Friday, 11 July 2014

The proportionate universalism of MUP

In the past few days I’ve been catching up with videos from two conferences earlier in the year I wasn’t able to go to – those of Alcohol Research UK (ARUK) and the New Directions in the Study of Alcohol Group (NDSAG).

One that particularly got me thinking was John Holmes at NDSAG talking about minimum unit pricing (MUP) and whether it can be considered an equitable intervention that helps address health inequalities.  I’ve written about the Sheffield research and the predicted effects of MUP on different socio-economic groups before, but this time I started to think more directly about alternative policies.

As far as I can work out, there are two key reasons why MUP is considered a superior policy measure to increasing tax on alcohol across the board.

(One key argument against MUP is that any increase in revenue would be for the industry rather than the government.  It’s the same worry that some people have raised regarding initiatives to make food production healthier.)

The first is that it wouldn’t affect the on-trade, like pubs and bars, as prices there are almost always already above the 45p/50p per unit proposed – usually by some distance.  This is considered a good thing, because of the community value of pubs, and the fact that drinking under some form of supervision (by the licensee or social norms) is generally considered safer, and possibly a better way for young people to learn ‘how’ to drink.

The second, and what I’m interested in here, is that MUP wouldn’t affect all drinkers – or at least not equally or significantly.  Although it might seem like a population-wide measure in one sense, MUP wouldn’t affect everyone – or even all drinkers – equally.

Nick Sheron has suggested that MUP is ‘exquisitely targeted’ at the most problematic drinkers, but actually it’s more complicated than that.  As the graph from the Sheffield research shows, when we look at harmful drinkers, those from the lowest income quintile get twice as much of their units from sub-MUP level drinks (40.6%) than the highest quintile (20.3%).  So this is a policy that will affect those on lower incomes more.

Of course, if what we’re concerned with is alcohol consumption, then taxes on alcohol are already ‘exquisitely targeted’ – in fact, better than MUP.  Those who consume the most alcohol will pay the most tax, regardless of their income bracket or their preferred drink.  This would especially be the case if we had a more straightforward system than currently, and just taxed each unit of alcohol at the same rate (as the IFS has recommended) – though for reasons I can’t fully understand, this isn’t currently possible under EU regulations.  (True, these taxes would also affect on-trade alcohol, but then there are other ways to make that industry more viable if that’s a genuine concern of policymakers.)

However, this brings us back to the question (implicit till now but almost inevitable in a post on this blog): what is the policy trying to deal with?  Alcohol consumption, I’m going to assume, is not an evil in itself.  The reason that public health policies aim to address it is that there are risks associated with certain levels of consumption.  Those risks relate to mortality and morbidity of various kinds.  So what MUP would (or should?) be trying to do is reduce health harm related to alcohol.

This means that, as John Holmes points out, the particular targeting of MUP needn’t be seen as a bad thing.  He calls this as a form of ‘proportionate universalism’, using the term coined by Michael Marmot, the doyen of health inequalities research.  It can be argued that the targeting only makes MUP a ‘regressive’ policy if the health effects of alcohol consumption are ignored.  If the assumption is that the aim of the policy is to improve health, the group with the most significant health harms from alcohol are the lowest quintile, and it’s their consumption that will be most affected by MUP – and therefore hopefully their health will improve most significantly.  That’s the proportionate universalism.

However, it could also be seen as a form of ‘seduction and repression’ to target those from lower socio-economic groups, who are assumed to be the ‘problem’ – as in David Cameron’s ’20 tins of Stella for a fiver’ claim.  (I’ve got an academic article coming out on this very topic in October – a mere 12 months after it was accepted for publication.)

If we’re trying to deal with alcohol consumption per se, then we know tax is a more straightforward and ‘equitable’ way to do this.  If we’re trying to address health harms amongst the poorest in society – and remember this is the only way that MUP can be justified as equitable – we know that even where these harms are apparently related to alcohol, there’s something more going on that we don’t yet understand.  In this context, pinning our hope on MUP when we don’t even understand what’s going on seems a bit premature.

MUP might be, for some people, the best policy available, and perhaps that explains why it seems to have been the only show in town in terms of alcohol policy over the past 5 years.  However, I can’t help but think sometimes that it seems to be a solution searching for a problem – and a whole range of people see it as a solution to the problem they’re most concerned with: ‘binge’ drinking, ‘harmful’ home drinking, health inequalities, and so on.

As usual, I’m not arguing that we shouldn’t introduce MUP, but if it’s really an intervention to address health inequalities, perhaps we should return to Michael Marmot’s analysis and think about the broader ‘determinants of health’ – and not just make alcohol more expensive for a specific group within society, who already have little income to spare.  Otherwise, it looks a bit too much like this is a policy that ‘targets’ those of the heaviest drinkers who have the lowest incomes, even if this targeting might also ‘benefit’ them.


  1. 3. Your point that MUP can only be equitable if harms are accounted for: to some extent I agree with this. However, remember all the substantive income differences in MUP's effects are in the heavier drinkers. As I said in my presentation, we don't take account of the utility people get from their drinking because nobody has come up with a good way to measure this for an intoxicating and addictive substance. If we were to assume the utility value of much of heavy drinkers' consumption is low (which i accept is an assumption some would disagree with) and combine that with the estimated spending reductions we see for lower income drinkers compared to spending increases for higher income drinker, the equity picture becomes much less clear cut even without looking at the harms.

    4. As ever I dispute your suggestion that MUP has been the only show in town. Yes it gets all the headlines but there's a huge amount of policy work being done on licensing, EMRO, cumulative impact and public health objectives by Government, advocates and researchers, we have a DH-commissioned project on how treatment could be better resourced, there's massive interest in brief interventions, several countries are looking at advertising and advocates are hugely interested in it (although UK Gov are hugely nowhere near taking action), there are loads of councils doing reducing the strength campaigns (coupled with some Responsibility Deal stuff), there's a review of the drinking guidelines ion-going, lots of interest in the Good Behaviour Game as a form of educational intervention and lots of interest in warning or calorie labels on products. MUP gets attention because of the high-profile and strength of the evidence base and because there's a clear policy problem which advocates almost universally agree could be solved this way. But I know a lot of them would be surprised to hear you thought MUP was the only thing they're interested in.

    5. A solution searching for a problem: I wondered if you watched Jan Gill's presentations from NDSAG? She shows exactly what the problem is. Her sample of dependent drinkers have two major spikes in the distribution of prices paid for the alcohol that sustains (and helped create) their dependence. First around the 15-20ppu mark - white ciders. Second around the 35ppi mark - low cost spirits/bulk bought beers. That's the problem MUP is trying to solve - the facilitation of long-term heavy drinking through high availability of very low cost alcohol. Note that Jan's participants were not happily drinking - they were recruited in hospital wards where they had been admitted due to alcohol-related health problems, problems which a significant proportion have died from during the course of the study. Obviously that doesn't mean the policy should be immediately introduced, but to suggest it's a problem looking for a solution really surprises me.

    1. I just feel uncomfortable when we’re looking at heavy drinkers and arguing for a policy that affects those on lower incomes more – and arguing that this is ‘equitable’ because they suffer greater health harms for a given level of consumption, when by definition it’s not simply that consumption that’s causing the problem. On the basis that this is a policy to correct people’s irrationally high consumption of alcohol, it seems to suggest that the consumption of people on lower incomes is more irrational than that of those on higher incomes, even controlling for consumption level.

      On my idea of MUP being a solution in search of a problem and the only show in town, I admit you have a point. Both points come from the same frustration: depending on who’s talking about it (and to whom) MUP can be an intervention to address ‘binge’ drinking, dependent/harmful drinkers, or a population-level move to have a marginal effect on all those people drinking marginally above the sensible guidelines. I just don’t believe it would – or can – have all those effects. It’s become this cipher for everyone to pin their hopes to. It’s not the only show in town in that sense, but it’s the main event, around which wide groups of people have coalesced, because they believe MUP to be the solution to their specific ‘problem’.

      In terms of your point that people would be disappointed to think I see them as only caring about MUP, it’s amazing how whatever the story, the quote from organisations like Alcohol Concern ends up mentioning price – and specifically MUP. That is quite clearly their key policy aspiration.

  2. Hmmm - the first half of my comment got lost!

    It said some nice stuff about the article summarising the video well and making some relevant points but that there were 5 things I disputed. The first two basically questioned whether tax was more equitable and exquisitely targeted.

    To my knowledge, there is no equity analysis of tax in existence which looks at the public health implications as well as the consumption and spending implications. Given the complexity of the tax system and the consumption and spending preferences of different groups - I don't think any firm claim can be made about the equity of tax vs. MUP at the moment.

    In terms of targeting, perhaps this would be true of tax if we had a system which taxed by strength - but we don't and won't for the forseeable future. MUP is partly a response to that and partly a response to other problems like differential pass-through of tax.

    See also my fifth point - tax would only address this if levied at higher rates in combination with the Government's below cost sales ban.

    1. Thanks for the comments, John – they’re very fair. To give a fair response, I’ve written a fair bit, so to hopefully avoid the problem you had, I’ve split it into two comments.

      First, on your point about the targeting of tax. I was really simply making the point that if we are concerned about general alcohol consumption then tax is even better targeted than MUP, by definition, since MUP (at least according to the modelling) only affects those buying products at the bottom of the market, whereas tax would treat all alcohol equally and would be directly proportional to the alcohol purchased. As I acknowledge, for some reason I can’t fathom, this isn’t currently possible under EU regulations – but perhaps the more relevant point is the political will to increase tax. I think that a more sensible tax structure combined with (a) BBCS and (b) measures to increase the relative attractiveness of the on-trade would be the best policy, but agree that this would be some way off.

      However, since MUP is a public health policy, we’re not just talking about alcohol consumption per se, which complicates things. In that context, MUP might be seen as more targeted – but then we get to my point about not knowing why the health harms are distributed unequally, and therefore is it equitable to deal with just the alcohol consumption (which we know isn’t the sole causal factor in alcohol-related health harm) – particularly when that’s associated with pleasure.

      Of course as you point out it’s possible that this isn’t pleasurable for the Jan Gill participants, for example – and these are mostly the people you’d say would be affected by MUP. However, it’s still difficult to argue for the differential effect by income group when we don’t know what causes the differential outcomes.