Background
In an effort to tackle the perceived negative impact of super-strength alcohol in the United Kingdom (UK), a number of local licensing authorities have encouraged ‘Reducing the Strength’ (RtS) schemes [
1‐
4]. According to guidance issued by the Local Government Association, “the definition of high strength varies, but for the purposes of Reducing the Strength schemes has tended to refer to products from around 6.5 per cent ABV [alcohol-by-volume] upwards” ([
5] p.6). These products are usually classified as strong beers and ciders sold at low prices. Super-strength lager is often sold as single 500 ml cans and well-known brands include Carlsberg’s Special Brew, Tennent’s Super, Kestrel Super and Skol Super. White cider is primarily sold in 500 ml cans, 1 litre or 3 litre plastic bottles and most available brands are 7.5 % ABV. Well-known brands include White Ace, Frosty Jacks and White Star.
At the time of the intervention described in the paper (2013–2014) a single 500 ml can of 9 % ABV beer contained more than the maximum daily alcohol intake for men (3–4 units) and women (2–3 units) recommended by UK health guidance [
6]. A single 3 litre bottle of white cider also exceeded the recommended weekly alcohol intake (21 and 14 units for men and women, respectively) [
6]. The UK Chief Medical Officer recently updated the alcohol guidelines, recommending that men and women consume no more than 14 units of alcohol per week, spread over at least three drinking days [
7]. Super-strength products continue to be sold in quantities that exceed these recommendations.
Alcohol consumed in large quantities for prolonged periods is causally associated with both acute and long-term health problems [
8‐
10]. Wider societal problems associated with super-strength alcohol include street drinking and homelessness, anti-social behaviour, underage drinking and family breakdown [
11]. There is no evidence that super-strength alcohol has a unique or ‘special’ type of harm that would not be experienced from consuming the same units of alcohol in another form [
12], rather it is the availability (convenience and branding) and low unit cost of these drinks that raise them as an issue of interest to public health practitioners [
13]. One Australian study demonstrates a positive association between high-strength beer and cask wine consumption at a population level and alcohol-related criminal activity and alcohol-related morbidity [
14]. There is evidence linking the price of alcoholic beverages and the volume consumed at a population level [
15].
RtS schemes have become increasingly popular as a method to address the negative impact of super-strength products, and since 2012, approximately 80 schemes have been launched across England [
16]. The intervention was originally launched in Ipswich, Suffolk, although Thames Reach, a large homeless charity, has been campaigning against super-strengths since 2005 [
11]. RtS schemes vary in nature with regards to the specific drinks or populations targeted, but in general, local authorities ask local retailers licenced to sell alcohol for consumption off premise (such shops are called ‘off-licences’) in specific areas to voluntarily remove super-strength alcohol from sale [
5].
RtS speaks to both the physical and economic aspects of availability [
17]. If compliance is widespread, the intervention removes an entire group of products from an area, thereby reducing the quantity and variety of different types of alcohol available. Where super-strength beers and ciders represent the cheapest products on sale, the intervention will also raise the price of the cheapest available unit of alcohol in participating shops. Due to the relatively lower rate of alcohol levied on still ciders, white cider is almost universally the cheapest unit of alcohol available in shops. A study of heavy drinkers’ habits identified those who drank white cider as the population group consuming the most alcohol [
18]. An organisation working with homeless and street drinkers identified super-strength lager as a preferred drink, and a cause of harm, amongst these groups [
11].
Both UK and international health agencies recommend increasing the cost of alcohol to address alcohol-related harms, and evidence suggests that higher alcohol prices will most affect those who drink at harmful levels [
19‐
21]. Off-licences, primarily small independent retailers, as opposed to supermarkets, have been found to sell 95 % of all alcohol consumed by heavy drinkers in Scotland. White cider was found to be exclusively available at these outlets [
13]. Voluntary bans on super-strength products in Portsmouth have reported high levels of shop compliance with the intervention [
5] and Ipswich, Suffolk has reported a reduction in crime and anti-social behaviour [
22], although to date no robust evaluations have been published.
In this paper, we address the question of whether a targeted, voluntary approach to reducing alcohol availability can achieve the prerequisite of successfully enlisting retailers to volunteer. We also present early data on the effect an RtS scheme may have on the cheapest available alcohol. This is directly relevant to national and international debates over the relative merits of voluntary and compulsory approaches for reducing alcohol availability, as well as debates over local verses national level interventions [
23‐
25]. It also has parallels with other interventions aimed at restricting particular alcohol products, such as restrictions on the sale of cask wine in parts of Australia [
26,
27].
In 2013–2014 RtS schemes were implemented in the London Boroughs of Islington and Camden. In a related paper (currently submitted) we explore responses to RtS from the perspective of target populations of drinkers and front line staff who work with them. We have also conducted a separate quantitative study of RtS’s impact on alcohol sales using retail data (also currently submitted). The aim of this study is to evaluate the Islington and Camden schemes by assessing the effect on the cheapest available unit of alcohol in off-licences and retailers' willingness to participate. Using quantitative and qualitative process data, it explores whether a voluntary reduction in alcohol availability through this intervention is feasible, what influences retailers’ choice to participate or not, and how retailers believe their participation will influence alcohol purchasing amongst the targeted population.
Methods
As part of a mixed methods evaluation we present data from local authority audits of off-licences and qualitative findings from interviews with retailers. The evaluation was conducted by members of Islington and Camden’s joint public health team in collaboration with independently funded researchers from London School of Hygiene & Tropical Medicine (LSHTM). Local authority auditing processes did not require ethical approval. The LSHTM team obtained ethical approval through the London School of Hygiene & Tropical Medicine Ethics Committee.
Intervention
In 2013–2014, voluntary RtS projects were introduced in areas considered to have street drinking and alcohol-related anti-social behaviour problems within two neighbouring London local authorities, Islington and Camden. The Islington and Camden intervention areas contained 63 and 78 off-licences, respectively. Each local authority implemented RtS independently by recruiting alcohol retailers to voluntarily remove super-strength beers and ciders (defined as cheaply sold drinks with ≥6.5 ABV) from sale in their shops with a view to reducing health and social harms associated with street drinking, but also recognising potential benefits to wider populations.
The projects were designed and implemented by licensing teams in partnership with police and public health practitioners. Repeated visits were made to local premises to advocate for voluntary participation on grounds of social responsibility. Letters and visits to off-licences by the licensing and licensing police teams were used to raise the profile of the scheme. In addition, in Camden a launch event was organised by the council, which was attended by public health, the business improvement district and the local media.
Sampling
The local authorities held data on all local off-licences; all stores in the intervention areas were included in the audit to provide data on compliance with RtS. Shops known to be selling super-strength alcohol pre-intervention were included in the qualitative fieldwork. Stores were sampled for qualitative fieldwork based on the assumption that around 40 of the 78 stores selling super-strength would be sufficient to provide a purposive sample that covered different geographical areas, shop types and shops that participated or declined to participate in RtS.
Sampled stores were visited to obtain consent to participate in the study from licence holders, managers or staff (which we refer to collectively as ‘retailers’). Retailers that did not participate in RtS were over-sampled to ensure this group was well represented. Visits took place between 3 and 6 months after intervention implementation commenced. Two researchers conducted each visit from a pool of five researchers. All interviewers were professionals with experience of conducing qualitative research.
Data collection
Data on sign-up and adherence was provided by local licensing teams who made regular visits to off-licences to record the prices of alcoholic beverages and to audit whether ≥6.5 ABV beers and ciders were on sale. Where possible, public health practitioners objectively assessed the unit cost of alcohol in RtS participating shops. Pre-intervention prices were obtained from shop managers or shop staff and relied on their recall of the product prices. The price, container size and brand of the cheapest beer, cider wine and spirits available in both individual and multi-buy deals was recorded on a pro-forma during visit. Where a drink type was not available this section was left blank. Where the cheapest unit of any drink type was not clear, data on several cheap products was collected for later calculation and comparison.
A topic guide was developed to enable interviews to explore retailers’ views on the scheme, reasons for (not) participating in RtS, and views on how the scheme impacts on purchasing amongst the target population as well as broader impacts on the retailer and community. This guide was developed in collaboration with the licensing team who implemented the schemes and was designed to elucidate the motivations for participation, as well as the barriers. The guide provided a starting point for discussion but there was also sufficient scope within the interview for the participants to guide the discussion. The main themes in the topic guide were: knowledge of RtS, rationale for (non-) participation, impact on alcohol availability, challenges of participating in the scheme, impact on the shop, response from super-strength drinkers, intervention sustainability and suggestions to improve the intervention. Participant responses were recorded in writing during the interviews on a pro-forma with space for verbatim quotes. To aid recruitment, interviews were conducted in the shops as this was convenient for participants. However, we did not regard shops as a suitable location to audio-record the interviews due to the presence of customers.
Due to the short time span between implementation and evaluation no efforts were made to assess the wider impact of the scheme on levels of drinking, health harms or anti-social behaviour.
Analysis
The cheapest unit of alcohol available, regardless of drink type, was calculated for each individual off-licence using the price, container size and ABV data. The median cheapest unit was then calculated across the entire intervention area and this data was plotted in terms of median and inter-quartile range pre- and post-RtS. A sub-analysis was conducted on only those shops that participated in RtS in order to understand the potential effect if the intervention achieved universal sign-up.
Post-visit interview notes were written up and reviewed by two researchers to draw out common themes. These were reviewed by a third author and through discussion amongst the research team, we drew out the shopkeepers’ prevalent and divergent opinions about RtS.
Discussion
This study is one part of a multi-methods and multi-site evaluation of RtS. It has been designed to produce early evidence on the feasibility of an intervention that relies on voluntary participation from shops. We found relatively high rates of participation by off-licences in the intervention areas and evidence that across the intervention area the median price of the cheapest unit of alcohol available increased. The rise was relatively small, although the target population of homeless and street drinkers have few financial resources making them susceptible to relatively small changes in economic availability [
28]. The qualitative findings suggest that even a relatively small minority of non-participating shops can potentially deter voluntary compliance with the intervention and undermine its impacts if customers find it easy to access shops where they can still buy super-strength products. The relatively small geographical implementation area and voluntary nature of the intervention make this substitution of shops viable. The localised and voluntary nature of the intervention also presents other challenges for implementers. For instance, our findings suggest that larger retail chains make decisions to participate at a regional or national level, which means that local authorities wanting to implement RtS may be obliged to negotiate with the head offices of multiple national supermarket chains to ensure their participation.
The fact that RtS is a local-level intervention, generally delivered on a small scale, also has implications on the kinds of research approaches that are feasible and useful in this context. The local-level delivery means that the number of shops involved and the drinking population targeted were small, making sufficiently powered quantitative analysis difficult. In this paper we have included some basic quantitative data on shop uptake and minimum prices but rely on qualitative findings based on a purposive sample of half the total ‘population’ of off-licences known to have sold super-strength prior to the intervention.
The research also represents collaboration between local practitioners and academic researchers intended to maximise the utility of the study as a resource for informing practice. One requirement to achieve this was that the study provided timely findings about outcomes that local practitioners could plausibly seek to influence, such as intervention uptake and compliance [
29‐
31]. Lengthy academic timescales have been described in previous literature as a barrier to evidence informed decision making if findings are reported too late to affect decisions driven by political timescales [
32,
33].
It is recognised that public health researchers generally value evaluations with robust study designs that include greater numbers of participants to provide adequate statistical power for measuring health outcomes, preferably compared with a suitable control group [
34,
35]. We too value such studies but we still argue the case for evaluations that cater specifically for the more immediate needs of decision-makers. Guidance on the evaluation of complex interventions recommends such studies to explore the feasibility of interventions and help inform decisions about whether larger scale intervention and evaluation are justified, so we would argue that our approach conforms to accepted standards of good evaluation practice [
35].
Limitations
Within the timescales of the evaluation we are unable to demonstrate any longer term outcomes such as reduced crime, anti-social behaviour, acute health harms or improved long-term health. Follow-up visits were not made to all off-licences as part of the evaluation and sampling was purposive rather than random. This research should be viewed as a ‘snapshot’ over a relatively small period of time rather than as the final and continuing result of the intervention.
The interviews were conducted by local authority staff. It is possible that this would influence the potential for interviewer bias, if (for example) participants decided that it was in their interests to emphasise their compliance and enthusiasm for RtS. Non-participation was low but interviewees were able to refuse for any reason they chose. We do not rule this bias out but we do highlight that many responses quoted in this article identified perceived problems with the intervention, and included some participants who described their refusal to participate in the intervention.
The involvement of independently funded academic researchers is intended to safeguard against the conflict of interest inherent in a local authority evaluating its intervention. However, whilst this form of ‘co-production of evidence’ between practitioners and academics is currently advocated amongst researchers, practitioners and grant holding bodies, it raises questions about the extent to which academic researchers involved can justifiably describe themselves as ‘independent’.
As many of the off-licences were small independent shops, the only member of staff available for interview was often serving customers at the same time the interview was being conducted, which meant that interviews were necessarily kept short. As a result, price data was not collected for all shops. In addition, prices of super-strength alcohol pre-intervention relied on the recall and accurate reporting of the interview. We believe this pragmatic approach helped to keep response rates high but at the expense of a richer dataset. Interviews were conducted in English, which shop staff could speak but not always as a first language. In the absence of audio-recoding, we are reliant on interviewers’ written fieldnotes. Participants were not contacted to verify these notes.
Policy implications
Although voluntary and community initiatives are often small scale and may have less impact than more comprehensive policy interventions, they are sometimes seen as useful for tackling specific local problems particularly in contexts where resources are limited [
36]. Examples of such interventions include the Alcohol Linking Program [
37], the Queensland Safety Action Project [
38] and the Swedish Stockholm Prevents Alcohol and Drug Problems (STAD) initiative [
39].
Reducing the Strength projects are a clear example of an innovative local solution to a national problem and over 80 local authorities have implemented RtS schemes in the absence of a national minimal unit price (MUP). Prior to the introduction of RtS, a litre of 7.5 % ABV white cider retailed for around £1.50 in Islington and Camden, which is 20p per unit of alcohol. In England the 40p MUP proposed by the Coalition government in 2012 would have delivered a minimum price of £3.00 per litre of 7.5 ABV% beer or cider [
40,
41]. An alternative alcohol pricing policy came into force in May 2014 banning the sale of alcohol below the total cost of duty and VAT combined [
42]. This effectively introduced a MUP that varies by drink as duty differs substantially between alcohol types. This established a minimum price for one litre of 7.5 % ABV white cider of 48p or 6.4p per unit of alcohol [
40,
43], a price far below the current cost and even further below the proposed MUP from 2012. The policy did have some effect on the minimum price of a super-strength lager establishing a minimum price of £1.30 per can [
40,
43], higher than the price in some Islington and Camden off-licences during the research (pre-legislation). Research modelling concluded that a 40p to 50p MUP would result in 40 to 50 times greater effect on consumption than the floor price approach [
40].
From the local authority’s perspective, persuading retailers to voluntarily participate in RtS represents an extremely resource intensive way of achieving outcomes that could be potentially derived from a national MUP policy. RtS focuses on the complete removal of a narrow range of products, primarily super-strength beers and white ciders, whereas a MUP would allow consumers to buy these products, but at a price linked to their alcoholic content, and hence likely level of harm, rather than their tax regime. In contrast, voluntary schemes such as RtS are inherently susceptible to the problem that retailers stand to potentially benefit by not complying if they attract customers away from compliant shops.
The perceived merits and limitations of voluntary alcohol interventions such as those involving alcohol retailers have been widely debated in the academic literature and policy circles [
36]. The research literature on interventions to reduce population-level alcohol harms provides evidence that mandatory rather than voluntary approaches are more likely to be effective [
44]. Moodie et al. concluded in 2013 that despite common reliance on industry self-regulation and public-private partnerships in policy, there is no evidence of their effectiveness [
45]. Babor has argued that voluntary codes are subject to under-interpretation, under-enforcement and poor compliance [
8]. A review of voluntary UK social responsibility measures found poor compliance and interventions that were judged to be not fit for purpose [
46]. A study of Australia’s voluntary labelling scheme found the labels were difficult to understand and did not have the desired health impact [
47].
The alcohol industry has stated its interest in what is sometimes called responsible retailing. Heineken, for example delisted two high strength ciders, White Lightning and Strongbow Black, in 2008 citing recognition of the links between the product and social harms following a visit to an AddAction project [
48]. The UK’s Public Health Responsibility Deal, a public-private partnership where industry and government actors sign up to pledges aimed at improving public health [
49], included a pledge to reduce the total alcohol in a single serving carbonated drink (e.g. a can of lager or cider) to less than the maximum recommended daily intake for an adults. The manufacturers of some super-strength drinks have signed up to this pledge [
50]. In some cases, this has resulted in a reduction of can sizes to 450 ml, although the products have not been removed from sale. Changes under this Responsibility Deal were evaluated as being unlikely to contribute significantly to reductions in alcohol consumption [
49].
Our findings suggest that there is some support amongst retailers for a more interventionist approach on alcohol sales, echoing evidence from a previously published cross-sectional survey of small retailers in Scotland, which found support for another regulatory intervention, MUP [
51]. These findings provide a reminder that regulation need not necessarily take place against the perceived interests of the private sector (or parts of it, assuming the private sector is heterogeneous), and it is possible that some private sector stakeholders view regulation as a fairer and economically less risky option than voluntary participation in schemes like RtS. Our findings also suggest that voluntary interventions can be perceived in different ways, with some shop keepers exercising their right not to participate in RtS, others apparently supporting the intervention, whilst others gave a more pragmatic view that participation could help them maintain good relationships with local authorities and so safeguard their business against unspecified future actions from the licensing authorities. Hence, we see that the conceptual boundaries between voluntary and mandatory action begins to look more fluid and subjective when viewed at close quarters in relation to this intervention. We speculate that within mandatory frameworks there may be points at which there is a choice, and we suggest that within voluntary frameworks the available choices may be weighted by understandings or perceptions of potential costs and benefits.
Acknowledgments
The authors wish to acknowledge the invaluable input of Jon Paris, Community Safety Analyst, and the Licensing Teams in Camden and Islington Councils, in particular Licensing Officers Darren Petford and Niall Forde.