Home Affairs Committee

Oral evidence, 22 January 2018.

Witnesses

Rosanna O'Connor, Professor Sheron, Sgt Urwin, Professor Gilmore and Professor Garde.

Chair

Good afternoon. Thank you all for attending our panel for the examination of minimum unit pricing. For those who are following from outside the room, it would help if you could start by introducing yourselves and whom you represent. First, Tim Loughton would like to make a statement.

Tim Loughton

It is a declaration of interests. Although I have no remunerated interests, I am chair of the all-party parliamentary group on wine and spirits, for which the WSTA is the secretariat.

Chair

Thank you. Can we start with Professor Sir Ian Gilmore?

Professor Gilmore

I am Ian Gilmore. I am a physician and liver specialist from the University of Liverpool. I came to this from the point that 80% of my patients with cirrhosis were dying because of alcohol. I helped to set up the Alcohol Health Alliance 10 years ago. We now have more than 50 organisations, all concerned about the impact of alcohol on health. They include nurses, midwives and every other group you can think of. Our primary principle has been to produce evidence-based policy, so minimum unit pricing became a very early priority of ours. We had the roller-coaster of 2012, when we thought that it was coming, and then it was not. Another key priority has been harm to third parties—to victims of violence and children. I hope that we will get a chance to discuss both of those.

Chair

You are here representing the Alcohol Health Alliance.

Professor Gilmore

Yes.

Chair

Professor Garde?

Professor Garde

I am Amandine Garde. I am from the University of Liverpool, where I am professor of law. I set up the law and non-communicable diseases unit, which looks at how evidence-based policies can best be framed to withstand potential challenges by the alcohol, food and tobacco industries. In particular, I have worked a lot with the World Health Organisation and UNICEF on children’s rights-based approaches to marketing to children.

Sgt Urwin

I am Sgt Mick Urwin, from Durham Constabulary’s harm reduction unit. I am here in my capacity as the co-chair of the National Police Chiefs Council licensing group. Therefore, I am representing the National Police Chiefs Council.

Rosanna O'Connor

Good afternoon. I am Rosanna O’Connor. I am Public Health England’s director for alcohol, drugs and tobacco.

Professor Sheron

I am Nick Sheron. I am a liver doctor in Southampton. I am also a clinical adviser to Public Health England.

Chair

Thank you. Can I start by asking you to set out where you see the key benefits of introducing minimum pricing would be, both for health and for the criminal justice system?

Professor Gilmore

I am sorry if in my introduction I gave rather more than you wished about where the Alcohol Health Alliance is coming from. As I said, it is very much an evidence-based group. What has become evident over the years is that price is the biggest single driver of how much a society drinks and how much harm it gets from alcohol. Price is absolutely key. Within price, the evidence has become very strong—even stronger than it was in 2012—that, unlike taxation, it is targeted at those who are most vulnerable: the heaviest drinkers, the lowest socioeconomic groups and children. They are the ones who gravitate to the cheapest alcohol, which is hit by minimum unit pricing, whereas there is virtually no impact whatsoever on the on-trade, on the price of a pint of a beer in a pub. It is really about going for the drinks that we know are favoured by those who are most vulnerable, particularly white ciders and very cheap own-label spirits like vodka.

Chair

How will that translate into public health benefit? Rosanna O’Connor and Nick Sheron may want to comment on that.

Rosanna O'Connor

On the public health benefits of MUP?

Chair

Yes.

Rosanna O'Connor

Every year, 16,000 people die from alcohol-related harm. It costs the country a minimum of £21 billion annually. The evidence shows very clearly the link between price, consumption and harm, and that reducing the price is the most effective way of reducing harm. Minimum unit price targets the cheapest, high-strength alcohol. Therefore, it is specifically aimed at having the greatest impact on the heaviest daily drinkers. Evidence shows that, if you put up the price, it is the most cost-effective way of reducing harm. Obviously, there are two ways you can increase price; one is through taxation, and the other is through minimum unit price. The benefit of minimum unit price is that it is exquisitely targeted at the heaviest daily drinkers, who are drinking cheap, strong alcohol. Let’s not forget that, beyond the individual drinker to whom cheap, strong alcohol causes so much harm, there is a significant impact on the people around that drinker—on the family and children of dependent drinkers. There is a massive burden on the NHS, with something like 1 million alcohol-related admissions a year. While we sit here, during the hour you have allotted for us, there will be something like 114 alcohol-related admissions to the NHS. There is also the impact on the criminal justice system and the enormous cost to the economy.

Chair

Professor Sheron, could you talk a bit more about the impact on emergency departments and the departments you have been involved with in your clinical profession?

Professor Sheron

I am a liver specialist. Pretty much all liver-related admissions come through emergency departments, because people do not realise that they have liver disease until they are admitted as an emergency, with bleeding oesophageal varices or because they are bright yellow or have a big yellow tummy. Eighty per cent of those deaths are alcohol-related. If you go into our emergency department in Southampton on a Friday or Saturday night, you will find that the vast majority of people there are suffering as a result of over-misuse of alcohol. The mortality from alcohol splits into four categories. There are people who run into trouble because they get too drunk. Those tend to be young people. They tend to be the ones who suffer from traffic accidents and violence, and who end up in emergency departments. About a quarter of the deaths are due to liver disease. They occur in middle-aged people. I did a ward round a couple of weeks ago. It took me five hours. A third of my patients were under the age of 40. The average age of death from liver disease is the early 50s. If you die at 30, that is 35 years of working life lost. For years and years, the leading cause of death has been ischemic heart disease—heart attacks. The likelihood is that liver disease will overtake that in the next two or three years, because liver disease mortality has been rising so much. The third category is hypertension, which tends to affect older people, while a quarter is due to cancer. Alcohol has its fingers in many pies. The workload on emergency departments is the visible side of that, but a lot of the harm is invisible harm.

Chair

Sgt Urwin, could you talk in your role about where you see the benefits of minimum pricing would be in the criminal justice system and the work of frontline officers?

Sgt Urwin

Obviously, the impact of alcohol is a significant demand on policing per se. Around half a million violent crime offences committed in the last year—40% of violent crime—were alcohol-related. We see minimum unit pricing as affecting three main areas that concern us. One is preloading. We now see as a regular occurrence on Friday and Saturday nights young people coming out having had too much to drink already, because they have drunk cheap alcohol that they have purchased from off-licences before going on a night out. They turn up at bars already drunk, so they are refused entry. That can be a flashpoint with door staff. They are then separated from their group of friends and either left to fend for themselves and get themselves home or to wander off into the darkness. That creates its own vulnerability issues. Likewise, we are seeing our night-time economies become quieter. Licensed premises are closing, because they cannot compete with the off-licences. Secondly, we see it from an under-age drinking point of view. Regularly, week in, week out, we take alcohol off young people who are under the age of 18. We take large quantities of cheap cider of young people; it costs them about £3.70 for 3 litres that contain 20-plus units. They are having one of those each. That causes tremendous issues around vulnerability and safeguarding. Because we are very proactive, young people find more ways of hiding and go to more secluded, vulnerable areas—by rivers, by woods—out of the way. They are not causing particular antisocial behaviour issues, because they cannot be seen, but they are putting themselves in very vulnerable positions, especially around sexploitation. They are being exploited as a result of that. The third issue is around street drinking. Our street-drinking population tend to cause lower-level crime and antisocial behaviour. They drink very similar products to the under-age drinkers—high-volume ciders, in large quantities. We do not see minimum unit price as a way of eliminating that, because it is not a silver bullet. It will not stop under-age drinking, street drinking or preloading, but it might reduce the quantities that are involved when people go on a night out or that under-age drinkers are consuming.

Chair

What about the impact on your frontline staff in terms of assaults or the behaviour of people they are trying to assist?

Sgt Urwin

Forty per cent of officers say that they have experienced sexual assault or harassment while dealing with alcohol-related issues, certainly in the night-time economy. Having to police and deal with those incidents puts pressures on the service, bearing in mind austerity and reduced resources. The number of incidents we deal with may be a small proportion, percentage-wise, of all incidents we deal with, but the issue is the amount of time it takes up. If you are dealing with someone who is drunk, you cannot investigate the offence they have committed until eight or 12 hours later. That is time in custody and time of the investigating officer. The issues around safeguarding and vulnerability put a lot of pressure on existing case loads. You are unable to investigate effectively because people have had too much to drink.

Chair

What about the impact in other areas, such as domestic violence? How big an impact does alcohol have in that area?

Sgt Urwin

The statistics will tell you that about 40% to 50% of domestic violence is alcohol-related. As a frontline officer, I would say that it was nearly double that—nearer 90%. Either you have an offender who uses it, and it is a mechanism to start the abuse, or you have a victim who is using it as a coping mechanism. We see alcohol in vast numbers of our domestic violence cases.

Chair

Professor Garde, one area that is of interest to the Committee is how much more evidence we have now, either way, since 2013, when the policy was dropped after it had been proposed that the Government take it up?

Professor Garde

We have had the Sheffield study. Some colleagues on the panel will be best placed to analyse that evidence and its quality. We know that the introduction of minimum unit pricing in Scotland has been held compatible with European Union law, so we have quite a lot of certainty that, although the introduction of minimum unit pricing may cause some European trade discussions, it does not constitute an unjustified barrier to trade. We have plenty of evidence both from the judgment of the Court of Justice of the European Union of 23 December 2015 and from decisions in the UK, particularly the decision of the UK Supreme Court of 15 November 2017. I can expand on the various tests, but one thing I would like to mention is that there has been clear confirmation at European level that member states, or parts of a member state, are responsible for the protection of the health of their citizens and can set the level of protection they want to achieve, as well as the means they choose to use to achieve those objectives. Interestingly, the Court of Justice, as well as the Supreme Court, has been very clear that member states can experiment. If you have a measure that is reasonably likely to contribute to an alcohol strategy and a specific objective of reducing the consumption of alcohol by hazardous drinkers, member states can experiment with that measure.

Chair

We will now explore the evidence around this in some detail, starting with Paul.

Dr Williams

Professor Gilmore, I would like to explore the evidence on exactly what effect minimum unit pricing would have, first, on harmful drinkers. I would also like to look at the evidence around what effect it would have on moderate drinkers.

Professor Gilmore

That is a really important question, because there is a myth out there that heavy drinkers are dependent and, therefore, are immune to the influence of price, and would continue to drink the same amount if the price went up, but would take to crime to feed their habit. The evidence is actually to the contrary. The evidence that has been worked out in great detail, particularly by the Sheffield group, and by others, is that heavy drinkers are more price sensitive than moderate drinkers. They spend so much anyway that they gravitate to the cheapest forms of alcohol. We are not looking to stop people drinking. Clearly, if someone is alcohol dependent, many psychiatrists would wish to move to a situation where they were not drinking at all. We know that someone who is drinking heavily—perhaps two, three or four bottles of wine or a couple of bottles of spirits a day—is significantly improved by cutting that down. Improvements in health do not come just from total abstention; getting a heavy drinker to cut down from 4 litres to 2 litres of wine a day will bring about very significant health gains. That is setting aside the situation for heavy drinkers. They are price sensitive; they are probably more price sensitive, because they are counting their pennies to feed their addiction, if they are alcohol dependent.

Dr Williams

That evidence comes from modelling. Is that right?

Professor Gilmore

First, modelling is based on real-life figures. They have access to all sorts of data—sales data, health data, ONS data and so on—which can be split by socioeconomic group. There are many instances where price has changed for various reasons, or come down. When its neighbour, Estonia, was coming into the EU, Finland cut duty and saw harm increase. There are situations like the minimum floor price in provinces in Canada that are very much analogous to minimum unit price and where they have seen an impact on heavy drinkers. It is not just abstract modelling. There has been a tendency to paint the Sheffield data as being an entirely hypothetical situation. It is not. It is looking at real-life changes over the years in consumption and harm. Modelling inevitably looks forward and predicts what will happen with something like minimum unit price in this country, in various communities where it has not been before.

Dr Williams

I am sorry, I interrupted you. You were about to talk about the impact on moderate drinkers.

Professor Gilmore

Yes. That is really important. As has been said already, there is virtually no impact whatsoever on the price of drinks in bars, clubs and the on-trade. That is important, because we do not want to see pubs close. They have a social value, particularly in rural communities, but, with the differential between the on-trade and the off-trade widening hugely over the last 20 years, we have turned from a country of people drinking in pubs and bars into a country that drinks 80% of everything except beer at home. The majority of beer is now drunk at home, whereas 20 years ago it was probably about 10 pints of beer in a pub for one pint at home. That has been a big change, but the change is all in what people buy in the off-licence. We know that moderate drinkers do not buy as much cheap alcohol as heavy drinkers. It has been calculated that the financial impact of a minimum unit price for a moderate drinker who is not well off would be something like £1.32 a year.

Dr Williams

What about if I buy a couple of bottles of wine a week from Aldi or Lidl? Will minimum unit pricing not increase the cost of those bottles of wine?

Professor Gilmore

It depends on which wine you choose from Aldi. They do not just sell things at £3.50 a bottle. The change would come in at about £4.70 a bottle. A bottle costing less than £4.70 would rise in price, but even at supermarkets that may attract people looking for cheap alcohol more, that is still in the minority of their products.

Dr Williams

Rosanna O’Connor, is there anything you would like to add about the impact of minimum unit pricing either on harmful drinkers or on moderate drinkers?

Rosanna O'Connor

I would like to echo some of what Ian said. The thing about minimum unit price is that it is exquisitely targeted at people who are drinking the strongest, cheapest alcohol. That is a staggeringly small group of people. About 4% of the population drink just under a third of the alcohol consumed in the country. It is about 2 million people.

Dr Paul Williams

Wow.

Rosanna O'Connor

I thought wow as well, when that emerged from our evidence review. We are talking about a small—

Chair

Four per cent of the population are drinking a third of the alcohol.

Rosanna O'Connor

Yes.

Professor Sheron

It is 4.4%.

Rosanna O'Connor

Yes. I am rounding the figures. The third is 30-something per cent.

Chair

It is quite a staggering figure. It would be nice to be clear about that.

Rosanna O'Connor

It is a staggering figure. It is in the evidence. It is just over 4% of the population drinking just under a third of the alcohol. We are talking about a small group of people, whose daily heavy drinking of these very cheap, strong ciders, mostly, is doing them so much harm. If on your way home you stop and have a pint in a pub—

Dr Williams

Dry January, I am afraid.

Rosanna O'Connor

Okay. I will need a drink as I go home from here tonight. If I stop for a £6 bottle of wine, it will cost exactly the same the other side of a 50p MUP, as will a drink in a pub in February. What will change is the very low-priced alcohol. A very low-priced bottle of cider, for example, that costs around £3.60 now for 22.5 units of alcohol would cost just over £11 on the implementation of a 50p MUP. The result would be a significant impact on a small group of people. That is why it is such a targeted policy, for such great health gains.

Dr Williams

I can see the impact on own-label spirits, for preloading, and on cider, for street drinking, but what about the effect on a low-income, moderate drinker? There will be some benefits from this for heavy drinkers; hopefully, their behaviour will change. We do not want them to spend more money; we want them to change their behaviour, but the criticism is that the cost will be borne by low-income, moderate drinkers.

Rosanna O'Connor

The cost—other than a minimal cost—will not be borne by low-income, moderate drinkers. I think I am right that the modelling shows that, for a moderate drinker, the increase is likely to be about 20p a month, at 50p minimum unit pricing. At 60p, it is likely to be about 61p a month, or £7 a year.

Dr Williams

Is that because moderate drinkers are not drinking these cheap brands—the own labels and ciders?

Rosanna O'Connor

They are certainly not drinking them at the rate at which the heavy daily drinkers are drinking them. Nick may be better on this. The number of units that people who come into his services are drinking is quite staggering.

Professor Sheron

This has been modelled by the Sheffield group. The very low figures are because people from low-income groups do not drink much alcohol in the first place. When they do, they drink some of their alcohol in pubs and some at home. Later you will speak to the IFS, which has modelled this. If you look at the cost to someone drinking exactly 14 units—in other words, at the borderline of the safe guidelines—and buying alcohol below the minimum unit price, the average impact for a wine drinker would be £1.26 a week. For a spirits drinker, it would be the same. For a lager drinker, it would be almost £2.

Dr Williams

A week.

Professor Sheron

Yes, per week. For a cider drinker, it would be about £3 a week. These are people drinking 14 units, which is the maximum. The absolute maximum impact is for somebody like my patients with alcohol-related cirrhosis, whose average consumption is 120 units a week. That is the median. The mean is higher; it is 150. A typical Frosty Jack’s drinker drinks 16 litres of that and pays about £20 for it. That would go up threefold. Instead of paying £20, they would pay nearly £70.

Dr Williams

Or, on the other side, they would still spend £20, but they would get fewer units of alcohol.

Professor Sheron

In fact, rather than drink 7.5%-by-volume cider, they are likely to drink cider that is 3% or 4% by volume. If they go down to 3%, they can drink 13 litres. It is not that they are not drinking at all. They do not have to stop completely, but they have to cut their alcohol intake substantially.

Dr Williams

If you are a moderate drinker and are drinking 14 units a week, on average, the cost of this to you will be just over £1 a week.

Professor Sheron

It is somewhere between £1 and £2—about the same as a Costa coffee a week—if you are drinking 14 units. It is not that it does not have an impact on low drinkers; of course it does. The IFS data suggest that it will impact on about 70% of alcohol sold in the off-trade. The average price of beer sold in the off-trade is 48p, and it will go up to 50p. It has an impact, but a very small one. However, it has a very significant impact on my patients with cirrhosis. Bear in mind that there is a threefold to fivefold excess of people in the lowest socioeconomic group among those patients. That harm is felt overwhelmingly in poor communities. As a result of that, MUP has a much greater effect, in terms of harm reduction, in lower socioeconomic groups. It reduces the social gradient and health inequalities much more than other mechanisms. That is really important.

Chair

Ian, is there anything you want to add about the health inequalities aspect of the policy?

Professor Gilmore

I just want to emphasise that it is really important. I woke up to this when I was lucky enough to be a commissioner on Michael Marmot’s review for the Prime Minister about five or six years ago. It really came home to me how the impact of alcohol harm is disproportionately focused on the poorest in society.

Chair

We will come on to some challenge now from Ben.

Mr Bradshaw

We all want to reduce alcohol-related harm; the question this Committee has to answer is whether minimum unit pricing is the best way of doing so. Do you accept the official statistics that alcohol consumption in Britain has fallen by a fifth in the last 15 years, even more dramatically among young people, and that alcohol-related crime has fallen by 40%? I assume that was a yes, because you did not challenge it.

Professor Gilmore

No. We would like to—

Mr Bradshaw

Do you want to challenge the official alcohol consumption figures?

Professor Gilmore

Those are the overall figures. What I would like to challenge is who is doing the drinking and the harm that is seen.

Mr Bradshaw

That was not my question. Thank you for—

Professor Gilmore

There have been different falls for different populations within that.

Rosanna O'Connor

I was going to say, because you invited us, that the last survey of young people smoking, drinking and taking drugs showed a slight upturn in their use, but that is not a trend.

Mr Bradshaw

No, not on alcohol, where the figures have fallen very dramatically over the last 15 years. The reason why I put the question is that in some of the evidence we have seen people were claiming that alcohol consumption as a whole has gone up. That is simply wrong; it has fallen dramatically. Could you also confirm that the real price of alcohol has not fallen, as some of the evidence presented to us claimed? It has actually risen by 23% more than RPI since 1980, and the UK pays 40% of all the alcohol duty in the European Union. Do you want to challenge that? No; that is fine.

Rosanna O'Connor

Hang on.

Professor Sheron

Are you talking about the affordability of alcohol?

Mr Bradshaw

No, the real price of alcohol, compared with the retail price index.

Professor Sheron

The real price of alcohol is its affordability. You have to take into account the price of alcohol, the retail price index and people’s incomes.

Mr Bradshaw

And wages.

Professor Sheron

And wages.

Mr Bradshaw

Based on that, you would like to claim that the real cost of alcohol has fallen since 1980.

Professor Sheron

The affordability of alcohol has increased since 1980. The data were submitted in our written submission. You see the different lines here as the affordability of different types of alcohol. That increased until 2008. I do not know whether you can see it. I have copies.

Mr Bradshaw

What has happened since 2008?

Professor Sheron

In 2008, the then Chancellor introduced the duty escalator, and we had the economic downturn. The affordability of alcohol fell, and liver and alcohol-related mortality fell with it. Those duty changes were reversed in 2013, and the affordability of alcohol started to increase again. Alongside that, alcohol-related mortality has increased. I can circulate that graph.

Rosanna O'Connor

It is in the submission.

Chair

Nick, can I point out to you that, when you show us a chart like that, it does not appear on the official record? If you are quoting from a paper, could you give us your reference for the paper?

Professor Sheron

I am sorry. This is in the Public Health England Lancet paper of last year and the Public Health England Lancet report. It is peer-reviewed evidence.

Rosanna O'Connor

From 16 December.

Mr Bradshaw

It was not in our dossier of evidence. If you would like to submit it to the Committee, we can compare it with the other data we have been given, which completely contradict it.

Professor Sheron

The Lancet paper was submitted as an attachment to the PHE written evidence.

Mr Bradshaw

I beg your pardon; I did not see that.

Professor Sheron

You have this paper.

Mr Bradshaw

Okay. It was not in the version that I was sent, but there we are.

Rosanna O'Connor

We can recirculate it.

Mr Bradshaw

Thank you. Do you accept that minimum unit pricing will affect all drinkers, including moderate drinkers, and those on low incomes most? The IFS is quite clear in its evidence to the Committee. It says that most off-trade will be affected by minimum unit pricing. That means that all drinkers, in essence, will be affected. If you are on a low income, your real income has fallen dramatically since 2008, so you are the ones who will feel it most.

Professor Sheron

That is the question that I just answered. I said that the impact on somebody drinking 14 units a week would, on average, be between one and two quid a week—about the price of a cup of coffee.

Mr Bradshaw

Are you quoting the Sheffield study?

Professor Sheron

I am quoting the IFS study. My extreme drinkers—my patients with cirrhosis—are 1.3% of the population. By the way, people drinking more than 75 units drink 14% of all the alcohol. The impact on them is very considerable. It is absolutely correct to say that there is a small impact on low-risk drinkers. Because they are not drinking very much, it is a very small impact. If you are drinking at the much higher levels that are typical of my patients in hospital—the ones who have seen a fourfold increase in mortality—the impact is much greater. It impacts only on alcohol in the off-trade. It does not affect the price of a pint in a pub anywhere.

Mr Bradshaw

We know that. I raised the issue because I was slightly concerned that the Sheffield study, which you often and repeatedly refer to, defined moderate drinkers as those consuming 5.5 units a week. I do not think that is many people’s idea of a moderate drinker.

Professor Sheron

Can I come back to that? That is the average consumption of people in that socioeconomic group, from survey data. The data that I am giving you from the IFS is for people consuming 14 units a week—people who are absolutely on the cusp. They are representative of the people you are talking about, who are not drinking five units a week, but are drinking the very most that they should, within safe guidelines.

Mr Bradshaw

I do not think 5.5 units is most people’s idea of a moderate drinker, but there we are. We will have to agree to disagree.

Professor Sheron

That is from the surveys.

Mr Bradshaw

Professor Gilmore, a moment or two ago, you said that you thought that the best and most powerful effect would be on dependent alcoholics, essentially. Again, you based that on the Sheffield study, as I understand it, not on real life. If you talk to people who are involved in alcohol treatment programmes, they tell you that, if the most alcohol-dependent people cannot afford alcohol, they will do anything to get a drink; they will do drugs, steal or go without food. Do you not think that there is evidence that would support their argument that a far better thing to do, if you want to tackle problem drinking, is to tax it, where the revenue comes to the Government, and to spend that money on alcohol treatment programmes, which have been cut dramatically under this Government?

Professor Gilmore

You may be surprised to know that I, too, have experience of real life. I have looked after patients with alcohol problems for 40 years. I have worked hand in hand with alcohol treatment centres for those 40 years, and I dispute that what you are saying is the normal experience of those people. One of the problems that we have with alcohol is the mindset that people are incurable and are revolving-door patients in A&E. Of course, you only see the ones who come back, not the ones who respond to treatment. Treatment is very successful at all levels of dependency. It is more cost-effective than many of the things we do; I could talk about the treatment of cholesterol, blood pressure and other things, so I refute your basic premise.

Mr Bradshaw

You deny it. You do not refute it.

Professor Gilmore

I am sorry; I deny it.

Mr Bradshaw

Thank you. You did not answer my question about minimum unit pricing. One of the questions that I have about this is that with minimum unit pricing, unlike alcohol duty, the money goes straight to the retailers and the producers. The Treasury does not get any of it to spend on alcohol treatment. Would it not be far better to use duty and taxation than to use minimum unit pricing, both in terms of its effects, which I will come to in a second with Rosanna, and in terms of its revenue-raising potential to do some good in alcohol treatment?

Professor Sheron

That is not correct. MUP raises income to the Treasury, through VAT. I had a discussion with the Treasury lead on excise duty, Chris Evans, about it this morning. It has a neutral impact on revenue. You are absolutely correct to say that, if you increase taxation, it increases revenue. The Government have given away £4.695 billion in tax cuts to the drinks industry since 2013 by reducing tax on alcohol, but MUP is tax-neutral. A combination of MUP and, for example, a duty escalator would raise a considerable amount of revenue. That is what we would recommend.

Professor Gilmore

Yes. They are not mutually exclusive. If they had the same health impact, we would recommend duty. As you well know, Scotland looked hard at this, and whether they could have some form of windfall tax on industry to bring the money back. I fully agree about the woeful state of treatment services.

Mr Bradshaw

It would be very helpful if we could see the data you have just referred to, Professor Sheron, about MUP raising as much money for the Treasury as taxation and duty. I am slightly sceptical about that.

Professor Sheron

I am sorry, but that is not what I said. I said that MUP is tax-neutral, because of the increase in VAT. That is in the Sheffield modelling data.

Mr Bradshaw

Ah, Sheffield again.

Professor Sheron

A combination—

Mr Bradshaw

I will come on to the Sheffield data in a minute.

Professor Gilmore

The Treasury itself looked at this in 2011-12. Their opinion was that it would not be disadvantageous.

Mr Bradshaw

Rosanna, I was very interested in what you said earlier. You used the term “exquisite” twice to refer to minimum unit pricing. In Public Health England’s review of evidence for this Committee, you make it quite clear in paragraph 113 that “taxation or duty is the best way to reduce alcohol-related harm.” That is a direct quote from your evidence. You say that that is where the evidence is “strong and consistent” and that minimum unit pricing has only moderate evidence backing it. As you yourself say, that is based entirely on Canada, which, as I am sure you know, has a completely different system, and the evidence from Canada is very strongly contested. I do not quite understand why your evidence to the Committee orally has been so different from your written evidence, which made quite clear that duty and taxation were by far the most effective way of tackling alcohol-related harm.

Rosanna O'Connor

In our evidence review, we found that price is one of the strongest measures that will impact on consumption and harm. If we were to suggest two ways forward, we would recognise that MUP was not a silver bullet and that a combination of taxation and minimum unit price was probably best. Your session this afternoon is on minimum unit price. I referred to that as exquisitely targeted, because it is targeted just at those people who are drinking a large amount of strong, cheap alcohol, and doing so—

Mr Bradshaw

You have made that point before. We are discussing minimum unit pricing—not just the arguments for it, but the potential arguments against it. That is why I quoted from the evidence that you yourself submitted to this Committee.

Professor Sheron

Can I—

Mr Bradshaw

Please do not interrupt me. Your own evidence says quite clearly that using taxation and duty is a far better way of tackling alcohol-related harm than using MUP. That is the case. That is what you put in your evidence, isn’t it?

Rosanna O'Connor

Yes. Your quotation of it is interesting. I want to ask Nick to come back on the differences between the ways in which different pieces of evidence were used in the report.

Professor Sheron

I was the lead author of the report. It is absolutely correct that there is a mass of evidence for the impact of fiscal policy—taxation—on alcohol-related harm. MUP is a relatively new concept. It originated as a workaround to the fact that Scotland did not have powers to levy duty; I was actually on the committee that came up with it as an idea. The evidence behind MUP specifically is considerably less well developed than the evidence for taxation. The specific question of taxation versus MUP was the key point that was discussed by the Supreme Court verdict. Their unanimous verdict, looking at the evidence, was that there was no doubt in their mind that, even though MUP is a relatively recent thing—you are absolutely correct; there is modelling evidence and evidence from Canada, and that is about it—it is far more likely to be effective in reducing alcohol-related harm, because it does not put up the price of alcohol across the board, it does not increase the price of alcohol in pubs and clubs, and it is targeted at cheap alcohol. Time will tell whether or not that is the case. In terms of the overall mass of evidence, what you say is correct. The quality of evidence for taxation is higher than it is for MUP. That is why we rated that evidence only as moderate in the evidence review.

Professor Garde

Can I add something on this specific point? When you assess the proportionality of a measure, which is exactly what was at the heart of the litigation, both at European Union level and at UK level, the question is whether the measure is necessary. The necessity review requires that you compare policy alternatives. There was quite a lot of discussion in the cases about whether or not taxation and MUP were alternatives. As Nick started to discuss, the UK Supreme Court was convinced by the evidence put forward by Scotland that taxation was not an alternative to MUP, which was a more specific and targeted measure. It is very difficult to compare and present two options that should be complementary in an overall alcohol reduction strategy. They are not alternatives; they are different.

Mr Bradshaw

That is fine. Courts rule on law; we decide on policy efficacy, which is not necessarily always the same. You have all referred to the Sheffield study, in one way or another. I have two short questions.

Chair

Andrew was going to explore the Sheffield study.

Mr Bradshaw

Yes. I have an initial question on that, if you do not mind. Do you accept that the Sheffield study has been challenged, and that it has not been replicated or reviewed by anybody else?

Professor Gilmore

When you say that it has not been reviewed, do you mean—

Mr Bradshaw

I mean that it has not been replicated or reviewed by anybody else.

Professor Gilmore

To my knowledge, all its publications have been peer-reviewed by independent experts.

Mr Bradshaw

But it has not been replicated by anybody else. It is a single study.

Professor Gilmore

They have done many studies, in many countries. For example, they have looked at how their modelling measures up to what actually happened in Canada, to see whether there is an opportunity to compare their prospective modelling with what actually happened. There was very close correlation, and it is being reviewed.

Mr Bradshaw

Do you accept that what has happened in some provinces in Canada is not the same as what is being proposed here, in that it is not based on alcohol levels and the industry in Canada is state-run? The claims made for the Canadian findings are also very strongly contested.

Professor Gilmore

Yes, I know. They are particularly contested by the drinks industry.

Mr Bradshaw

Not just by the drinks industry, actually.

Rosanna O'Connor

The evidence in our evidence review, which was published in December 2016, was the most rigorously peer-reviewed publication that PHE has published, just because we knew that it would be contested. The work that Sheffield did for us in modelling MUP at different levels, because we needed the best available advice to give Government, was heavily peer-reviewed: internationally, then at national level, and then again by The Lancet, before they published. We must not dismiss modelling as just modelling, as if it is something inferior. It is the way in which the Treasury develops fiscal policy. In fact, the evidence from Canada suggests that the Sheffield modelling has been very conservative.

Mr Bradshaw

That is one claim that has been made about the Canada experience.

Chair

Andrew has some other points about the Sheffield studies.

Andrew Selous

We have obviously had some challenge on the basis of the evidence. The three academics on the panel have quoted the evidence from Canada and Sheffield in favour of minimum unit pricing. Is there more evidence that you think is needed? Are there more studies that should be undertaken? Obviously, you are using what is out there. As academics, you have come to a conclusion on that. In your normal practice for reviewing evidence, would you typically expect to have more or better evidence to come to that type of conclusion?

Professor Gilmore

Different levels of evidence are used in different contexts. Quite often, Government policy is made in an evidence vacuum. It is not always possible to get evidence. We certainly support the principle that Scotland will look at it again after five years, with a so-called sunset clause. Whatever is done, in any country, must be very carefully evaluated. We would encourage England and Westminster to adopt a minimum unit price now. We think it is timely and would fit very well with Wales and Scotland, but we would want to see it evaluated. If we wait five years to see what happens in Scotland, the best evidence we have is that more than 1,000 extra people will die.

Andrew Selous

I will come to what else we may see from Scotland in a second, but I want to press you again on that point. I am probably looking at the three academics on the panel; I will come to Professor Sheron first, perhaps. Is it your opinion as independent academics that, based on the quality, the robustness and the amount of data that we have from Canada and from the Sheffield study, there is enough sound evidence to come to a conclusion in favour of MUP?

Professor Sheron

There is absolutely enough evidence, in my opinion. The key thing is that the principle that if you put up the price you reduce alcohol-related harm has been proven beyond doubt, in thousands of studies. The specific question of the Sheffield modelling is, how many deaths do you prevent by putting MUP up by a certain amount? That is modelling; it is an estimate. I spoke to Sheffield about it this morning. They have taken the most conservative figures. There is a range of elasticities. By elasticity, I mean the amount that alcohol consumption falls in response to an increase in price. Those are figures released by the Treasury. Sheffield has taken the lower elasticities in the range. For the connection between consumption and alcohol-related harm, they have taken conservative figures. In my opinion, they are probably under-calling the impact of MUP. Look at the impact of the 2% duty escalator. Alcohol-related deaths were going up by 8% until 2008. When the duty escalator was introduced, there was an immediate downturn in alcohol-related deaths. When the duty escalator was repealed, there was an immediate upturn. The overall difference in those deaths per year was about 300 in England and Wales, for a 2% increase in price. Sheffield models about that for total deaths, so it is probably quite conservative. I absolutely agree with you that, in terms of the precise impact on economics, crime and deaths, we do not know the answer; Sheffield is an estimate. Will it reduce deaths, crime and the rest of it? Yes, undoubtedly. There is absolutely no doubt about that. More and more data will come in. It will be introduced in Scotland before England and Wales, so we will see a fascinating natural experiment, where things diverge, and the data will get better. At the moment, it is beyond doubt that it is going to work. The question is, how well will it work?

Andrew Selous

I understand from the clinicians on the panel that you see the urgency week by week in your consulting rooms, and in the number of deaths, and so on, which you have referred to. If we are able to suspend that for a moment, which I know we are not, is there any further evidence, from an academic perspective, that you would like to see come out of minimum unit pricing in Scotland before you would advise that it be taken forward in England?

Professor Sheron

I would not advise delaying, because the human cost is considerable. As an academic, I will be absolutely fascinated to see those data when they come through. It will take a little while. If MUP is introduced in Scotland in May, we expect it to start having an impact on deaths within 12 months. In Canada, with a 10% increase in MUP, there was a 32% fall in directly attributable mortality within a year. However, the deaths figures are delayed by at least 12 to 18 months. That is now two and a half years. Also, the number of deaths in Scotland is relatively low. In terms of directly attributable mortality, you are probably looking at a change of 30 or so deaths a year, which is within noise. Just as we did with the duty escalator, we will need to wait for three or four years to see the impact of those successive reductions, until there is a statistically important change. Realistically, it will be five or six years from now before we are able to calculate the full impact, with hindsight. When we have that hindsight, we will see that it started to impact on deaths almost immediately.

Andrew Selous

That is very helpful.

Professor Sheron

It becomes a political decision at that point.

Andrew Selous

Ms O’Connor may want to lead on my next question. Are there any other measures that you think might be more effective for public health than minimum unit pricing and that should be prioritised by the Government ahead of, or alongside, minimum unit pricing?

Rosanna O'Connor

As I said earlier, we do not see minimum unit price as the silver bullet. Our evidence review found a number of policy areas where changes or tweaks to policy would be helpful: pricing—taxation and MUP—investment in treatment, and drink-driving. There is a range of measures, all of which impact on alcohol harms. If we were to pursue one now, we would probably say, “Let’s do this.”

Andrew Selous

It would be minimum unit pricing.

Rosanna O'Connor

Yes, and we should do it in tandem with Wales and Scotland.

Andrew Selous

You have given us these figures in written evidence, but could you say for the public record, on the transcript, what you estimate to be the opportunity cost over one year of delaying the implementation of minimum unit pricing in England, if that is what the Government decide to do, pending the impact in Scotland? Could you summarise the opportunity cost in terms of harm to health, for the benefit of those listening and people looking at the transcript?

Rosanna O'Connor

I will talk to a 60p minimum unit price, because I do not have the 50p figures to hand. At a 60p MUP, we would see something like 3,000 alcohol-related deaths—

Andrew Selous

Three thousand fewer deaths per year, if you had MUP.

Rosanna O'Connor

Over five years.

Andrew Selous

Over a five-year period.

Rosanna O'Connor

There would be 88,000 fewer alcohol-related hospital admissions, over five years. There would be a reduction of something like 350,000 alcohol-related crimes and in the region of 1,068,000 fewer alcohol-related days off work. There would be very significant gains.

Chair

We now come to Tim.

Tim Loughton

Professor Sheron, can I query one stat you used earlier? You said that moderate drinkers consume 5.5 units a week, and that is based on an average. What is it an average of?

Professor Sheron

I said that the Sheffield model models the impact on low-risk drinkers and that the average intake in that group, from the survey data they used in the modelling, was about five units. Then I gave you the figures for 14 units. It was not actually my figure of five, but Ben’s.

Mr Bradshaw

It is 5.5. It is the Sheffield figure.

Tim Loughton

It says 5.5 in the Sheffield study. That is based on the whole adult population.

Professor Sheron

It is based on surveys.

Tim Loughton

Of whom?

Professor Sheron

Of the English population. It is English modelling. There is the Health Survey for England, for example.

Tim Loughton

It is the whole population.

Professor Sheron

No, it is a survey. The Health Survey for England asks questions of 20,000 people every year. That modelling is then used to calculate the figures for alcohol intake.

Tim Loughton

That 20,000 includes teetotallers.

Professor Sheron

It will include teetotallers. The survey sample is the survey sample.

Tim Loughton

Is that perhaps where this rather low-sounding unit figure for moderate drinking comes out, because it is an average for drinkers and teetotallers, of which there are quite a few?

Professor Sheron

Yes. It is an average for low-risk drinkers, who include abstainers. That is correct.

Professor Gilmore

We would have to get into the weeds of the Sheffield model to establish whether it is mean or median data. It has certainly been very carefully peer-reviewed.

Tim Loughton

I am sure that it has been very carefully peer-reviewed, but what it shows is that the average for a moderate drinker will be more than 5.5 units a week, if you exclude non-drinkers. Yes?

Professor Sheron

Yes.

Tim Loughton

There seems to be some confusion around the impact on moderate drinkers. Ms O’Connor, you said that it would affect them by only 20p a month.

Rosanna O'Connor

Yes.

Tim Loughton

Professor Sheron said that it would affect them by £1.26 a week, based on 14 units. That seems to be quite a big difference. Let us take wine. The biggest volume users of wine are those who tend to buy the cheaper end of supermarket wines. Typically, the biggest increases, as you see before Christmas, are for three bottles of Californian wine for £10, for example, with an average strength of 13% to 14%. On that basis, a bottle costs £3.33. A 50p minimum unit price would take it to £4.15, which is not 20p a month—it is a 25% increase. Do you agree with those figures? That is quite a big impact for moderate drinkers, not just a few pennies.

Rosanna O'Connor

Yes.

Professor Sheron

You are conflating two completely different sets of data. The data I gave you were the IFS data. I am taking the intake of somebody drinking 14 units a week—someone on the division between low-risk and increased-risk drinking. If you take the IFS figures and ask what that means in terms of the actual amount per week, the average is about £1.68 per week, for someone drinking 14 units. You are interviewing the IFS next, so you can ask them.

Tim Loughton

We are. You are now saying £1.68 a week.

Professor Sheron

That is what I said previously.

Tim Loughton

You said £1.26 a week.

Professor Sheron

I said £1.26 for wine, £1.26 for spirits, £1.96 for lager, £2.94 for cider and £0.98 for beer. The average is £1.68. I said that it was less than the cost of a cup of coffee.

Tim Loughton

It would be misleading to suggest that the impact on moderate drinkers would be around 20p a month, as was suggested.

Professor Sheron

That is why I said that you were conflating two completely different questions.

Tim Loughton

It was not my question; it was the claim made by Ms O’Connor about the impact on moderate drinkers, without any justification for who those moderate drinkers were. We now know that moderate drinkers include non-drinkers.

Professor Sheron

She was quoting from the Sheffield data. The Sheffield modelling of that group gives you that figure.

Tim Loughton

Okay. I am not really concerned about Sheffield’s modelling; I am concerned about the actual impact it will have on real-life people. The real-life people on whom it has been modelled include non-drinkers, on whom the impact will clearly be zero. Ms O’Connor, as Mr Bradshaw said, you used the phrase “exquisitely targeted.” So far, we seem to have focused on the alarming figure, if it is correct, that 4.4% of the population are responsible for over a third—a large chunk—of the drinking. They are the real problem. The real problem is in the lower socioeconomic bands of people, particularly people who go for high-strength cider, where there is an anomaly in the taxation system. Why don’t you concentrate on them, rather than on the whole population, including moderate drinkers, who will be impacted by this?

Rosanna O'Connor

Clearly, taxation would impact on everybody.

Tim Loughton

You just said that it would not.

Rosanna O'Connor

A rise in duty would.

Tim Loughton

Whereas MUP would not.

Rosanna O'Connor

MUP is targeted, whereas an increase in duty would be across the board. We would all be affected.

Chair

Professor Gilmore wants to comment.

Professor Gilmore

I have not brought with me the data for the percentage of the population that is teetotal, but it is pretty low. It is less than 20% of the population.

Tim Loughton

That is quite big.

Professor Gilmore

It would change the figure from six units to seven units, on average. You would change the denominator by a relatively small amount. It would have very little impact on the figure you are quoting.

Tim Loughton

That also depends on whether you count only complete teetotallers or non-teetotallers who have a sherry at Christmas.

Professor Gilmore

Believe it or not, there are lots of people out there who do not drink up to 14 units a week.

Tim Loughton

Sure.

Professor Gilmore

There are lots of people who genuinely drink three, four or five units a week, or less.

Tim Loughton

But what might slightly confuse people is when, apparently, a figure based on the average consumption of a moderate drinker—obviously, we are trying to get more people to be moderate drinkers—is factoring in a large chunk of the population who drink nothing at all. It is rather disingenuous to use that 5.5 figure.

Professor Gilmore

I am saying that, statistically speaking, it will make very little difference. It might put it up from five units to six or seven, but nowhere near your 14, by changing the denominator by 20%.

Tim Loughton

On your figures, without knowing what qualifies as a teetotaller, it is at least 20%, so it is still significant. You have defined where the real problem is, which is a substantially smaller part of the population apparently than teetotallers, so why are we not just concentrating measures on them, which may not be just fiscal ones? Why do these people drink to harm themselves? Why, Professor?

Professor Sheron

About 80% of the tendency to become an alcohol misuser is inherited.[1] We have a number of twin studies that show that. Only about 20% or 30% of the population have the genes that mean they will get liver disease, so 60% or 70% of people can drink as much as they like, for as long as they like, and they will never get liver cirrhosis. Alcohol-related liver cirrhosis is much like diabetes or heart disease. There is a combination of underlying genetics and environment. It would be lovely, wouldn’t it, to have a perfect policy that affected only people who would get alcohol-related harm, but in a pragmatic, real world those policies do not exist. What we have is evidence of which policies are effective and cost-effective, and those are fiscal policies. They are dramatically more effective and cost-effective, just as they are with tobacco, than anything else, so, if you are serious about reducing alcohol-related harm, this is the way to do it. All policies have a collateral impact. The collateral impact of MUP on the low-risk drinker who will be most affected—in other words, the one drinking 14 units a week—is less than the price of a cup of coffee. It is £1 or £2 a week. It is not 20p a week; it is £1 or £2 a week. Let’s be honest about it. It will have an impact on those people.

Tim Loughton

Those are very useful points. There will be collateral damage, whether we have more collateral damage because people are abusing coffee and it is wrecking their system in another way, or collateral damage because Ms O’Connor needs a drink when she gets home in order to relieve the stress caused by this Committee. If she is not able to afford it, one could say it might have some collateral damage to her mental health. We know all that, but what you have defined even more in those figures is a small and explicit part of the population on whom we need to focus in the most preventive way. My contention is: are there ways we can do it without the broad brush of a fiscal measure across the piece? You admitted when challenged by Mr Bradshaw that the amount people are drinking has fallen over the last 20 years or so, over which time the real price of alcohol had gone up. What evidence is there in this wonderful Sheffield study, or others, to show what proportion of those reduced drinkers were drink abusers—the sort of patients you are dealing with? On the basis that there is a fiscal link, surely the number of heavy abusers of drink should have come down proportionately because they are affected by what it costs, according to what everybody on the panel has said. What is the evidence for that?

Professor Sheron

That is exactly what we have seen. I do not know about the distribution of the alcohol consumption population. The data are there in surveys. What I can tell you is that if you look at directly attributable alcohol-related mortality, of which 80% is liver disease, you can track the increase in that mortality as the affordability of alcohol has increased. You can see the inflection in that mortality as alcohol affordability came down with the duty escalator. Then you can see it go up again as the duty escalator was repealed. That shows you the behaviour of that population of very heavy drinkers.

Tim Loughton

But that is contrary to the evidence you just gave us.

Professor Sheron

It is not contrary at all.

Tim Loughton

Let me explain why. If you accept that the amount being drunk by a nation has fallen over the last 20 years at the same time as the cost of alcohol has gone up, surely you should be able to show, if what you are saying is correct, that, of the whole of the population who are drinking less, drink abusers should have reduced as well. You told us earlier, Professor Sheron, that liver cirrhosis is about to overtake heart-related diseases as a major killer.

Professor Sheron

As the cause of working years of life lost.

Tim Loughton

Has this problem reduced or is it quite high, as you have suggested to the Committee—because you cannot have it both ways?

Professor Sheron

Here are the overall alcohol consumption figures, which again are in your evidence; it has been submitted to you as an attachment. You can see that since 1980 alcohol consumption overall has increased. Recently, it has decreased a little bit. This is slightly out of date; it has gone up a little bit since. The other thing that has happened is a real change in the alcohol market, to which Professor Gilmore referred. Twenty years ago, we were buying 70% of our alcohol in pubs; now we buy 70% of our alcohol in supermarkets. What has happened is a very significant reduction in the amount of alcohol that is drunk as relatively weak beer. A typical bitter in pubs is 3.4% to 3.8%. There has been a dramatic increase in the proportion of alcohol as wine, an increase in the proportion of alcohol as spirits and an increase in the proportion of alcohol as strong cider. That is the overall alcohol consumption. When you are looking at alcohol-related mortality, you are looking very specifically at the behaviour of that 4%. By the way, if you look at the overall alcohol market—this figure is also in your evidence; it is the distribution of drinkers and consumption—increasing risk drinkers drink about 70% of all the alcohol. For the 4% of harmful drinkers, it is 30% of the alcohol; the extreme drinkers, my patients, account for 14% of the alcohol. The majority of the alcohol consumed in the UK is drunk by people who are drinking a little bit too much, and some much too much, but you have to look at the overall change in the alcohol market to explain the increase in alcohol-related mortality. It is not a direct correlation with overall alcohol consumption; that is too simplistic.

Professor Gilmore

It is also worth pointing out that there are harms from alcohol in people who are drinking at lower levels. Many of the common cancers, like breast cancer, are known to be related to alcohol consumption, even within so-called safe limits. If a woman drinks 14 units a week, she is at greater risk than if she drinks seven units a week, so if the whole population consumption is eased down, there will be health gains.

Tim Loughton

I and I think everybody else on this Committee would like to see this nation drinking less and better in terms of both quality and pacing yourself, or whatever. That is not in contention. What is in contention is whether this measure is going to achieve that, and whether there is evidence to show that in the past price has had a direct impact on those who abuse alcohol most of all, not the higher impact it might have on breast cancer and things like that, which I entirely understand, but the impact on those who are being treated directly for alcohol-related problems in accident and emergency, such as liver disease and so on. The Sheffield study does not appear to me to make that case unequivocally.

Professor Sheron

You have to look at that evidence in the round. The evidence for the link between the price of alcohol and alcohol-related harm has been reviewed by the World Health Organisation, the Academy of Medical Sciences—Ian was on that committee—the Royal College of Physicians and the OECD in a report last year. All those august bodies come to the same conclusion, which is the same conclusion reached with tobacco: the most effective and cost-effective way to reduce alcohol-related harm is to reduce the affordability of alcohol. Minimum unit price has much less evidence behind it because it is a relatively new kid on the block. The attraction is that it affects only cheap alcohol and does not put up the price of a pint in a pub. As far as I am concerned, pubs are not the problem. Fewer than 5% of my patients buy their alcohol in pubs. I am talking about people who buy the cheapest booze and drink it at home in huge quantities. I would love to have a policy that is even more targeted, but that is just wishful thinking. The policy that we know will work, which has a cost but a small one, is MUP.

Chair

Your preference is to have the duty escalator and MUP.

Professor Sheron

Absolutely, because, apart from anything else, that will claw back money for the Exchequer, and we cannot afford to give away money in tax cuts.

Chair

We have concentrated very much on the medical side of things. Is there anything you would like to add from your point of view, Sgt Urwin?

Sgt Urwin

From my point of view, minimum unit price targets the drink we are taking off young people week in, week out. It is a very targeted harm-reduction measure. I do not claim to be an academic; I look at it from a very practical point of view. On a Friday or Saturday night, when we are taking home young people who cannot stand up, or have to be admitted to hospital, because of how much cheap cider they have drunk—Frosty Jack, which has been mentioned, is the most popular one with young people—and when we have to sit with the mother of a 16-year-old girl who has died overnight from drinking that type of cider, we struggle to explain why they can get their hands on it at that particular price. The expression “pocket-money prices” is bandied about a lot, but that is exactly what it is. For instance, the cost of Frosty Jack, £3.69, will go up to about £11 because of its 22‑unit content. Young people will go for the cheapest they can get, as will most people who want a bargain. They do not spend a lot of money on alcohol. How they get it is a different issue, but they have to shell out however much it is. If it is £3.69, they will have a bottle each. If that goes to £11, maybe they will not have a bottle each but will share it with somebody else, so it reduces their consumption. I fully agree with what was said earlier that under-age drinking has reduced. It has, but the line quoted time and time again is about the ones who are drinking too much and too often. That is what we see week in, week out, not only with under-age drinkers but with street drinkers as well. Street drinkers tend to pool their money, and they buy as much as they can for the money they have. If prices go up, they will have less to share among themselves. I come back to the point that treatment services need to be geared up to deal with that. There may need to be some discussion about minimum unit price and the amount of money that comes back into the industry and how they fund certain programmes going forward. Our aim is to look at vulnerability and safeguarding in a policing context. If we continue to allow young people access to cheap alcohol that costs less than their school dinner money, we need to look at it seriously. It is causing a lot of harm, and we need to deal with that.

Douglas Ross

Can I go back to some of the studies? Then I would like to follow up some points with Sgt Urwin. How would you defend a case, if it was made to you, that you all agree with minimum unit pricing and the Sheffield study agrees with you, in that it is also supportive of MUP, and therefore you cannot see any flaws in that study? How do you defend that argument?

Professor Sheron

I don’t think we did defend that argument. What we said was—

Douglas Ross

Where are the flaws in the Sheffield study?

Professor Sheron

You are trying to twist my words.

Douglas Ross

We do not have a lot of time. If you are saying that is not your argument, what are the problems of the Sheffield study that you can highlight to this Committee?

Professor Sheron

What I said was that the Sheffield study takes a series of measurements and elasticities and puts them all together, and the aim of the modelling is to calculate the number of deaths per policy: 50p gives you so many deaths, so many crimes and so many admissions, and 60p gives so many and so on. Those are not precise figures; they are conservative estimates. In my opinion, the actual figures will be higher. We will not know what the actual figures are. If you want to pick a hole in the Sheffield study, it is perfectly reasonable to say, “How do you know it is going to be 3,000 deaths? Couldn’t it be 2,000 or 4,000?” The answer is, “Yes, it could.” We do not know. This is a best estimate, but we think that is about what it is going to be. In my opinion, it will probably be more, because they are very conservative. That is the issue with modelling. It is not a question of flaws. That is the nature of the beast. These are estimates. It is the same as Treasury modelling.

Douglas Ross

There are lots of factors, estimates and assumptions, yet that is built into the study that resulted in the Scottish Government’s policy on minimum unit pricing. As academics, how often would you use one study and base all progress thereafter on that study, which you yourself have said could be wildly inaccurate?

Professor Sheron

It is not one study; it is a whole series of studies, but I accept that it is done by only one group. There is only one natural experiment, from Canada. We do not know how exact the figures are. In terms of the overall—

Douglas Ross

Before you move away from Canada, since you mention it, do you also accept that the figures quoted were from 2002 when some aspects of MUP had already been introduced, so we are not looking at a new baseline, as in Scotland, or as in England if it was introduced?

Professor Sheron

Minimum price, not minimum unit price, was introduced in certain states in Canada 20 years ago. What has happened is that the prices of different beverages were changed at different times. In British Columbia, in one year the prices of all different beverages were put up at one time. There is a wonderful graph, which we can submit to you, showing the change in MUP. You can see within a year a 30% fall in directly attributable mortality, which stays at that level. That is very convincing evidence. We are about to get more evidence from Scotland. There is no doubt that, if you put the price of alcohol up and the affordability of alcohol down, it has an impact on harm. The question is that we do not know the exact size of that impact.

Douglas Ross

Sgt Urwin, what is your knowledge of Buckfast?

Sgt Urwin

Very little, apart from knowing that it is something heavy drinkers like.

Douglas Ross

Buckfast is a very high volume tonic wine that is certainly found in a number of parts of Scotland and, I assume, the rest of the UK, but maybe you have been saved from this particular product.

Mr Bradshaw

It is a Scottish affliction.

Douglas Ross

Maybe. Buckfast is a very strong tonic wine.

Mr Bradshaw

It is made in Devon.

Douglas Ross

My wife is a police officer. When she finds under-age drinkers, their drink of choice is Buckfast. Buckfast does not change in price with minimum unit pricing. How are we dealing with the problem of under-age drinkers, when people are getting started on very high levels of alcohol at a young age if Buckfast is not impacted by this legislation?

Rosanna O’Connor

I think we would have to go away and look at Buckfast and see whether you are right.

Douglas Ross

It is already above the MUP level—the 50p level.

Rosanna O’Connor

Minimum unit price is not the answer to everything. We are suggesting, because the evidence suggests, that it is a solution to reduce some of the very problematic drinking that takes place.

Douglas Ross

If I asked my constituents in Moray to pick one drink that causes most trouble among youths in Moray, they would all pick Buckfast, yet the legislation that has been introduced in Scotland and will affect people in Moray does not cover Buckfast.

Professor Sheron

It will not have very much effect on most alcopops either. As Rosanna said, no policy is perfect. If you want to target the behaviour of young people, the next most effective thing after putting up the price is to tackle marketing. The introduction of alcopops is a very good example. Before they were introduced in 1992, children on average were drinking one unit of spirits a week; after their introduction, they were drinking five units of spirits a week. The really interesting thing is that, if you look at population-level consumption of vodka, when they got to the age of 18 it doubled, which is the power of marketing, so there are other things you can do.

Professor Gilmore

Mr Bradshaw is right. Buckfast is made in an abbey in the south-west of England. I think £6 million went to the abbey in the last 12 months from the proceeds. Fortunately, it is a Scottish and Northern Ireland thing, but a recently published study by Jonathan Chick and others at Edinburgh showed that the consumption of cheap white cider by dependent drinkers accounted for the total sales of white cider in Scotland. White cider is a major problem in Scotland, as well as Buckfast.

Douglas Ross

We are dealing with one drink and not the other.

Professor Gilmore

In terms of volume taken, white cider is well ahead of Bucky.

Rosanna O’Connor

But maybe not among the population that you are particularly talking about.

Douglas Ross

I am amazed that Professor Gilmore knows so much about it five minutes after saying he knew nothing about it.

Rosanna O’Connor

He is very modest.

Professor Gilmore

I was trying to attract your attention to say that I know all about Buckfast. It is known in Northern Ireland as Lurgan champagne, and it is full of caffeine.

Douglas Ross

That is part of it.

Professor Gilmore

Part of its attraction is that it keeps drinkers going when they would otherwise fall asleep.

Douglas Ross

Perhaps you could get the figures for white cider you are quoting, because they would be quite useful to the Committee. Sgt Urwin, you were saying that in terms of dealing with youngsters and new drinkers the example in Scotland will not deal with it, so perhaps we could get your response.

Sgt Urwin

That is why we are saying it is not the silver bullet; it is about making it part of a harm-reduction toolbox. Young drinkers in my locality will not drink Frosty Jack; they drink Smirnoff vodka, which is at the top end the market. It is about making it part of a harm-reduction package around education and awareness. I have officers who go into schools and give education awareness. We have seen a big drop in under-age drinking in our area because of the package of measures we have put in place, but we are not seeing a reduction in the cohorts of young people who are drinking the Frosty Jacks of the world because they can still get it very cheaply. Bear in mind that Buckfast will not be touched by minimum unit pricing in Scotland. There need to be bigger and wider measures than just the minimum unit price aspect. Other things have to be put in place around education and awareness that get across the message how damaging those types of drinks are.

Professor Garde

The courts, legality, policy and advocacy are not so far apart. I see them as a continuum. If you thought about legality from the very outset, policy and advocacy sometimes would be of even better quality. The courts have recognised that there is no silver bullet and that we need to consider things as a whole and as a strategy. The Health Committee clearly recognised it in its March 2017 report on obesity prevention. The same logic applies to alcohol. Taxation and minimum unit pricing are not alternative measures; increasing price and making alcohol less affordable will not tackle the entire problem. This needs to be emphasised very strongly. We need to target marketing, and that has not been done so much here. Scotland is trying it, and Ireland is trying to do more. The point is that we cannot see things in a very isolated way, as if price will cure all the problems and Buckfast should not be marketed. I do not know whether it is.

Douglas Ross

From what I have picked up, I think the panel would say that England should go ahead with this now and not wait for the five-year sunset clause in Scotland, which I will come to in a minute. If NHS England and the Government here do not go down that route, what should they be doing, while it is implemented in Scotland, to look at the unintended consequences that may arise from MUP in Scotland when it is not in place south of the border?

Sgt Urwin

From an enforcement agency point of view, we have to recognise the cross-border issue. Booze cruisers, for want of a better expression, could be a possibility, however slim it might actually be. The cost of the petrol to come all the way from the top of Scotland down to England to get your booze and then go back again would negate that from a financial point of view. We have a minuscule black market at the moment in alcohol, counterfeit and illicit goods and non-payment of duty, but I am very confident that we have the right mechanism in place in England in our enforcement agents—customs, trading standards and so on—and our information-sharing protocols. I am not unduly concerned by the threat of people in white vans coming and trying to flog counterfeit alcohol. We have a very small market at the moment, and we have the mechanism in place to cope with that.

Rosanna O'Connor

It is an unknown, isn’t it? It has not happened previously. Obviously, we would want to keep a close eye on it. If MUP is not introduced in England while Scotland and Wales go ahead, there will be significant learning for us from both those natural experiments.

Douglas Ross

A sunset clause will be introduced in Scotland, five years from when it is implemented. The whole legislation could fall the following year if the Parliament does not approve it. MSPs in Scotland have to see something in the sunset clause that proves it works. What should they be looking for in five years’ time as a measure of success? Professor Sheron, I think you are suggesting a reduction in the first year of 30 deaths as a result of drink. On average, at the moment in Scotland there are 3,000 a year, so that is a 1% reduction in the number of deaths in Scotland as a result of alcohol in the first year. Is that the success they should be looking at? I do not mean it to be funny; I was asking, based on what you said earlier, whether that would be a success, or where would success be in terms of a sunset clause?

Professor Sheron

I said at the very beginning that there are four main causes of alcohol deaths: people dying as a result of being drunk, who tend to be young people; those dying as a result of liver disease, who tend to be middle-aged people; people dying from hypertensive strokes; and people dying from cancer—about 10% are cancers. In the case of death from liver disease, the death certificate will say “alcohol-related cirrhosis”; for deaths from alcohol dependency it says “alcohol dependency.” If you die of breast cancer as a result of drinking it does not say “alcohol-related breast cancer.” There are 100% attributable diseases and there are partially attributable diseases. The 100% attributable diseases are a fraction of about a quarter to a third of the total deaths. They are the only ones you can track. When I am talking about 30 deaths, I mean 30 deaths from alcohol-related liver disease.

Douglas Ross

Those are within the 3,000 deaths.

Professor Sheron

They fall within the 3,000. You are able to track only a small proportion of those overall deaths, and you will need to see deaths reducing year on year; you will need to see those trends. We anticipate that that change will be highly significant. I anticipate that it will be considerably more than 30 deaths a year. The duty escalator reduced deaths in Scotland by 70 deaths a year, again alcohol-related liver disease. I do not think there is any doubt that we will have sufficient data to show that it is effective, but there is a lag in the pipeline. All those data will be delayed by a year or two, and we will probably need the full five years. There are all the other measurables as well. MESAS is collecting data on alcohol-related admissions, crimes and all the rest, and you will see changes in all those things. For me, mortality will be the most important one.

Rosanna O'Connor

If I were you, I would widen it and expect to see an impact in areas other than the ones Nick talked about, particularly a reduction in alcohol-related crime and in alcohol appearing in whatever the Scottish equivalent is of serious case reviews, and an increase in the number of people coming into treatment. Alcohol treatment is very effective. In England, there is a successful completion rate of about 61% for those leaving alcohol treatment. You want a broader set of measures than the ones Nick talked about, however useful and important those are.

Professor Gilmore

We are very honest, balanced people, and we have said several times this is not a magic bullet; we would like to see a whole range of policies, but we have to say that the evidence round those other policies like education, information, labelling and availability is weaker. If we wanted only one thing, we would say it should be minimum unit price, not just on the strength of the evidence but on the size of the impact, which is much bigger than things like labelling, information and education.

Chair

Are you confident that we will be able to count the effect on health inequality, which is a key point about this as well?

Professor Gilmore

Yes.

Rosanna O'Connor

Yes.

Stuart C. McDonald

I want to follow up some of the questions you have had to respond to in relation to how well targeted minimum unit pricing is. Thinking of an alternative scheme—for example, increases in duty—could you explain for the record how that works? How effective is that in targeting at-risk drinkers, and what would the equivalent impact be on non-at-risk drinkers or moderate drinkers?

Professor Sheron

Increasing taxation works. We have seen that it works. The policy we had between 2008 and 2013 reduced alcohol-related mortality. The problem is that, if you increase tax, it puts up the price of a pint of beer every year. Then pubs complain because they are shutting down. Pubs are not the problem. It is not that it does not work; it is much more diffuse. The Sheffield modelling says that, to have the same impact as a 60p MUP, you would have to put up tax by 28%. That is a cracking increase in tax on the price of a pint in a struggling pub. It is not that you cannot make tax as effective; you can, but there would have to be swingeing tax increases. By saying it is targeted, we mean that it is affecting cheap, strong alcohol, not cheap alcohol. The solution for the 7.5% cider drinker is to drink 3% cider—13 l­itres at 3%, not 16 litres at 7.5%.

Stuart C. McDonald

To be clear, there would have to be a 28% increase in duty to achieve the same effect in what terms?

Professor Sheron

Now you’ve got me.

Professor Gilmore

Harm reduction.

Professor Sheron

But I don’t know what specific harm.

Chair

I think it is in our evidence.

Stuart C. McDonald

The next question might sound flippant, but it is not meant to be. It is a serious question. We have heard questions about the Sheffield modelling that has been done. Has anyone produced any alternative models that undermine the conclusions that the Sheffield studies reached?

Rosanna O'Connor

Not that I am aware of.

Stuart C. McDonald

Should we read anything into that? Is it just that people have not got round to it?

Professor Gilmore

I think they were very early into this, and they have been very refined. They have done lots of studies looking at different variables; they have not done just one study. There is huge interest. It has been endorsed by the OECD and the WHO, and other modellers and statisticians. Those interested in public health visit them, and their papers are sent out to independent critical reviewers. Although I have not seen all the literature, I do not remember seeing any serious academic criticism. Clearly, we would like to see other units working on it and going into the area. They are almost a victim of their own success, because they have become so good at the modelling and can handle large amounts of data that they tend to be the go-to academics when a new country wants to look at this. You are absolutely right. We would like to see others moving into the area. At the moment, they are the victims of their own success, but I would say again and again that internationally they are under very close scrutiny for their methodology. Their methodology is described in great detail and will say whether, for example, teetotallers are or are not taken into account. I have as much confidence as I have in other forms of basic research in the data they are producing.

Stuart C. McDonald

There have been a lot of questions about what is happening in Scotland, and there is an argument that Westminster should wait to see what happens there. Is there a danger that the fact it does not go ahead in England might undermine some of the results we get from Scotland, principally because of the possibility of cross-border trade?

Professor Gilmore

As an academic, I would love to see a control group and a group that implemented it. As a doctor treating patients, I would love to see it implemented in England, because I know that the best estimate of the lives lost in England during that time by not implementing it would be over 1,000. You are right; there is a danger that not implementing it in England will muddy the waters.

Stuart C. McDonald

Has that been modelled at all? Do we have any idea about the extent to which it could become a problem, and on what does it depend? I assume that factors like how big the price differential is will be important.

Chair

Can we bring in Professor Garde since this is her area as well?

Professor Garde

What we know is largely about the international cross-border impact between European countries. A very strong argument put forward in the Scotch whisky litigation was that the increase in Scotland would make it more difficult for cheap Bulgarian wine to be sold on the Scottish market. It was not so much the internal issues that were touched upon. Questions about those types of differential were not discussed in any great depth at all by the Court of Justice or the UK Supreme Court, so we do not know exactly, despite the point being raised, whether or not there were cross-border issues of significance. None the less, the differential could still be justified by the lives saved and the public health impact that MUP could have. The answer to the question is that I am not aware of studies that looked specifically at the internal cross-border impact. As Sgt Urwin said earlier, they are likely to be minimal, but I do not have the figures. We know that in any event there may be very strong arguments in favour of imposing MUP sooner rather than later.

Professor Sheron

I asked the Sheffield group that specific question this morning and they did not have data on that.

Rosie Cooper

As someone who is in favour of minimum unit pricing, I have been listening to the debate very carefully. There is a big elephant, which is this question, and there is probably a good reason for it, so I am hoping you might explain. I understand that if you increase taxation it affects all drinkers, but why is it not possible to have, as Ben suggested earlier, a minimum unit price but that the increase goes to the Treasury and is actually used for drinking programmes? It could be ring-fenced or hypothecated. Why is that too hard?

Professor Sheron

The preferred PHE option is a combination of MUP and a duty escalator, which would achieve that. To go a little into the future, it is possible to achieve an MUP and have all the revenue go to the Exchequer. It depends on Brexit. We have to get rid of the EU law, because at the moment we are not allowed to zero-rate alcohol for VAT. If we zero-rated alcohol for VAT, we would increase the alcohol duty to compensate for that and increase it so that the minimum unit price was 50p. Then there would be a situation where, because pubs and clubs pay more tax because they pay VAT on top of duty, their price would stay the same and the price in supermarkets and off-licences would go up. You can set that wherever you like. You can set an MUP at 50p and all the revenue would go to the Treasury. That is something we could look at in the future.

Rosie Cooper

It seems like a very simple, sensible idea where everybody wins.

Chair

But not possible under current arrangements.

Professor Sheron

It depends on your views about Brexit, but let’s not go there.

Rosanna O'Connor

Obviously, depending on the circumstances, it is something we would explore.

Rosie Cooper

Everybody needs to win in this equation for it to work.

Mr Bradshaw

The impression was given a little earlier, Rosanna, that you could not vary duty. As I understand it, in the Budget, the Government put up duty on high-strength cider more than on beer, so there is already a differential the Government can play with. That is the case, isn’t it?

Rosanna O'Connor

They recently consulted on the cider banding.

Mr Bradshaw

You kindly suggested you might look at Buckfast. When you are in the south-west, could you also look at the cider industry, because that would be the industry most seriously affected by MUP, not just white ciders but farm-gate ciders? The cider industry in our region has had a fantastic renaissance in recent years, including planting new cider orchards, which is great for biodiversity and the rural economy. I would ask that, as well as proselytising this measure, you talk to small-scale cider producers about the devastating impact it would have on their businesses.

Rosanna O'Connor

I quite understand why you would be particularly worried about that group of producers, but it is unlikely that small independent craft-type producers would be affected by a minimum unit price, because their prices will already be higher than a minimum unit price.

Mr Bradshaw

Not at the farm gate. The last time they were one of the strongest opponents to this proposal.

Sgt Urwin

That is not what we are taking off young people and street drinkers.

Mr Bradshaw

I know, but this would hit it; it is a blunt instrument.

Professor Sheron

A lot of farm-gate ciders do not pay tax anyway because they are below the threshold, and we certainly would not want to change that.

Stuart C. McDonald

Can I go back to the alternative of increasing duty? One of the problems of increasing duty, as I understand it, is that you will not necessarily see an increase in price in the problematic products being sold in some shops, because they can absorb the cost.

Rosanna O'Connor

It can be absorbed elsewhere, so the market is retained and cheap cider remains cheap strong cider for the same people who were purchasing it previously.

Chair

We have had some very detailed questions and answers. Thank you very much. Examination of witnesses

Witnesses

Miles Beale, Brigid Simmonds and Kate Smith.

Chair

We thank the second panel very much for their patience. For those following from outside the room, could you introduce yourselves and who you represent?

Miles Beale

My name is Miles Beale. I am chief executive of the Wine and Spirits Trade Association.

Kate Smith

My name is Kate Smith. I am a senior research economist at the Institute for Fiscal Studies.