Regional differences in population levels of alcohol-related harm exist across Great Britain, but these are not entirely consistent with differences in population levels of alcohol consumption. This incongruence may be due to the use of self-report surveys to estimate consumption. Survey data are subject to various biases and typically produce consumption estimates much lower than those based on objective alcohol sales data. However, sales data have never been used to estimate regional consumption within Great Britain (GB). This ecological study uses alcohol retail sales data to provide novel insights into regional alcohol consumption in GB, and to explore the relationship between alcohol consumption and alcohol-related mortality. Alcohol sales estimates derived from electronic sales, delivery records and retail outlet sampling were obtained. The volume of pure alcohol sold was used to estimate per adult consumption, by market sector and drink type, across eleven GB regions in 2010–11. Alcohol-related mortality rates were calculated for the same regions and a cross-sectional correlation analysis between consumption and mortality was performed. Per adult consumption in northern England was above the GB average and characterised by high beer sales. A high level of consumption in South West England was driven by on-trade sales of cider and spirits and off-trade wine sales. Scottish regions had substantially higher spirits sales than elsewhere in GB, particularly through the off-trade. London had the lowest per adult consumption, attributable to lower off-trade sales across most drink types. Alcohol-related mortality was generally higher in regions with higher per adult consumption. The relationship was weakened by the South West and Central Scotland regions, which had the highest consumption levels, but discordantly low and very high alcohol-related mortality rates, respectively. This study provides support for the ecological relationship between alcohol-related mortality and alcohol consumption. The synthesis of knowledge from a combination of sales, survey and mortality data, as well as primary research studies, is key to ensuring that regional alcohol consumption, and its relationship with alcohol-related harms, is better understood.

Background and Aims: On 1 May 2018, Scotland became the first country in the world to introduce minimum unit pricing (MUP), a strength‐based floor price below which alcohol cannot be sold, across all alcoholic beverages. The legislation contains a sunset clause meaning a comprehensive mixed‐methods evaluation of its impact across a range of outcomes will inform whether it will continue beyond its sixth year. In this study, we assessed the impact of MUP on off‐trade alcohol sales (as a proxy for consumption) after its first year. Design, Setting and Participants: Controlled interrupted time–series regression was used to assess the impact of MUP on alcohol sales among off‐trade retailers in Scotland in the year after it was introduced, with England and Wales (EW) being the control group. In adjusted analyses, we included household disposable income, on‐trade alcohol sales and substitution between beverage categories as covariates. Measurements: Weekly data on the volume of pure alcohol sold by off‐trade retailers in Scotland and EW between January 2013 and May 2019, expressed as litres of pure alcohol per adult. Findings: The introduction of MUP in Scotland was associated with a 3.5% [95% confidence interval (CI) = 2.2–4.9%] reduction in off‐trade alcohol sales per adult after adjustment for the best available geographical control, disposable income and substitution. In unadjusted analysis, the introduction of MUP was associated with a 2.0% (95% CI = 0.4–3.6%) reduction in off‐trade alcohol sales per adult in Scotland. In EW, there was a 2.4% (95% CI = 0.8–4.0%) increase during the same time‐period. The reduction in off‐trade alcohol sales in Scotland was driven by reduced sales of spirits, cider and perry beverage categories. Conclusion: The implementation of minimum unit pricing for alcohol in Scotland in 2018 appears to have been associated with a reduction in off‐trade alcohol sales after its first year.

A ban on multi-buy discounts of off-trade alcohol was introduced as part of the Alcohol Act in Scotland in October 2011. The aim of this study was to assess the impact of this legislation on alcohol sales, which provide the best indicator of population consumption. Interrupted time-series regression was used to assess the impact of the Alcohol Act on alcohol sales among off-trade retailers in Scotland. Models accounted for underlying seasonal and secular trends and were adjusted for disposable income, alcohol prices and substitution effects. Data for off-trade retailers in England and Wales combined (EW) provided a control group. Weekly data on the volume of pure alcohol sold by off-trade retailers in Scotland and EW between January 2009 and September 2012. The introduction of the legislation was associated with a 2.6% (95% CI = -5.3 to 0.2%, P = 0.07) decrease in off-trade alcohol sales in Scotland, but not in EW (-0.5%, 95% CI = -4.6 to 3.9%, P = 0.83). A statistically significant reduction was observed in Scotland when EW sales were adjusted for in the analysis (-1.7%, 95% CI = -3.1 to -0.3%, P = 0.02). The decline in Scotland was driven by reduced off-trade sales of wine (-4.0%, 95% CI = -5.4 to -2.6%, P < 0.001) and pre-mixed beverages (-8.5%, 95% CI = -12.7 to -4.1%, P < 0.001). There were no associated changes in other drink types in Scotland, or in sales of any drink type in EW. The introduction of the Alcohol Act in Scotland in 2011 was associated with a decrease in total off-trade alcohol sales in Scotland, largely driven by reduced off-trade wine sales.

Aims: To assess the validity and reliability of using alcohol retail sales data to measure and monitor population levels of alcohol consumption. Methods: Potential sources of bias that could lead to under- or overestimation of population alcohol consumption based on alcohol retail sales data were identified and, where possible, quantified. This enabled an assessment of the potential impact of each bias on alcohol consumption estimates in Scotland. Results: Overall, considering all the possible sources of overestimation and underestimation, and taking into account the potential for sampling variability to impact on the results, the range of uncertainty of consumption during 2010 was from an overestimate of 0.3 l to an underestimate of 2.4 l of pure alcohol per adult. This excludes the impacts of alcohol stockpiling and alcohol sold through outlets not included in the sampling frame. On balance, there is therefore far greater scope for alcohol retail sales data to be underestimating per adult alcohol consumption in Scotland than there is for overestimation. Conclusion: Alcohol retail sales data offer a robust source of data for monitoring per adult alcohol consumption in Scotland. Consideration of the sources of bias and a comprehensive understanding of data collection methods are essential for using sales data to monitor trends in alcohol consumption.

The unequal distribution of income is a fundamental determinant of health inequalities. Decision making around economic policies could be enhanced by showing their potential health effects. We used scenario modelling to assess the effects of 12 income-based policies on years of life lost (YLL) and inequalities in YLL in Scotland for the 2017-21 period. In this modelling study, we used EUROMOD version H1.0+, a tax-benefit microsimulation model, to estimate the effects of hypothetical fiscal policies on household income for Scottish households in the 2014/15 Family Resources Survey (n=2871). The effects were modelled excluding housing costs. Income change from baseline was estimated for each quintile of the 2016 Scottish Index of Multiple Deprivation (SIMD) after weighting to account for differential non-response to the Family Resources Survey, and incomes were equivalised according to the Organisation for Economic Co-operation and Development's modified equivalence scale. A regression analysis of cross-sectional data was used to estimate the relationship between income change and all-cause mortality, followed up by a sensitivity analysis to account for uncertainties around the assumptions on effect size. Informing Interventions to reduce health Inequalities (Triple I), a health inequalities scenario modelling tool, was used to estimate policy effects on YLL and government spending after five years of theoretical implementation. The Triple I model used population estimates for 2016 stratified by sex, 5-year age group, and SIMD quintile, which were obtained from the National Records of Scotland. Preliminary estimates of relative policy costs were calculated from the EUROMOD-derived combined effects of each policy on tax bills, National Insurance contributions, and benefits receipts for Scottish households. Taxation-based policies did not substantially affect household incomes, whereas benefits-based policies had large effects across the quintiles. The best policy for improving health and narrowing health inequalities was a 50% increase to means-tested benefits (approximately 105 177 [4·7%] YLL fewer than the baseline of 2·2 million, and a 7·9% reduction in relative index of inequality). Effects on YLL and health inequalities were inversely correlated in response to changes in taxation policy. Citizen's Basic Income (CBI) schemes also substantially narrowed inequalities (3·7% relative index of inequality for basic scheme, 5·9% for CBI with additional payments for individuals with disability), and modestly reduced YLL (0·7% for the basic scheme and 1·4% with additional payments). The estimated government spending associated with a policy was proportional to its effect on YLL, but less closely related to its effect on inequalities in YLL. Policies that affect incomes could potentially have marked effects on health and health inequalities in Scotland. Our projections suggest that the most effective policies for reducing health inequalities appeared to be those that disproportionately increased incomes in the most deprived areas. Although modelling was subject to various assumptions, the approach can be useful to inform decisions around addressing the upstream determinants of health inequalities. None.

This paper tests the extent to which differing trends in income, demographic change and the consequences of an earlier period of social, economic and political change might explain differences in the magnitude and trends in alcohol-related mortality between 1991 and 2011 in Scotland compared to England & Wales (E&W). Comparative time trend analyses and arithmetic modelling. Three approaches were utilised to compare Scotland with E&W: 1. We modelled the impact of changes in income on alcohol-related deaths between 1991-2001 and 2001-2011 by applying plausible assumptions of the effect size through an arithmetic model. 2. We used contour plots, graphical exploration of age-period-cohort interactions and calculation of Intrinsic Estimator coefficients to investigate the effect of earlier exposure to social, economic and political adversity on alcohol-related mortality. 3. We recalculated the trends in alcohol-related deaths using the white population only to make a crude approximation of the maximal impact of changes in ethnic diversity. Real incomes increased during the 1990s but declined from around 2004 in the poorest 30% of the population of Great Britain. The decline in incomes for the poorest decile, the proportion of the population in the most deprived decile, and the inequality in alcohol-related deaths, were all greater in Scotland than in E&W. The model predicted less of the observed rise in Scotland (18% of the rise in men and 29% of the rise in women) than that in E&W (where 60% and 68% of the rise in men and women respectively was explained). One-third of the decline observed in alcohol-related mortality in Scottish men between 2001 and 2011 was predicted by the model, and the model was broadly consistent with the observed trends in E&W and amongst women in Scotland. An age-period interaction in alcohol-related mortality was evident for men and women during the 1990s and 2000s who were aged 40-70 years and who experienced rapidly increasing alcohol-related mortality rates. Ethnicity is unlikely to be important in explaining the trends or differences between Scotland and E&W. The decline in alcohol-related mortality in Scotland since the early 2000s and the differing trend to E&W were partly described by a model predicting the impact of declining incomes. Lagged effects from historical social, economic and political change remain plausible from the available data.