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Public Health
Wales NHS Trust
Response to
the Health, Social Care and Sport Committee on the Public Health
(Minimum Price for Alcohol) (Wales) Bill
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Date: 10 November 2017
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Version:
1
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1
Introduction
Public Health Wales welcomes the opportunity
to provide evidence on the Public Health (Minimum Price for
Alcohol) (Wales) Bill.
Public Health Wales strongly supports
implementation of the minimum unit price for alcohol in Wales.
There is compelling evidence, which is outlined in more detail
below, that introducing a minimum unit price in Wales would lead to
significant improvements in health and well-being.
Our views on minimum unit pricing were
previously articulated in some detail in our submissions to the
consultations on the White Paper in 2014 and the Public Health
(Wales) Bill in 2015. This paper has updated the original response
to reflect current statistics and evidence to inform the areas for
consideration outlines in the Terms of Reference for the scrutiny
of the Bill by the Health, Social Care and Sport Committee.
As the areas for scrutiny identified for consideration by Health,
Social Care and Sport Committee on the Public Health (Minimum Price
for Alcohol) (Wales) Bill vary to some extent to those consulted on
and responded to the White Paper in 2014. This paper presents the
original considerations which have been updated where
relevant.
Evidence
published since previous responses further reinforces evidence
cited in original submissions and provides a greater insight into
the harm caused by alcohol to individuals, their families and the
wider community. This includes;
·
Public Health
England (2016) The Public Health Burden of Alcohol and the
Effectiveness and Cost-Effectiveness of Alcohol Control Policies -
An Evidence Review.
·
UK Chief
Medical Officers’ Low Risk Drinking Guidelines
(2016)
·
Alcohol
Health Alliance, (2016). ‘Cheap Alcohol, the Price We
Pay’
·
Alcohol’s Harms to Others: the harms from other
people’s alcohol consumption in Wales (Quigg et al,
2016).
·
Public Health Wales (2015) Adverse Childhood Experiences and their
impact on health-harming behaviours in the Welsh adult
population.
·
Welsh Government, (2014) Model-based appraisal of minimum unit
pricing for alcohol in Wales An adaptation of the Sheffield Alcohol
Policy Model version 3.
2
Terms of Reference
2.1
The general
principles of the Public Health (Minimum Price for Alcohol) (Wales)
Bill and the extent to which it will contribute to improving and
protecting the health and well-being of the population of Wales, by
providing for a minimum price for the sale and supply of alcohol in
Wales and making it an offence for alcohol to be sold or supplied
below that
The following points were originally made in
response to the 2014 Public Health White Paper. The response
provided by Public Health Wales to the White Paper in June 2014 has
been used as a framework to provide this response as many of the
views remain unchanged. The statistics and evidence sources
in the original submission have been updated and are provided
below.
2.1.1
Public Health Wales strongly supports implementation of the minimum
unit price for alcohol in Wales. There is compelling evidence,
which is outlined in more detail below, that introducing a minimum
unit price in Wales would lead to significant improvements in
health and well-being. Recent decades have seen increases in
alcohol consumption and health harms associated with alcohol across
Wales. These increases are linked with real terms reductions in the
cost of alcohol. A minimum unit price is a targeted measure that
will impact beneficially on the heaviest drinkers and other groups
particularly at risk from alcohol related harms – such as
young people. Moderate drinkers will experience relatively little
change in the amount they have to pay for alcohol.
2.1.2
Minimum Unit Price (MUP) sets a floor price for a unit of
alcohol[1],
meaning that alcohol could not legally be sold below that price.
This would not increase the price of every drink, only those that
are sold below the minimum price; for example very cheap spirits,
beer and wine. MUP is based on two fundamental principles that are
widely supported by scientific evidence:[2][3][4]
·
When the price of alcohol increases consumption by most drinkers
goes down including, critically, consumption by hazardous and
harmful drinkers (i.e. heavier drinkers)
·
When alcohol consumption in a population declines, rates of
alcohol-related harms also decline.
2.1.3
Drinking alcohol increases the risk of developing over 60 different
health problems[5],[6]
including a range of cancers, liver disease, high blood pressure,
injuries and a variety of mental health conditions. It also
increases the risk of causing harms to the health of others.
2.1.4
The UK CMO’s guidance on low risk drinking was based on a
comprehensive review of the evidence about the health harms
associated with alcohol consumption. The review found that the risk
of developing health problems increases with the amount of alcohol
consumed on a regular basis. The UK Chief Medical Officers advise
that to keep health risks from alcohol to a low level it is safest
not to drink more than 14 units a week on a regular basis. [7]
2.1.5
The 2011 General Lifestyle Survey (GLS16)[8]
showed that the percentage of persons that drank more than 3-4
units on at least one day in Wales (28 per cent) was similar to
Scotland (31 per cent) and England (31 per cent). Those drinking
more than 6-8 units on at least one day was the same in Wales (15
per cent) as in England (15 per cent) and similar to Scotland (16
per cent). Residents of England and Wales (13 per cent and 12 per
cent respectively) were more likely than men in Scotland (7 per
cent) to have had an alcoholic drink on at least five days in that
week.
2.1.6
National Survey for Wales 2016-17[9]
reported that twenty percent of adults (16+) reported drinking
above the recommended weekly guidelines. 13 per cent of people aged
16 and over reported binge drinking (men drinking more than 8 units
or women drinking more than 6 units on a single occasion). Men were
more likely than women to report drinking above the recommended
weekly guidelines (27 per cent of men compared with 14 per cent of
women) and to report binge drinking (18 per cent of men, 13 per
cent of women).
2.1.7
Importantly, social surveys consistently record lower levels of
consumption than would be expected from data on alcohol sales,
partly because people often underestimate how much alcohol they
consume.
2.1.8
Sales data show that 10.8 Litres of pure alcohol was sold per adult
(16+) drinker in England and Wales in 2016[10].
One unit is 10ml of pure alcohol so this equates to an estimated
average consumption of 20.8 units per drinker per week. This is a
much greater level than recorded in surveys and suggests that more
people exceed weekly guidelines than surveys would suggest.
2.1.9
The past three decades have seen a steady increase in alcohol
consumption and although the reasons behind this are complex and
multi-factorial, affordability is a key factor. It has been
reported that alcohol is 60% per cent more affordable than in
1980[11]
and the increase in affordability of alcohol has been linked with
increased alcohol consumption and related health harms[12],[13].
2.1.10 A
price review by the Alcohol Health Alliance UK[14],
found that 3-litre bottles of 7.5% ABV cider (containing the
equivalent of 22 units) for just £3.59 in 2017 (or 16p per
unit).
2.1.11 A
2005 review by the World Health Organisation (WHO)[15]
of 32 European alcohol strategies found that the most effective
measures to curb alcohol related health harms include changes to
price and availability.
2.1.12 By
comparison other measures (public service campaigns, education
initiatives, and voluntary self regulation preferred by the alcohol
industry) have more limited impacts on drinking patterns and
problems.[16]
2.1.13 This
evidence has led several countries to consider MUP policy[17].
2.1.14
Sufficient modelling has been undertaken for Wales, in England and
elsewhere to estimate the benefits that a 50 pence MUP would have
on alcohol consumption and related health harms. However, this was
based on levels of affordability of alcohol in 2014, and we
consider that MUP should be linked to an inflationary measure to
ensure it remains an effective measure to reduce alcohol health
harms. Should the introduction of MUP be delayed the initial MUP
should be adjusted from 50p to account for inflationary trends up
to the point of its introduction.
2.1.15 Both
US and UK data show that the heaviest drinkers gravitate towards
the cheapest alcohol[18],[19].
As a result MUP affects heavy drinkers’ consumption much more
than light or moderate drinkers. Consequently, MUP is a targeted
measure which primarily impacts heavy drinkers.
2.1.16 In
Wales, modelling[20]
suggests that a 50 pence MUP would result in:
·
a high risk drinker drinking 293 fewer units per year
·
a moderate drinker drinking 6.4 fewer units per year
·
an annual reduction in alcohol related deaths of 12.3 per cent and
in alcohol related hospital admissions of 10.3 per cent.
2.1.17 The
reductions are also substantially larger for high risk drinkers in
poverty (e.g. a reduction of 487.3 units per year vs. 243.0 units
per year for high risk drinkers not in poverty).
2.1.18
Concerns around the possibility of a hard-hitting impact on those
with low incomes have been a critical consideration of MUP
debate,[21],[22]
however, for the majority of people on low incomes who are
abstainers, light or moderate drinkers, the financial impacts of
MUP are very small.
2.1.19 The
modelling report for Wales (2014) estimates that moderate
drinkers[23]
(62% of the population) consume on average 5.5 units per week,
spending £310 per year on alcohol. High risk drinkers[24]
(7% of the population) consume on average 78.1 units per week,
spending £2,960 per annum. These patterns differ somewhat when
examined by income group, with moderate drinkers in poverty
estimated to drink 4.9 units per week, spending £200 per
annum, whilst moderate drinkers above the defined poverty line
consume 5.6 units per week and spend £340 per annum.
2.1.20
Based on a minimum unit price of 50p it is estimated that high risk
drinkers will spend an extra £32 (1.1%) per year whilst
moderate drinkers’ spending increases by £2 (0.8%). It
is important that this should is seen in the context of national
costs from alcohol related harms (health, social, economic and
criminal justice) being equivalent to around £900 in 2014 per
family. These harm-related costs could be substantially reduced if
a MUP was introduced.
2.1.21
Modelling suggests that an MUP of 50 pence per unit would result in
a reduction of 53 deaths and 1,400 fewer hospital admissions per
year in Wales, 10,000 fewer days sickness absence and would reduce
criminal offences by 3,684, with a total value of an estimated
saving of £882 million over the 20 year period
modelled.[25]
2.1.22 The
inclusion of impacts of MUP on crime is an important health and
well-being consideration. Therefore, as well as harm to the
individual who is drinking, alcohol consumption can also impact the
wellbeing of wider society through reducing alcohol-related crime,
including those relating to violent, anti-social and disorderly
behaviour, acquisitive crime and criminal damage.
2.1.23 The
Crime Survey for England and Wales reports that within the year
2014/15 there was 592,000 violent incidents where the victim
believed the offender(s) to be under the influence of alcohol,
accounting for 47 per cent of violent offences that year. Alcohol
routinely accounts for over 40 per cent of all violent crimes
committed[26]31
and, as well as youth violence, is strongly associated with
domestic violence, child abuse and self-directed violence (e.g.
suicide)[27]
2.1.24 In a
recent survey over half those questioned (59.7% of adults aged 18
years and older) in Wales had experienced at least one harm from
someone else’s drinking in the last 12 months. Nationally,
this is estimated to be equivalent to 1,460,151 people[28].
2.1.25
Young people are particularly vulnerable to the harmful effects of
consuming alcohol[29]
and harm from other people’s drinking. Results from the first
Welsh Adverse Childhood
Experience (ACE) study in 2015[30],[31]
demonstrate the long term impact of parental alcohol misuse and
other alcohol related negative experiences such as abuse, domestic
violence and having a family member in prison. The study found that
experiencing four or more traumatic experiences in childhood
increases the chances of committing violence against another person
in adulthood by 15 times. A vicious cycle of harm is also created
as children that have four or more adverse childhood experiences
are four times more likely to grow up to be a high risk drinker
themselves.
2.1.26 A
MUP of 50 pence would not impact the cost of alcohol in licensed
settings (e.g. pubs) but would increase the cost of the cheapest
alcohol sold in off-licences settings (e.g. supermarkets). This is
an important affect as the difference in costs between the two
settings is driving health harming behaviours such as pre-loading
with alcohol especially in young people, before going out for a
night[32].
2.1.27 MUP
in Canada has proved a successful measure for reducing
alcohol-related harms; including reducing alcohol-related
deaths.[33]
2.1.28 In
British Columbia with a population of 4.6million, a 10 per cent
increase in the average minimum price of all alcoholic beverages
was associated with a 9 per cent decrease in acute
alcohol-attributable admissions and a 9 per cent reduction in
chronic alcohol-attributable admissions two years later[34].
It was estimated from this that a 10 cent (approximately 6 pence)
increase in average minimum price was associated with 2 per cent
(166) fewer acute admissions in the first year and 3 per cent (275)
fewer chronic admissions two years later. Canada is one of six
countries that have introduced some form of MUP and in every case
the observed impacts on reducing consumption (and consequently
preventing related harms) have been larger than those
estimated.
2.1.29 The
estimated costs to the health service in Wales of alcohol-related
harm are between £70 and £85 million each year.[35]
These costs have increased since the 1970s, as alcohol has become
more affordable and alcohol-related deaths and disease have risen.
Therefore, Wales appears to be price sensitive to alcohol with
harms increasing as alcohol becomes more affordable.
2.1.30
Using the ONS definition, in 2016 there were 504 alcohol related
deaths registered in Wales, an increase of 8.9 per cent on the
previous year. 336 of these were men (66.7 per cent, up from 61.8
per cent of deaths in 2015) and 168 were women (33.3 per cent, down
from 38.2 per cent in 2015).[36]
2.1.31
10,081 individuals were admitted to hospital in Wales with a
condition caused solely by alcohol (e.g. alcoholic liver disease or
alcohol poisoning) in the year 2016-17, accounting for 13,512
admissions. The number of individuals admitted for alcohol specific
conditions has continued to fall in 2016-17 for both men and women,
however, this decrease was only marginal, 0.1 per cent, from
2015-16 and 1.4 per cent since 2012-13.33
2.1.32 When
considering alcohol specific conditions plus alcohol related
conditions (those that are caused by alcohol in some, but not in
all cases; e.g. stomach cancer and unintentional injury) 35,521
people were admitted to hospital in Wales in 2016/17. This is a
slight increase on the previous year and there has been and
increase over the last five years of 6.7 per cent for males and 6.9
per cent for females.[37]
2.1.33 Many
of the health harms associated with alcohol fall disproportionately
on the most deprived communities, with levels of alcohol related
deaths across Wales increasing from the most affluent to the most
deprived quintile.34 Tackling alcohol related ill
health, therefore, is an important element in reducing inequalities
in health.
2.1.34
Based on evidence from Canada and elsewhere, MUP would help
substantially in reversing these health harming trends relating to
alcohol consumption in Wales.
·
that public health benefits should justify the measures implemented
and that the same outcome would not be achievable by a less
intrusive measure.
·
Public Health Wales believes that there is a strong case across
Wales that MUP is a measure proportionate to expected reductions in
health harms and numbers of lives saved.
There are some consequences arising
from the Bill that should be considered, but should not prevent the
Bill being passed by the Assembly.
2.2.1
Public Health Wales is not in a position to provide specialist
advice on enforcement; however we are aware that Local Authority
enforcement is currently stretched. Effective implementation of the
provisions is dependent on good and robust enforcement systems, it
will be essential therefore that sufficient resources are available
to enforce the legislation and that enforcement of this legislation
does not negatively impact on other public health related activity
within local authorities.
2.2.2
It will be important to ensure that resources are available to
provide adequate, appropriate and timely support for the small
percentage of dependant drinkers who will need help to reduce their
drinking.
2.3
The financial
implications of the Bill (as set out in Part 2 of the Explanatory
Memorandum);
2.3.1
There are no additional costs that we are aware of that have not
been considered within the financial implications of the Bill set
out in Part 2 of the Explanatory Memorandum.
2.3.2
It is welcomed that the financial implications include
£350,000 for the evaluation of the Bill to ensure that it
leads to the necessary outcome that it aims to achieve.
2.4
The appropriateness of the
powers in the Bill for Welsh Ministers to make subordinate
legislation (as set out in Chapter 5 of Part 1 of the Explanatory
Memorandum).
2.4.1
We support the powers for Welsh Ministers to make subordinate
legislation to specify the MUP. Based on the evidence provided in
the original submission, Public Health Wales regarded a level of 50
pence per unit MUP as an appropriate level at which to initially
establish a MUP in 2014. Sufficient modelling had already been
undertaken for Wales, in England and elsewhere to estimate the
benefits that a 50 pence MUP would have on alcohol consumption and
related health harms. This was, however, based on the prices of
alcohol in 2014 and we consider that MUP should be linked to an
inflationary measure to ensure it remains an effective measure to
reduce alcohol health harms. Consequently, the introduction of MUP
should be adjusted upwards from 50p (in 2014) to account for
inflationary trends since that date both at its date of
introduction and then routinely at least on a three year
basis.
2.4.2
Public Health Wales recommends a range of other evidence based
measures should be considered in order to reduce the harms caused
by alcohol to Welsh citizens. None of these require MUP so are not
dependent on MUP being in place but would work in synergy to reduce
alcohol harms to health. Not all of these measures can be
unilaterally implemented in Wales as devolved powers do not allow
their introduction. However, we believe Wales can still act as a
powerful advocate for creating a culture where people are better
informed about the harms associated with alcohol consumption and
the real costs of alcohol are reflected in the price at which it is
sold. Further work is required to identify the best way of
delivering these through action and advocacy within existing
devolved powers. While provision of evidence to support all the
actions suggested below would be inappropriate in this consultation
we believe there is sufficient evidence already available to
support[xxxviii]:
·
Public health and community safety should be given priority in all
public policy-making about alcohol.
·
At least one third of every alcohol product label is an evidence
based health warning from an independent regulatory body.
·
Sales in shops should be restricted to specific times of the day
and designated areas with no promotion outside these areas.
·
Tax on alcohol products should be proportionate to volume of
alcohol to incentivise sales of lower strength products.
·
Licensing authorities should be empowered to tackle alcohol-related
harm by controlling total availability in their area.
·
Alcohol advertising should be strictly limited to newspapers and
other adult press while its content should be limited to factual
information.
·
There should be an independent body to regulate alcohol promotion,
including product and packaging design for public health and
community safety.
·
The legal limit for blood alcohol concentration for drivers should
be reduced to 50mg/100ml.
·
Graduated driver licensing should be introduced, restricting the
circumstances in which young and novice drivers can drive.
·
All health and social care professionals should be trained to
provide early identification and brief alcohol advice.
·
People who need support for alcohol problems should be routinely
referred to specialist alcohol services for assessment and
treatment.
·
Existing laws to prohibit the sale of alcohol to individuals who
are already heavily intoxicated should be enforced in order to
reduce acute and long term harms to their health and that of the
individuals around them.
[1]
25ml spirit (40%) is one unit, 175ml
of wine (13%) 2.3 units, a pint of cider (4.5%) 2.6 units, a pint
of beer (4%) 2.3 units
[2]
Stockwell and Thomas, (2013). Is
alcohol too cheap in the UK? The case for setting a Minimum Unit
Price for alcohol.. Institute of Alcohol Studies Report
[3]
Wagenaar AC, Salois MJ, and Komro KA
(2009) Effects of beverage alcohol price and tax levels on
drinking: a meta-analysis of 1003 estimates from 112 studies.
Addiction, 104, 179-90
[4]
Wagenaar, A., Tobler, A. and Komro,
K. (2010) Effects of alcohol tax and price policies on morbidity
and mortality: A systematic review. American Journal of Public
Health, published online September 23, 2010 at:
http://ajph.aphapublications.org/cgi/content/abstract/AJPH.2009.186007v1
[5]
World Health Organisation (2009)
Harmful Use of Alcohol [online] Available at:
http://www.who.int/nmh/publications/fact_sheet_alcohol_en.pdf
[7]
UK Chief Medical Officers’ Low Risk Drinking Guidelines.
[online] Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/545937/UK_CMOs__report.pdf
[8]
Office for National Statistics,
(2011) ‘General Lifestyle Survey’ [online]
Available at:
http://www.ons.gov.uk/ons/rel/ghs/general-lifestyle-survey/2011/index.html
[9]
Stats Wales, (2017)
‘National Survey for Wales’. [online] Available
at:
http://gov.wales/statistics-and-research/national-survey/?lang=en
[10]
Health Scotland, (2017). ‘MESAS monitoring
report 2017’ .
[online] Available at:
http://www.healthscotland.scot/publications/mesas-monitoring-report-2017
[12]
18 Institute for Social Marketing:
University of Stirling (2013) ‘Health First: An
evidence-based strategy for the UK’ [online] Available
at:
http://www.stir.ac.uk/management/about/social-marketing/
[13]
Anderson, P., Chisholm, D. and Fuhr,
D. (2009) Alcohol and Global Health 2: Effectiveness and
cost-effectiveness of policies and programmes to reduce the harm
caused by alcohol. Lancet, 373,
2234–46.
[14]
Alcohol Health Alliance, (2016).
‘Cheap Alcohol, the Price We Pay’. [online] Available
at:
http://12coez15v41j2cf7acjzaodh.wpengine.netdna-cdn.com/wp-content/uploads/2016/11/AHA-price-survey_FINAL.pdf
[15]
WHO fact sheet. 2005.
www.parpa.pl/download/fs1005e2.pdf.
[16]
Public Health England (2016) The
Public Health Burden of Alcohol and the Effectiveness and
Cost-Effectiveness of Alcohol Control Policies - An Evidence
Review.
[17]
Holmes, J., Meng, Y., Meier, P.S.,
Brennan, A., Angus, C., Campbell-Burton, A., Guo, Y., Hill-McManus,
D. and Purshouse, R.C. (2014) Eff ects of minimum unit pricing for
alcohol on different income and socioeconomic groups: a modelling
study. Lancet, 383, 1655-1664
[18]
Kerr, W. C. and T. K. Greenfield
(2007). "Distribution of alcohol consumption and expenditures and
the impact of improved measurement on coverage of alcohol sales in
the 2000 National Alcohol Survey." Alcoholism: Clinical and
Experimental Research, 31, 1714-1722.
[19]
Meier, P., Brennan, A., Purshouse,
R., Taylor, K., Raffia, R., Booth, A., O’Reilly, D.,
Stockwell, T., Sutton, A., Wilkinson, A. and Wong, R. (2008)
Independent review of the effects of alcohol pricing and
promotion, Part B. Modelling the Potential Impact of Pricing and
Promotion Policies for Alcohol in England: Results from the
Sheffield Alcohol Policy Model, Version 2008(1-1). University
of Sheffield, Sheffield, UK. Report commissioned by the UK
Department of Health.
[20]
Welsh Government, (2014) Model-based
appraisal of minimum unit pricing for alcohol in Wales
An adaptation of the Sheffield Alcohol Policy
Model version 3. [online] Available at:
http://www.senedd.assembly.wales/documents/s42760/ASMAI%2033%20University%20of%20Sheffield.pdf
[21]
Hansard. House of Commons Debate 14
March 2013. Hansard 2013; 560:
451–91.
[22]
Duffy, J.C. and Snowdon, C. (2012)
The minimal evidence for minimum pricing: the fatal flaws in the
Sheffield alcohol policy model. http://
www.adamsmith.org/blog/liberty-justice/the-minimal-evidence-forminimum-
pricing (accessed July 2, 2013).
[23]
Women drinking less than 14 units a
week and men drinking less than 21 units a week.
[24]
Women drinking more than 35 units a
week and men drinking more than 50 units a week
[25]
Welsh Government, (2014) Model-based
appraisal of minimum unit pricing for alcohol in Wales
An adaptation of the Sheffield Alcohol Policy
Model version 3. [online] Available at:
http://www.senedd.assembly.wales/documents/s42760/ASMAI%2033%20University%20of%20Sheffield.pdf
[26]
British Crime Survey, ONS;
http://www.ons.gov.uk/ons/taxonomy/index.html?nscl=Crime+in+England+and+Wales
[27]
World Health Organisation (2006)
Interpersonal violence and alcohol.
http://www.who.int/violence_injury_prevention/violence/world_report/factsheets/pb_violencealcohol.pdf
[30]
Public Health Wales (2015) Adverse
Childhood Experiences and their impact on health-harming behaviours
in the Welsh adult population
http://nww2.nphs.wales.nhs.uk:8080/PRIDDocs.nsf/7c21215d6d0c613e80256f490030c05a/d488a3852491bc1d80257f370038919e/$FILE/ACE%20Report%20FINAL%20(E).pdf
[32]
Barton, A. and Husk, K. (2012)
Controlling pre-loaders: alcohol related violence in an English
night time economy, Drugs and Alcohol Today, 12,
89-97.
[33]
Zhao, J., Stockwell, T., Martin, G.,
Macdonald, S., Valance, K., Treno, A., Ponicki, W., Tu, A. and
Buxton, J. 2013. The relationship between changes to minimum
alcohol price, outlet densities and alcohol-related death in
British Columbia, 2002-2009. Addiction.
URL:http://onlinelibrary.wiley.com/doi/10.1111/add.12139/pdf.
[34]
Stockwell, T., Zhao, J., Martin,G.
Macdonald, S., Vallance, K., Treno, A., Ponicki, W., Tu, A. And
Buxton, J. (2013) Minimum alcohol prices and outlet densities in
British Columbia, Canada: estimated impacts on alcohol-attributable
hospital admissions. American Journal of Public Health, 103,
2014-20.
[35]
Welsh Assembly Government (2008)
‘Working Together to Reduce Harm, The Substance Misuse
Strategy for Wales 2008-2018
[36]
Public Health Wales, (2017)
‘Data mining Wales: The annual profile for substance
misuse 2016-17’ [online] Available at:
http://howis.wales.nhs.uk/sitesplus/documents/888/FINAL%20profile%20for%20substance%20misuse%202016-17%20%282%29.pdf
[37]
Public Health Wales, (2017)
‘Data mining Wales: The annual profile for substance
misuse 2016-17’ [online] Available at:
http://howis.wales.nhs.uk/sitesplus/documents/888/FINAL%20profile%20for%20substance%20misuse%202016-17%20%282%29.pdf
[xxxviii]
Public Health England (2016) The
Public Health Burden of Alcohol and the Effectiveness and
Cost-Effectiveness of Alcohol Control Policies - An Evidence
Review. [online] Available at:
https://www.gov.uk/government/publications/the-public-health-burden-of-alcohol-evidence-review