Change in alcohol and tobacco availability, population health and the lived experience

This research project will measure change in the availability of alcohol and tobacco in Scottish neighbourhoods over time. We will 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) and 2008 (alcohol in four cities)). 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 these pathways. We 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 empirical results and gauge attitudes towards potential interventions.

Impact goals of this research are to:
1. Inform future alcohol and tobacco-related availability policy.
2. Influence the political and public discourse regarding tobacco and alcohol availability.
Our pathways to impact plan has been co-produced with our research partners, Alcohol Focus Scotland (AFS) and Action on Smoking and Health Scotland (ASH). We will also be supported by an Advisory Group, including representatives from AFS, ASH, Scottish Health Action on Alcohol Problems (SHAAP), NHS Health Scotland, the wider public and experienced researchers in the field. The Advisory Group will meet annually to review, and advise on, the projects progress and support the team in impact related activities.

Who might benefit from this research and how might they benefit?
The research findings will form important evidence for key audiences. Our pathway activities (summarised in the Pathways to Impact document) are wide and varied, including infographics, policy briefs, science festival event, road shows, mapping and data sharing web tool and end of project workshop. This reflects our need to engage with multiple and diverse audiences. The stakeholders who may benefit can be broadly grouped into four audiences: Policy makers, politicians, decision makers and aligned groups; organisations tackling alcohol and tobacco related harm; the wider public and; academic and non-academic researchers and students interested in health-place relationships.

1. Policymakers, politicians, decision makers and aligned groups: Alcohol Licensing Boards, Alcohol and Drug Partnerships, Scottish Government, Members of the Scottish Parliament and NHS Scotland.
Alcohol and tobacco sales are regulated in different ways. Alcohol is subject to a licensing regime, with five underpinning objectives. One of these objectives is Protecting and Improving Public Health. To date there is little evidence of the implementation of this, potentially due to a lack of area specific research. In contrast, for tobacco, there is no licensing system with all registered retailers permitted to sell tobacco products. The findings, qualitative and quantitative, from the proposed research will provide evidence to underpin the public health objective and benefit key decision makers regarding current licensing of alcohol. The evidence will also inform current debates on the potential of a tobacco licensing system.
2. Organisations tackling alcohol and tobacco related harm: Alcohol Focus Scotland (AFS), Scottish Health Action on Alcohol Problems (SHAAP) and Action on Smoking and Health Scotland (ASH).
Alcohol and tobacco related harm are key drivers of mortality and morbidity in Scotland and there are many groups dedicated to reducing this harm. Evidence of the longitudinal association, or lack of, between availability and harm has been identified as a research priority amongst this group of key stakeholders. In particular, research that brings together qualitative and quantitative evidence can be used by these organisations to influence key decision makers listed above.
3. The Public.
The wider public are an important audience and their experience of local environments is often excluded from decision-making. We will merge their voices, on both their experience and attitudes towards policy options, with the quantitative results. We will use this evidence to influence the public discourse guiding decision makers. The public will then benefit through improved representation in the policy making process. We will engage the wider public in all stages of this research and listen to their voices in shaping our dissemination strategies.
4. Academic and non-academic researchers and students.
The data generated in this project can be used for related research (e.g. the association between alcohol and crime, or tobacco availability and childhood smoking). It can also be used in teaching statistics and mapping to students.