Using policy theories to interpret public health case studies: the example of a minimum unit price for alcohol

By James Nicholls and Paul Cairney, for the University of Stirling MPH and MPP programmes.

There are strong links between the study of public health and public policy. For example, public health scholars often draw on policy theories to help explain (often low amounts of) policy change to foster population health or reduce health inequalities. Studies include a general focus on public health strategies (such as HiAP) or specific policy instruments (such as a ban on smoking in public places). While public health scholars may seek to evaluate or influence policy, policy theories tend to focus on explaining processes and outcomes.

To demonstrate these links, we present:

1. A long-read blog post to (a) use an initial description of a key alcohol policy instrument (minimum unit pricing, adopted by the Scottish Government but not the UK Government) to (b) describe the application of policy concepts and theories and reflect on the empirical and practical implications. We then added some examples of further reading.
2. A 45 minute podcast to describe and explain these developments (click below or scroll to the end)

Minimum Unit Pricing in Scotland: background and development

Minimum Unit Pricing for alcohol was introduced in Scotland in 2018. In 2012, the UK Government had also announced plans to introduce MUP, but within a year dopped the policy following intense industry pressure. What do these two journeys tell us about policy processes?

When MUP was first proposed by Scottish Health Action on Alcohol Problems in 2007, it was a novel policy idea. Public health advocates had long argued that raising the price of alcohol could help tackle harmful consumption. However, conventional tax increases were not always passed onto consumers, so would not necessarily raise prices in the shops (and the Scottish Government did not have such taxation powers). MUP appeared to present a neat solution to this problem. It quickly became a prominent policy goal of public health advocates in Scotland and across the UK, while gaining increasing attention, and support, from the global alcohol policy community.

In 2008, the UK Minister for Health, Dawn Primarolo, had commissioned researchers at the University of Sheffield to look into links between alcohol pricing and harm. The Sheffield team developed economic models to analysis the predicted impact of different systems. MUP was included, and the ‘Sheffield Model’ would go on to play a decisive role in developing the case for the policy.

What problem would MUP help to solve?

Descriptions of the policy problem often differed in relation to each government. In the mid-2000s, alcohol harm had become a political problem for the UK government. Increasing consumption, alongside changes to the night-time economy, had started to gain widespread media attention. In 2004, just as a major liberalisation of the licensing system was underway in England, news stories began documenting the apparent horrors of ‘Binge Britain’: focusing on public drunkenness and disorder, but also growing rates of liver disease and alcohol-related hospital admissions.

In 2004, influential papers such as the Daily Mail began to target New Labour alcohol policy

Politicians began to respond, and the issue became especially useful for the Conservatives who were developing a narrative that Britain was ‘broken’ under New Labour. Labour’s liberalising reforms of alcohol licensing could conveniently be linked to this political framing. The newly formed Alcohol Health Alliance, a coalition set up under the leadership of Professor Sir Ian Gilmore, was also putting pressure on the UK Government to introduce stricter controls. In Scotland, while much of the debate on alcohol focused on crime and disorder, Scottish advocates were focused on framing the problem as one of public health. Emerging evidence showed that Scotland had dramatically higher rates of alcohol-related illness and death than the rest of Europe – a situation strikingly captured in a chart published in the Lancet.

Source: Leon, D. and McCambridge, J. (2006). Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data. Lancet 367

The notion that Scotland faced an especially acute public health problem with alcohol was supported by key figures in the increasingly powerful Scottish National Party (in government since 2007), which, around this time, had developed working relationships with Alcohol Focus Scotland and other advocacy groups.

What happened next?

The SNP first announced that it would support MUP in 2008, but it did not implement this change until 2018. There are two key reasons for the delay:

1. Its minority government did not achieve enough parliamentary support to pass legislation. It then formed a majority government in 2011, and its legislation to bring MUP into law was passed in 2012.  
2. Court action took years to resolve. The alcohol industry, which is historically powerful in Scotland, was vehemently opposed. A coalition of industry bodies, led by the Scotch Whisky Association, took the Scottish Government to court in an attempt to prove the policy was illegal. Ultimately, this process would take years, and conclude in rulings by the European Court of Justice (2016), Scottish Court of Session Inner House (2016), and UK Supreme Court (2017) which found in favour of the Scottish Government.

In England, to the surprise of many people, the Coalition Government announced in March 2012 that it too would introduce MUP, specifically to reduce binge drinking and public disorder. This different framing was potentially problematic, however, since the available evidence suggested (and subsequent evaluation has confirmed) that MUP would have only a small impact on crime. Nonetheless, health advocates were happy,  with one stating that ‘I do not mind too much how it was framed. What I mind about is how it measures up’.

Once again, the alcohol industry swung into action, launching a campaign led by the Wine and Spirits Trade Association, asking ‘Why should moderate drinkers pay more?’

This public campaign was accompanied by intense behind-the-scenes lobbying, aided by the fact that the leadership of industry groups had close ties to Government and that the All-Party Parliamentary Group on Beer had the largest membership of any APPG in Westminster. The industry campaign made much of the fact there was little evidence to suggest MUP would reduce crime, but also argued strongly that the modelling produced by Sheffield University was not valid evidence in the first place. A year after the adopting the policy, the UK Government announced a U-turn and MUP was dropped.

How can we use policy theories and concepts to interpret these dynamics?

Here are some examples of using policy theories and concepts as a lens to interpret these developments.

1. What was the impact of evidence in the case for policy change?

While public health researchers often expect (or at least promote) ‘evidence based’ policymaking, insights from research identify three main reasons why policymakers do not make evidence-based choices:

First, many political actors (including policymakers) have many different ideas about what counts as good evidence.

The assessment, promotion, and use of evidence is highly contested, and never speaks for itself.

Second, policymakers have to ignore almost all evidence to make choices.

They address ‘bounded rationality’ by using two cognitive shortcuts: ‘rational’ measures set goals and identify trusted sources, while ‘irrational’ measures use gut instinct, emotions, and firmly held beliefs.

Third, policymakers do not control the policy process.

There is no centralised and orderly policy cycle. Rather, policymaking involves policymakers and influencers spread across many authoritative ‘venues’, with each venue having its own rules, networks, and ways of thinking.

In that context, policy theories identify the importance of contestation between policy actors, and describe the development of policy problems, and how evidence fits in. Approaches include:

The study of framing

The acceptability of a policy solution will often depend on how the problem is described. Policymakers use evidence to reduce uncertainty, or a lack of information around problems and how to solve them. However, politics is about exercising power to reduce ambiguity, or the ability to interpret the same problem in different ways.

By suggesting MUP would solve problems around crime, the UK Government made it easier for opponents to claim the policy wasn’t evidence-based. In Scotland, policymakers and advocates focused on health, where the evidence was stronger. In addition, the SNP’s approach fitted within a wider political independence frame, in which more autonomy meant more innovation.

The Narrative Policy Framework

Policy actors tell stories to appeal to the beliefs (or exploit the cognitive shortcuts) of their audiences. A narrative contains a setting (the policy problem), characters (such as the villain who caused it, or the victim of its effects), plot (e.g. a heroic journey to solve the problem), and moral (e.g. the solution to the problem).

Supporters of MUP tended to tell the story that there was an urgent public health  crisis, caused largely by the alcohol industry, and with many victims, but that higher alcohol prices pointed to one way out of this hole. Meanwhile opponents told the story of an overbearing ‘nanny state’, whose victims – ordinary, moderate drinkers – should be left alone by government.

Social Construction and Policy Design

Policymakers make strategic and emotional choices, to identify ‘good’ populations deserving of government help, and ‘bad’ populations deserving punishment or little help. These judgements inform policy design (government policies and practices) and provide positive or dispiriting signals to citizens.

For example, opponents of MUP rejected the idea that alcohol harms existed throughout the population. They focused instead on dividing the majority of moderate drinkers from irresponsible minority of binge drinkers, suggesting that MUP would harm the former more than help the latter.

Multi-centric policymaking

This competition to frame policy problems takes place in political systems that contain many ‘centres’, or venues for authoritative choice. Some diffusion of power is by choice, such as to share responsibilities with devolved and local governments. Some is by necessity, since policymakers can only pay attention to a small proportion of their responsibilities, and delegate the rest to unelected actors such as civil servants and public bodies (who often rely on interest groups to process policy).

For example, ‘alcohol policy’ is really a collection of instruments made or influenced by many bodies, including (until Brexit) European organisations deciding on the legality of MUP, UK and Scottish governments, as well as local governments responsible for alcohol licensing. In Scotland, this delegation of powers worked in favour of MUP, since Alcohol Focus Scotland were funded by the Scottish Government to help deliver some of their alcohol policy goals, and giving them more privileged access than would otherwise have been the case.

The role of evidence in MUP

In the case of MUP, similar evidence was available and communicated to policymakers, but used and interpreted differently, in different centres, by the politicians who favoured or opposed MUP.

In Scotland, the promotion, use of, and receptivity to research evidence – on the size of the problem and potential benefit of a new solution – played a key role in increasing political momentum. The forms of evidence were complimentary. The ‘hard’ science on a potentially effective solution seemed authoritative (although few understood the details), and was preceded by easily communicated and digested evidence on a concrete problem:

1. There was compelling evidence of a public health problem put forward by a well-organised ‘advocacy coalition’ (see below) which focused clearly on health harms. In government, there was strong attention to this evidence, such as the Lancet chart which one civil servant described as ‘look[ing] like the north face of the Eiger’. There were also influential ‘champions’ in Government willing to frame action as supporting the national wellbeing.
2. Reports from Sheffield University appeared to provide robust evidence that MUP could reduce harm, and advocacy was supported by research from Canada which suggested that similar policies there had been successful elsewhere.

Advocacy in England was also well-organised and influential, but was dealing with a larger – and less supportive – Government machine, and the dominant political frame for alcohol harms remained crime and disorder rather than health.

Debates on MUP modelling exemplify these differences in evidence communication and use. Those in favour appealed to econometric models, but sometimes simplifying their complexity and blurring the distinction between projected outcomes and proof of efficacy. Opponents went the other way and dismissed the modelling as mere speculation. What is striking is the extent to which an incredibly complex, and often poorly understand, set of econometric models – and the ’Sheffield Model’ in particular – came to occupy centre stage in a national policy debate. Katikireddi and colleagues talked about this as an example of evidence as rhetoric:

1. Support became less about engagement with  the econometric modelling, and more an indicator of general concern about alcohol harm and the power of the industry.
2. Scepticism was often viewed as the ‘industry position’, and an indicator of scepticism towards public health policy more broadly.

2. Who influences policy change?

Advocacy plays a key role in alcohol policy, with industry and other actors competing with public health groups to define and solve alcohol policy problems. It prompts our attention to policy networks, or the actors who make and influence policy.

According to the Advocacy Coalition Framework:

People engage in politics to turn their beliefs into policy. They form advocacy coalitions with people who share their beliefs, and compete with other coalitions. The action takes place within a subsystem devoted to a policy issue, and a wider policymaking process that provides constraints and opportunities to coalitions. Beliefs about how to interpret policy problems act as a glue to bind actors together within coalitions. If the policy issue is technical and humdrum, there may be room for routine cooperation. If the issue is highly charged, then people romanticise their own cause and demonise their opponents.

MUP became a highly charged focus of contestation between a coalition of public health advocates, who saw themselves as fighting for the wellbeing of the wider community (and who believed fundamentally that government had a duty to promote population health), and a coalition of industry actors who were defending their commercial interests, while depicting public health policies as illiberal and unfair.

3. Was there a ‘window of opportunity’ for MUP?

Policy theories – including Punctuated Equilibrium Theory – describe a tendency for policy change to be minor in most cases and major in few. Paradigmatic policy change is rare and may take place over decades, as in the case of UK tobacco control where many different policy instruments changed from the 1980s. Therefore, a major change in one instrument could represent a sea-change overall or a modest adjustment to the overall approach.

Multiple Streams Analysis is a popular way to describe the adoption of a new policy solution such as MUP. It describes disorderly policymaking, in which attention to a policy problem does not produce the inevitable development, implementation, and evaluation of solutions. Rather, these ‘stages’ should be seen as separate ‘streams’.  A ‘window of opportunity’ for policy change occurs when the three ‘streams’ come together:

• Problem stream. There is high attention to one way to define a policy problem.
• Policy stream. A technically and politically feasible solution already exists (and is often pushed by a ‘policy entrepreneur’ with the resources and networks to exploit opportunities).
• Politics stream. Policymakers have the motive and opportunity to choose that solution.

However, these windows open and close, often quickly, and often without producing policy change.

This approach can help to interpret different developments in relation to Scottish and UK governments:

Problem stream

• The Scottish Government paid high attention to public health crises, including the role of high alcohol consumption.
• The UK government paid often-high attention to alcohol’s role in crime and anti-social behaviour (‘Binge Britain’ and ‘Broken Britain’)

Policy stream

• In Scotland, MUP connected strongly to the dominant framing, offering a technically feasible solution that became politically feasible in 2011.
• The UK Prime Minister David Cameron’s made a surprising bid to adopt MUP in 2012, but ministers were divided on its technical feasibility (to address the problem they described) and its political feasibility seemed to be more about distracting from other crises than public health.

Politics stream

• The Scottish Government was highly motivated to adopt MUP. MUP was a flagship policy for the SNP; an opportunity to prove its independent credentials, and to be seen to address a national public health problem. It had the opportunity from 2011, then faced interest group opposition that delayed implementation.
• The Coalition Government was ideologically more committed to defending commercial interests, and to framing alcohol harms as one of individual (rather than corporate) responsibility. It took less than a year for the alcohol industry to successfully push for a UK government U-turn.

As a result, MUP became policy (eventually) in Scotland, but the window closed (without resolution) in England.

Further Reading

Nicholls, J. and Greenaway, J. (2015) ‘What is the problem?: Evidence, politics and alcohol policy in England and Wales, 2010–2014’, Drugs: Education, Prevention and Policy 22.2  https://doi.org/10.3109/09687637.2014.993923

Butler, S., Elmeland, K., Nicholls, J. and Thom, B. (2017) Alcohol, power and public health: a comparative study of alcohol policy. Routledge.

Fitzgerald, N. and Angus, C. (2015) Four nations: how evidence–based are alcohol policies and programmes across the UK?

Holden, C. and Hawkins, B. (2013) ‘Whisky gloss’: the alcohol industry, devolution and policy communities in Scotland. Public Policy and Administration, 28(3), pp.253-273.

Paul Cairney and Donley Studlar (2014) ‘Public Health Policy in the United Kingdom: After the War on Tobacco, Is a War on Alcohol Brewing?’ World Medical and Health Policy, 6, 3, 308-323 PDF

Niamh Fitzgerald and Paul Cairney (2022) ‘National objectives, local policymaking: public health efforts to translate national legislation into local policy in Scottish alcohol licensing’, Evidence and Policy, https://doi.org/10.1332/174426421X16397418342227, PDF

Podcast

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Using policy theories to interpret public health case studies: the example of a minimum unit price for alcohol – Understanding Public Policy (in 1000 and 500 words)

By James Nicholls and Paul Cairney, for the University of Stirling MPH and MPP programmes. There are strong links between the study of public health and public policy. For example, public health scholars often draw on policy theories to help explain (often low amounts of) policy change to foster population health or reduce health inequalities. Studies include a general focus on public health strategies (such as HiAP) or specific policy instruments (such as a ban on smoking in public places). While public health scholars may seek to evaluate or influence policy, policy theories tend to focus on explaining processes and outcomes,. To demonstrate these links, we present this podcast and blog post to (1) use an initial description of a key alcohol policy instrument (minimum unit pricing in Scotland) to (2) describe the application of policy concepts and theories and reflect on the empirical and practical implications.  Using policy theories to interpret public health case studies: the example of a minimum unit price for alcohol | Paul Cairney: Politics & Public Policy (wordpress.com)

1. Using policy theories to interpret public health case studies: the example of a minimum unit price for alcohol 47:09
2. Policy in 500 Words: policymaking environments and their consequences 11:47
3. Policy in 500 Words: bounded rationality and its consequences 18:39
4. Policy in 500 Words: evolutionary theory 51:09
5. Policy in 500 Words: The Advocacy Coalition Framework 33:19

Action on Sugar: Learning from Tobacco

In many ways, tobacco control has set the agenda for controls in other areas, such as (most notably) alcohol. We can see this by simply comparing recent calls for action on sugar in food with existing curbs on tobacco use, taking out the ones that are not comparable or might seem a step too far (at least for now, warns the IEA and DP). Here are the types of policy instruments for tobacco and I have put an asterisk next to the latest recommendations on food.

I. Regulation (through legislation or voluntary agreements)

1. Bans or restrictions on advertising and promotion (e.g. to disassociate the product with physical activity).*
2. Sales to children.
3. Smoking and eating in public places (second-hand smoke).
4. Modify and regulate ingredients, such as the levels of tar in cigarettes and the levels of sugar, salt and fat in food.*
5. Customs enforcement on smuggling and counterfeit products.

II. Finance

1. Taxation and other levies to discourage consumption of certain products.*
2. Spending on directed health services, including cessation services.
3. The reform of economic incentives, including agricultural incentives and tax expenditures on arts and sports sponsorship by companies.*
4. Litigation against companies (more a US than UK practice).

III. Capacity building

1. Funding for community development programs and organisations to combat use.

IV. Education

1. Health warning labels on packaging.*
2. Health education campaigns.*

V. Learning and information tools

1. Legislative hearings* and executive reports (US) and reports by the Chief Medical Officer (UK).
2. Funding scientific research on the harms of products.*

Donley Studlar and I tried to do something more extensive on tobacco alcohol in these tables – tobacco alcohol table 25.7.13 – before taking them out in the last cut of our forthcoming article (draft here Cairney Studlar Public health in the UK March 26 2014). See also: http://blogs.lse.ac.uk/politicsandpolicy/for-those-who-seek-to-strengthen-alcohol-regulation-the-experience-of-tobacco-control-shows-that-comprehensive-policy-change-is-neither-quick-nor-inevitable/

Everything would be shite in an independent Scotland

Adversarial politics is annoying, and people are bastards, but there is something particularly stupid about a debate that produces people gloating about how shite things would be in an independent Scotland. We might normally expect some critical analysis about stories coming from vested interests, but not if there is a line to maintain. Today’s example comes from the Daily Mail (which specialises in bile and breasts) and Financial Times (which, today, is held up as a provider of the truth carved in stone): supermarket prices will go up in an independent Scotland. Fuel and production costs will push up food costs (kept artificially low, and spread across the UK, by supermarkets just now) and Scottish Government public health policy will keep or push up the cost of tobacco and alcohol. So what might a more critical analysis of this news produce?

1. In almost any other case, the story would be about multinational companies protecting their profits at the expense of the consumer. As with energy prices, this would normally feed into the debate about the cost of living. Yet, in this case, one side of the independence debate is forming a coalition of convenience with those companies.
2. We should not necessarily see the food/ booze & fags argument as separate. The supermarkets have form here, signalling to the consumer that they don’t like restrictions on their trade because they would otherwise make decent profits on cigarettes and alcohol (Sainsbury has even produced a leaflet blaming the Scottish Government for a restriction in sales), and prepared to fight the Scottish Government to protect it. In this case, we should not be surprised that some of it spills over to the independence debate.
3. Prices differ in different parts of the country anyway. It is felt particularly in rural stores which effectively keep price differences by offering only a selected range of (more expensive) products in smaller stores. Your shopping will likely be more expensive in the smaller store in Montrose than in the megasupermarket in Dundee.
4. There is a big difference between some senior staff in supermarkets giving non-quoted scoops in the papers, or named people giving vague comments, and named chief executives actually speaking out in public with substance and subjecting these arguments to critical analysis.

Of course, this is grist to the mill for people who claim that the Yes campaign is ridiculously positive, with no room for anything going wrong. But it usually ends up with people appearing to gloat that everything would be that bit shiter in an independent Scotland.

Update 1: by the end of the day, this (oh dear) might be the story instead

Wouldn't it be great if @Tesco @Sainsburys @Morrisons @Asda just left Scotland after Yes vote http://t.co/zNc4X2fQE9 #IndyRef #PersonalView

— Stan Blackley (@stanblackley) December 9, 2013

compare with the more sensible:

.@murdo_fraser Except supermarkets said no such thing: http://t.co/d98tlmVICB And energy experts said exact opposite! http://t.co/ioFtChI5O5

— Kevin Pringle (@KevinJPringle) December 9, 2013

https://twitter.com/KevinJPringle/status/410135761728847872

Update 2: other coverage is available (I’ve just clicked on any ‘related content’ on my wordpress thing)

Update 3: one of the big bones of contention for supermarkets has been resolved, which is presumably enough for them to stop intervening in the #indyref http://www.bbc.co.uk/news/uk-scotland-scotland-business-25676222

Related articles

• Food prices in an independent Scotland (bbc.co.uk)
• Independent Scotland could pay more for food, supermarkets warn (telegraph.co.uk)
• Food price rise alert for Scotland (bbc.co.uk)
• Independent scots to pay more for food (economicvoice.com)

After the War on Tobacco, Is a War on Alcohol Brewing?*

The United Kingdom now has one of the most comprehensive tobacco control policies in the world, a far cry from its status two decades ago. Some influential public health voices have called for a similar campaign against alcohol consumption. But is the comparison appropriate? We identify the factors which were important in the relatively successful campaign for tobacco control, then analyse the obstacles and opportunities facing the movement for more stringent alcohol control. Alcohol policy today bears a striking resemblance to tobacco policy pre-1990s, when the UK started on its path to becoming a major regulatory state in the world. Can alcohol policy be changed in a similar way?

Paper here  Cairney Studlar 2014 WMHP Alcohol and Tobacco Policy UK

See also – https://paulcairney.wordpress.com/public-health/

See also: http://blogs.lse.ac.uk/impactofsocialsciences/2013/07/16/evidence-matters-tobacco-and-alcohol-comparison/

*We submitted the paper to a US journal, where this framing is more normal. The idea of a public health crusade is also in good currency in some libertarian circles.

Alcohol: the Harmful versus Healthy Debate

I predict a lot of debate and attention to the idea that alcohol consumption is healthy or harmful. A key strategy for public health groups and other advocates of further alcohol controls (such as a minimum unit price of alcohol) is to reframe the debate – by challenging the idea that alcohol can be healthy, in particular circumstances, if consumed in small amounts. A key strategy for the alcohol industry is to maintain that image so that they can argue that alcohol policy should be targeted at problem drinkers only. One is a public health argument calling for general policy measures that influence the drinking habits of the population (e.g. raise prices, ban promotion). The other is an individualised argument calling for specific measures that deal with particular people (e.g. provide NHS services for alcoholism; change police powers to deal with anti-social behaviour). So, the *way we understand the evidence* is key battle ground in the policy debate. That is why you will find public health groups so bothered by the fact that the industry takes such an important part in the production, dissemination and interpretation of the evidence within government and when communicating with the public (e.g. drinkaware.org is funded by the industry).

The obvious contrast, at least in the UK, is between alcohol and tobacco. In the latter, in the not-too-distant past, tobacco companies had similar amounts of joy in government and public circles: funding scientific research; arguing that the link between smoking (and then passive smoking) and ill health was not proven; and portraying the issue as one of individual choice based on their thoughts on the evidence and how they might way it up against their enjoyment of smoking. Key strides were made in tobacco control when the evidence on harm (from smoking and passive smoking) were ‘set in stone’ within government and stated unequivocally to the public. A good example is in health education before and after tobacco company influence. In the heyday of smoking (when men were men), the public health advice was overshadowed by tobacco advertising. It was also more likely to be harm reduction in nature – e.g. smoke pipes rather than cigarettes (not too long after companies introduced healthful (not really) filtertips and moved from high to low tar). Then, the health advice changed markedly to reflect a ‘no safe level’ message (as in the health advice suggesting that a move from high to low tar was like jumping from the 38^th floor of a building rather than the 39^th).

Now, in my day, as an undergraduate, we might try to interpret that sort of story in terms of early insights on Power by people like Bachrach and Baratz. Power is not simply about visible conflicts in which one group wins and another loses (such as in a policy debate in government). Rather, groups may exercise power to reinforce social attitudes (perhaps to make sure that the debate does not get that far). If the weight of public opinion is against government action, maybe governments will not intervene. In this case, if the vast majority of people think that moderate alcohol consumption is healthy (or not harmful), they may not support control measures that affect the whole population. In fact, it is a measure of public health group success that it even *occurs* to us to consider the issue. Still, a key part of the minimum-unit-price debate is that it punishes responsible drinkers as much as problem drinkers. This will not be such a powerful argument if the vast majority of the public begins to believe that we are *all* problem drinkers (well, apart from me – I don’t touch the stuff).

See also: http://blogs.lse.ac.uk/politicsandpolicy/archives/34735

‘Alcohol’s evaporating health benefits’ http://linkis.com/www.bmj.com/content/kpLcG

Why is there more tobacco control policy than alcohol control policy in the UK?

The obvious answer is that drinking is less bad for you than smoking. Or, if you are the optimistic sort, drinking is really, really, really, really, really good for you – mm, mm, delicious and nutritious. And it’s cool. And it’s sexy and it makes you sexy. Especially when you are pissed.

The non-obvious answer is that, although the same sort of public health evidence has been produced to suggest that: (a) both smoking and drinking are unhealthy; and, (b) both should be controlled using similar instruments – the alcohol-is-unhealthy evidence is less accepted in government and alcohol control policies are a harder sell (for now). Alcohol can still be advertised, there is less tax on booze and the alcohol industry has a regular say in the interpretation of the evidence (and what we should do about it).

The aim of this ICPP paper (link) is to explain the difference between policy choices in tobacco and alcohol. It says: here is what would have to happen for alcohol control to mimic tobacco control (I do the same in a comparison of tobacco controls in different countries here). We can break the policy process down into five key factors:

1.     Institutional change. Government departments, and other organisations focused on health policy, would take the main responsibility for alcohol control, largely replacing departments focused on finance, trade, industry, tourism and employment (and crime).

2.      Paying attention to, and ‘framing’ the problem. The government would no longer view alcohol primarily as a product with economic value, central to the ‘night time economy’.  It would be viewed primarily as a public health problem; a set of behaviours and outcomes to be challenged.  This happened with tobacco, but it is trickier in alcohol because the government may only be worried about aspects of alcohol consumption (such as the binge drinking and anti-social behaviour of certain individuals) rather than the broader notion of public health.

3.      The balance of power between participants.  The department of health would consult public health and medical groups at the expense of groups representing the alcohol industry. This is central to the type of evidence it gathers, the interpretation of the evidence, and the advice it receives.

4.      The socioeconomic context.  The economic benefit of alcohol consumption would fall (or, the tax revenue would become less important to the Treasury), the number of drinkers would fall and opposition to alcohol control would decline (although it already seems fairly low).

5.      The role of beliefs and knowledge.  The scientific evidence linking alcohol consumption to ill health would have to be accepted and ‘set in stone’ within government circles.  The most effective policies to reduce alcohol consumption would also be increasingly adopted and transferred across countries.

Change in these factors would be mutually reinforcing.  For example, an increased acceptance of the scientific evidence helps shift the way that governments ‘frame’ or understand the alcohol policy problem.  The framing of alcohol as a health problem allows health departments to take the policy lead.  Alcohol control and alcohol use go hand in hand: a decrease in drinking rates reduces the barriers to alcohol control; more alcohol control means fewer drinkers (or less drinking).

It is tempting to think that this sort of process is more likely under Labour and less likely under the Conservatives – and there is some evidence to back up this argument. However, the point of the paper is that these long term processes develop during the terms of both parties. Major policy change, of the level we have witnessed in tobacco (but not as much in alcohol), takes several decades. Indeed, you can be suitably impressed or depressed with my hunch that alcohol control is at least a decade (if not two or more) behind tobacco.

See also: http://paulcairney.blogspot.co.uk/2013/06/alcohol-harmful-versus-healthy-debate.html
Compare with: http://velvetgloveironfist.blogspot.co.uk/2013/07/the-real-reason-for-public-smoking-bans.html and http://dickpuddlecote.blogspot.co.uk/2013/07/an-lse-guide-on-how-to-denormalise.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+DickPuddlecote+(Dick+Puddlecote)