Background
In recognition of the harmful effects of alcohol use in the European Region, the World Health Organization (WHO) recommends that measures be put in place to reduce population-level alcohol use. One such recommendation is minimum unit pricing (MUP).1 MUP specifically targets the heaviest drinkers who buy the cheapest alcohol. By reducing its affordability, less alcohol will be purchased and consumed, reducing the harm that alcohol causes to people who drink and others.

MUP on alcohol was introduced in Scotland in May 2018, the first nation in the world to do so. It sets a minimum floor price of 50 pence per unit of alcohol (one unit is the equivalent of 8 g of pure alcohol or ethanol). Ireland followed suit in October 2018 as part of the Public Health (Alcohol) Act 2018. MUP came into effect in January 2022 at 10 cent per gram of ethanol or €1 per standard drink (10 g of pure alcohol).2 MUP is also in operation in some Canadian provinces; Belarus; Kyrgyzstan; the Republic of Moldova; the Russian Federation; Ukraine; the Northern Territory in Australia; Wales; and Jersey. As MUP was only introduced in Ireland in 2022, it is too early to tell yet what effect it has in reducing alcohol-related harms. However, as MUP has been in place in Scotland for over four years, there is much interest in Ireland in the potential impact it has had there. Two publications in late 2022 examined the impact of MUP in Scotland: one examining the experiences of stakeholders who work directly with people experiencing homelessness,3 while the other looked at the impact on road traffic collisions and drink-driving incidents.4

1. Stakeholders’ perspectives and experiences of MUP and people experiencing homelessness
This study examined the impact of MUP on marginalised groups by interviewing stakeholders from statutory and third-sector organisations across Scotland who work with people experiencing homelessness and those who are street drinkers. Alcohol use disorder is higher among this group compared with the general population and their drinking patterns differ due to the types and amount they drink, making them particularly susceptible to alcohol-related harms.

Methods
Using qualitative semi-structured interviews with 41 stakeholders, the study sought to determine the stakeholders’ views on MUP, their perception of the consequences of the commencement of MUP, its impact on service provision, and the implications for policy among people experiencing homelessness and street drinkers. The data from interview transcripts were analysed using thematic analysis.

Results
Findings from the study indicated that despite initial concerns about the potential impact MUP could have on this vulnerable group, there was no significant negative effect on people experiencing homelessness and service providers supporting them. There was support for MUP and acknowledgement of the need for such a policy. However, participants acknowledged that they felt poorly informed about MUP before its commencement and that due to the complex needs of their clients (along with alcohol use) had anticipated some of the outcomes, but there were some groups adversely affected. For example, one stakeholder reported an increase in hospital admissions for alcohol withdrawal symptoms, while a small minority reported an increase in accessing food banks, which may have been as a result of prioritising alcohol over food, although it was acknowledged that this may have been more likely due to the ongoing Covid-19 pandemic at the time of the study. Furthermore, there were reports of clients swapping formerly cheap cider for spirits and concern was raised that if they drank at the same levels they had previously, this would increase their risk of injury from falls, head injuries, and gastric bleeds. A number of participants raised concerns about a move to illicit drug use (commonly street ‘benzos’ and Valium) in response to the increase in costs of alcohol. However, this was reported in addition to alcohol use rather than a replacement for alcohol. A number of participants said that they heard anecdotal reports of clients drinking hand sanitiser or buying ‘contraband’ alcohol or buying alcohol at pre-MUP prices in small independent shops following the introduction of MUP, although such reports appeared confined to those with limited access to benefits.

Participants raised an important issue about how MUP does not address the underlying reasons for alcohol use among this population. They emphasised how services need to work together to provide trauma-informed care to their clients and not be restricted to entry criteria, such as alcohol or drugs or mental health issues. Also criticised were long waiting lists for detoxification programmes.

Yet the majority of feedback from stakeholders was that MUP provided them with an opportunity to discuss the client’s alcohol use with them, to encourage accessing treatment, and that the price increase reduced their alcohol use. Initial concerns about an increase in crime to fund alcohol use were unfounded.

Participants noted that to be better prepared for the needs of their clients, any future discussions regarding MUP should consider their views in order to best anticipate service changes to accommodate their clients.

Conclusion
MUP is intended to reduce alcohol use at a population level, but for those experiencing homelessness, it is essential that services and supports are in place to support them directly due to their complex needs, in particular those without or with limited benefits. The study found that although the participants expected adverse effects among their clients as a result of the introduction of MUP, these did not materialise to the degree anticipated.

2. Alcohol price floors and externalities: the case of fatal road crashes
Building on the evidence of the impact of MUP in Scotland, another study examined the impact MUP had on fatal road traffic collisions (RTCs) and accidents involving drink drivers.4 This is an important indicator of alcohol-related harm. The study highlighted the proportion of fatal RTCs attributed to alcohol in a selection of countries and it is worth noting that Ireland is ranked highest.5

Methods
The study involved the use of administrative data on RTCs and a range of quasi-experimental modelling approaches. Road Accidents Data (RAD) in Britain were used to examine all fatal RTCs between 2009 and 2019 and all accidents where a positive breath test specimen for alcohol was recorded.

Results
In examining the fatal RTCs and the accidents where drink driving was involved in the months before and after the introduction of MUP, the results indicated that there was no change in the number of incidents in Scotland compared with the rest of Britain (where MUP is not in place), implying that the policy did not affect such accidents.

Conclusion
The study suggests that MUP resulted in a reduction in alcohol use and consequently had a significant impact on alcohol-related RTCs, although the authors note that the majority of RTCs involving alcohol are caused by on-trade consumption that is not impacted by MUP. The findings from this study are valuable to countries such as Ireland who have recently introduced MUP.

Overall conclusion
Both studies from Scotland provide important evidence to contribute to the MUP impact portfolio. This evidence is especially useful to Ireland as MUP was introduced in early 2022 with some scepticism and criticism. Although the two studies differ methodologically, they both confirm that the concerns regarding the commencement of MUP did not materialise. MUP is an important element of a suite of recommendations that complement each other to reduce alcohol-related harms, and the Public Health (Alcohol) Act 2018 places Ireland at the forefront of those countries taking legislative action to address these issues.

1. World Health Organization (WHO) Regional Office for Europe (2020) Alcohol pricing in the WHO European Region: update report on the evidence and recommended policy actions. Copenhagen: WHO Regional Office for Europe. https://www.drugsandalcohol.ie/32286/
2. Office of the Attorney General (2018) Public Health (Alcohol) Act 2018. Dublin: Irish Statute Book. https://www.drugsandalcohol.ie/33698/
3. Dimova ED, Strachan H, Johnsen S, et al. (2023) Alcohol minimum unit pricing and people experiencing homelessness: a qualitative study of stakeholders’ perspectives and experiences. Drug Alcohol Rev, 42(1): 81–93.
   https://www.drugsandalcohol.ie/37215/
4. Francesconi M and James J (2022) Alcohol price floors and externalities: the case of fatal road crashes. J Policy Anal Manage, 41(4): 1118–1156. https://www.drugsandalcohol.ie/37307/
5. World Health Organization (2021) Global Health Observatory data repository, 2020. https://www.drugsandalcohol.ie/29703/