1. Did evidence matter for the development of minimum unit pricing of alcohol in Scotland? Lessons from studying the policy process Alcohol Research UK conference, 16 th March 2016 S Vittal Katikireddi E-mail: vittal.katikireddi@glasgow.ac.uk Twitter: @vkatikireddi Senior Clinical Research Fellow in Public Health MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

3. Does evidence matter for policy?

5. Research Utilisation Knowledge-driven – development of knowledge results in the creation of new applications and therefore policies e.g. OCP Problem-solving – Decision-makers face a problem and draw upon evidence to help solve that problem Interactive – back-and-forth dialogue with research one of many inputs into policy process Political – Strengthen an existing position Tactical – to delay decision-making Enlightenment – Conceptual shift in thinking about a policy issue Weiss, C. H. (1979). "The Many Meanings of Research Utilization." Public Administration Review 39(5): 426-431.

6. Alcohol Harms in Scotland Figure: Time trends in age standardised mortality rates for liver cirrhosis per 100,000 between 1950 and 2002 Source: Leon, D. A. and J. McCambridge (2006). "Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data." The Lancet 367(9504): 52-56.

7. Framing the minimum unit pricing debate Katikireddi, S. V., et al. (2014). "Changing Policy Framing as a Deliberate Strategy for Public Health Advocacy: A Qualitative Policy Case Study of Minimum Unit Pricing of Alcohol." Milbank Quarterly 92(2): 250-283.

8. Rose’s Population Strategy Rose, G. (1992). The strategy of preventive medicine. Oxford, Oxford University Press. Smith, K. (2013). Beyond Evidence Based Policy in Public Health: The Interplay of Ideas, Palgrave Macmillan.

9. Moving to a population framing Advocate: [...] what was clear to me in assessing it was the first thing we have to do in order to create a conducive climate that, a climate that would be conducive to discussions about minimum unit pricing, was to change the frame of the alcohol problem. Because the frame of the alcohol problem, which was the industry frame, if you accept that frame of the problem then, you know, you will not support population measures, cos you think the problem is youth binge drinkers or whatever. June 2008: Changing Scotland’s relationship with alcohol – “ Alcohol misuse is no longer a marginal problem […]. That’s why we are aiming, consciously, to adopt a whole population approach. This isn’t about only targeting those with chronic alcohol dependencies […] Our approach is targeted at everyone, including the “ordinary people” who may never get drunk but are nevertheless harming themselves by regularly drinking more than the recommended guidelines. If we can reduce the overall amount that we all drink in Scotland, and if we can change the way we drink, then we will all reap the benefits. ” Katikireddi, S. V., et al. (2014). "Changing Policy Framing as a Deliberate Strategy for Public Health Advocacy: A Qualitative Policy Case Study of Minimum Unit Pricing of Alcohol." Milbank Quarterly 92(2): 250-283.

10. The Sheffield Model Purshouse, R. C., et al. (2010). "Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model." The Lancet 375(9723): 1355-1364. : (10.1016/S0140- 6736(10)60058-X

11. Sheffield model as influential “single most often referred to piece of work” Instrumental roles – targeted nature of policy – level of MUP Govt commissioned – Academic: my experience is that of all the research that’s ever done, I mean, it’s when Government asks and commissions research that it seems to have the most impact, that’s my experience. It often, it’s uncanny, you know. When the Government asks, ‘can you do this research, can you model this,’ and it’s done, then they, it’s fitted neatly into some existing process of decision-making. Katikireddi, S. V., et al. (2014). "Perspectives on Econometric Modelling to Inform Policy: A UK Qualitative Case Study of Minimum Unit Pricing of Alcohol." The European Journal of Public Health 24(3): 490-495.

12. Sheffield as a rhetorical tool BUT often did not appear to change actors’ viewpoints Rhetoric as having “ three elements: logos – the argument itself; pathos – appeals to emotions (which might include beliefs, values, knowledge and imagination); and ethos – the credibility, legitimacy and authority that a speaker brings and develops over the course of the argument ” Logos – Targets those most at risk Ethos – Developed through public and academic validation Pathos – Highlights health as a value Russell, J., T. Greenhalgh, et al. (2008). "Recognizing rhetoric in health care policy analysis." Journal of Health Services Research and Policy 13(1): 40-46.

13. Reasons for the Sheffield model’s influence Answers policy Qs Reputation – Politician: we had was two sets of experts. One for minimum pricing, one very lukewarm suggesting that it may not be worth the efforts, and they just had that debate in front of politicians and Sheffield came out with glowing colours, and that wasn’t a certainty. The reason they came out with glowing colours was because their evidence base was robust, because if it wasn’t robust the other guy would have exposed that. So that was the most powerful thing in terms of our Committee and using an evidence base to say minimum pricing will work. Pathos – Industry: the outward bit is about x number of people will die or not die. And it becomes quite a stark, it becomes quite an emotional debate. And that’s difficult for a, that’s difficult for a retailer to engage in. In that kind of debate. Katikireddi, Srinivasa, Shona Hilton, and Lyndal Bond. "The role of the Sheffield model on the minimum unit pricing of alcohol debate: the importance of a rhetorical perspective." Evidence and Policy (2015).

14. Understanding policymaking Smith, K. E. and S. V. Katikireddi (2013). "A glossary of theories for understanding policymaking." Journal of Epidemiology and Community Health 67: 198-202.

15. A synthesis of the policy process Policy Problem – Change in well-respected indicators highlighted ‘crisis’ – Change in framing helped consider PH approaches Policy – Developed considering powers available – Role of SRs and econometric modelling Politics – Party political change – Smoking ban and willingness for state intervention Kingdon, J. W. (1984). Agendas, Alternatives, and Public Policies. London, HarperCollins. Katikireddi, S. V., et al. (2014). "Understanding the Development of Minimum Unit Pricing of Alcohol in Scotland: A Qualitative Study of the Policy Process." PLoS ONE 9(3): e91185.

16. Implications for alcohol advocacy Need for tailoring evidence to devolved institutions – Benchmarking against other jurisdictions Importance of evidence to achieve a conceptual change – Causal stories and ideas Role of SRs and modelling studies – Often helpful in highlighting values i.e. what’s important Variable support for instrumental use of evidence – Interaction with policymakers might be helpful – Political context is king Katikireddi, S. V. and K. E. Smith (2014). Minimum unit pricing of alcohol in Scotland. Studying Public Policy. M. Hill. Bristol, Policy Press.

17. Acknowledgements Chief Scientist’s Office of Scotland and the Medical Research Council – MC_UU_12017/4 MRC/CSO Social and Public Health Sciences Unit – Lyndal Bond – Shona Hilton – Sally Macintyre University of Oxford/Institute of Education – Chris Bonell University of Edinburgh Katherine E Smith