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Research aims and methodology

This report presents the final results of a study which assesses the impact of Minimum Pricing of Alcohol [MPA] on service users and service providers across Wales at a point four years post-implementation of the new legislation. The study is one part of a suite of four evaluation studies commissioned by the Welsh Government to assess the process and impact of the introduction of MPA in Wales, with the other three studies being: a contribution analysis; work with retailers; and an assessment of impact on the wider population of drinkers. It is the second of two ‘post-implementation’ reports that will examine alcohol consumption patterns and related behaviours among hazardous, harmful, and dependent drinkers currently engaged with Welsh alcohol treatment services. The first report, 24 months post-MPA implementation, containing interim evaluation findings, was published in June 2023 (Perkins et al., 2023).

This study was conducted by a consortium of researchers from Figure 8 Consultancy (Dundee), the University of South Wales, and Wrexham University.

The explicit aim of this component of the research was to assess both the experience and impact of MPA on service users and services across Wales (including exploring the extent to which switching between substances may have been a consequence of the legislation and the impacts of minimum pricing on household budgets). More specifically, the study had ten objectives, six focusing on people receiving support from alcohol services (i.e., service users who would be considered harmful, hazardous, or dependent drinkers), and four focusing on individuals working as providers of services to people with alcohol problems (i.e., service providers).

Service users

  • To explore how service users prepared for the change in the legislation.
  • To explore service users’ perceptions of the legislation.
  • To explore what changes service users made, if any, to their use of alcohol after the introduction of a minimum unit price for alcohol.
  • To explore what changes service users made, if any, to their use of alternative substances after the change in legislation.
  • To explore service users’ perceptions of changes (including substance switching) that other people made after the introduction of the legislation. 
  • To explore the impact of the new legislation on service users’ household expenditure and other aspects of their lives (e.g., relationships, employment, health).

Service providers

  • To explore the approaches service providers used to help people prepare for the introduction of a minimum price for alcohol.
  • To explore service providers’ perceptions of changes in substance use (including substance switching) that service users made after the introduction of minimum unit pricing for alcohol. 
  • To explore with service providers the impact of the new legislation on the lives of service users (e.g., household expenditure, health, relationships, employment, etc).
  • To explore with service providers how useful the support materials or guidance that were provided were, as well as any additional materials that may be required.

A combination of interviews and online survey questionnaires were used to enable the research objectives to be met.

The research focused on adults aged 18 and over who were either resident in Wales or involved in the delivery of alcohol services within Wales.

Fifteen interviews were conducted with 17 service users, with one interview containing three service users. Four of the interviewees had been interviewed previously for the interim findings report, with 13 new interviewees this time around.

Thirteen interviews were conducted with 15 service providers (including operational management and frontline staff), with one interview containing three members of staff. Six of the interviewees had been interviewed previously for the interim findings report, with nine new interviewees this time around.

Surveys were completed by 121 service users from 14 of the 22 Local Authority areas in Wales, and 90 service providers from 21 out of the 22 Local Authority areas.

Background and context

The background and context for MPA have been set out in detail in three previous reports (Holloway et al., 2019; Buhociu et al., 2021; Holloway et al., 2022), the most recent of which provides an updated literature review building upon the reviews completed in the two earlier reports. Further updates covering the most recent literature are provided in the Contribution Analysis final report (Final report: review of the introduction of Minimum Pricing for Alcohol in Wales - Welsh Government) and the ‘Assessing the Impact of MPA on the wider population of drinkers’ final report (Assessing the impact of Minimum Pricing for Alcohol on the wider population of drinkers: Final Report - Welsh Government) and is where we would direct readers to look for up-to-date references.

The earlier of these reports (Holloway et al., 2019) is considered to be the baseline report for this study as it considered the potential for substance switching following the introduction of MPA based on the views of the same targeted stakeholder groups (i.e., service users and service providers), and therefore contains relevant background content.

Levels of alcohol-related harm and hazardous and harmful drinking remain an issue in Wales despite Welsh Government implementing a range of activities that are consistent with its current substance misuse strategy (Livingston et al., 2018). There is strong international academic evidence that increasing the price of alcohol is one of the most effective ways of controlling levels of alcohol consumption and reducing alcohol-related harm (Nelson et al., 2013; Wagenaar et al., 2009).  However, up until recently, pricing as a key element has been missing from the Welsh Government’s approach to reducing alcohol-related harm.

The Public Health (Minimum Price for Alcohol) (Wales) Bill was passed through the National Assembly for Wales (now called Senedd Cymru – the Welsh Parliament) in June 2018 and received Royal Assent, becoming an Act, on 9 August 2018. It included provisions to introduce a minimum price for the sale and supply of alcohol in Wales (at 50p per unit of alcohol) and to make it an offence for alcohol to be sold or supplied below that price. The legislation took effect on 2 March 2020.

In the Welsh Government’s view, whilst the Bill’s objective was to tackle alcohol-related harm, including alcohol-attributable hospital admissions and alcohol-related deaths in Wales, and an effective epidemiological approach at health protection, it was also likely to target those hazardous and harmful drinkers who tend to consume greater amounts of low-cost and high-alcohol content products. 

Whilst the new legislation is based on a whole population approach to tackling alcohol-related harm, this research was commissioned specifically to focus on the experiences and impact of MPA on those receiving support for alcohol-related problems. The findings presented in this report must therefore be considered in this context.

Main findings

Changes to alcohol and other drug use

There is little new to add to the existing evidence base regarding changes to alcohol and/or other drug use of hazardous, harmful, and dependent drinkers as a result of the introduction of MPA in Wales. 

The findings of this study confirm what is already known in this regard (i.e., a substantial reduction in the availability of cheap (below 50p per unit) alcohol (particularly ciders), with some price-sensitive drinkers reporting shopping around for cheaper alcohol and shifting towards stronger, premium products (particularly vodkas) due to minimal price differences. We found minimal evidence to suggest individuals who were primary drinkers (and not already using drugs) were likely to switch to start using drugs as a result of higher alcohol prices. Polysubstance use remains prevalent amongst this drinker population, with some increases reported in the use of crack cocaine, ketamine, and illicit benzodiazepines.

Financial hardship, exacerbated by the cost-of-living crisis, does not appear to be deterring consumption amongst the study cohort. Instead, dependent drinkers in particular reported extended prioritisation of alcohol over essential living expenses, leading to further vulnerability.

MPA was described by service providers as taking place within a general trend of changing alcohol presentations to services, with only a small element of contribution being attributed to MPA rather than other, more significant, factors such as the COVID-19 pandemic and the cost-of-living crisis. Respondents noted that a wider range of people have been seeking alcohol treatment in recent years, including older individuals, employed people, and younger users. An increase in referrals for women was also noted. Some service providers have observed a rise in demand for alcohol withdrawal management services over the study period and relate this, at least in part, to an increased unaffordability of alcohol.

Awareness, understanding, and interpretation of MPA, and support for implementation

Initial reactions to the introduction of MPA were reported as having been mixed amongst both service users and service providers, with some remembering its introduction and others only noticing its effects later. Some service users initially supported the policy, hoping it would reduce alcohol consumption, but later expressed disappointment after experiencing its impact. Many service providers reported the policy is now rarely discussed, and newer staff and service users are often unaware of it.

Consistent with the findings in the interim study for this research (Perkins et al., 2023), the majority of service users who engaged in this study wrongly assumed and reduced their understanding of the policy down to one of targeting the alcohol dependent population, rather than delineating between the actual intended target population (i.e., hazardous and harmful drinkers) and those that are most impacted (i.e., the lowest income dependent drinking population). Because of this false assumption we found that a majority of study respondents continue to view this policy as a punitive one on an already vulnerable population. Similarly, whilst most service providers offered support for MPA’s aims, at the same time they expressed concerns about its practical impacts. Many believe the policy disproportionately affects poorer individuals and dependent drinkers, creating a financial burden without sufficient support services.

There is widespread questioning amongst the service providers in the study as to why it is not possible for revenues from the policy to be reinvested in alcohol treatment services, particularly detoxification and rehabilitation, which are considered to be underfunded.

Service providers argued MPA alone is insufficient to reduce harmful drinking. They highlighted the need for additional strategies to address the underlying causes of alcohol dependence, such as mental health issues and social isolation.

Impact of MPA

As mentioned above, the majority of views of study respondents is that although not the primary target audience for the policy, the group of low-income, dependent drinkers in Wales are those that are most negatively impacted. Study respondents provided both first and second hand accounts of how such individuals consistently prioritise alcohol over essential living expenses, leading to further financial hardship, health deterioration, and increased reliance on food banks and social services.

Both service users and providers reported some rises in low level criminal activities over recent years, such as shoplifting, peer exploitation, and aggressive bullying, as individuals seek ways to fund their alcohol consumption. Additionally, some providers noted an increase in sex work and borrowing to sustain drinking habits.

It is important to note respondents’ reports and perceptions relating to the effects of MPA on themselves, their social circles, and the wider community of people with an alcohol problem (including the impacts noted above), cannot be directly attributed to the pricing policy. Rather, MPA continues to be experienced as being contributory to the challenges faced by those managing dependent drinking, for whom reported health, social and legal outcomes may be better understood as a function of excessive alcohol use, economic disadvantage, and support service availability/accessibility (amid COVID-19 and the cost-of living crisis) that are often insufficient to meet needs.

Many service users reported reduced spending on essentials such as food and bills due to the higher cost of alcohol, along with a subsequent increased reliance upon loans, food banks, and other support services.

Confounding factors

Service users and service providers agree the economic downturn over recent years, the rising cost of living, and welfare benefit levels have had a significant impact on alcohol consumption, almost certainly in a more significant way than MPA in isolation. Many service users on low incomes reported their struggles to balance essential living costs with alcohol expenses as a result of all these factors.

Both groups highlighted the profound effect of the COVID-19 pandemic on alcohol consumption. For service users, public health protective measures led to increased home drinking and higher alcohol consumption due to isolation and boredom. Service providers similarly reported an increase in alcohol referrals and dependency, noting that post-pandemic many individuals have continued to struggle with alcohol use.

Service users and providers alike pointed out difficulties for individuals in accessing treatment services, particularly in remote areas. Geographic disparities in service availability have meant individuals in certain areas facing greater challenges in seeking help, and this uneven access to services has complicated the evaluation of MPA’s impact. 

Overall, service providers found it hard to distinguish the contribution MPA has played in reducing harms associated with alcohol across Wales. This is because it was hard for them to differentiate between changes that are attributable to the COVID-19 pandemic as well as the current cost of living crisis, as opposed to solely the introduction of MPA.

Next steps for the MPA policy

Service providers stressed the need for regular reviews of MPA to ensure its relevance and effectiveness. They were supportive of maintaining or even raising the minimum unit price. Service users, however, generally expressed more scepticism about the policy's impact on reducing harmful drinking, seeing it as insufficiently targeted. Overall, they were less convinced the policy should be continued, although there were mixed views regarding this point.

Service providers acknowledged the risk of disproportionately impacting financially vulnerable individuals through a continuation of MPA, and both groups called for enhanced public health campaigns and accessible support services as a means of mitigation. Service providers suggested targeted support could help those struggling with alcohol dependency, whilst service users advocated for greater investment in alcohol services. Service users also expressed frustration at a perceived lack of transparency on who has control over increased revenues from MPA.

Some service providers proposed stricter regulations on the sale of high-strength alcohol, with an aim of reducing accessibility for the most vulnerable populations. A few service users agreed but cautioned that price increases might push individuals toward unregulated, potentially harmful sources of alcohol.

Conclusions

Overall, the key message of this study is that the evidence observed continues to resonate with the existing evidence collated over the last five years by our research team in the form of eight studies commissioned by the Welsh Government (Research into minimum pricing for alcohol (MPA) - Welsh Government).

The evidence more broadly resonates with the findings of the wider-range of larger-scale evaluation studies either conducted, or commissioned, by Public Health Scotland between 2018 and 2023 (Evaluation of minimum unit pricing (MUP) of Alcohol - Public Health Scotland).

Another key message that needs to be highlighted as a result of this study is the observed, and continuing, misunderstanding and misinterpretation of the MPA policy amongst both service users and service providers. We therefore need to repeat the key message from the interim report (Perkins et al., 2023) that this misunderstanding and misinterpretation is in relation to the intention of the policy and demonstrates there is still more work for the Welsh Government to do in educating the alcohol and drug treatment sector and workforce. 

The exploration of MPA with these drinker and provider populations has highlighted that through the purposeful removal of cheap alcohol products (below 50p per unit), the financial pressure on those seeking to maintain dependency has significantly increased. The consequence of this is a policy often misunderstood as targeting such low-income vulnerable drinkers rather than viewing them as an adversely effected group resulting from a wider overall population measure. This has led to negativity towards MPA amongst service providers and service users, and a perception of a policy that fails to support dependent drinkers.

Service providers mentioned MPA is no longer a regular topic of conversation amongst staff or with service users, which could reduce its long-term impact and effectiveness. Service users similarly noted a lack of ongoing awareness and understanding, with many seemingly forgetting about the policy's existence. This suggests MPA has not been fully integrated into the broader public discourse on alcohol consumption and public health with these groups.

Service providers and service users have both noted a broader demographic shift in those presenting with alcohol-related issues following the implementation of MPA, albeit only a small element of contribution was attributed to MPA rather than other, more significant, factors such as the COVID-19 pandemic and the cost-of-living crisis. Over the last four years there has been an observed increase in older adults, employed individuals, and younger people recognising the impact of their alcohol and drug use. Notably, there was a reported rise in females seeking help.

Service providers and service users have observed some shifts towards purchasing stronger, alcoholic beverages, such as spirits and wine, due to the pricing constraints imposed by MPA. This shift is seen as a way for service users to maximise their alcohol intake despite higher prices.

Since the implementation of MPA there has been a lot of conflation about difficulties in maintaining affordability between MPA, COVID-19, benefit system changes, and the cost of living crisis. There is a shared understanding amongst service providers and service users that financial hardship almost always leads individuals to prioritise alcohol over essential living expenses. For most drinkers this does not include law breaking activity (e.g., shoplifting to fund higher alcohol prices) or in relation to switching to cheaper products or substances as a result of higher alcohol prices (e.g., switching to using illicit, stolen, or non-beverage alcohol, or other substances).

Both groups noted that a small number of drinkers resorted to cross-border purchasing to obtain cheaper alcohol, although this was generally noted as being for those with the means (income) and method (transport) for being in easy reach of the border with England.

There have been some reports of increases in poly-drug use noted by both service providers and service users, with some individuals increasing their use of drugs like crack cocaine and illicit benzodiazepines, as either a cheaper alternative or as a complement to alcohol.

Social stigma and limited accessibility to services were significant barriers highlighted by both groups. Service users often felt judged or stigmatised when seeking help, which was compounded by a scarcity of accessible service provision, particularly in remote areas.

Despite the wide range of negative attitudes and feelings expressed towards the policy, it is important to note the majority of individuals interviewed for the study ultimately considered that the MPA legislation should be retained. The main reason for this was a desire not to return to pre-MPA days where significantly cheap alcohol (especially strong white ciders) were readily available and consumed by those who experience problems with alcohol. The proviso expressed by many was that if MPA is retained then priority needs to be given to providing additional treatment and support options to mitigate the harmful impact being experienced by low income dependent drinkers.

Recommendations

Recommendation 1

There is a clear need to enhance treatment responses across Wales for dependent drinkers to ensure there is the right sort of treatment available that is both sufficient and accessible in its availability across the country. We would especially highlight the need for increased inpatient detoxification provision, along with a focus on quicker pathways into such detoxification programmes. This needs to go hand-in-hand with post-detoxification support, particularly for those living alone. We would also recommend special attention is given to the needs of low-income dependent drinkers, and that other mitigating actions are required beyond the provision of inpatient detoxification programmes, such as through the development of managed alcohol programmes.

Recommendation 2

A dedicated programme of support should be provided to treatment agencies to focus their attention and expertise in actively engaging individuals around managing their finances and alleviating poverty whilst in treatment. The priority should be for treatment agencies to be proactive in engaging with conversations about finances rather than just signposting to Citizens Advice Bureau, food banks, etc.

Recommendation 3

If MPA is renewed then a campaign of promotion across providers through to drinkers needs to be revisited. This should include explicit messaging about (1) the target audience for MPA, and (2) the impact on dependent, low-income drinkers.

References

Buhociu, M., Holloway, K., May, T., Livingston, W., & Perkins, A. (2021). Assessing the Impact of Minimum Pricing for Alcohol on the Wider Population of Drinkers - Baseline. Cardiff: Welsh Government.

Holloway, K., May, T., Buhociu, M., Livingston, W., Perkins, A., & Madoc-Jones, L. (2019). Research into the potential for substance switching following the introduction of minimum pricing for alcohol in Wales. Cardiff: Welsh Government.

Holloway, K., Buhociu, M., Murray, S., Livingston, W. & Perkins, A. (2022). Assessing Impact of COVID-19 and the Early Impact of Minimum Pricing for Alcohol on the Wider Population of Drinkers. Cardiff: Welsh Government.

Holloway, K., Buhociu, M., Murray, S., Livingston, W. & Perkins, A. (2024). Assessing the Impact of Minimum Pricing for Alcohol on the Wider Population of Drinkers: Final Report. Cardiff: Welsh Government

Livingston, W., Perkins, A., McCarthy, T., Madoc-Jones, I., Wighton, S., Wilson, F., & Nicholas, D. (2018). Review of Working Together to Reduce Harm: Final Report. Cardiff: Welsh Government.

Livingston, W., Perkins, A., Holloway, K., Murray, S., Buhociu, M., & Madoc-Jones, I. (2024). Final Report: Review of the Introduction of Minimum Pricing for Alcohol in Wales. Cardiff: Welsh Government.

Nelson TF, Xuan Z, Babor TF, Brewer RD, Chaloupka FJ, Gruenewald PJ, Holder H, Klitzner M, Mosher JF, Ramirez RL, Reynolds R, Toomey TL, Churchill V and Naimi TS. (2013). Efficacy and the strength of evidence of U.S. alcohol control policies. American Journal of Preventive Medicine, 45 (1):19–28.

Perkins, A., Livingston, L., Cairns, B., Dumbrell, J., Holloway, K., Buhociu, M., Murray, S., & Madoc-Jones, I. (2023). Assessing the Experiences and Impact of Minimum Pricing for Alcohol on Service Users and Service Providers: Interim Findings. Cardiff: Welsh Government.

Wagenaar, A. C., Salois, M. J., & Komro, K. A. (2009). Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction, 104(2), 179-190.

Contact details

Report authors: Andy Perkins, Wulf Livingston, Josh Dumbrell, Sophie McCluskey, Sam Steele, Katy Holloway, Marian Buhociu, Shannon Murray, and Iolo Madoc-Jones (2024)

Views expressed in this report are those of the researchers and not necessarily those of the Welsh Government.

For further information please contact:
Social Research and Information Division
Knowledge and Analytical Services
Welsh Government
Cathays Park
Cardiff
CF10 3NQ

Email: Research.HealthAndSocialServices@gov.wales

Social research number: 5/2025
Digital ISBN 978-1-83625-864-3

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