Minimum alcohol price policies The Canadian Experience in action: The Canadian Experience Tim Stockwell, PhD Director, Centre for Addictions Research of BC Professor, Department of Psychology, University of Victoria Calling Time on Europe's Alcohol Problem, European Parliament, Brussels, Belgium 24 April, 2013

Grateful thanks to Jinhui Zhao, Chris Auld, Gina Martin, Kate Vallance & Scott Macdonald Centre for Addictions Research of BC, Victoria, Canada Gerald Thomas Canadian Centre on Substance Abuse, Ottawa, Canada Norman Giesbrecht & Ashley Wettlaufer Centre for Addiction and Mental Health, Ontario, Canada Bill Ponicki & Andrew Treno Prevention Research Center, Berkeley, USA Jane Buxton & Andrew Tu BC Centre for Disease Control, Vancouver, Canada Canadian Institutes for Health Research (Funding body)

Most of Canada's 11 provinces set minimum prices for alcohol in liquor stores and/or bars

A private liquor store in Victoria, British Columbia

Minimum Pricing: Measures to set a floor price for alcohol In approximate order of effectiveness (low to high): Bans on below-cost alcohol (UK) Fixing a minimum profit margin (US) Setting a minimum retail price per litre of beverage (Canada) Setting a minimum price per unit of alcohol (Scotland)

for Alcohol Price Policies Rationale for Alcohol Price Policies Despite popular beliefs to the contrary… Increased alcohol prices lead to reduced rates of illnesses and injuries associated with heavy drinking patterns

Effects of two tax increases on deaths from alcohol related diseases in Alaska Year Wagenaar et al, American Journal of Public Health, 2009

Alcohol price and tax strategies have strong scientific evidence for effectiveness Summary analyses of all high quality published studies indicate A 10% increase in price leads on average to a 5% reduction in consumption Price increases lead to reductions in hazardous drinking e.g. "binge drinking“ Price increases also lead to reductions in serious alcohol-related injuries and illnesses Minimum pricing is just one variation - theory and evidence to date suggests it is particularly well targeted towards heavy drinkers and should be effective

important for public health policy? Why is cheap alcohol important for public health policy? Heavy drinkers prefer cheap alcohol: e.g. Top 10% of US drinkers by volume spend on average 79c per standard drink versus $4.75 for lowest 50% ie light drinkers Kerr and Greenfield (2007) Greater responsiveness to price changes near lower end of “price-quality spectrum” favoured by higher volume drinkers Gruenewald et al (2006) In theory, minimum pricing might be a particularly well targeted and effective alcohol pricing strategy

A Canadian illustration of Gruenewald et al’s Price-Quality Spectrum: 3 retail prices in $/standard drink (13.45g) Cheapest Median Most expensive 58 cents $3.25 $994

Distribution of sales of 4,275 alcohol products in Ontario by price per standard drink, 2009

Canada is one of 6 countries to have minimum alcohol prices Others are Russia, Moldovia, Ukraine, Uzbekistan, and the US (5 states have minimum mark-ups) Prior to 2012, no empirical evaluations of effectives but influential modeling of likely effectiveness by Meier, Brennan et al for the UK (The Sheffield Model) Canadian provinces are ideal for effectiveness research: many policy changes and excellent data

Do increases in the minimum alcohol prices lead to reduced consumption?

Case Study 1: British Columbia Stockwell, Auld, Zhao and Martin (2012) Does minimum pricing reduce alcohol consumption? The experience of a Canadian province. Addiction, 107(5), 912 – 920. The BC government monopoly has set minimum prices for several decades based on $ rates per litre of beverage NOT per litre of ethanol Only spirit prices have been regularly updated in keeping with the cost of living.

Comparing 2010 minimum prices in dollars per standard drink in British Columbia, Ontario and Saskatchewan Beverage % Alcohol Content BC Official Minimum Ontario Price* Saskatchewan Coolers/Cider 7% $0.73 $1.00 $1.25 Beer 8% $0.75 $1.49 Wine 12% $1.02 $1.41 Fortified wine 22% $0.56 $0.81 $1.04 Spirits (Tequila) 40% $1.35 $1.43 $1.31 Spirits (Rum) 75.4% $0.72 $0.76

Minimum price of different alcohol beverages in CPI-adjusted dollars per standard drink in British Columbia, 1989-2010

Statistical analysis of British Columbia price and sales data Time series analysis of 80 annual quarters of data over 20 years controlling for the effects of: Season Overall trends in data Trends in average alcohol prices Trends in household income Inflation-adjusted minimum prices used to predict volume of alcohol sales for each main beverage

Estimates of minimum price effects for different types of alcohol Percentage decrease in consumption of ethanol for a 10% increase in minimum price: ANY BEVERAGE TYPE VERSUS ALL OTHERS: -16.1%*** Beer = - 1.5%* Spirits = - 6.8%** Wine = - 8.9%* AVERAGE MIN PRICE FOR ALL DRINKS = - 3.4%** *P<0.05 **P<0.01.

Case Study 2: Saskatchewan Evaluation of a public health inspired proposal to increase all minimum prices SIMULTANEOUSLY with higher prices for higher strength beverages [ie similar to MUP] Four strength categories for beer (<6.5% to >8.5%) with minimum prices set between the equivalent of $1.58 and $2.48 per standard drink Two strength categories for wine, 2 for coolers and 3 for spirits

Impacts on Consumption Stockwell, Zhao et al, American J Public Health, 2012

Statistical analysis of Saskatchewan price and sales data ARIMA time series analysis of 52 “financial periods” between April 2008 and March 2012 controlling for the effects of: Season Overall trends in data Trends in average alcohol prices Trends in household income Inflation-adjusted minimum prices used to predict volume of alcohol sales for each main beverage

Estimates of minimum price effects for different types of alcohol Time series ARIMA models indicate: A 10% increase in average minimum price associated with 8.4% reduction in consumption Stronger effects for off premise then on premise sales Stronger effects for higher alcohol strength varieties of beer, wine and cocktails

Do increases in the minimum alcohol prices lead to reduced alcohol-related harm?

Statistical analysis of British Columbia price and harm data Mixed model regression analysis of 32 annual quarters of data between April 2002 and March 2010 for 89 health areas controlling for the effects of: Season Overall trends in data Densities of liquor outlets Trends in household income Inflation-adjusted minimum prices used to predict rates of alcohol attributable hospital admissions

Impacts on Harm I Stockwell, Zhao et al, American Journal of Public Health, 2013 Model predicts a 10% minimum price increase is associated with a 9% drop in admissions (p<0.01)

Estimated impacts on alcohol attributable hospital admissions % Change in alcohol attributed admissions with a 10% increase in average minimum price: Type of hospital admission Immediate impact Delayed impact after 2 years Acute -8.95% ** -1.67% Chronic -5.31% -9.22% * *P<0.05 **P<0.01. Stockwell, Zhao et al (2013) American Journal of Public Health, April 18

Impacts on Harm II Zhao et al, Addiction, 2013

Estimated impacts on alcohol attributable deaths % Change in alcohol caused deaths associated with a 10% increase in average minimum price. Type of admission Immediate impact Delayed impact after 2 years 100% Alcohol -31.72%* -9.26% Chronic -0.81% -19.85% ** *P<0.05 **P<0.01. Zhao, Stockwell, Martin, Macdonald, Vallance, Treno, Ponicki, Tu and Buxton (2013) Addiction

Misleading and false industry criticisms We only found effects for “hypothetical” alcohol related deaths using the attributable fraction method Deaths in BC actually increased during study period We only had 16 data points in BC harm studies We ignored liver cirrhosis deaths

The Sheffield Model makes conservative estimates of health outcomes for British Columbia (pop. 4.4 million) Comparative estimates of health outcomes of an increase in the average Minimum Price in BC from CA$1.15 to CA$1.50/Standard Drink [Equivalent to £0.43p to £0.55p per UK Unit] Health Outcome Immediate Delayed Sheffield Model CARBC Studies Sheffield Model [10 years] [2 years] Change in Alcohol Attributable Deaths (N) 39 100 56 276 Change in Alcohol Attributable Hospital Admissions (N) 244 1432 610 1893

Some Conclusions Gruenewald et al’s theory is likely correct and minimum pricing per standard drink may be the most targeted, feasible and acceptable variant of the most effective alcohol policy: increasing the real price of alcohol Canadian studies suggest the Sheffield Model underestimates the health benefits of Minimum Unit Pricing for the UK Replication studies in other jurisdictions are required See: Stockwell and Thomas (2013) Is alcohol too cheap in the UK? Institute for Alcohol Studies, London, UK, 24 April.

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