Lockdown and licensed premises: COVID-19 lessons for alcohol policy

Trends in alcohol expenditure among risky drinkers: A population study in England, 2014-2023

BACKGROUND

This study aimed to estimate time trends in alcohol expenditure among risky drinkers in England over the past decade, to understand whether these trends are driven by changes in prices paid or volumes purchased, and to explore differences between population subgroups.

METHODS

Nationally-representative monthly cross-sectional survey. Participants were 44,382 adults (≥18y) drinking at risky levels (AUDIT-C ≥ 5; 'risky drinkers'). Linear regression modelled trends between March-2014 and October-2023 in (i) mean weekly inflation-adjusted expenditure on alcohol, (ii) mean weekly alcohol consumption in units, and (iii) mean inflation-adjusted expenditure per unit of alcohol, overall and by age, gender, social grade, region, and smoking status.

RESULTS

There was an uncertain decrease in mean weekly expenditure from £18.90 [95 %CI=£18.30-£19.50] in March-2014 to £17.90 [£17.60-£18.30] in May-2016, then an uncertain increase to £18.60 [£18.30-£18.90] between May-2016 and June-2018. This was followed by a further decline to £16.90 [£16.60-£17.30] by April-2021 and subsequent rise to £18.60 [£17.90-£19.40] by October-2023. Changes in weekly alcohol expenditure were more closely mirrored by changes in mean expenditure per unit of alcohol than by changes in mean weekly alcohol consumption in units. Notable subgroup differences included sharp rises in weekly alcohol expenditure since 2021 among younger ages (driven by a rise in expenditure per unit of alcohol) and current smokers (driven by a rise in weekly units of alcohol consumed).

CONCLUSIONS

In England, the average amount adult risky drinkers reported spending on alcohol each week has fluctuated since 2014, with a notable decrease around the start of the COVID-19 pandemic in 2020 and a subsequent rise since restrictions were lifted and since the cost-of-living crisis has led to high rates of inflation. Except for current smokers, this pattern appears to have been driven predominantly by changes in the price paid per unit rather than changes in consumption.

An 'alcohol health champions' intervention to reduce alcohol harm in local communities: a mixed-methods evaluation of a natural experiment

Background

Globally alcohol consumption is a leading risk factor for premature death and disability and is associated with crime, social and economic consequences. Local communities may be able to play a role in addressing alcohol-related issues in their area.

Objectives

To evaluate the effectiveness and cost-benefit of an asset-based community development approach to reducing alcohol-related harm and understand the context and factors that enable or hinder its implementation.

Design

A mixed-methods evaluation. Area-level quasi-experimental trial analysed using four different evaluation methods (a stepped-wedge design where each area was a control until it entered the intervention, comparison to matched local/national controls and comparison to synthetic controls), alongside process and economic evaluations.

Setting

Ten local authorities in Greater Manchester, England.

Participants

The outcomes evaluation was analysed at an area level. Ninety-three lay persons representing nineareas completed questionnaires, with 12 follow-up interviews in five areas; 20 stakeholders representing ten areas were interviewed at baseline, with 17 follow-up interviews in eight areas and 26 members of the public from two areas attended focus groups.

Interventions

Professionals in a co-ordinator role recruited and supported lay volunteers who were trained to become alcohol health champions. The champion's role was to provide informal, brief alcohol advice to the local population and take action to strengthen restrictions on alcohol availability.

Main outcome measures

Numbers of alcohol-related hospital admissions, accident and emergency attendances, ambulance call-outs, street-level crime and antisocial behaviour in the intervention areas (area size: 1600-5500 residents). Set-up and running costs were collected alongside process evaluation data exploring barriers and facilitators.

Data sources

Routinely collected quantitative data on outcome measures aggregated at the intervention area and matched control and synthetic control areas. Data from policy documents, licensing registers, meeting notes, invoices, time/cost diaries, training registers, questionnaires, interviews, reflective diaries and focus groups.

Results

The intervention rolled out in nine out of ten areas, seven of which ran for a full 12 months. Areas with better-established infrastructure at baseline were able to train more champions. In total, 123 alcohol health champions were trained (95 lay volunteers and 28 professionals): lay volunteers self-reported positive impact. Champions engaged in brief advice conversations more readily than taking action on alcohol availability. There were no consistent differences in the health and crime area-level indicators between intervention areas and controls, as confirmed by using three different analysis methods for evaluating natural experiments. The intervention was not found to be cost-beneficial.

Limitations

Although the sequential roll-out order of the intervention was randomised, the selection of the intervention areas was not. Self-reported impact may have been subject to social desirability bias due to the project's high profile.

Conclusions

There was no measurable impact on health and crime outcomes. Possible explanations include too few volunteers trained, volunteers being unwilling to get involved in licensing decisions, or that the intervention has no direct impact on the selected outcomes.

Future work

Future similar interventions should use a coproduced community outcomes framework. Other natural experiment evaluations should use methodological triangulation to strengthen inferences about effectiveness.

Trial registration

This trial is registered as ISRCTN81942890.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/129/03) and is published in full in Public Health Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

COVID-19 as a catalyst for alcohol policy change: A case study of the Gove Peninsula

In many ways, the COVID-19 pandemic provided a natural experiment for alternate ways of living and working. Although alcohol supply was one of many aspects impacted by COVID-19 restrictions, few of those alcohol-related measures have been continued. This commentary presents a unique case study from the Gove Peninsula in northern Australia, where pandemic restrictions acted as a catalyst for a review of an established alcohol management system. A permit system was introduced on the Gove Peninsula in 2008 to control who can purchase takeaway alcohol and how much they could buy each day. Development of the system was rooted in the principles of community development and self-determination. This commentary describes how COVID-19 and associated changes in levels of alcohol harms mobilised community support for a review of the system, that had operated unchanged for the past decade. COVID-19 was adventitious in revealing compelling localised information which encouraged examination of potential improvements to the system. An updated regime is now being trialled, which sets daily limits on the alcohol purchases of everyone in the area. This experience illustrates the benefits of timely and relevant data to assist communities in formulating local solutions to local problems.

Reducing alcohol harms whilst minimising impact on hospitality businesses: 'Sweetspot' policy options

BACKGROUND

During COVID-19, hospitality businesses (e.g. bars, restaurants) were closed/restricted whilst off-sales of alcohol increased, with health consequences. Post-covid, governments face lobbying to support such businesses, but many health services remain under pressure. We appraised 'sweetspot' policy options: those with potential to benefit public services and health, whilst avoiding or minimising negative impact on the hospitality sector.

METHODS

We conducted rapid non-systematic evidence reviews using index papers, citation searches and team knowledge to summarise the literature relating to four possible 'sweetspot' policy areas: pricing interventions (9 systematic reviews (SR); 14 papers/reports); regulation of online sales (1 SR; 1 paper); place-shaping (2 SRs; 18 papers/reports); and violence reduction initiatives (9 SRs; 24 papers/reports); and led two expert workshops (n = 11).

RESULTS

Interventions that raise the price of cheaper shop-bought alcohol appear promising as 'sweetspot' policies; any impact on hospitality is likely small and potentially positive. Restrictions on online sales such as speed or timing of delivery may reduce harm and diversion of consumption from on-trade to home settings. Place-shaping is not well-supported by evidence and experts were sceptical. Reduced late-night trading hours likely reduce violence; evidence of impact on hospitality is scant. Other violence reduction initiatives may modestly reduce harms whilst supporting hospitality, but require resources to deliver multiple measures simultaneously in partnership.

CONCLUSIONS

Available evidence and expert views point to regulation of pricing and online sales as having greatest potential as 'sweetspot' alcohol policies, reducing alcohol harm whilst minimising negative impact on hospitality businesses.

Alcohol policy changes during the first three-months of the COVID-19 pandemic: Development and application of a classification scheme

BACKGROUND

Policy changes in response to the COVID-19 pandemic have impacted on alcohol control. This study describes the development and application of a classification scheme to map alcohol policy changes during the first three-months of the COVID-19 pandemic in five countries and/or subnational jurisdictions.

METHOD

A pre-registered systematic review of policy decisions from March to May 2020, in Australia/New South Wales, Canada/Ontario, Chile, Italy and the United Kingdom. One author extracted the data for each jurisdiction using a country-specific search strategy of government documents. We coded policy changes using an adapted WHO classification scheme, whether the policy was expected to tighten or loosen alcohol control, have mainly immediate or delayed impact on consumption and harm and impact the general population versus specific populations. We present descriptive statistics of policy change.

RESULTS

We developed a classification scheme with four levels. Existing policy options were insufficient to capture policy changes in alcohol availability, thus we added seventeen new sub-categories. We found 114 alcohol control policies introduced across the five jurisdictions, covering five (out of ten) WHO action areas. The majority aimed to change alcohol availability, by regulating the operation of alcohol outlets. All countries introduced closures to on-premise alcohol outlets and, except Chile, allowed off-sales via take away or home delivery. We also observed several pricing policies introducing subsidies to support the alcohol industry. Seventy-four percent of policy changes were expected to tighten alcohol control and 12.3 % to weaken control. Weakening policy changes were mostly related to retail mode switching or expansion (allowing take away or home delivery).

CONCLUSION

Alcohol control policies during the first three months of the COVID-19 pandemic were targeted primarily at alcohol availability and about one tenth might weaken alcohol control. Temporary changes to alcohol retail during the COVID-19 pandemic, if made permanent, could significantly expand alcohol availability.

The effect of a minimum price per unit of alcohol in Scotland on alcohol-related ambulance call-outs: A controlled interrupted time-series analysis

BACKGROUND AND AIMS

On 1 May 2018, Scotland introduced a minimum unit price (MUP) of £0.50 for alcohol, with one UK unit of alcohol being 10 ml of pure ethanol. This study measured the association between MUP and changes in the volume of alcohol-related ambulance call-outs in the overall population and in call-outs subsets (night-time call-outs and subpopulations with higher incidence of alcohol-related harm).

DESIGN

An interrupted time-series (ITS) was used to measure variations in the daily volume of alcohol-related call-outs. We performed uncontrolled ITS on both the intervention and control group and a controlled ITS built on the difference between the two series. Data were from electronic patient clinical records from the Scottish Ambulance Service.

SETTING AND CASES

Alcohol-related ambulance call-outs (intervention group) and total ambulance call-outs for people aged under 13 years (control group) in Scotland, from December 2017 to March 2020.

MEASUREMENTS

Call-outs were deemed alcohol-related if ambulance clinicians indicated that alcohol was a 'contributing factor' in the call-out and/or a validated Scottish Ambulance Service algorithm determined that the call-out was alcohol-related.

FINDINGS

No statistically significant association in the volume of call-outs was found in both the uncontrolled series [step change = 0.062, 95% confidence interval (CI) = -0.012, 0.0135 P = 0.091; slope change = -0.001, 95% CI = -0.001, 0.1 × 10-3 P = 0.139] and controlled series (step change = -0.01, 95% CI = -0.317, 0.298 P = 0.951; slope change = -0.003, 95% CI = -0.008, 0.002 P = 0.257). Similarly, no significant changes were found for the night-time series or for any population subgroups.

CONCLUSIONS

There appears to be no statistically significant association between the introduction of minimum unit pricing for alcohol in Scotland and the volume of alcohol-related ambulance call-outs. This was observed overall, across subpopulations and at night-time.

Metabolic management of accidental intoxication

PURPOSE OF REVIEW

Unintentional intoxication comprises a major chunk of all intoxications. Most patients are in the pediatric age group with another set of patients being the elderly. Substances found to cause accidental intoxication vary from country to country and even within different regions of a country. Frequent reviews of current literature are needed to be abreast of trends.

RECENT FINDINGS

Prescription drugs and household chemicals are major culprits when it comes to accidental intoxication. Acetaminophen, digoxin and metformin are some of the prominent prescription drugs frequently associated with unintentional intoxications. Increasingly alcohol based hand sanitizers are becoming an important etiology of these events, following their increased usage during the COVID-19 pandemic. Pattern recognition to identify class of intoxicant and supportive care including prevention of further absorption and increased excretion are cornerstones of therapy. Antidote when available should be used promptly.

SUMMARY

Knowledge about current epidemiology of accidental intoxications, toxidrome pattern recognition and appropriate antidote usage beside adequate and timely supportive care help in successful management of the unfortunate victim of accidental intoxication.

Drinking alcohol at home feels different from drinking in public places: a qualitative study of midlife Australians

This paper shows how drinking in one's own home affords different affective experiences to drinking in public settings such as bars, pubs and restaurants. A thematic analysis of interviews with 40 Australians aged 30-65 identified three main variations in alcohol-associated feelings, sensations and urges. Alcohol was used at home to decelerate, but in contrast, people were enlivened when drinking in public venues. Drinking in public generated a sense of vigilance and greater requirement to self-monitor than usually felt necessary at home. For some, drinking at home seemed more habitual; governed by urges rather than intentionality, than drinking outside it did. Policy and interventions that target drinking in the home should be prioritised, such as those focussed on off-premise pricing and availability.

Public health engagement in alcohol licensing in England and Scotland: the ExILEnS mixed-method, natural experiment evaluation

Background

International systematic reviews suggest an association between alcohol availability and increased alcohol-related harms. Alcohol availability is regulated through separate locally administered licensing systems in England and Scotland, in which local public health teams have a statutory role. The system in Scotland includes a public health objective for licensing. Public health teams engage to varying degrees in licensing matters but no previous study has sought to objectively characterise and measure their activity, examine their effectiveness, or compare practices between Scotland and England.

Aim

To critically assess the impact and mechanisms of impact of public health team engagement in alcohol premises licensing on alcohol-related harms in England and Scotland.

Methods

We recruited 39 diverse public health teams in England (n = 27) and Scotland (n = 12). Public health teams more active in licensing were recruited first and then matched to lower-activity public health teams. Using structured interviews (n = 66), documentation analysis, and expert consultation, we developed and applied the Public Health Engagement In Alcohol Licensing (PHIAL) measure to quantify six-monthly activity levels from 2012 to 2019. Time series of PHIAL scores, and health and crime outcomes for each area, were analysed using multivariable negative binomial mixed-effects models to assess correlations between outcome and exposure, with 18-month average PHIAL score as the primary exposure metric. In-depth interviews (n = 53) and a workshop (n = 10) explored public health team approaches and potential mechanisms of impact of alcohol availability interventions with public health team members and licensing stakeholders (local authority licensing officers, managers and lawyers/clerks, police staff with a licensing remit, local elected representatives).

Findings

Nineteen public health team activity types were assessed in six categories: (1) staffing; (2) reviewing and (3) responding to licence applications; (4) data usage; (5) influencing licensing stakeholders/policy; and (6) public involvement. Usage and intensity of activities and overall approaches varied within and between areas over time, including between Scotland and England. The latter variation could be explained by legal, structural and philosophical differences, including Scotland's public health objective. This objective was felt to legitimise public health considerations and the use of public health data within licensing. Quantitative analysis showed no clear evidence of association between level of public health team activity and the health or crime outcomes examined, using the primary exposure or other metrics (neither change in, nor cumulative, PHIAL scores). Qualitative data suggested that public health team input was valued by many licensing stakeholders, and that alcohol availability may lead to harms by affecting the accessibility, visibility and norms of alcohol consumption, but that the licensing systems have limited power to act in the interests of public health.

Conclusions

This study provides no evidence that public health team engagement in local licensing matters was associated with measurable downstream reductions in crime or health harms, in the short term, or over a 7-year follow-up period. The extensive qualitative data suggest that public health team engagement is valued and appears to be slowly reorienting the licensing system to better address health (and other) harms, especially in Scotland, but this will take time. A rise in home drinking, alcohol deliveries, and the inherent inability of the licensing system to reduce - or in the case of online sales, to contain - availability, may explain the null findings and will continue to limit the potential of these licensing systems to address alcohol-related harms.

Future work

Further analysis could consider the relative success of different public health team approaches in terms of changing alcohol availability and retailing. A key gap relates to the nature and impact of online availability on alcohol consumption, harms and inequalities, alongside development and study of relevant policy options. A national approach to licensing data and oversight would greatly facilitate future studies and public health input to licensing.

Limitations

Our interview data and therefore PHIAL scores may be limited by recall bias where documentary evidence of public health activity was not available, and by possible variability in grading of such activity, though steps were taken to minimise both. The analyses would have benefited from additional data on licensing policies and environmental changes that might have affected availability or harms in the study areas.

Study registration

The study was registered with the Research Registry (researchregistry6162) on 26 October 2020. The study protocol was published in BMC Medical Research Methodology on 6 November 2018.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/129/11.

Qualitative study of states' capacity to support alcohol prevention policies during the COVID-19 pandemic in the USA

INTRODUCTION

The onset of the COVID-19 pandemic accelerated rates of alcohol purchasing and related harms in the USA. The increases followed governors' emergency orders that increased alcohol availability, including the allowance of alcohol home delivery, alcohol to-go from restaurants and bars, and curbside pickup from retailers.

METHODS

Semi-structured interviews were conducted with 53 participants involved in state-level alcohol prevention policy across 48 states. Interviewees' perspectives on changes to alcohol prevention policies during the COVID-19 pandemic, including capacity to respond to alcohol-focused executive and legislative changes to alcohol availability, were explored. Initial codes were developed collectively and refined through successive readings of transcripts using a phenomenological, action-oriented research approach. Themes were identified semantically after all transcripts were coded and reviewed.

RESULTS

Four themes were developed including: (i) alcohol prevention policies and capacity during COVID-19; (ii) industry-related challenges during COVID-19; (iii) limited pre-COVID-19 alcohol prevention capacity; and (iv) needs to strengthen alcohol prevention capacity.

DISCUSSION AND CONCLUSIONS

The pandemic exacerbated states' capacity limitations for alcohol prevention efforts and created additional impediments to public health messaging about alcohol health risks related to greater alcohol availability. Participants offered a myriad of strategies to improve alcohol prevention and to reduce alcohol-related harms. Recommendations included dedicated federal and state prioritisation, more funding for community organisations, greater coordination, consistent high-quality trainings, stronger surveillance and widespread prevention messaging. States' alcohol prevention efforts require dedicated leadership, additional funding and support to strengthen population-based strategies to reduce sustained alcohol-related harms associated with increases in alcohol availability.

Promoting health in the digital environment: health policy experts' responses to on-demand delivery in Aotearoa New Zealand

Services offering on-demand delivery of unhealthy commodities, such as fast food, alcohol and smoking/vaping products have proliferated in recent years. It is well known that the built environment can be health promoting or harmful to health, but there has been less consideration of the digital environment. Increased availability and accessibility of these commodities may be associated with increased consumption, with harmful public health implications. Policy regulating the supply of these commodities was developed before the introduction of on-demand services and has not kept pace with the digital environment. This paper reports on semi-structured interviews with health policy experts on the health harms of the uptake in on-demand delivery of food, alcohol and smoking/vaping products, along with their views on policies that might mitigate these harms. We interviewed 14 policy experts from central and local government agencies and ministries, health authorities, non-Government Organisations (NGOs) and university research positions in Aotearoa New Zealand using a purposive sampling strategy. Participants concerns over the health harms from on-demand services encompassed three broad themes-the expansion of access to and availability of unhealthy commodities, the inadequacy of existing restrictions and regulations in the digital environment and the expansion of personalized marketing and promotional platforms for unhealthy commodities. Health policy experts' proposals to mitigate harms included: limiting access and availability, updating regulations and boosting enforcement and limiting promotion and marketing. Collectively, these findings and proposals can inform future research and public health policy decisions to address harms posed by on-demand delivery of unhealthy commodities.

Mechanisms of impact of alcohol availability interventions from the perspective of 63 diverse alcohol licensing stakeholders: a qualitative interview study

Aims

Interventions restricting temporal and spatial availability of alcohol are associated with reduced harm, but the pathways by which specific interventions have impact are poorly understood. We examined mechanisms of impact from the perspective of diverse licensing stakeholders.

Methods

Fifty-three in-depth interviews were conducted with licensing stakeholders (from public health teams [PHTs], police, local authority licensing teams and lawyers, and alcohol premises licensing committees) from 20 local government areas. Interviewees were recruited as part of the Exploring the impact of alcohol licensing in England and Scotland (ExILEnS) study. Data were analyzed thematically and preliminary themes/subthemes were discussed during online groups with a different sample of public health and licensing professionals (n = 10).

Findings

Most interviewees struggled to articulate how availability interventions might lead to changes in alcohol consumption or harms. Five overarching mechanisms were identified: access, visibility, premises and area-level norms, affordability, and management of the night-time economy, with specific pathways identified for certain subgroups/premises types. The mechanisms by which alcohol availability interventions may impact on alcohol consumption and harms are diverse, but were poorly understood.

Conclusions

These findings will inform licensing and availability policy and advocacy, highlighting the need for further scrutiny of the evidence underpinning identified mechanisms, and primary research to address knowledge gaps.

Decline in youth drinking in high-income settings: Implications for public health in low-income countries

Declining drinking among youth in many high-income countries has attracted scholarly attention and debates. Still, researchers are yet to globalize such research or examine its public health implications for low-resource settings. This commentary has two interrelated purposes. First, using evidence from Nigeria, it highlights how declining youth drinking in high-income countries may impact public health in low-income countries. Second, it highlights the necessity for research to examine youth drinking behaviours simultaneously worldwide. The declining drinking trends among young people in high-income countries have occurred simultaneously with global alcohol corporations being more aggressive in low-income countries like Nigeria. Relatedly, alcohol corporations may employ evidence regarding declines in drinking to argue against implementing stringent policies or other effective interventions in Nigeria (and other low-income settings), claiming their apparent success in the falling drinking trends in high-income settings. The article argues that research on the drinking decline among young people should be globalized because without commensurate attempts to examine their drinking behaviours/trends worldwide simultaneously, public and/or global health may be harmed for the reasons explored in this article.

Framings of risk and responsibility in newsprint media coverage of alcohol licensing regulations during the COVID-19 pandemic in England

INTRODUCTION

Licensing is recognised as a World Health Organization (WHO) 'best buy' for reducing alcohol harms. In response to the 2020 COVID-19 outbreak, many countries-imposed restrictions on outlets selling alcohol to reduce virus transmission. In England, while shops selling alcohol were deemed 'essential', multiple restrictions were imposed on licenced outlets such as pubs and bars. Media reporting of licensing restrictions during the pandemic might have shaped public discourses of alcohol risks and responsibilities.

METHODS

This study aimed to understand how alcohol licensing changes in England were framed in newsprint media. Two hundred and fifty-three relevant articles from UK newsprint publications were identified through the Nexis database, published within six time points between March and December 2020 reflecting key changes to licencing in England. Thematic analysis, drawing on framing theory, was conducted to identify 'problems' framed in the reporting of these changes.

RESULTS

Four dominant framings were identified: (i) licensed premises as 'risky' spaces; (ii) problematic drinking practices; (iii) problematic policy responses; and (iv) 'victimisation' of licensed premises. The presence of these framings shifted across the reporting period, but consistently, social disorder was constructed as a key risk relating to licensing changes over health harms from alcohol consumption.

DISCUSSION AND CONCLUSIONS

The analysis shows newsprint media reproduced narratives of 'inevitable' drinking culture and social disorder, but also emphasised expectations for evidence-based policy-making, in the context of licensing during the pandemic. Discourses of dissatisfaction with licensing decisions suggests potential for public health advocacy to push for licensing change to reduce alcohol health harms, in England and internationally.