Oireachtas Joint and Select Committees
Thursday, 12 March 2015
Joint Oireachtas Committee on Health and Children
General Scheme of Public Health (Alcohol) Bill 2015: (Resumed) Alcohol Research Group
We will resume in public session. I want to remind people about mobile phones as they interfere with broadcasting of the session. The second segment of our meeting today is to continue our pre-legislative scrutiny of the heads of the Public Health (Alcohol) Bill 2015. I warmly welcome Dr. John Holmes and Mr. Colin Angus to this committee meeting. Apologies for holding you, as you have seen our previous meeting ran over time, but it was important that we let it run on.
Dr. Holmes is part of the Sheffield Alcohol Research Group which plays a leading role in carrying out key international research to examine the impact of minimum unit pricing on drinking behaviour. Dr. Holmes has spoken on this topic in the Scottish Parliament and in Westminster. I would ask that members give him due consideration and thank him most sincerely for coming before us today.
Witnesses are protected by absolute privilege in respect of their evidence to the committee. If you are directed by the Chairman to cease giving evidence on a particular matter and continue to do so, you are entitled thereafter only to qualified privilege in respect of the evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given. Members and witnesses are reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable. I invite Dr. Holmes to make his opening remarks.
Dr. John Holmes:
I thank the committee for inviting us to give evidence today. As the Chair said, the Sheffield Alcohol Research Group has been conducting work looking at alcohol policies in general and minimum unit pricing in particular since 2008. The Irish Government and the Northern Ireland Executive commissioned us in 2013 to examine the potential effects of minimum unit pricing in their respective countries and we will focus on that work in our presentation today. However, before coming to that, I would like to give the committee a little background on the wider evidence on the effectiveness of using alcohol prices to reduce alcohol-related harm.
A major review in 2009 examined the evidence on the impact of alcohol price changes on alcohol consumption. It found that increases in alcohol prices were consistently and significantly associated with falls in consumption. This was the case for total alcohol and also for each alcoholic beverage such as beers, wines and spirits. We saw the same thing for younger and older drinkers and we saw that binge drinkers were also responsive to price changes. These findings have been replicated across at least two other major reviews. An example finding is that, on average across different times and places, a 10% increase in the price of all alcohol is associated with an average 4.4% fall in consumption.
However, our primary interest is not whether alcohol price increases reduce consumption but whether they reduce the harm caused by alcohol. A further review of 50 studies concluded that indeed they do. Based on the findings of that review, the researchers estimated that a doubling of alcohol taxes in the US would lead to a 35% reduction in alcohol-related mortality, an 11% reduction in car crash deaths and smaller reductions in sexually transmitted diseases, violence and crime associated with alcohol.
Minimum pricing is a specific form of price increase targeting the cheapest alcohol which, as you will see later, is disproportionately purchased by the heaviest drinkers. Therefore, there is good reason to expect it will have an impact on alcohol-related harm. Several Canadian provinces have had this kind of policy in place for many years and recent evaluations have shown that those policies have reduced the harm from alcohol in those provinces. The Canadian policies are not quite the same as minimum unit pricing as proposed in Ireland and the UK, because minimum prices are not directly linked to the strength of the drink. However, the same basic principle of a minimum price, below which alcohol cannot be sold to consumers, does apply.
The Canadian evaluations have shown that, all else being equal, increases in minimum prices are associated with falls in alcohol consumption, in alcohol-related hospital admissions and also in deaths due to alcohol. The graph in figure No. 1 of the opening statement, which has been circulated to members, shows one example study. The black line is the average minimum price of all alcohol in British Columbia between 2002 and 2009. The grey line is the rate of wholly alcohol-attributable deaths in the province. These are the deaths very closely associated with heavy drinking such as alcohol poisoning and alcoholic liver disease. The graph shows that a sharp and sustained increase in minimum prices in 2006 was swiftly followed by a sharp and sustained fall in deaths closely associated with heavy drinking. This prima facieevidence of policy effectiveness was supported by the statistical analysis which estimated that a 10% increase in minimum prices would be associated with a 32% fall in those deaths closely associated with heavy drinking. So there is good evidence from Canada that minimum prices and minimum price increases lead to substantial falls in the harm caused by alcohol, all else being equal.
I will now turn to our own work. We were asked by the Irish Government to estimate the potential impact in Ireland of different levels of minimum unit pricing, MUP, using our Sheffield alcohol policy model, SAPM, as we call it. For a given alcohol policy, our model provides estimates of changes in alcohol consumption, in consumer spending on alcohol, in revenue to retailers and Government, in the rates of various different alcohol related harms, in the costs of those harms to individuals' quality of life and in the direct costs to public services. A key feature of the model is that we do not just estimate these effects at a population level, we are also able to estimate the effects on different groups in the population defined by age, gender, income and how much alcohol people drink.
At this point I will be talking about low risk drinkers, increasing risk drinkers and high risk drinkers. Low risk drinkers are drinking within the Government's drinking guidelines of around 17 standard drinks per week for males and 11 standard drinks per week for females. High risk drinkers, the heaviest drinkers, are those consuming more than 40 standard drinks per week for males and 28 standard drinks or more for females. Increasing risk drinkers fall between those two levels.
The model methodology for SAPM is too complex for this short presentation and we are happy to discuss it in more detail during the questions. The basic idea is summarised in the figure No. 2. The SAPM works sequentially so we first estimate the impact of introducing MUP on prices. We then use those price changes to estimate how peoples' consumption would change. Then we use those consumption changes to estimate how rates of the different harms would change. Finally, we use the changes in the rates of harm to estimate how the costs of harm would change. Although each of these steps involves quite complex statistical work, the methods we use are largely orthodox in scientific terms. What has made our work so influential and impactful is that we look at a very broad range of outcomes, which is unusual for this kind of model. We are also able to look at the impacts on different groups in society and hopefully the committee will see why that is useful.
I will now turn to results. First we estimated the impact of different levels of minimum price on consumption. Figure No. 3 shows that as the minimum price gets higher, the consumption reductions get bigger. This is fairly obvious because one is affecting more of the market if one introduces a higher minimum price. Above a minimum price of about 60 cent per standard drink one starts to get quite large reductions in consumption. At 70 cent per standard drink one gets a consumption reduction of 1.9%. At 80 cent per drink one gets a 3.8% reduction. At 90 cent per standard drink one gets a 6.2% reduction. For the remainder of our presentation I will focus on a minimum price of €1 per standard drink just as an indicative example.
Based on our modelling, we estimate that a €1 minimum unit price introduced in Ireland would reduce total alcohol consumption by around 8.8%. By the 20th year after the introduction of this policy, when we would expect to see the full effects, that reduction of 8.8% would result in around 200, or 16%, fewer deaths per year, and around 6,000, or 10%, fewer alcohol-related hospital admissions. From year 1 of the policy, and every year thereafter, we would expect to see around 1,500 fewer alcohol-related crimes and over 100,000 fewer days absent from work due to alcohol. A cost breakdown is provided in table No. 1 in the handout but the headline figure is that over 20 years, the total reduction in the cost of alcohol-related harm is estimated to be around €1.7 billion. This accounts for costs to the police and health services, and also a financial valuation of improved quality of life.
The impact on retailers is likely to be positive, as minimum unit pricing is not a tax. Money from the higher prices is held by the retailers. We estimate that off-trade retailers, that is, shops and supermarkets, would receive approximately €69 million extra per year from alcohol sales. Although the policy does not directly affect pubs and restaurants because their prices are already higher than the minimum price threshold, we would expect to see changes in consumer behaviour. For example, people who are buying less alcohol in the supermarket might go to the pub more. For that reason, we expect there may be a slight increase in on-trade revenue as well.
Regarding tax revenue, the negative impact on the Exchequer would be modest, as lost duty from falling alcohol sales would be largely offset by rising VAT revenue from higher alcohol prices.
A key feature of the policy of minimum unit pricing is that it does not affect all drinkers equally. The main driver is how much cheap alcohol different groups buy. Low-risk drinkers purchase very little cheap alcohol - that is, one or two standard drinks per week for less than €1 per standard drink - irrespective of whether they are in poverty. Even low-income low-risk drinkers do not buy much of this cheap alcohol. Compare this to high-risk drinkers, who purchase substantial quantities of cheap alcohol. Although high-risk drinkers in poverty buy more cheap alcohol than those not in poverty - 43 standard drinks per week versus 26 - it is clear that those on higher incomes still buy cheap alcohol. It is not just low-income people who will be affected.
The Sheffield alcohol policy model, SAPM, takes account of these different purchasing patterns, and the estimates of annual reductions in consumption for each of these groups reflect this. We estimate that the annual reduction in consumption for low-risk drinkers would be very small; they would be largely unaffected. It is estimated that low-income low-risk drinkers would reduce their consumption by just 25 standard drinks per year, which is equivalent to drinking three fewer bottles of wine per year. That is a small reduction. Compare this to high-risk drinkers, who, it is estimated, would reduce their consumption by well over 500 standard drinks per year for those in poverty and 480 standard drinks per year for those not in poverty. This is equivalent to approximately 60 to 70 bottles of wine per year. That shows the much greater impact on high-risk drinkers.
A concern for some parties has been the potential financial impact on low-income drinkers. Our modelling does not support these concerns. We estimate that spending would fall in most groups. Rather than spending more to maintain their level of consumption, most drinkers tend to reduce their consumption and spend less on alcohol as a result. Spending is only estimated to increase in the higher-income groups. It is worth noting from the graph that these spending changes are fairly small. The largest reduction is €159, but most reductions are in the tens of euros. When one compares that against how much high-risk drinkers spend on alcohol per year - an average of over €5,000 - we are not making much of a dent in people's alcohol spending. Spending is not the significant factor; it is the pattern of consumption, and who is affected by those consumption patterns.
All research has limitations. Our aim, which we hope to talk about in greater detail, is to be transparent about these and help policy makers understand their implications for our estimates. Some of the key limitations of the SAPM include our assumption that prices of products above the minimum unit price threshold will be totally unaffected. We assume that prices below the threshold come up to the threshold and everything above it is unaffected. This is unlikely to be the case in reality because, for instance, Diageo is unlikely to want Smirnoff to become the cheapest vodka on the market. We are likely to see what we call premiumisation - products being pushed up to assume a certain place in the market. What that means is that we are probably underestimating the impact of the policy. Our estimates are probably a little conservative.
There is a lack of clear evidence for the impact of such policies on the use of illicit alcohol or alcohol substitutes such as illicit drugs. We know from elsewhere that when prices increase we see falling levels of harm, and this suggests that any negative side effects are not sufficient to outweigh the benefits. We do not ignore these limitations and, where appropriate evidence is available, we test the sensitivity of our results to a range of assumptions, data sets and analytical methods. What those sensitivity analyses have shown is that although the numerical results change, the broad conclusions stay the same. There is strong and consistent evidence that price increases reduce alcohol consumption and related harm. Minimum pricing is a targeted form of price increase, as it tackles disproportionately cheap alcohol purchased by heavier drinkers. We estimate that it would not penalise low-risk drinkers, irrespective of income, because they buy little of this cheap alcohol. In contrast, high-risk drinkers buy large quantities of cheap alcohol and would be affected. These conclusions have been found to be robust to a range of alternative assumptions, data and analytical methods.
I warmly welcome Dr. Holmes and Mr. Angus, and thank them for their submission and oral presentation. I have already indicated that I will support the Bill, but I have some concerns about minimum unit pricing. I do not wish to be obstructive, but I want to tease out the issues, because I have concerns about the effectiveness of minimum unit pricing and its impact across society. I have some concern for those who are least well off, who I fear may bear the greatest impact. Their general health may improve from drinking less. Even in the submission we heard on Tuesday, I had a sense that there was a targeting of those on lower incomes because of the expectation that the statistics will show greater improvement from the targeting of this group of people. I would like to see the targeting equalised because I do not believe that alcohol abuse is the reserve of those who are least well off in our society. I am cognisant of the cases I know personally of people who are very comfortably well off but are in difficulties because of abusing drink.
It is interesting that Dr. Holmes referred to research in the US that proposes to double alcohol taxes in the United States. I am not opposed to increasing the cost of alcohol, but I have argued consistently that we should look at increasing the excise duty on alcohol per unit measure right across the board. This would have a greater impact across the board. Contrary to what was said in the presentation - I mean no disrespect to retailers such as shops and supermarkets - we should take alcohol sales out of these settings. It is inappropriate that, as Dr. Holmes has acknowledged, shops and supermarkets will make some €69 million extra from alcohol sales on the basis of €1 minimum unit pricing.
This is from what has been put on the record this morning. I argue that if we were to increase excise duties, that €69 million would be in the public purse and could be employed to address the consequences of alcohol abuse not only in direct assistance for the abuser but for those who suffer most as a consequence of alcohol abuse. I am particularly mindful of the fact that the incidence is greater among men, so I refer to wives, partners and children or those in immediate contact, who can suffer inordinately.
I have put this argument all along, but I concede that I have not won it, as the thrust is going in the other direction. I am giving everything I can if it will be of benefit. My concern is that we could better utilise this money if it were ring-fenced for the purpose I describe. In this instance, we will see greater profits created, and I am not convinced that we will see such a significant decrease in sales of products. Diageo in Ireland, for example, will have very little to fear. I would prefer for these companies to be worried, but they are not. That also applies to other manufacturers and those international companies which sell their products here through various outlets. Will the witnesses comment on some of the points I made? I have not posed them as direct questions but I am giving a view on the matter.
Will the witnesses comment on who would be affected by minimum unit pricing? I get the sense that the witnesses are concurring with my view when they indicate that minimum unit pricing does not affect all drinkers equally, as it will not. I have traditionally been a voice for those who are more marginalised and are from lower to middle-income backgrounds. I am concerned because they are not all alcohol abusers. We should make no mistake about that. Nevertheless, for the vast majority, this will have a deleterious impact on their weekly financial condition. The delegation has indicated that those on higher incomes are still buying these products and will be affected by the policy. That is true for those who buy these products, but it is not a case of equal impact.
I thank the witnesses for coming here and giving their insight. I wish both of them well.
I welcome the witnesses. In my day job I do a bit of biomedical research, and it is very nice to hear a really professional and top-quality research-based presentation in these halls. I have a couple of quick questions. I may have missed the witnesses mentioning the average price of a unit of alcohol purchased in Ireland now. Do we have some idea of the quartiles and what percentage of units of alcohol are purchased for less than 50 cent, between 50 cent and 75 cent, etc.? I presume the delegation's expertise extends to comparative research and other strategies for reducing alcohol consumption. Are the witnesses aware of anything else that has worked as well as this? Is there any other strategy of alcohol control across society that has worked as well as pricing?
We have had a bit of chat in this committee about the antics of the tobacco industry and a fair bit of discussion about pseudo-science and so on. Have the witnesses encountered much disinformation funded heavily by the industry which attempts to discredit their research? Will they give advice on how to handle that? Getting to the question of price elasticity, do the witnesses have any sense that there is a ceiling effect beyond which one would be dealing with compulsive or addiction-driven drinkers who will not be price-sensitive in their demand for alcohol? I commend the witnesses for their great research and wonderful presentation.
I welcome the delegation. There are three categories of drinker, and, as a non-drinker, I believe it important that people realise there are such discrete categories. It was stated that low-risk drinkers are males who consume fewer than 17 standard drinks per week or females who consume fewer than 11 standard drinks per week, or an average of two drinks per day. People may think that two drinks per day is not a terribly high figure. The next category is that of increased-risk drinkers - males who consume between 17 and 40 drinks per week and females who consume between 11 and 28 drinks. Again, many people might not believe three or four drinks per day is a high figure. The alarming category is that of high-risk drinkers - males who consume 40 or more drinks per week or females who consume 28 or more drinks per week. That amounts to five or six drinks per day, and the witnesses have estimated that this would cost a family €100 per week. I believe that the minute a person takes his or her first drink, he or she becomes a low-risk drinker.
If a minimum price regime came into effect next week and brought about a 10% increase in prices, how long would it take to affect alcohol consumption? It was stated earlier that if alcohol prices were increased by 10% across different areas there would be a 4.4% decrease in consumption. Would that happen in Ireland? How would we know if the process works? This will affect supermarkets and off-licences. How will we know if these businesses sell below the set price? The Canadian Government's initiatives were mentioned, but have the actions of any other countries been studied? What level of success is there in other countries? Why are some countries successful while others are not?
It is estimated that in Ireland, 1,500 hospital beds are taken up every night by patients experiencing alcohol-related harm. Alcohol consumption in Ireland has doubled in the past 50 years. We badly need to address the major problem we have with alcohol in Irish society, especially the availability of cheap alcohol to underage and young drinkers and those who binge drink or drink hazardously. My main concern is the health of drinkers, who may suffer liver diseases, and the safety of families. Not a day or a week goes by in which I do not have men, women and children coming to my constituency office to tell me about alcohol-related problems. Apart from minimum unit pricing, what other action could be taken to reduce the consumption of alcohol, especially for high-risk drinkers?
I pay tribute to the delegation for their fantastic presentation, which has been very well researched. I agree with previous speakers in that it is a very valuable document and we must take it very seriously.
Our attitude towards drinking was summed up to me in the past week when I spoke to somebody who had returned from holidays. Half an hour into the flight, the crew of the aircraft asked for medical assistance from among the passengers, and when a medical person went to help, it turned out that the person requiring help was a passenger suffering from withdrawal, as that person had been drinking at least 14 units of alcohol per day on holidays.
This leads me to my question. I agree fully about minimum pricing, but what needs to be done in addition to that? I am thinking particularly about what needs to be done to educate young people when they are starting off in college. There is a university and an institute of technology in the area I represent. I have seen a huge change in drinking patterns over the last ten years. Young people are now buying drink, particularly spirits, to consume in their own apartments. The disadvantage of that change is that there are no measures when one is drinking in one's own apartment. On the basis of their experience, what do the witnesses consider to be the best way to transmit information to young people? What changes would they make in this whole area? Do they believe there are no changes that can be made? Is there evidence from other countries of how drinking among young people was dealt with? When young people start in college, it is the first time they have real freedom, especially if they are staying away from home. It is an extremely important time as regards getting the message out. Their behaviour during those years can set the pattern for the rest of their lives. Does the research group have any evidence of how other countries are dealing with that? How have they tackled it?
I join others in thanking Dr. Holmes and Dr. Angus for coming here today and for the report we received yesterday afternoon. We have done our quick read, but we have not read it in detail. I will certainly give a lot more time to it.
The questions raised by Deputy Ó Caoláin are probably ones we are going to be hearing more of as we go through the legislative process with the public health (alcohol) Bill. They would have been to the fore in my head when I first came to the issue of minimum unit pricing. I was happy to read the fifth conclusion in the research group's document, which relates to the health effects of this measure on those in poverty. We need to strike a balance between those effects and the other impact this measure might have.
Senator Crown asked about the ceiling or tipping point. How do we determine where we set the minimum price? It might seem very compelling to say that if we keep increasing the minimum price, we will save many more lives. Where is that point? How do we determine where to set the price? When we are looking at the legislation, how best do we ensure we set the price appropriately?
Dr. Holmes referred in his presentation to "premiumisation", which is the idea that the drinks industry will increase the price of its products to ensure its brands retain a premium status. Could this mean that people will switch to cheaper alcohol? Has the research group looked at the effects of that? How can we be sure the consumer will be protected? If a minimum unit price is set, and we see general prices going up over time, how do we ensure that price is appropriate for the marketplace as time goes on? Does it have to be linked to something? I can understand what will happen on day one. How do we provide for a system that is sufficiently robust?
Senator Crown spoke about misinformation. It is excellent for us to have the evidence that has been presented here. I note the point made by Dr. Holmes about illicit drugs. This is one of the main themes in the correspondence I have received on this issue. It has been suggested that minimum unit pricing will lead to an increase in people taking drugs. It seems from the research group's presentation that there is no evidence to support that at the moment. There is no basis for somebody to put forward that proposition. If the witnesses could give us any more information on that, I would welcome it. I imagine we will hear more and more about this argument.
Did the research group look at any parallel strategies when it was doing its study? Senator Burke spoke about education. Does this have an effect? Dr. Holmes referred to the experience in Canada. Did the drinks industry there oppose the approach to minimum unit pricing that was taken in Canada? Maybe they could give us some information that would help us to understand that. We know that the drinks industry in Scotland is taking an ongoing court case against minimum unit pricing. To me, that is another reason we know it works. Maybe that is just me being me. I would be interested to know what kind of evidence or so-called evidence - "misinformation" is a much better word to describe it - they are putting forward.
I apologise for not being here for part of the meeting. I had to go to my office to meet somebody. I have read the research group's document and I listened to Dr. Holmes's contribution on the monitor in my office. I have three or four questions. This committee receives many documents. This is very much an evidence-based document. I have to say it is one of the most interesting documents I have read in a long time. It highlights many different areas about which we might not have not thought previously, which we will have to look into. If the questions I am about to ask have already been asked, I apologise and ask Dr. Holmes and Dr. Angus to skip over them.
Do the witnesses believe minimum unit pricing will bring people back towards social drinking in local pubs and restaurants? There is a feeling among a certain cohort that if something can be done to increase the price of alcohol, it might encourage people to drink less at home and bring them into more controlled social surroundings. Do the witnesses believe minimum unit pricing will reduce the consumption of alcohol among those under the age of 25? Do they believe people in lower socioeconomic groups will reduce their consumption of alcohol if minimum unit pricing is introduced, or will they continue to drink as they do at present? The document provided by the research group shows that people in these groups drink an average of 43.2 standard drinks per week. Will they continue to drink at home or will they go to the local pub? Do the witnesses believe education plays a role in giving young people an opportunity to understand the serious health issues that are associated with drinking alcohol? I refer particularly to binge drinking among young teenagers. I apologise if some of my questions have been asked already.
Dr. John Holmes:
I will answer some of the questions that have been asked. My colleague, Mr. Colin Angus, will respond to some of them as well. An overarching point that applies to pretty much everything that has been said is that there is no perfect alcohol policy. Minimum pricing is not going to solve every problem. When I read through the heads of the proposed public health (alcohol) Bill, I was encouraged to see that the Government is taking quite a comprehensive approach. Something similar was done with the alcohol strategy in the UK, although it was eventually gutted. Not much that was effective was left in the end. The key thing is that minimum pricing should not be considered on its own. The question of what minimum pricing will do should be considered alongside the question of what other policies will do. What does the Government's policy strategy as a whole achieve? Does it hit all the different things the Government wants to hit? Deputy Ó Caoláin made the point that minimum pricing is particularly effective because it targets the very high levels of consumption of very cheap alcohol among low-income, high-risk drinkers. We need to be very precise here. We have examined this issue in the UK. We had a paper published in The Lancetlast year looking at this in particular. We need to be careful not to make sweeping statements. It is not that minimum pricing will target the poor - it is that it will target low-income drinkers who are consuming at very high levels. Low-income drinkers who are consuming at low levels will be largely unaffected because they are simply not buying much of the cheap alcohol that the policy affects.
Deputy Ó Caoláin made the relevant point that low-income drinkers who drink at high levels are still low-income drinkers, or people who are financially constrained. I would respond to that by mentioning that the evidence we have on how alcohol harm occurs suggests that a person with a low income or of a low socioeconomic status suffers a greater risk of harm for each drink he or she consumes than an equivalent person of higher socioeconomic status. A low-income person who drinks 30 units, or standard drinks, per week is at greater risk than a high-income person who drinks the same amount. If we want to tackle the harm caused by alcohol, to a certain extent we have to target the low-income heavy drinkers because they are the people who are experiencing a lot of the harm. We need to ensure we go about that in an equitable way that does not aggravate other problems. We would argue, on the basis of the evidence we have gathered, that minimum pricing seems to do that. It seems that people would respond to these price increases not by spending a greater percentage of the family budget on alcohol but by reducing their spending on alcohol, reducing their alcohol consumption and improving their health as a result. I agree with the suggestion that has been made that this improves the well-being of those around these people as well. I guess that is my main response to that.
The question of how people are affected by this is a little more complex than it might come across in the service level and in my short presentation.
While people from all social backgrounds are likely to be buying some alcohol affected by this measure, not all alcohol products are affected equally. There is a threshold and some alcohol products will be a little below the threshold, while some will be a long way below it. Lower risk drinkers tend to drink a little of this alcohol. The higher risk drinkers are the ones who are buying this alcohol which is very cheap. They will experience some big price increases. This has to do with how alcohol is sold because if one is buying large quantities, one can buy it at much cheaper prices per standard drink. The same applies if one is buying cheap spirits which is only bought regularly by heavy drinkers. They buy certain products which are only bought regularly by those drinking at risky levels.
Tax was raised as an issue. A key point is that tax should not be seen as an alternative to minimum pricing. They should be seen as complementary strategies. If members want to tackle heavy drinking among higher income groups - they should want to do this - tax may be a better targeted option. However, there are some problems with it. The way alcohol is taxed is not fully within the Government's control; it is partly under the control of the European Union. For example, a bottle of 10% strength wine will cost less per unit than a bottle of 14% strength wine. This is because the European Union specifies that wine must be taxed by volume, not by alcohol content. The same applies to cider. One of the reasons we have very cheap high strength cider in the United Kingdom is we have very low taxes on it and also the tax rate does not increase as the alcohol gets stronger. One of the recommendations I make to the committee in the long term is that the Government make the case in Europe for alcohol to be taxed based on the strength of all products. This would allow a much more rational and health-focused taxation system. The UK Government is also looking at this issue.
Mr. Angus will talk about price distribution.
Mr. Colin Angus:
I will add a comment on tax. If members imagine tax as an alternative to minimum pricing, there are issues of targeting in the sense that they would affect all of the alcohol products everyone is buying, not just the very cheap alcohol favoured by the drinkers who suffer the most harm. We recently published some research which looked at the way retailers responded to changes in tax. It shows that they did not just flatly increase the price of all products in line with what we all expected following the tax increase. In the case of very cheap products they increased the price by less than we would have expected and over-shifted onto expensive products. Retailers are doing what members do not want them to do. They are increasing the price of the alcohol they want to affect the most by the least amount and increasing greatly the price of the alcohol in which they are less interested because it is very expensive and not drunk by the drinkers suffering most of the harm.
Dr. John Holmes:
It also loads an extra cost onto moderate drinkers who are buying slightly more expensive alcohol and paying the extra cost involved to subsidise cheap alcohol for heavier drinkers.
A few members asked about other policies that might work and how they might fit in a wider strategy. As I said, a broad strategic approach is needed which touches a wide range of bases. International evidence suggests pricing is one of the most effective ways of tackling the issue of the hard caused by alcohol. The way it is implemented is clear. The effects are consistent in that it tackles both consumption and harm, but that is not to say pricing is the only option the committee could consider.
A few members mentioned education. Education is important, but the evidence suggests that on its own it will not reduce problem drinking because there are too many other influences on the reasons people drink. There is too much advertising which shapes alcohol as a desirable product and appeals to young people in certain ways, while there is too much cheap alcohol available. Therefore, the level of availability is too high to say education will solve the problem. However, we do need to teach young people about the dangers of alcohol, but that education might be more effective if the system in which alcohol was retailed and promoted was got right first. It is, therefore, about having a comprehensive strategy.
There are proposals before members on the labelling of products. There is not a great amount of evidence that it will reduce consumption, but there is evidence that it will increase consumers' understanding of the risks associated with drinking, It should knowledge of what is contained in the alcohol and specific risks such as drinking during pregnancy. This is more likely to affect behaviour if the influence on behaviour of cheap alcohol and advertising was reduced. There is also a point to be made about consumer rights in that people have a right to know what they are drinking.
With regard to the industry and disinformation, we have experienced a good deal of this. Members raised questions about the way the industry had responded to this policy, which is supported in Canada. I am not sure if it supported it when it was brought forward several decades ago, but it generally support it because it makes it money, as we have discussed. However, in the United Kingdom the off-trade retailers who will be most affected are strongly opposed to it because they do not want alcohol sales to be regulated. We suspect that they know this policy will have an impact and it will impact most on the heaviest drinkers. The top 10% of drinkers in the United Kingdom consume 30% of the alcohol drunk, while the top 30% consume 80%. When we talk about the industry selling responsibly, it makes a huge chunk of its profits from those who drink alcohol above what is deemed to be the responsible level. It is, therefore, in its interests to ensure policies which regulate drinking or seek to reduce heavy drinking are not implemented.
Dr. John Holmes:
That is a difficult question. The point in setting out units is largely to help the public understand the quantities they drink because drinks have different strengths and the problem is that they generally do not know the strength of what they are consuming. It would be helpful for consumers if unit or standard drink information was placed on products. If it were placed alongside information indicating what the chief medical officer or the Department of Health recommended as a low risk drinking level, that would be helpful.
On the information the industry gives and the way it has consistently attacked our research, it has been the practice for it or consultancies it has funded to attack it, or it subject to attacks from libertarians who are ideologically opposed to public health policies generally. They have tried to misrepresent our research by misrepresenting the methods used or the results to place it in a slightly different light. They often pick up on small elements and either misrepresent them or exaggerate their importance. Let me give a few examples. International evidence suggests heavier drinkers are slightly less responsive to price than other drinkers. They are just a little less responsive, but we often find that the industry presents them as being unresponsive, which is wrong. It is simply not the case.
Mr. Colin Angus:
To follow up on that point, a recent study found that they were potentially more responsive to price, but the difference was not statistically significant. However, the industry misrepresents this in stating they are not more responsive to price. That is what we have been saying all along; it will try to defame the evidence, irrespective of the findings.
Dr. John Holmes:
Another example is that we have regularly updated our estimates of the impact of minimum pricing over time both in Scotland and England. Each time, because of inflation, an increasingly smaller proportion of the market is affected if we keep to the same minimum unit price. The industry has represented this as us correcting rather than updating our estimates. There is a sense that we are being undermined in a slightly underhand way. The reason it undermines it is it does not have any evidence to support its case that pricing policies are ineffective.
All the international evidence agrees that increasing the price of alcohol reduces consumption and reduces harm. They have tried to undermine this because they do not have evidence to suggest anything different. When the committee hears evidence from the industry, I urge the members to press industry for the details of its evidence because that is where it begins to become clear that the industry's evidence is not quite what it appears.
Mr. Colin Angus:
This was a point picked up in a recent House of Lords committee report in the United Kingdom, entitled A New EU Alcohol Strategy? There is a short paragraph in the report about the industry approaches which states that the researchers, whom that committee had in at the beginning, stated the industry is always sniping at their research. The short summary states the House of Lords committee, after it had spoken to the industry, sympathised with the academics because the industry was quick to pick holes in the research and try to knock it but was reluctant or unable to provide evidence to support its own perspective. it would merely knock the evidence of others without being able to support its own position with evidence.
There are a few other points. It might be helpful to give a few descriptive statistics about the population. According to the definitions Dr. Holmes described, 78% of the population drink at moderate levels. That is the vast majority. The 22% of the population who drink at increasing or high-risk levels are drinking 66% of all of the alcohol and spending 61% of the total spent on alcohol. The consumption or spending is concentrated predominately in this small group, and these consumers account for almost all alcohol related deaths and 87%, by our estimates, of alcohol related hospital admissions. Therefore, the problem is quite concentrated in a relatively small group who also happen to be those who buy the cheapest alcohol, which is why minimum pricing is a well-targeted measure.
On the distinction between those in poverty and those not in poverty, to return to the beginning of the questions, those in poverty are more likely to be abstainers. Some 30% of those living in poverty do not drink at all compared with 20% of the rest of the population. Those who drink alcohol at increasing risk levels drink less than their counterparts living above the poverty line. That switches around when one looks at the high-risk drinkers. High-risk drinkers in poverty drink more, and are buying a lot more of the very cheapest alcohol right at the bottom of Dr. Holmes' distribution. The proportion of the population which is drinking at these high-risk levels is similar among those in poverty and those not in poverty, at just over 5%. In terms of absolute numbers, they number 36,000 of those in poverty and 150,000 of those not in poverty. It is inaccurate to state that all the high-risk drinkers are in the lowest income groups. There are many people on higher incomes who are drinking at harmful levels. As Dr. Holmes stated, those living in poverty are buying the cheapest alcohol and suffering the highest rates of harm. The rates of deaths and hospital admissions is approximately 40% higher among them than among those not living in poverty. These are the people one would want to target if one's aim is reducing harm.
On price distributions, I have some beautiful graphs in the report that I was proud of having produced which disaggregate prices into different types of drink. In doing that, I can no longer tell the committee exactly the median for all types of drink.
Dr. John Holmes:
There were some questions about the timing of effects. Our model works only on a yearly basis. We estimate that when prices go up, we would see a change in consumption within a year. That is what the evidence internationally suggests. When prices change, one sees a quite short-run effect. I suspect it is not immediate, but I would anticipate that within weeks one would begin to see quite big changes in consumption because, ultimately, consumers make purchasing decisions based on the prices they see. There are some slightly more lagged cultural changes that happen as well as a result of a price.
The health effects are not immediate. That is because some of those who are drinking heavily today will not die from their drinking until ten or 20 years in the future. It takes time to develop liver cirrhosis and alcohol-related cancers. Similarly, there are also people alive today who, even if they stopped drinking today, will die of liver cirrhosis. They have already contracted it. It is not curable. They might die later if they stop drinking, but they will die of it. There is what we call a time lag and, after 20 years, we assume we will see the full health effects where all those effects are played out and we see the full impact. One will see quite a big chunk of the health effects immediately and the report provides some evidence on what we estimate one would see following the first year, but one would see the full effects emerge over the next 20 years.
Whether we would see in Ireland the 4.4% reduction in consumption that has been reported on average in the international literature is quite difficult to answer because it is an average across many countries at different times.
Dr. John Holmes:
Ireland is quite different, depending on which countries one is looking at. The United States is a number of different countries combined into one and there are quite different cultures. There is everything from Utah, which is totally dry, to California and New York, both of which are similar to Europe, to some of the southern states which have strong religious influences. It is quite different.
I would say that Ireland is likely to see an impact. It is likely to be substantial and to be of that order of magnitude, but I could not say it will be 2% or 7%. I would not like to put a specific number on that.
Dr. John Holmes:
Largely, yes. In terms of alcohol, the main difference between Ireland and Northern Ireland is that the taxes are a bit higher in the Republic, particularly on certain products, especially wine and cider. Broadly, there are similar drinking cultures. The cost of living is also a bit higher in the Republic but broadly I would expect to see similar effects between the two countries. I would not expect the effects of minimum unit pricing to vary massively across the United Kingdom and Ireland.
Mr. Colin Angus:
As well as the different tax rates, there are a few other reasons one might believe that the same level of minimum unit price might have a greater impact in Northern Ireland. Partly, that is to do with where they do their drinking. In the Republic, consumers do more of their drinking in the on-trade - in pubs and restaurants - where alcohol is more expensive anyway and will be almost entirely unaffected by a minimum price. In Northern Ireland, distribution is slightly different. Consumers do more of their drinking at home and more of their total alcohol consumption is potentially affected. They also have a slightly higher baseline rate of alcohol related health harm and they stand to gain slightly more for each incremental reduction in consumption, but the order of magnitude is similar.
Dr. John Holmes:
I was asked what is happening in other places in Canada. Minimum pricing, or at least something close to what is being proposed in Ireland and in the United Kingdom, has not really been tried anywhere else in Canada. Russia and some of the other former Soviet states have had minimum prices, say on vodka or beer, but those countries are quite different because they have large illicit markets, high rates of alcohol consumption and significant problems of alcohol dependence of an order of magnitude greater than we see in western Europe. What has gone on in those countries, because the policies and context are different, cannot tell us much that is helpful.
The United Kingdom and Ireland are pioneers in terms of trying to implement this policy in a systematic way. That means we do not have a significant amount of evaluation evidence. We only have what has come from Canada. That is why our modelling has become so important.
What is important about our modelling is that it is not directly based on previous minimum price policies. It synthesises all the best evidence we have available on the relationship between prices and consumption and between consumption and harm. We bring that together, ask what we know and set out what we do not know. We also try and help policy-makers think about what those things we do not know might mean for the effects of a policy. The general conclusion has been that there are some uncertainties, there may be some unintended consequences but we remain pretty confident that harm reductions overall would ensue from a policy.
There were questions about what else works, and the point was raised about very high-risk drinkers or dependent drinkers. Minimum pricing is not a silver bullet. It is a public health policy. It is about the 20% to 30% of people who drink above recommended limits and thereby increase their risk of health problems. It is not about those very heavy dependent drinkers who have a much more narrowly defined problem. If one wants to tackle those people, there are alternative policies which can help. We are talking about treatment, in particular. A recommendation we would certainly make is adequate resourcing and alcohol treatment services. Treatment has been shown to be effective.
Many dependent drinkers buy large quantities of cheap alcohol, so they will be directly affected by minimum pricing. Therefore, we would expect to see some reduction in their consumption. It might not stop them being dependent drinkers, but it might reduce their drinking from 120 standards drinks per week, or far more in some cases, to 100 standard drinks per week. That might not sound like a lot, but in terms of their risk of suffering health problems, it really makes a difference, particularly when one aggregates that across a few hundred thousand people drinking at that level.
Dependent drinkers do not emerge out of nowhere. They become dependent drinkers for many reasons. One of the things that facilitates their addiction is the availability of large quantities of cheap alcohol. We do not model this aspect and there is not a huge amount of evidence for same, but it is reasonable to expect that the removal of very cheap alcohol from a market will prevent some of tomorrow's dependent drinkers reaching very high consumption levels.
There were questions on how I might change the culture of drinking and whether people would return to pubs and restaurants. That is not something we model directly. Our work is quite data-driven. There is a lot of evidence on how much people drink but there is not a lot of evidence on where they are drinking their alcohol. Therefore, we have to make some inferences and map across from evidence on retail revenue for different sectors. I will explain what we expect to see. We know from various research that one of the reasons people drink less in pubs is because supermarkets and shop prices are much lower. That is a factor which helps people to drink at home instead. As prices go up, we would expect to see some people return to pubs and restaurants. Cultural issues have also driven this change. In the heyday of the pub we did not have the wine market we have now and wine is a product that people primarily consume at home. Society has also changed. People work longer hours, they generally go out more, they live less in communities, particularly middle-class people, and they commute more and live more in the city and urban centres. There are other reasons for the decline in the pub market than just prices. None the less, we would expect some impact, or at least we would hypothesise there could be some impact from minimum pricing.
I was asked about the impact on young people. I can say that people are affected by this policy to the extent that they buy the alcohol that is affected, or at least that is what we can be more confident about. Young people tend not to buy huge amounts of this cheap alcohol because they tend to drink more of the on-trade. The price in the pub will not be affected by the policy as it is already well above the minimum price threshold. That said, young people buy cheap alcohol and are price responsive because they tend to have lower incomes. Therefore, we would expect the policy to have some impact on them. When we looked at this aspect in the UK, although we did not look at the impact on young people directly in our Irish report, we did do so in our UK and Scottish reports and we have seen some impacts. They are greater than the impacts on moderate drinkers and smaller than the impacts on heavy drinkers, but none the less they exist.
The committee has recently concluded a debate on plain packaging on tobacco. Would a warning label help? Would the placing of pictures on bottles warning about the negative effects of alcohol work rather than just text?
Dr. John Holmes:
I believe it would help. As far as I am aware, explicit graphic warnings placed on alcohol products has not been done anywhere in the world. Warning messages have been done and the evidence suggests, particularly in America, that they heighten people's awareness and change their intentions.
Dr. John Holmes:
Yes, I refer to text messages and not graphics. They change people's intentions but they do not necessarily affect behaviour. It comes down again to the point that in a very liberalised alcohol market with relatively little regulation on how alcohol is marketed, the prices at which it can be sold and the level of overall availability in shops, simple messaging might not be enough on its own to change behaviour. Nonetheless, there are impacts, just not necessarily on behaviour.
There were questions on how to choose minimum price and increase it over time. In terms of choosing it, one must balance the impact on moderate drinkers against the impact of bigger health benefits. Clearly, the higher one goes with a minimum price, the bigger the health effects, although if one goes so high, it may result in a big restructuring of the alcohol market. The industry might fundamentally decide this is not the way to should sell certain products any more and make other products. In that case our estimates would start to become rather less robust.
One trades off in terms of the bigger health impact. It is obvious that the greater the level of alcohol consumed by low risk drinkers that is affected, the bigger the effects one will have on them. The question for the committee and the Government is how much impact they are willing to accept on low-risk drinkers to get the bigger health effects. That is not a question we can answer. We could make a recommendation but it would just be our personal view that is based on our personal values, so I am not sure that is especially helpful.
In terms of how one increases minimum pricing over time, the Scottish Government has faced this question as well but has not answered it, as far as I am aware. It said that it needed a mechanism and needed to think about what that mechanism would be, but it has not made a decision yet. Some obvious things to think about are inflation. We talk a lot in alcohol research about affordability, which is inflation adjusted to take account of household and personal incomes. The committee and Government may want to look at whether one can set a threshold that stays the same in order that a minimum price keeps cheap alcohol equally affordable over time. Within that, one might like to think about equally affordable for whom. One might find one is making it increasingly unaffordable because the metric is from the population and not from low-income people. If the metric is based on affordability generated by a population average and not from the low-income people, one might find that one changes affordability for certain groups more than others over time. There are some quite complex things to think about. We hope to start research on this issue in the near future.
Mr. Colin Angus:
Inherent in all the results that we have presented in our report is that the minimum price would be inflated to remain the same in real terms across time. If the Government decided to set a minimum price but not introduce some kind of inflation mechanism, it is our belief that the expected effects would be less than those that we have provided.
Dr. John Holmes:
I would agree with that to a certain extent but I think an historian would have a much longer answer. The evidence that exists has been reviewed but it has been found to be quite inconsistent. Sometimes and with some drugs, people will substitute them for alcohol. Other people with other drugs will treat them as complements. That means that if they stop drinking, they will also stop taking the other drugs or they will reduce both.
Dr. John Holmes:
We have not done so. There has been some movement to do so in the UK by the UK alcohol industry as part of the public health responsibility deal with which the committee may be familiar. The industry promised to take 1 billion units out of the market by reducing the strength of some existing beverages. That has involved beers like Stella and Heineken being reduced from 5% alcohol by volume to 4.8%. It also involved introducing and promoting new low-strength beverages.
On the surface, that is probably a good thing. It is a good thing if we provide more options to consumers. It is a good thing if we provide people with the opportunity to drink lower strength drinks, if they want to.
There is very little evidence that these policies are effective in reducing consumption because we do not know who is drinking those lower strength drinks. It might be that the moderate drinkers are now drinking the same amount they were before but are adding some lower strength drinks on days they would not otherwise have drunk. Similarly, abstainers may now be drinking some low-strength drinks. We do not know what is going on. The industry has made some claims that it has succeeded in this billion unit pledge. We dispute that and the committee will hear more about that in the coming weeks.
A nice example of substitution versus complements for illicit drugs is that young people’s alcohol consumption is falling off a cliff in the UK. There are far more abstainers and far more young people drinking at lower levels than ever in recent years. This seems to be a very consistent and robust trend. The interesting point is that it is not being replaced by young people doing other things. They are not taking up smoking, or smoking more cannabis or taking more ecstasy. The data does not cover legal highs so we do not know what is happening there. The suggestion seems to be that when alcohol consumption is falling among young people, consumption of other substances is falling as well.
I forgot to make one point about the industry. Our research has been published in a wide variety of scientific journals, the world's leading medical journals, British Medical Journaland The Lancet. The World Health Organization, WHO, has also picked it up and recommended it, as have the National Institute for Health and Care Excellence, NICE, in the UK and a whole range of royal medical colleges in the UK and abroad, and their equivalents. By contrast there has not been a single publication in a peer-reviewed scientific journal which has criticised our work in any substantial way. There have been a couple of suggestions for how we might build on it but nothing has said this work is simply wrong. That is quite important. The publications the industry cites are soft publications, think tank reports, things they have submitted to committees such as this one. There is no credible scientific attack on our research that has not been funded by the alcohol industry.
Mr. Colin Angus:
I would like to pick up on some issues around the edges such as numbers for the impact on household budgets for people on low incomes. For the low risk drinkers we estimate a reduction of €4.50 per year, almost no impact on their spending. For increasing risk drinkers it is €41 and for high risk it is a reduction of €60. They are small savings impacts. We do not estimate that the policy would lead to a reduction in the budget for other things for people in low income households because although the alcohol they buy is more expensive, they buy less of it and that cancels it out.
There was a question about people substituting down, in other words, if the market reshuffles itself do people start buying cheaper alcohol. In a sense that is incorporated in the price elasticities that we use to estimate all of this. That is incorporated into our estimates of impact on consumption. What it does not consider is if one believes that cheaper alcohol is fundamentally worse in some way than the same volume bought at a higher price. The evidence does not necessarily suggest that. The harmful component is the alcohol. The evidence even suggests that illicit alcohol is harmful only in the sense that it is strong and has lots of alcohol not because it has some other nasty chemicals that are also bad for one.
Younger people tend to drink more on average and it is true that they drink more in the pubs. The gradient across age is not that great. By our estimates, approximately 38% of their consumption is in the off trade whereas it is 46% or 47% for 35 to 54 year olds. There is not a huge difference. One might expect, although we do not have the figures here, that the impact of the policies on their consumption overall is quite similar. It is important to note that young people do not tend to suffer as much alcohol-related harm because they are young and not as ill. Young people do not tend to die as much as older people. That is a fact of life. If one is interested in the harm outcomes one will see that the policy has a much smaller impact on young people. That is because their baseline rate of harm is very low to start with.
After publication of the heads of the Bill some comments on the price issue were similar to what Deputy Ó Caoláin said, and there was the question of whether this penalises low risk drinkers for the ills of others.
Dr. John Holmes:
This is a difficult issue. The low risk drinkers are largely unaffected but they are affected to a small degree. Although costs for the harm caused by alcohol vary, they run into several billion euro in Ireland. The low risk drinkers are paying for that, through taxes and as victims of some of the problems such as alcohol-related crime and the general social disorder. Some victims of alcohol-related harm are some of the most vulnerable people in our society. The poor suffer worse consequences of their drinking than the better off. There are victims of alcohol-fuelled domestic violence, the broader victims of alcohol-related crime and the dependent drinkers whose drinking is facilitated and perpetuated by the availability of cheap alcohol. It is for the Government to balance the different priorities and reach a decision. There are solid arguments about why everyone in society should make a contribution to reducing the harm alcohol causes because that will benefit society as a whole and some of the most vulnerable people in society.
Having heard this compelling evidence, I believe some or all of the increase in revenue which is generated for someone by unit pricing should be taken into the public Exchequer and used for research. I also believe that we will have in Ireland a near unique opportunity to do original research but also to confirm the Canadian research if we do this. We should set about doing this prospectively and put structures in place to collect all of the relevant health and consumption data. If we are asked to renew this legislation at some stage we will be in a good position to show its real impacts.
On a very minor medical point, the reason some people think the same number of units of different forms of alcohol has different effects is that some of the other effects of alcohol that we are aware of, apart from the effect on the liver, cancer causation, etc., are due to some of the congeners in alcohol. For instance, one might have a worse hangover for the same number of units of alcohol in different kinds of drink depending on some of the other chemicals present. It does not mean less damage to the liver if one does not have a hangover from a “purer” or less adulterated alcoholic drink. That is not how it works.
After such a long examination of the detail of the witnesses’ case, we have come full circle and Senator Crown has now reflected on something I argued for at the outset. I am not going to labour the point but it will be a missed opportunity to use the additional revenue for good and required purposes, particularly focused on the victims of alcohol abuse. That sadly will continue. We need to be mindful of that and I do not want to see the opportunity missed but it would appear from the draft legislation that course will not be taken.
Dr. John Holmes:
To follow up on that, in Scotland a levy on the big supermarkets was proposed. Rather than treat it as a tax and take money from all retailers there would be a levy on the large ones which would claw back some of the additional money they got from alcohol sales.
I am not sure what happened in that regard. Minimum unit pricing has not yet been introduced in Scotland. I am not sure whether that provision made it into the legislation. The committee might consider the introduction of a levy on specific retailers as an alternative to minimum pricing.
On the point about evaluation, obviously we agree that research is necessary. We discussed that issue with officials from the Department prior to the meeting. In Scotland, one of the limitations in terms of how it has been able to evaluate its alcohol strategy has been the lack of good quality baseline data. Data collection needs to be done prior to commencement of the parliamentary process. It is not acceptable to wait until the legislation has been passed to commence data collection. A lack of sufficient baseline data results in a weak evaluation. Data collection needs to commence early if a proper evaluation is to be made.
Mr. Colin Angus:
In addition, by the time a measure has gone through the legislative process the industry is likely to have already started to respond. As per the Scottish pricing data, bottles of wine which were previously sold for just under the minimum price threshold have increased during the past three or four years to just above that threshold. It is unlikely that that is a coincidence. Some of the impact of the policy will be lost because the industry will already have started to react it.