Can Scottish inventiveness curb the nation’s alcohol habit?

Posted by John Mooney, Senior Lecturer in Public Health, University of Sunderland

 Churchill is defeated by a Temperance movement MP - Dundee election result in 1922

“Of all the nations of this earth, perhaps only the ancient Greeks surpass the Scots in their contribution to mankind…” 

Sir Winston Churchill

This often cited sentence from the great orator’s canon of memorable expressions, frequently (in social media posts at least), is accompanied by a story of the number of times in a normal day ‘the typical Englishman’ is obliged to thank his Northern cousins for gifts bestowed:

From the spreading of ‘Dundee marmalade’ in the morning to his whisky night-cap it is easy to lose count of those almost innumerable causes for daily gratitude. In these days of Prophet Greta, perhaps the less said about ‘TarMacAdam’ and the internal combustion engine the better… but in our defence there is always Kirkpatrick MacMillan’s bicycle to offset that carbon footprint!

It’s no accident of course that pride of place be afforded in the above account to Scotland’s national drink of distilled and malted barley – renowned the World over for its unparalleled quality and distinctive dalliance on the palate. Scotland’s broader relationship with alcohol however, has not traditionally been a reputation to which one might raise a glass and is perhaps better summed up by the lovable and tragic Rab C Nesbit (right). The real tragedy of course being the excessive and abiding toll of alcohol related illness and premature death for which Scotland is infamous and also near the top of the World league table, for all the wrong reasons...

And yet, the nation’s pioneering spirit (of the non-liquid variety!) and very inventiveness in the face of a challenge may yet serve up another exemplar for others to follow. In May 2018 Scotland became the first country in the World to introduce legislation that set a minimum floor price for a unit of alcohol (MUP). While other fiscal mechanisms have been tried and tested for tackling cheap alcohol, MUP has consistently shown the greatest promise in modelling studies, since it cannot be “absorbed” by the retailer [1].

Sure enough, the first evaluation of the population level impact of MUP has found the policy to be associated with reduced alcohol purchasing. In line with model predictions, the reductions were largest for those households purchasing the most alcohol and for those drinks with the cheapest alcohol content [2, 3]. The very modest impacts on household budgets and the effect of reducing alcohol purchasing / consumption the most for those at greatest risk of harm also in line with predictions [4], helps counter any serious criticisms that the policy represents a regressive measure by unfairly targeting the economically disadvantaged. In the words of the Glaswegian novelist Val McDermid, on BBC Television’s Question Time in 2017: “There is nothing regressive about preventing people in Scotland’s poorest communities drinking themselves to death with cheap alcohol”.

Returning to the bigger picture, Scotland’s appetite for policy innovation to tackle alcohol harms is by no means restricted to minimum pricing. Rather, MUP is seen as only one component of a ‘whole system’ approach to tackling this most intractable and culturally embedded of public health problems. Bringing drink driving levels into line with the lower threshold in place across the rest of the EU [5] and incorporating health outcomes as a long overdue legitimate alcohol licensing objective [6], being two potential ingredients in the mix…

The Scottish ‘double edged’ relationship with alcohol can be best summed up by another snippet of Churchillian wisdom, a man who by all accounts was not unaccustomed to enjoying a ‘brandy before breakfast’:

"Whisky has killed more men then bullets, but most men would rather be full of whisky then bullets." 

Sir Winston Churchill

Perhaps the pragmatic recognition of a population’s natural affinity for a risky behaviour responsible for such a significant health burden is the first step towards realising that only meaningful restrictions in access mediated through price and availability, as well as legislative sanctions, might yet constitute the best defence against our worst excesses. Most Scots, myself included, know only too well of the devastating impact alcohol can exert on friends, families and communities. Maybe that is why we are most responsive to the remedies!


References:

1. Meier PS, Holmes J, Angus C, Ally AK, Meng Y, Brennan A: Estimated Effects of Different Alcohol Taxation and Price Policies on Health Inequalities: A Mathematical Modelling Study. PLoS Med 2016, 13(2):e1001963-e1001963.
2. Mooney JD, Carlin E: Minimum unit pricing for alcohol in Scotland. BMJ 2019, 366:l5603.
3. O’Donnell A, Anderson P, Jané-Llopis E, Manthey J, Kaner E, Rehm J: Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18. BMJ 2019, 366:l5274.
4. Holmes J, Meng Y, Meier PS, Brennan A, Angus C, Campbell-Burton A, Guo Y, Hill-McManus D, Purshouse RC: Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: A modelling study. The Lancet 2014, 383(9929):1655-1664.
5. Haghpanahan H, Lewsey J, Mackay DF, McIntosh E, Pell J, Jones A, Fitzgerald N, Robinson M: An evaluation of the effects of lowering blood alcohol concentration limits for drivers on the rates of road traffic accidents and alcohol consumption: a natural experiment. Lancet 2019, 393(10169):321-329.
6. Mooney JD, Sattar Z, de Vocht F, M Smolar M, Nicholls J, Ling J: Assessing the feasibility of using health information in alcohol licensing decisions: a case study of seven English local authorities. In: Lancet Public Health Science: 2016; Cardiff: The Lancet; 2016: 78.

Image:

1. Election result in Dundee in the 1920s when Churchill was defeated by a Temperance movement MP. With thanks to Eric Carlin, Director of the Scottish Health Action on Alcohol Problems (SHAAP).