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.

Those harms are not distributed evenly across the population, and in fact aren’t even neatly related to levels of alcohol consumption.  Mark Bellis and his team are currently researching why it is that even controlling for levels of (reported) alcohol consumption, it’s those from the lower socio-economic groups that suffer the highest levels of alcohol-related health harm.

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.