Interventions on Control of Alcohol Price, Promotion and Availability for Prevention of Alcohol Use Disorders in Adults and Young People Commissioned by: NICE Centre for Public Health Excellence Produced by: ScHARR Public Health Collaborating Centre Authors: Rachel Jackson Maxine Johnson Fiona Campbell Josie Messina Louise Guillaume Petra Meier Elizabeth Goyder Jim Chilcott Nick Payne Correspondence to: Vivienne Walker School of Health and Related Research (ScHARR) University of Sheffield Regent Court 30 Regent Street Sheffield S1 4DA [email protected] About the ScHARR Public Health Collaborating Centre The School of Health and Related Research (ScHARR), in the Faculty of Medicine, Dentistry and Health, University of Sheffield, is a multidisciplinary research-led academic department with established strengths in health technology assessment, health services research, public health, medical statistics, information science, health economics, operational research and mathematical modelling, and qualitative research methods. It has close links with the NHS locally and nationally and an extensive programme of undergraduate and postgraduate teaching, with Masters courses in public health, health services research, health economics and decision modelling. ScHARR is one of the two Public Health Collaborating Centres for the Centre for Public Health Excellence (CPHE) in the National Institute for Health and Clinical Excellence (NICE) established in May 2008. The Public Health Collaborating Centres work closely with colleagues in the Centre for Public Health Excellence to produce evidence reviews, economic appraisals, systematic reviews and other evidence based products to support the development of guidance by the public health advisory committees of NICE (the Public Health Interventions Advisory Committee (PHIAC) and Programme Development Groups). Contribution of Authors Rachel Jackson was the author, Maxine Johnson, Fiona Campbell, Josie Messina were additional reviewers. Louise Guillaume developed and undertook literature searches. Petra Meier provided topic expertise. Elizabeth Goyder, Jim Chilcott and Nick Payne were the senior leads. Acknowledgements This report was commissioned by the Centre for Public Health Excellence of behalf of the National Institute for Health and Clinical Excellence. The views expressed in the report are those of the authors and not necessarily those of the Centre for Public Health Excellence or the National Institute for Health and Clinical Excellence. The final report and any errors remain the responsibility of the University of Sheffield. Elizabeth Goyder and Jim Chilcott are guarantors. 2 CONTENTS 1 List of Abbreviations 4 2 Executive Summary 6 3 Background 25 4 Review Methods 4.1 Key principles of methods for identification of evidence 28 4.2 Review 1 29 4.3 Review 2 32 4.4 Review 3 35 5 Review Findings 5.1. Review 1 39 5.2 Review 2 51 5.2.2.1 Minimum legal age of alcohol purchase 53 5.2.2.2 Enforcement of minimum legal age of alcohol purchase 67 5.2.2.3 Management of the sale of alcohol to intoxicated individuals 88 5.2.2.4 Licensed hours and days of alcohol sale 115 5.2.2.5 Alcohol outlet density 154 5.2.2.6 Interaction between off-licence and on-licence availability of 174 alcohol 5.3 Review 3 181 6 Discussion 197 7 Appendices 201 8 References 250 3 1. LIST OF ABBREVIATIONS A list of abbreviations used throughout this report is presented below. LIST OF ABBREVIATIONS AAF Alcohol-attributable fraction ABV Alcohol by volume A&E Accident & Emergency AMI Adaptations of motivational interviewing BAL Blood alcohol level BI Brief intervention CI Confidence Interval CTRL Control EBI Extended brief intervention ED Emergency Department FME Forensic Medical Examiner G Gram GGT Gamma-glutamyltransferase GP General Practitioner Hr Hour HRQL Health Related Quality of Life ICER Incremental cost effectiveness ratios ITT Intention to Treat L Litre MCV Mean corpuscular volume MI Motivational interviewing Ml Millilitre MLDA Minimum legal drinking age MNI Minimal intervention MVA Motor vehicle accident Min Minute NHS National Health Service NICE National Institute for Health and Clinical Excellence NNT Number Needed to Treat NS Not Significant OR Odds Ratio 4 PDG Programme Development Group QUOROM Quality Of Reporting Of Meta-analyses RCT Randomised Controlled Trial RR Relative Risk WHO World Health Organisation Wk Week U Unit Vs Versus 5 2. EXECUTIVE SUMMARY Background Alcohol misuse is associated with significant clinical and social consequences. The National Institute for Health and Clinical Excellence has been asked by the Department of Health to develop public health guidance to promote the prevention and early identification of alcohol- use disorders in adults and adolescents. Objectives To undertake an assessment of the clinical and cost-effectiveness of i) measures to detect alcohol misuse amongst adults and young people; ii) brief interventions to manage alcohol misuse among adults and young people; and iii) interventions to improve management of England’s alcohol market. Methods Systematic reviews of effectiveness evidence to address the above areas have been undertaken. Results This report includes the findings of the systematic reviews of the effectiveness of price controls, interventions in the management of the availability of alcohol, and the control of alcohol promotion. Review 1: The effectiveness of price controls in reducing alcohol consumption, alcohol misuse, alcohol-related harm or alcohol-related social problems among adults and young people A considerable evidence base relating to the impact of price/taxation on alcohol consumption and related outcomes was identified. Nine pieces of evidence, including one very extensive systematic review, were included. Evidence demonstrated a clear relationship between price/tax increases and reductions in the demand for alcohol. A positive relationship between alcohol affordability and alcohol consumption was reported as operating across the European Union. The evidence base showed a relationship between price/tax increases and reductions in alcohol-related harms. A positive relationship between alcohol consumption and liver cirrhosis, traffic injuries, and traffic deaths was also observed. Limited evidence suggested that minimum pricing may be an effective approach in reducing alcohol consumption. 6 Review 2: The effectiveness of interventions in managing alcohol availability to reduce levels of consumption, alcohol misuse, alcohol-related harm or alcohol-related social problems among adults and young people A large body of evidence relating to the management of alcohol availability was identified across the following sub-sections: Minimum legal age of alcohol purchase Seven papers were included, including one very extensive systematic review. Findings were suggestive of an inconclusive negative relationship between minimum legal age of alcohol purchase and alcohol consumption. Additional work provided further evidence of a negative association between minimum legal age and alcohol-related outcomes. Enforcement of minimum legal age of alcohol purchase Nineteen papers were included. Whilst serving staff appeared to support the principle of enforcement, the commitment of managers towards their responsibilities varied. Furthermore, servers and licensees appeared to perceive little risk as a result of serving alcohol to underage people. Training interventions were not shown to have a significant impact on sales; whilst the effectiveness of compliance checks by police was variable. Management of the sale of alcohol to intoxicated individuals Eleven papers were included. A wide range of interventions were evaluated that differed considerably in terms of structure and content. No conclusive impact of server training on the alcohol consumption of customers was observed. Some evidence indicated that server training was linked with reductions in some alcohol-related harms. Server training appeared to increase server knowledge, and positive aspects of server behaviour, including refusals of service to intoxicated customers. UK-specific unpublished evidence suggests that community initiatives are proving beneficial in promoting responsible beverage service. Licensed hours and days of alcohol sale Twenty seven pieces of evidence were included. Whilst levels of alcohol consumption and crime and disorder appear to have remained stable following the introduction of the Licensing Act, a temporal displacement of crime and disorder and also emergency department alcohol- related attendances was apparent, with a greater proportion of incidents taking place in the early hours of the morning. Evidence also suggests that the Licensing Act has had resource implications, particularly for police and health professionals. Other UK-specific and international evidence was also identified and presented, with increases in licensing hours typically associated with increased consumption and/or harms. Alcohol outlet density Nineteen papers were included. A clear positive association between increases in alcohol outlet density and increases in alcohol consumption was observed among both adults and 7 young people. Further limited evidence was also identified that found a positive relationship between alcohol outlet density and alcohol-related harms. Interaction between off-licence and on-licence availability of alcohol Three papers were included. Identified evidence indicated that pre-drinking is a prevalent activity in the UK and other countries, and is associated with increased overall alcohol consumption and greater risk of alcohol-related harms. Review 3: The effectiveness of the control of alcohol promotion (e.g. advertising) in reducing levels of consumption, alcohol misuse, alcohol-related harm or alcohol-related social problems among adults and young people Eight pieces of evidence were included, including findings from extensive systematic reviews. Evidence was identified from three large systematic reviews that was supportive of a relationship between alcohol advertising and promotion and alcohol consumption, particularly among young people. Exposure to alcohol advertising and promotion was associated with the onset of adolescent alcohol consumption and with increased consumption amongst adolescents who were already drinking at baseline. A moderate but consistent association was also observed between point of purchase promotions and effects on alcohol consumption among underage drinkers, binge drinkers and regular drinkers. Outdoor and print advertising media may increase the probability of onset of adolescent alcohol consumption and also influence quantity and frequency of alcohol consumption among young people. Ownership of an alcohol promotional item or branded merchandise may be associated with increased initiation of drinking. Exposure to television and other broadcast media was linked with onset of and levels of alcohol consumption. The content of alcohol advertising was reported to be attractive to young people, conveying desirable lifestyles and images of alcohol consumption. Younger age groups and 15 to 17 yr old girls were reported to be potentially experiencing the greatest impact of alcohol advertising. The evidence for the impact of advertising bans was inconclusive. Evidence statements Review 1: Evidence statement 1.1: A comprehensive systematic review was identified that demonstrated a clear association between price/tax increases and reductions in consumer demand for alcohol.1 These conclusions were based on two rigorous meta-analyses of price elasticities conducted by Gallet, 2007 and Wagenaar et al., 2008. Further evidence was supportive of a negative relationship between the price of alcohol and alcohol consumption among young people.2,3 A 8 positive relationship between alcohol affordability and alcohol consumption operating across the European Union was identified.4 1 Booth et al., 2008 (Systematic review, ++) 2 Sutton & Godfrey (Grouped data regression analysis) UK 3 Grossman et al., 1987 (Logit estimation analysis) USA 4 Rabinovich et al., 2009 (Mixed methods study) European Union Applicability: The majority of the studies included in the review by Booth originated in the USA. The papers by Sutton & Godfrey and Grossman et al. were specific to the UK and USA respectively. The report presented by Rabinovich et al. (commissioned by RAND Europe) covered the European Union. Evidence statement 1.2: The systematic review by Booth et al. (2008) reported that there is some evidence that young people, binge drinkers and harmful drinkers tend to show a preference for cheaper drinks. 1 Booth et al., 2008 (Systematic review, ++) Applicability: The majority of the studies included in the review by Booth originated in the USA. Evidence statement 1.3: A limited evidence base was identified that indicated that minimum pricing may be effective in reducing alcohol consumption.1,2 Consulted members of the community were supportive of such measures.1 1 Booth et al., 2008 (Systematic review, ++) 2 Record & Day (unpublished) (Statistical analysis) UK Applicability: The evidence relating to minimum pricing in the Booth review was drawn from a study conducted in an Australian setting. The work by Record & Day was specific to the UK. Evidence statement 1.4: An evidence base comprising a large number of primary studies was identified that demonstrated a relationship between price/tax increases and reductions in harms.1 Additional evidence indicates that decreases in the price of alcohol contribute towards increases in alcohol-related deaths, particularly in deaths attributable to chronic causes such as alcoholic liver disease.2 Population groups specifically affected included the older population, the unemployed and individuals with lower levels of education, social class and income.2 However, the same authors observed no increase in interpersonal violence rates following the 9 decrease in alcohol prices.3 Wagenaar et al., 2009 demonstrated that increases in tax were associated with decreases in alcohol-related disease mortality.4 1 Booth et al., 2008 (Systematic review, ++) 2 Herttua et al., 2008a (Before and after study, ++) Finland 3 Herttua et al., 2008b (Before and after study, ++) Finland 4 Wagenaar et al., 2009 (Time series analysis, ++) USA Applicability: The majority of the studies included in the review by Booth originated in the USA. The work by Herttua et al. was conducted in Finland, whilst Wagenaar et al. based their study in Alaska. Evidence statement 1.5: Results of a meta-regression analysis of own price elasticity estimates found a longitudinal trend whereby consumer demand for alcohol beverages was increasingly inelastic until 1969 and subsequently decreasingly inelastic. The study authors discuss whether this effect might be potentially attributable to a substitution of alcohol with increasingly available illicit drugs. However, no evidence is currently available to support this hypothesis. 1 Fogarty, 2006 (Meta-regression analysis) Applicability: Elasticity estimates were drawn from a range of international studies, with the majority coming from the UK, USA, and Canada; and the remaining estimates from Australia, New Zealand, the Netherlands, France, Belgium, Germany, Portugal, Spain, Italy, Ireland, Scandinavia, Kenya and Japan. Evidence statement 1.6: The same meta-regression analysis also demonstrated that the higher the relative market share of a beverage, the more inelastic the consumer demand.1 Therefore, it can be anticipated that the most popular beverages within a market will be least responsive to changes in alcohol price or taxation. 1 Fogarty, 2006 (Meta-regression analysis) Applicability: Elasticity estimates were drawn from a range of international studies, with the majority coming from the UK, USA, and Canada; and the remaining estimates from Australia, New Zealand, the Netherlands, France, Belgium, Germany, Portugal, Spain, Italy, Ireland, Scandinavia, Kenya and Japan. 10