises licence
applications.
• etc
Alcohol (Minimum Pricing) (Scotland) Act 2012 –
MUP (minimum price per unit of alcohol):all alcohol
sold through licensed premises in Scotland
Proposed 50 pence- to be reviewed every 2 years
Will expire after 6 years unless provision made for it to
continue after the end of 5 years by Scottish
Government (‘Sunset Clause’)
Will not be implemented until current Scottish judicial
proceedings concluded
Predicted benefits of a 50p/unit min. price
(Sheffield University: modelling based on previous national
and international data)
overall Scottish consumption by 7.2%
Scottish hospital admissions by 8,900
10 years total societal cost
(crime, health, by £1.3 billion)
Legislated but not yet implemented
Judicial Review underway following legal
challenge to the Scottish Government
(began Tuesday 15th January)
( by the Scotch Whisky Association – representing large
producers of distilled spirits )
MUP date
• April 2012
• April 2013
• ?
The current scenario
•
•
•
•
Recession
Falling real incomes
Reducing social security benefits
Possibly strategic price adaptations by
producers or retailers
Affordability
increased by
45% from
1980-2007
(nb rising
disposable
income)
Sales
(Scot Eng )
follow
affordability
Figure from
MESAS, 2012
Evaluating effects of minimal pricing on health
• Sales data
• Hospital discharge data/ mortality data
• General population surveys (but heavy
drinkers’ under-represented)
• Monitor possible unwanted effects:
dependent drinkers: substitute alcohols/other
drugs/stealing/smuggling/illicit distilling ?
QMU Study
Beverage
purchasing
and effects of
minimum
pricing
among 600
heavy
drinkers
attending
hospitals in
Glasgow and
Edinburgh
12 months
24 months
36 months
Time-point 1
Time-point 2
Time-point 3
M
U
P
Supplemented
with Qualitative
interviews
Original Plan.
6 months
12 months
18 months
24 months
Data collection
Time-point 1
Time-point 2
Time-point 3
Time-point 4
M
M
U
U
P
P
?
Revised study.
Supplemented
with Qualitative
interviews
Inclusion criteria
Attending an alcohol problems service outpatient appointment
or
Admitted to hospital, and having a diagnosis of
an alcohol-related condition (whether or not
another diagnosis has also been made)
Exclusion
• under 16 years old;
• unable to understand the questions or give
understandable answers in English;
• clinically significant memory impairment e.g.
Korsakov's dementia;
• unwilling to be contacted for 3 further follow-up
interviews.
Alcohol drunk and price paid
Drinks questionnaire ; last 7 days of last period of
drinking using the Time Line Follow- Back method
(beverage, volume purchased, cost and location
(off/on/free/ home brewed etc) of purchase for each
day.
From this, and using manufacturer’s data, the price per
‘unit’ (8 gram) of ethanol was calculated.
• Illicit, substitute, smuggled or stolen?
• Any illicit drugs?
• What alcohol-related disorder linked to that
admission/consultation?
(Also Record Linkage to NHS and mortality records )
Alcohol related problems
questionnaire (ARPQ)
Some preliminary findings
1 Drinking, purchasing and harms among sick
drinkers
2 Between-city differences
3 Determinants of inequalities in harms
4 Purchasing during era of decreasing
affordability
BASELINE DATA:
Current study
(Glas+Edin) 2012 ->
Pilot study (Edin
2008/9)
Black et al 2010
Addiction 106, 729–736
N
643
377
% male
73
68
Mean Age (years)
( range)
46
(18-79)
47
Consumption (typical or
last week) mean units
(95%CI)
215
(204.2-225.8)
197
(184.8-210.7)
Median Unit price (pence) 40p
(14 – 145)
37p
(9-140)
% of all units bought as
OFF sales
90.9
95.2
The more
that’s
drunk,
the more
harms
r
p
All
0.357
0.01
Male
0.326
0.01
Female
0.459
0.01
The ‘Glasgow Effect’
Reduced life expectancy in Glasgow (e.g. males
5.4 years lower than in Edinburgh in 2001)
Relates to social deprivation, and is particularly
accounted for by suicide, drug deaths and
alcohol liver disease
Leyland et al
Between city differences : causes of problems
SES is more predictive of ARPQ in Edinburgh (OR
0.9, p<.001) than Glasgow (OR 0.6, n.s.)
Consumption is more predictive of ARPQ in Edin
than Glasgow
i.e. Is there is something else in Glasgow, in
addition to low SES, that contributes to
problems, especially mental health problems ..
A ‘Glasgow effect’?
Between city differences: Source
Purchasing from
‘Independent’
outlets) (‘corner
shops’) predicted
‘problems’ in
Edinburgh, not
Glasgow ; but
MUCH commoner
in Glasgow:
Social economic class (SES) inequalities (2)
Mental health problems (OR 1.97,p< .001), not liver
problems (OR 1.12, n.s)., linked to lower SES
SES not a predictor of health problems among
women (viz: Females were more likely than men to be
from higher SES - OR 0.62, p<.05)
In the wider
population,
sales follow
affordability
Figure from
MESAS, 2012
% of all off-sales units purchased at or
below 50 pence/unit
2008/9
2011/12
Glasgow patients
80%
Edinburgh patients 83%
77%
Wider Scotland
66%
(Health Scotland, 2012)
81%
i.e. moderate drinkers are following their
preferred beverages into a higher price range,
and overall are reducing consumption;
..........while very heavy drinkers stay purchasing
cheaply for as long as they can.
Patients are resisting the current downward
trend in affordability, because the cheap
alcohol is still there.
The proportion of their consumption that patients buy at less than 50p/unit
has INCREASED while affordability has fallen
...because those purchases (those products!) are still available
Cheap cider is for sick drinkers
Future work
• Linkage with NHS hospital and with Deaths
Register (nb 22 deaths already documented in
in first 3 months of recontacting)
• Trends in drink purchasing against background
UK economic changes (incl benefits) and
marketing fashions
• Profiling the drinker resistant to treatments/
and changes in the sourcing of alcoholic
beverages in the UK
• ??effects of MUP
Heather Black - Leading RA;
conducted the Pilot
Robert Rush (statistician)
Fiona O’May (research fellow)
Christine Galloway , Shauna
Kielty (RAs Edinburgh)
Cheryl Rees and Jane Doogan
(RAs Glasgow)
Prof Barbara McPake (economist)
Lucie Michalova (coordinator)
Rebecca Lawrence , Helen
Leslie (Edinburgh)
Iain Smith, George Benson,
Ewan Forrest, Frances
Skelton (Glasgow)
GET GRAPH FROM ISD ( NRS)
Alcohol-Related deaths by area deprivation
In 2007, alcohol-related mortality rates in the most
deprived SIMD category were over seven (7.1) times
higher than in the least deprived category
(59/100,000 population compared to 8/100,000
population). By 2011, the relative difference had
reduced to 5.4 (45/100,000 population compared to
8/100,000 population). Trends in rates across
quintiles have varied. For example, there has been a
marked downward trend in the most deprived
quintile, decreasing from 59/100,000 population in
2007 to 45/100,000 population in 2011 (a 24% fall).
In contrast, rates in the least deprived quintile
remained static (at 8/100,000 population) (Figure
6.5).
Figure 6.5: Alcohol-related deaths (underlying
cause), by deprivation category, 2007 - 2011
Source: ISD Scotland (NRS).
Proportion of each drinks category sold in the off-trade below different prices per
unit, 2008-2011 (MESAS, 2012)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
<30ppu
2008
2009
2010
2011
<40ppu
2008
2009
2010
2011
<50ppu
2008
2009
2010
2011
All alcohol
Spirits
Wine
Beer
Cider
22
14
10
6
27
13
3
1
8
4
2
1
25
18
18
10
53
46
43
34
57
50
43
35
71
63
53
37
38
34
25
20
60
50
48
43
78
74
70
62
81
77
72
66
88
84
79
76
72
68
62
52
85
79
76
72
86
86
82
79
Week’s consumption (Mean)
Scottish general population (Adults 16 years or
older)
from sales data:
23.5 units
from Scottish Health Survey: 11.6 units
Our sample
215.0 units
Mean weekly
consumption
Mean weekly
consumption
Glasgow
Edinburgh
p
228.4
(95%CI 212.4244.4)
199.4
(95%CI 185.4213.4)
0.009
males
females
228.2
(95%CI =
215.1-241.3)
180.4
(95%CI =
162.3-198.5)
<0.001
The White Cider drinkers
Greater proportion of
males in this group than
non white cider drinkers, p
= 0.014).
But no differences
between the cities in
gender distribution of
white cider drinkers.
Range 10- 29 pence
per unit
Comparison with other dependent drinkers
White cider
drinkers
Other dependent
drinkers
p
N
161
482
Mean age (95%CI)
40.3
(38.9 - 41.7)
47.5
(46.5 - 48.4)
0.01
Median ARPQ (IQR)
7.7
(3.0)
6.0
(3.5)
0.05
Mean Consumption (typical
or last week) UK units
(95%CI)
281.7
(257.6 - 305.9)
192.8
(181.5 - 204.1)
0.001
Mean Unit price (pence)
(95% CI)
23.9
(22.4 - 25.5)
50.2
(48.3 - 52.1)
0.001
Mean Expenditure per week
(£)
(95% CI)
£65.70
(58.5 - 72.9)
£90.53
(84.85 - 96.23)
0.001
Mean cigarettes/day
14.4
(12.6 - 16.2)
12.5
(11.4 - 13.7)
n.s.
Scottish general population: Trend
towards less sales at below 50ppu
In 2008, 81% of all off-trade alcohol was sold at less than 50ppu, falling to 66% in
2011.
• At the upper end of the price distribution, 95% of all off-trade alcohol was sold at
less than 70ppu in 2008, falling to 91% in 2011.
•
For instance, there was a 22% point decrease between 2008 and 2011 in the
proportion of alcohol sold at less than 40ppu, compared with only a 4% point drop
in the proportion sold at below 70ppu.
But the proportion that patients are buying at that level has INCREASED not
decreased ...because those purchases can still be made. There are fewer products
at 9p/unit, but still 14p/unit
Inequalities in male mortality by occupational class, perceived status and education
in Russia, 1994-2006.
•
•
Eur J Public Health. 2012 Jun;22(3):332-7. doi: 10.1093/eurpub/ckr130. Epub 2011 Sep 21.
Bessudnov A, McKee M, Stuckler D.
•
Russia's market reforms in the early 1990s led to marked social inequalities. We analysed
inequalities in risks of dying for Russian men by occupational class and perceived social status in the
post-transition era.
METHODS:
Cox proportional analysis of the hazard of dying by occupational class, education, household
income and perceived social status was performed for 593 deaths that occurred between 1994 and
2006 using a representative sample of Russia's male population (n = 6586 people, 40 046 personyears). Occupational class was coded based on the European Socio-Economic Classification; social
status was based on survey questionnaires about people's perceived economic, power and respect
status.
RESULTS:
•
•
•
•
Manual occupational class is significantly associated with greater hazards of dying
among men, after adjusting for age, education and other potential confounding
variables. Groups at highest risk were men who were manual workers, manual
supervisors and technicians, and lower sales and service workers. Substantial gaps
in life expectancy at age 21 of up to 10 years were observed between male
managers and professionals and manual workers.