Campaigning for Minimum Unit Pricing in Europe: Scotland the Brave! (2013-2015)

9 years - 9 case studies on European Public Health advocacy

Being exposed to European tobacco advocacy, alcohol was added to my responsibilities following a staff change in 2014. At that time, EPHA was member of the European Alcohol and Health Forum, and public health NGOs were demanding relentlessly the renewal of the European Alcohol Strategy - in vain. Nevertheless, it was a tiny, national level policy which became soon a European wide campaign, resulting one of the most precious victories of the alcohol control community. Why is alcohol one of the biggest public health problems of Europe? How could a purely national pricing policy make such a European resonance? What was the success driver of health NGO cooperation at European and national level? And what are the key, next avenues to fight alcohol related harm?

1. Why is alcohol one of the biggest public health problems of Europe?

The WHO European Region has the highest proportion in the world of total ill health and premature death due to alcohol.?Alcohol is recognized as a cause for more than 200 diseases and injuries, and in the European Region alone, alcohol use leads to almost 1 million deaths each year – about 2500 deaths every day. Alcohol produces dependence, alcohol is classified as group 1 human carcinogen along with other cancer-causing substances such as asbestos, radium and tobacco. Alcohol is a lethal commercial determinant of health, which deserves attention and policy action!

“Alcohol is no ordinary commodity and should not be treated as one. It hits the most vulnerable. Harm due to alcohol is greater for drinkers and their families with low incomes than for those with higher incomes, and this only exacerbates existing health inequalities. Alcohol consumption and its burden present some of the largest health and societal challenges in the WHO European Region.” explained Dr Nino Berdzuli, Director of the Division of Country Health Programmes at WHO/Europe.

2. How could a purely national pricing policy make such a European resonance?

Stand alone European advocacy simply does not exist: it is inextricably linked to national, sub-national and even local level developments. The ordinary EU legislative procedure - which results European laws - is just the classical way how European policies are made. Even in that case, the initiative of the European Commission is subject to public scrutiny, and ultimately the European Parliament and the EU Member States have the final word. However, there are other ways where national level policies are attached to European developments. Extending national policies in the EU and the EU preventing national action are two of them.

1. Extending national policies in the EU - the example of transfat

In the area of public health, EU member states dispose significant policy space at national, sub-national or regional level to go further what EU law foresees if they see it justified to protect public health. While this formally may result a fragmented internal market, the legal principle of public health protection allows that. Let's see the example of trans fat! Just a few years ago, there was no EU action on trans fat despite the fact that it poses a significant harm to health, especially in?increasing the risk of heart attack and heart disease, the single most common cause of death in the EU. Individual national governments - and not the EU - acted first: they realised that strictly limiting trans fats in all foods marketed in the EU will save thousands of lives every year. Many European countries have already introduced legal limits, including Austria, Denmark, Hungary, Latvia, Romania, Switzerland, Iceland, and Norway. Given those developments, the European Commission has completed its own impact assessment and after many years relentless advocacy and hard work, the EU became trans fat free as of 1st April 2021.

2. The EU preventing national action

Either the European Commission or the Member States have the right to raise concern if they consider a national policy is violating the rules of the internal market. In this way, the EU can clearly interfere at national level developments. EU member states have namely a notification obligation if they introduce any policy measure which may affect the competition within the EU. The rational behind this is to prevent market distorsion from protective measures which are often disguised as public health measures but their real aim it to defend domestic producers.

This is a valid, legal concern to be raised but this includes the possibility to abuse this procedure in order to stop, delay or weaken real public health national legislation.

During the notification procedure, the whole administration is involved at governmental level. In the area of alcohol it is usually not the health arguments and ministries but the alcohol industry interests dominate those interventions. This is why it is possible that good national level pubic health policies can be stopped for years or even definitely by the EU.

And this brings us to Scotland ...

What did happen in Scotland?

Evidence shows that as alcohol becomes more affordable, drinking and alcohol-related harm increases, and that one of the best ways to reduce the amount of cheap alcohol drunk by people in any country is by making alcohol less affordable.?Alcohol in Scotland was too affordable prior to implementing minimum unit pricing.?

Scotland implemented a minimum price of 50 pence per unit of alcohol to save lives, reduce hospital admissions and, ultimately, have positive impacts across the whole health system in Scotland and for wider society. Minimum unit pricing is not a tax; it is a targeted way of making sure alcohol is sold at a sensible price.

Minimum unit pricing set a floor price for a unit of alcohol, currently 50 pence per unit. This means alcohol can not legally be sold for lower than that. The more alcohol a drink contains, the stronger it is and therefore the higher the minimum unit price.

Legal actions and counteractions

In 2012, the Scottish Parliament passed the?Alcohol (Minimum Pricing) (Scotland) Act 2012?which allowed Scottish Ministers to introduce a system of minimum unit pricing for alcohol.?However, the legislation could not come into force because a consortium of global alcohol producers launched a legal procedure which was refered to the European Court of Justice.

3. What was the success driver of public health NGO cooperation at European and national level?

European and national NGOs campaigning hand in hand

European cooperation and building a positive, public health narrative was a key success factor which contributed to the positive outcome. The engine behind this was the Scottish Health Action on Alcohol Problems (SHAAP) who relied on its wide European Network, namely the European Public Health Alliance (EPHA), the European Alcohol Policy Alliance (Eurocare), the British Medical Association (BMA) and the Standing Committee of European Doctors (CPME). This campaign alliance together run a supportive, positive campaign called 'Minimum Unit Pricing saves lives' or #MUPSAVESLIVES.

On the margin of EPHA's 5th Annual conference on 5th September 2014, a campaign event took place in Brussels when the Scottish health professions joined with around 80 European colleagues and industry representatives to challenge the continued obstruction by global alcohol producers to the implementation of Scotland’s Alcohol Minimum Unit Pricing policy.

This event was a landmarking milestone in the battle leading to MUP: apart of presenting the strong case and public health arguments in the support of this policy, responsible industry representatives were also part of that narrative.

Advocacy action - concise arguments, 10 facts

As part of the event proceedings, campaigners collected at that time 10 facts to illustrate the case (page 19):

Alcohol Minimum Unit Pricing (MUP): 10 Key Facts (from 2014)

1. SHAAP is calling for Public Health advocates to support the Scottish case at the European Court of Justice (ECJ).
2. Twenty Scots die every week because of alcohol.
3. MUP saves lives.
4. Harmful drinkers benefit most from MUP.
5. MUP targets cheap, strong alcohol sold in supermarkets and off-licences.
6. MUP works with taxation to regulate alcohol price.
7. MUP is legal in Scotland but has yet to be implemented.
8. Global alcohol producers have blocked MUP implementation with legal challenges.
9. Europe will now decide.
10. European NGOs can support the Scottish case.

The European Court of Justice gave the green light to MUP entering into force

The legislation was challenged in court by the alcohol industry, which significantly delayed the implementation. The ECJ judgment C-333/14 on 23 December 2015 considered that the EU law cannot prevent MUP but it is up to the Scottish Court to decide whether it is appropriate or proportionate. This was a demonstrative example, how the European Court of Justice interpreted EU legislation in favour of public health. Following this, the highest Scottish Court gave the green light to the introduction of Minimum Unit Prices for alcohol in Scotland on 21 October 2016. Finally, on 15 November 2017?the UK Supreme Court confirmed the legislation was lawful. The legislation entered into force on 1st May 2018, giving health advocates another reason to be cheerful.

With that bold action it was demonstrated that regardless how big or small, national level action can make a significant difference. It also demonstrated that joining forces pays off and a concentrated European campaign of public health NGOs brought its fruits. Three years after Scotland became the first country in the world to introduce minimum unit pricing for alcohol, a new analysis published in The Lancet corroborates that it is an effective option to reduce the off-trade purchase of alcohol.

4. What are the key, next avenues to fight alcohol related harm?

EU alcohol policy has come close to deadlock. In 2006, the European Commission, in response to requests from European Union (EU) member states in 2001 and 2004, presented its first and only EU alcohol strategy, which expired at the end of 2012.??Since then, and despite calls from member states,?the European Parliament,?and health organisations,?the European Commission has not prepared a new EU alcohol strategy. The European Alcohol and Health Forum was disfunctional as it tried to solve the problem with voluntary commitments from the industry which resulted to collective resignation of 20 health NGOs. In the current political cycle alcohol control advocates have to look at the opening opportunities as for example, the European Beating Cancer Plan and the EU4Health programme are offering new avenues for alcohol control measures and funding.

Availability, marketing and taxation are among the WHO best buys: measures which are cost efficient and effective. Hence, during the last revision of the Audiovisual Media Services Directive the evidence backed health arguments were not included. There is therefore time for an intensive European Healthy Marketing Alliance campaign to turn the tide next time. Will it be one of the next success stories of the alcohol control community?

Zoltán Massay-Kosubek, former European public health advocate        

Why am I doing this? - Case study explainer

I have got a job at EPHA because I launched a blog. After leaving the Minsitry of Health and arriving in Brussels, I started to publish articles covering public health related policies from April 2012 onwards. This brought me to the EPHA Annual Conference in June 2012. Shortly after the event I was offered to join. I accepted the challenge. and the rest is now history.

What legacy do I leave behind??To mark the 9 years spent at the heart of European public health advocacy, I decided to create a series of farewell blog entries: I will develop 9 case studies - one dedicated to each year. These short articles are analysing key policy campaigns I led or co-shaped. These will be gradually published. Here are the other posts:

1. The Tobacco Products Directive Revision (2012-2013)

The EPHA?Annual Conference on "Restructuring Health Systems: How to promote health in times of austerity?"?(June 2012) I was an attendee there and I did not have the courage to speak publicly but I gathered my strengths to approach the organisers after the event.