Category Archives: Data

What next for tobacco control in Scotland?

New research from the CRESH team using data from 124,566 shopping baskets purchased in convenience stores across Scotland has found that the purchase price of tobacco is lower in more disadvantaged neighbourhoods, largely because of the higher sales of the cheapest brands in these areas.

Cigarette smoking is one of the leading causes of preventable ill-health, hospitalisations and deaths in Scotland. Approximately 19% of adults in Scotland smoke, this rises to 32% in our most deprived fifth of neighbourhoods and falls to 9% in the most affluent neighbourhoods. As Scotland moves towards a ‘Tobacco Endgame’ the Scottish Government have a target to reduce smoking prevalence to less than 5% by 2034. A recent review of smoking projections by CRUK however suggests that Scotland may miss this target by 16 years in the poorest neighbourhoods. It is important that we continue to explore all potential determinants of smoking, particularly those that drive smoking in our most deprived communities.

We know that tobacco price is one of the most important determinants of smoking behaviour and that many smokers are price sensitive. Whilst it may appear that all tobacco products are becoming increasingly expensive, research suggests that the average tobacco price in the UK has remained relatively unchanged in real terms over the past 20 years in spite of numerous tax increases. A practice, known as ‘undershifting’, has seen tobacco companies limit price increases on the cheapest brands and instead increase the price of the most expensive brands by larger margins, thus absorbing the tax increases on the cheapest cigarettes allowing them to remain cheap (Hiscock et al. 2018).  As a result, the price of the lowest priced cigarette brands has remained relatively steady and the tobacco market as a whole has become increasingly stratified by price between the cheapest ‘sub value’ , ’value’, ‘mid price’ and high priced ‘premium’ brands. We wanted to understand these differentials in price a little better, so we carried out some research that was published recently in Tobacco Control. We explored whether the price paid for tobacco (both cigarettes and roll your own tobacco) was different in different types of neighbourhoods. We compared areas by deprivation, by the density of tobacco outlets and by rurality.

We analysed tobacco purchase data provided to us by The Retail Data Partnership. We looked at more than 124,000 purchases in 274 stores across Scotland in April 2018. For cigarettes the average price paid for a pack of 20 was £8.49, ranging from £7.20 to £13.25. For roll your own tobacco (RYO) 30g the average price paid was £12.14, with prices ranging from £9.80 to £15.99. We found that the price paid for tobacco did vary by neighbourhood type. In neighbourhoods with the lowest average household income the average purchase was 50p less for a pack of 20 cigarettes, and 34p less for roll your own tobacco compared with the most affluent neighbourhoods.

We then asked whether this was driven by individual brands being cheaper in more deprived areas, or whether cheaper, sub-value, brands were just more popular in such places. We found little evidence that individual brands were priced differently. Although the cheaper brands are the most popular in all neighbourhoods and across Scotland, accounting for 52% of sales, there’s a big difference in popularity between more and less deprived areas, In the most deprived areas these brands account for 58%  of sales, but in most affluent areas it was just 39% (See Figure 1 below). So, it is the dominance of cheaper brands in more deprived areas that drives the 50p difference in average price paid per pack between deprived and affluent areas. Remember this matters because the tobacco companies work to subdue tax-based price rises on the cheapest brands.

We also explored whether the density of tobacco retailers and/or rurality had an impact on tobacco price. We found little evidence of a density effect, but we did find that the individual brands analysed were significantly cheaper in rural areas.

So what does this mean and what can we take from this research? It is clear from the CRUK review that we need to work harder in order to reach the 2034 target of less than 5% of the population smoking. Price is a lever that we can pull, but to date this has been largely done through tax increases. This research shows us that the cheapest brands are the most popular in all neighbourhood types, but much more so in our most deprived neighbourhoods where smoking rates are highest. We found that the price paid for tobacco is lower in more deprived areas compared to more affluent areas. Our results confirm that the dominance of cheaper, so called ‘sub-value’ brands in more deprived areas, is a driving force behind the difference in price paid for tobacco between neighbourhoods. This highlights the importance of cheaper tobacco products to the consumer and the market.  Cheap tobacco may help tobacco companies to retain price sensitive consumers who live in the most deprived areas, which, in turn, contributes to health inequalities. In addition to increases to the duty rates on tobacco, more radical policy responses are likely to be required. These include a combination of minimum unit pricing (MUP) and a price cap at the upper end. The MUP would raise the cost of cheaper cigarettes and the price cap at the upper end would prevent the more expensive brands being used to ‘protect’ the cheaper ones from tax rises.

With growing international interest in the ‘Tobacco Endgame’, policymakers should identify measures that counter industry tactics that enable the continued sales of cheap tobacco. We published this paper in the first week of the COVID-19 pandemic in the UK. These are clearly strange times and we should rightly focus on the public health impacts of the global pandemic, and in particular the vast health inequalities that are arising. We must not however forget that the public health challenges we were faced with before this pandemic remain. Tobacco, and other unhealthy commodities, require our attention and the inequalities that arise from them remain a matter of social justice.

You can find the paper here:

Shortt, N., Tunstall, H., Mitchell, R., Coombes, E., Jones, A., Reid, G. & Pearce, J. Using point-of-sale data to examine tobacco pricing across neighbourhoods in Scotland. Tobacco Control, Published Online First: 19 March 2020. doi: 10.1136/tobaccocontro

References

Hiscock R, Branston JR, McNeill A, et al. Tobacco industry strategies undermine government tax policy: evidence from commercial data. Tob Control 2018;27:488 LP – 497. doi:10.1136/tobaccocontrol-2017-053891

New ESRC funded study on Tobacco and Alcohol

We are delighted to announce that we have been awarded funding from the ESRC for a project exploring tobacco and alcohol environments in Scotland. The project ‘Change in alcohol and tobacco availability, population health and the lived experience’ will be funded for 3 years, beginning December 2019 for a total of £761, 470. The project will be led by Professor Niamh Shortt with co-investigators from the University of Edinburgh (Professor Jamie Pearceand Dr Tom Clemens), Glasgow Caledonian University (Professor Carol Emslie) and the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow (Professor Richard Mitchell).

This research will measure change in the availability of alcohol and tobacco in Scottish neighbourhoods over time and explore how this change relates to health outcomes and how residents experience the availability of alcohol and tobacco in their neighbourhoods. The findings will be important because smoking and alcohol consumption are leading causes of illness and death. In Scotland smoking causes one in every 5 deaths and one in 20 deaths is related to alcohol. This harm is not equally shared; those on the lowest incomes suffer the greatest harm. These illnesses and deaths are preventable. The World Health Organisation recommends that nations prioritise interventions that reduce the supply of alcohol and tobacco.

Why might neighbourhood supply of alcohol and tobacco matter? Research suggests that when there are a lot of outlets in a neighbourhood this impacts upon consumption in three ways. 1. The outlets may be more competitive and drive prices down to attract customers. 2. Oversupply may normalise the products when they are sold alongside everyday commodities, such as bread and milk. 3. Tobacco and alcohol may simply be easier to buy in areas where there are more outlets.

In order to explore the relationship between supply, behaviour and harm we need data on the location of every outlet in Scotland selling tobacco and/or alcohol. Ideally, to be able to say something about whether the relationship may be causal, we need this data over time. We have already collected data on the specific location of every outlet selling tobacco and licensed to sell alcohol over multiple time periods (2012 and 2016 (nationwide alcohol and tobacco – see paper here) and 2008 (alcohol in four cities – see paper here)). As part of this project we will collect updated data for 2019/20. This will allow us to measure this change over time. Using an approach called trajectory modelling we will group neighbourhoods that have had a similar degree of change; some neighbourhoods may have lost, or gained, local shops or pubs, whereas some may not have changed at all. We will then identify features of these neighbourhoods that may be driving this change, for example the age profile of the population or poverty levels. This will help policy makers understand the drivers of change in our neighbourhoods.

To measure the relationship between changing supply and harm we will link these trajectories, and our measures of availability at each time point, to alcohol and tobacco health outcomes (behaviour, illness and death). We will use statistical models to see whether areas experiencing an increase or decrease in outlets have seen a corresponding increase or decrease in these outcomes. This will allow us to get a better understanding of whether an over supply of alcohol and tobacco is related to smoking and alcohol consumption and harm. These findings will provide important evidence related to the provision of such commodities in our neighbourhoods.

Although these statistics are important to report we also need to understand why an oversupply of alcohol and tobacco may influence behaviour and harm. Whilst the literature suggests the pathways listed above, we know little about the experiences of individuals living in neighbourhoods with contrasting availability. We don’t understand the individual experience of any of these pathways. Professor Carol Emslie will lead a qualitative work package and researchrs will meet with groups of individuals, in neighbourhoods of contrasting trajectories, to talk to them about the supply of alcohol and tobacco. We will explore their experiences of neighbourhood and assess how their perceived notions of their neighbourhood availability contrast with our statistical measures. Finally, we will meet with residents, retailers and policy stake-holders to explore potential interventions related to supply. Policies at this level require public, retailer and political support. We will discuss the priorities held by various groups, present our quantitative results and gauge attitudes towards potential interventions.

Throughout the project will be committed to knowledge exchange, public events and speaking with non academic partners. If you wish to know more about this research, or would like one of the researchers to come to your organisation to provide you initial findings (once the project is under way) then contact the Principal Investigator here: niamh.shortt@ed.ac.uk

An atlas of change in Scotland’s built environment 2016-17

By Laura Macdonald from the MRC/CSO  Social and Public Health Sciences Unit, University of Glasgow @theSPHSU

Our neighbourhood environments change and evolve often; some changes are minor, while others involve major transformation. Change can take various forms; green space created or removed, existing housing or amenities demolished, new housing estates built, new motorways created, or existing transport infrastructure modified or extended. Change may affect neighbourhood residents’ physical or mental health, or health-related behaviours, to their benefit or to their detriment. To study how change in our neighbourhoods might affect our health we need robust information but data showing how our neighbourhoods are changing, at a fine geographic scale, for the whole of Scotland, did not exist – until now! This is why we created an atlas showing what’s changed, and an interactive mapping application which allows you to explore the data yourself. Continue reading An atlas of change in Scotland’s built environment 2016-17

Income deprivation and ethnicity

By Helena Tunstall & Stephanie Prady

Do deprivation indices based on means-tested benefits underestimate poverty in neighbourhoods with large minority ethnic populations? 

BorninBradford1Research has just been published which assesses how well the Income Deprivation Affecting Children Index (IDACI) identifies neighbourhood poverty in areas of Bradford with different ethnic populations.

This study was a collaboration between researchers at the University of York, the Bradford Institute for Health Research and CRESH. It compared neighbourhood IDACI scores, based upon social security benefit claims, to socio-economic data collected from families in the Born in Bradford (BiB) cohort study.

This study concludes that income deprivation measures based on means-tested benefits may underestimate deprivation in neighbourhoods with large minority ethnic populations due to the low take-up of benefits among poor families in some ethnic groups.

Continue reading Income deprivation and ethnicity

Empowering communities: An interactive tobacco and alcohol outlet density webmap for Scotland

Today we are launching an interactive webmap that allows users to map tobacco and alcohol outlet density, and related health outcomes, for neighbourhoods (‘datazones‘) across Scotland.  The underlying data we have collected and assembled can also be freely downloaded for use.  Our research from Scotland shows that outlet density matters for health:

  • areas with the highest alcohol outlet density have double the death rate of those with the lowest densities (see our blog postreport and infographic)
  • adolescents living in areas with the highest tobacco outlet density are almost 50% more likely to smoke than those with the lowest (see our blog post, paper and infographic).

ALCOHOL OUTLET DATA UPDATED 25 JUNE 2015:  Previous to this date the alcohol outlet density data had used an alternate measure of density than outlets per km2, resulting in values that were typically 30-40% lower than the actual value.  Whilst the figures have changed the general picture has not: an area of high density remains an area of high density.  The rest of the data are unaffected.

webmap

Continue reading Empowering communities: An interactive tobacco and alcohol outlet density webmap for Scotland

Smoking and Health in Scotland: key stats

smoking_infographic2Today we’re launching our hot-off-the-press infographic about Smoking and Health in Scotland.  In collaboration with Action on Smoking and Health (ASH) Scotland we’ve created this summary of some of the key statistics on smoking and health in Scotland, featuring some headline results from our own research.  Please use and circulate widely! Continue reading Smoking and Health in Scotland: key stats

Is multiple environmental deprivation related to population health in Portugal?

By Ana Isabel Ribeiro

In our recently published paper (open access version here) we describe the development of a multivariate measure of physical environmental deprivation for the 278 municipalities of Portugal, and demonstrate its strong relationship with mortality rates. Continue reading Is multiple environmental deprivation related to population health in Portugal?

Alcohol outlet densities correlate with alcohol-related health outcomes in Scotland: but so what?

By Elizabeth Richardson

In our recently-published study into alcohol outlets and health in Scotland we found strong correlations between the two: neighbourhoods with higher availability of outlets had higher rates of alcohol-related deaths and hospitalisations.  In fact, residents of neighbourhoods with the highest availability were more than twice as likely to die a drink-related death than those with the fewest outlets, all else* being equal (*deprivation and urban/rural status).

Altway, 2012
Source: https://www.flickr.com/photos/jeffcarson/8278481152/ under Creative Commons licence

But what does this actually mean? Continue reading Alcohol outlet densities correlate with alcohol-related health outcomes in Scotland: but so what?

Mapping life expectancy in Scottish Parliamentary Constituencies

By Helena Tunstall, Elizabeth Richardson & Jamie Pearce

New life expectancy at birth figures for 2011-2013 for Scottish Parliamentary Constituencies have just been released by National Records of Scotland (NRS). We’ve mapped and graphed these data to illustrate the latest geographical patterns of mortality in Scotland. Continue reading Mapping life expectancy in Scottish Parliamentary Constituencies

Are experimental studies always best?

Work has begun on our NIHR funded evaluation of Forestry Commission Scotland’s Woodlands In and Around Town (WIAT) scheme. WIAT aims to improve quality of life in towns and cities by bringing neglected woodlands into management, creating new woods and supporting people to use and enjoy their local woods. Our study, led by Catharine Ward Thompson at OpenSpace, is focused on whether changes to the local woodland environment affect people’s health. The WIAT evaluation is exciting partly because it’s a rare opportunity to ask what impact environment has on health, at a population level, via an experimental study.

The vast majority of evidence about how health and behaviour are affected by environment comes from cross-sectional studies. In cross-sectional studies, we measure both the environmental characteristic of interest (for example, how much green space there is in a neighbourhood), and the outcome of interest (for example, how healthy or happy the residents of that neighbourhood are) at the same time. Cross-sectional studies are great for suggesting links or associations between environmental characteristics and health or related behaviour, but they have many problems. In particular, we can’t be certain that the aspect of environment we are interested in causes the health outcome in question. In the case of green space and health for example, we worry that the apparent relationship between access to green space in a neighbourhood and good health among residents is really because the residents of greener neighbourhoods tend to be wealthier, and wealthier people are more likely to be healthier anyway. So, it might be that access to green space in a neighbourhood doesn’t cause better health, it’s just that healthier people are more likely to live in greener neighbourhoods.

Experimental studies are very different. In an experiment, we deliberately alter some aspect of the environment for one group of people (the intervention group), but not for another very similar group of people (the control group). We then compare what happens to health or related behaviour in the intervention and control groups. If health improves in the intervention group, but not in the control group, we can be more certain that the change in environment has caused the change in health. So, in our WIAT study, we’ll be comparing what happens to the health of communities whose woodlands are improved and promoted, with those whose woodlands are not. (That sounds a bit unfair on the ‘control’ communities but, in fact, they’ll be eligible to get their woods improved later).

A lot has been written recently about how important experimental studies are*, how much better they are for telling us ‘what works’ to improve health and behaviour, and how we need far more of them. The idea has taken hold, helped by research funding and by the fact that some key journals in public health and epidemiology now refuse to even peer review studies that are cross-sectional. Jim Dunn and Martin Bobak’s editorial* on taking over the editorship of JECH is a good indication of increased interest in experimental designs from leading journals. Mark Petticrew has also written* about it.

I am excited about the prospect of experimental studies being used to examine the impacts of environment on health and health-related behaviour. I believe that the characteristics of the places we live and work in can be a strong influence on our health and behaviour and, in turn, I think that environment could be an effective lever for improving population health and narrowing health inequalities. Experimental studies are, in theory, the best way of finding out if my ideas are right or not.

However, I do have a few concerns about the assumption that experimental approaches are always best for researching ‘what works’ to improve public health. Their strengths have been highlighted in the literature, but there has been relatively little critical thinking about them.

The processes by which environment influence our health and behaviour are complex and life long. Environment doesn’t simply determine health and behaviour; people and environments influence each other. Think about the cycling infrastructure in Copenhagen for example. The environment there enables and encourages people to cycle, so the city’s high rates of active travel are partly because of the environment. However, the environment is so conducive to active travel because the residents use it, protect it, value it and continue to improve it.

Our relationships with different aspects of environment are also formed over the whole of our lives. Catharine Ward Thompson’s work*, for example, shows that one of the strongest predictors of whether we visit woodlands as adults was whether we did so as children. That means just changing access to woodlands in the neighbourhood may not affect immediately, or at all, residents who don’t have ‘visiting the woods’ as part of their culture.

Do we know how long it will take for an environmental change to affect health and behaviour? My guess is that the time will vary by environmental characteristic and/or the health or behavioural outcome being measured. I think, in many cases, effects will be slow to materialise. Yet the reality of research, and research funding, is that it’s difficult to sustain an experiment for a long time. In turn, this might lead us, or perhaps other less critical audiences, to prioritise interventions on aspects of environment that show a quick effect, at the expense of those which may have a greater but slower effect. Worse, if brief experimental studies find no effect of environmental intervention on health, and we think experimental evidence is the best there is, it may lead to the assumption that environment does not affect health.

I worry that in the rush to use experimental designs to see ‘what works’ for public health, we have forgotten some of what we know about relationships between health and environment specifically, and about relationships between place and identity more broadly.  I think experiments are very important, but I’d like to see a more critical perspective.

What do you think?

*NB links to journal articles may require institutional/personal subscription to the journal