Changing Policy Framing as a Deliberate Strategy for Public Health Advocacy: A Qualitative Policy Case Study of Minimum Unit Pricing of Alcohol
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Context: Scotland is the first country in the world to pass legislation introducing a minimum unit price (MUP) for alcohol in an attempt to reduce consumption and associated harms by increasing the price of the cheapest alcohol. We investigated the competing ways in which policy stakeholders presented the debate. We then established whether a change in framing helped explain the policy's emergence. Methods: We conducted a detailed policy case study through analysis of evidence submitted to the Scottish parliament, and in‐depth, one‐to‐one interviews ( n = 36) with politicians, civil servants, advocates, researchers, and industry representatives. Findings: Public‐ and voluntary‐sector stakeholders tended to support MUP, while industry representatives were more divided. Two markedly different ways of presenting alcohol as a policy problem were evident. Critics of MUP (all of whom were related to industry) emphasized social disorder issues, particularly among young people, and hence argued for targeted approaches. In contrast, advocates for MUP (with the exception of those in industry) focused on alcohol as a health issue arising from overconsumption at a population level, thus suggesting that population‐based interventions were necessary. Industry stakeholders favoring MUP adopted a hybrid framing, maintaining several aspects of the critical framing. Our interview data showed that public health advocates worked hard to redefine the policy issue by deliberately presenting a consistent alternative framing. Conclusions: Framing alcohol policy as a broad, multisectoral, public health issue that requires a whole‐population approach has been crucial to enabling policymakers to seriously consider MUP, and public health advocates intentionally presented alcohol policy in this way. This reframing helped prioritize public health considerations in the policy debate and represents a deliberate strategy for consideration by those advocating for policy change around the world and in other public health areas.
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Qualitative research undertaken in preparation for, or alongside, natural experimental studies can help to identify which outcomes might change as a consequence of the intervention and which are priorities for decision makers.
“Qualitative research undertaken in preparation for, or alongside, NE studies can help to identify which outcomes might change as a consequence of the intervention and which are priorities for decision makers (42).”
From Natural Experiments: An Overview of Methods, Approaches, and Contributions to Public Health Intervention Research (2017) · cites this paper as [42]
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BackgroundInfluentialKatikireddi, S. V., Hilton, S., & Bond, L. M. (2015) · Evidence & Policy · doi:10.1332/174426415x14430986392944 · Cited by 26 · see citing works
“…public health benefits, with its origins and the policy process by which it emerged having been studied elsewhere (Katikireddi et al, 2014c; Katikireddi, 2013; Katikireddi et al, 2014b; Katikireddi and Smith, 2014; Hawkins and Holden, 2013; McCambridge et al, 2013; Holden and Hawkins, 2013).”
BackgroundMethodInfluentialSelf-citationInsights into Vodka consumer attitude and purchasing behaviors
Prentice, C., & Handsjuk, N. (2016) · Journal of Retailing and Consumer Services · doi:10.1016/j.jretconser.2016.05.009 · Cited by 26 · see citing works
What is the problem?: Evidence, politics and alcohol policy in England and Wales, 2010–2014
Nicholls, J. Q., & Greenaway, J. (2015) · Drugs Education Prevention and Policy · doi:10.3109/09687637.2014.993923 · Cited by 24 · see citing works
“Importantly, none of these were counterbalanced in England, by any high-profile ministerial advocacy or media support, in contrast to the Scottish situation (Katikireddi et al., 2014a).”
BackgroundInfluentialThe Alcohol Health Alliance: The emergence of an advocacy coalition to stimulate policy change
Thom, B., Herring, R., Thickett, A., & Duke, K. (2016) · British Politics · doi:10.1057/bp.2015.50 · Cited by 22 · see citing works
“It is also the approach that is associated with alcohol industry interests despite, in more recent years, less consensus among different sectors of the industry and trade regarding alcohol policy (Katikireddi et al., 2014; House of Lords, 2015).”
BackgroundSo, V., Millard, A. D., Katikireddi, S. V., Forsyth, R., Allstaff, S., Deluca, P., Drummond, C., Ford, A., Eadie, D. R., Fitzgerald, N., et al. (2021) · Public Health Research · doi:10.3310/phr09110 · Cited by 19 · see citing works
Self-citationA long‐brewing crisis: The historical antecedents of major alcohol policy change in Ireland
Lesch, M., & McCambridge, J. (2021) · Drug and Alcohol Review · doi:10.1111/dar.13331 · Cited by 21 · see citing works
Hellowell, M., Smith, K. E., & Wright, A. (2016) · Milbank Quarterly · doi:10.1111/1468-0009.12200 · Cited by 20 · see citing works
Understanding the Political Organization and Tactics of the Alcohol Industry in Ireland 2009–2018
Lesch, M., & McCambridge, J. (2022) · Journal of Studies on Alcohol and Drugs · doi:10.15288/jsad.2022.83.574 · Cited by 20 · see citing works
“In other contexts, particularly Scotland and England, the industry has focused its efforts on defeating MUP (Hawkins & McCambridge, 2020a; Katikireddi et al., 2014b), although the long-running contemporaneous legal case in Scotland may at least to some extent explain the weakness of opposition in…”
BackgroundFitzgerald, N., Angus, K., Howell, R. M., Labhart, H., Morris, J. K., Fenton, L., Woodrow, N., Castellina, M., Oldham, M., Garnett, C. V., et al. (2024) · Addiction · doi:10.1111/add.16743 · Cited by 19 · see citing works
“Framing has been identified as important in United Kingdom (UK) and international alcohol policy processes including in pricing [ 38], licensing [39] and marketing [ 9, 40, 41] and more generally [42 – 46].”
Reconceptualising the study of alcohol policy decision-making: the contribution of political science
Lesch, M., & McCambridge, J. (2020) · Addiction Research & Theory · doi:10.1080/16066359.2020.1773445 · Cited by 19 · see citing works
Lauer, J. A., Sassi, F., Soucat, A. L. B., & Vigo, A. (2021) · WORLD SCIENTIFIC (EUROPE) eBooks · doi:10.1142/q0365 · Cited by 20 · see citing works
Framing the policy debate over tobacco control legislation and tobacco taxation in South Africa
Zatonski, M. Z., Egbe, C. O., Robertson, L., & Gilmore, A. (2021) · Tobacco Control · doi:10.1136/tobaccocontrol-2021-056675 · Cited by 16 · see citing works
Reframing the wicked problem of pre-harvest burning: A case study of Thailand's sugarcane
Chaya, W. (2024) · Heliyon · doi:10.1016/j.heliyon.2024.e29327 · Cited by 16 · see citing works
Policy communities, devolution and policy transfer: The case of alcohol pricing in Wales
Lesch, M., & McCambridge, J. (2021) · Regional & Federal Studies · doi:10.1080/13597566.2021.1934454 · Cited by 15 · see citing works
“…law centred on whether the policy constituted a justifiable public health protection measure, this made it much easier for the Welsh government to maintain its preferred framing of the policy (i.e. as a public health measure), which was the same as in Scotland (Katikireddi, Bond, and Hilton 2014).”
BackgroundDevolution of power, revolution in public health?: Table 1
Katikireddi, S. V., Smith, K. E., Stückler, D., & McKee, M. (2016) · Journal of Public Health · doi:10.1093/pubmed/fdw031 · Cited by 14 · see citing works
“44,45 Crucially, the evidence suggests it will yield greater health benefits than equivalent taxation changes.”
Self-citationO’Sullivan, K. C., & Howden‐Chapman, P. (2017) · Indoor and Built Environment · doi:10.1177/1420326x17707327 · Cited by 14 · see citing works
“We have used the concept of ‘framing’, where advocates deliberately position issues such as fuel poverty as a population health problem, requiring broad policy responses.(64) Framing of building regulation as a population health problem, rather than individualistic ideas of fuel poverty such as a nationwide cultural p…”
MethodFraming tobacco control: the case of the Nigerian tobacco tax debates
Akin-Onitolo, A., & Hawkins, B. (2021) · Health Policy and Planning · doi:10.1093/heapol/czab095 · Cited by 13 · see citing works
Lesch, M., & McCambridge, J. (2022) · BMC Public Health · doi:10.1186/s12889-022-13267-w · Cited by 11 · see citing works
Bartlett, A., Lesch, M., Golder, S., & McCambridge, J. (2023) · BMC Public Health · doi:10.1186/s12889-023-16512-y · Cited by 10 · see citing works
“The dataset comprises the tweets of a single actor, and any effects the tweets had on the unfolding of events is unclear; this is not a study of South African alcohol policy [47, 48] or framing effects [73] but a study of framing in the context of alcohol policy [29–31 , 34 ].”
BackgroundResultvan Schalkwyk, M. C., Hawkins, B., Klein, D. E., & Koon, A. D. (2024) · Social Science & Medicine · doi:10.1016/j.socscimed.2024.117158 · Cited by 10 · see citing works
Heavy Drinkers’ Perspectives on Minimum Unit Pricing for Alcohol in Scotland
O’May, F., Gill, J., Black, H., Rees, C., Chick, J., & McPake, B. (2016) · SAGE Open · doi:10.1177/2158244016657141 · Cited by 10 · see citing works
Thornton, M., & Hawkins, B. (2017) · Social Science & Medicine · doi:10.1016/j.socscimed.2017.01.003 · Cited by 10 · see citing works
“The existence of co- and self-regulatory regimes was seen to obviate the need for further regulation, including MUP.”
BackgroundResultInfluentialSerban, S. T., Perdomo, S. P., Borges-Yáñez, S. A., Allen, P., Guarnizo-Herreño, C. C., Navarro‐Ramírez, M. K., Hobbs, M., Cohen, L. K., Tsakos, G., Baker, S. R., et al. (2025) · Community Dentistry And Oral Epidemiology · doi:10.1111/cdoe.70005 · Cited by 9 · see citing works
Cullen, D., Smith, K. E., & Collin, J. (2017) · Evidence & Policy · doi:10.1332/174426417x15071939491726 · Cited by 9 · see citing works
Politics and fantasy in UK alcohol policy: a critical logics approach
Hawkins, B., & van Schalkwyk, M. C. (2023) · Critical Policy Studies · doi:10.1080/19460171.2023.2188470 · Cited by 9 · see citing works
“By engaging with public health actors’ policy discourse, the Scottish Government signaled its intention to prioritize public health over commercial interests (Hawkins and Holden 2013; Katikireddi et al. 2014, 2014).”
BackgroundIreland’s Public Health (Alcohol) Bill
Calnan, S., Davoren, M. P., Perry, I. J., & O’Donovan, Ó. (2018) · Contemporary Drug Problems · doi:10.1177/0091450918768284 · Cited by 8 · see citing works
“MUP, meanwhile, has shades of “harder” forms of paternalism or at least “heavy nudging” (Bacchi, 2015, p. 136), it could be argued, as the measure seeks not merely to influence people’s choices but to essentially “eliminate very cheap alcohol from all stores and shops” by making it illegal to sell or advertise for sal…”
BackgroundInfluentialClarke, D. J. (2019) · International Journal of Health Policy and Management · doi:10.15171/ijhpm.2019.124 · Cited by 8 · see citing works
Afferri, A., Dierickx, S., Bittaye, M., Marena, M., Pacey, A. A., & Balen, J. (2024) · PLoS ONE · doi:10.1371/journal.pone.0301700 · Cited by 7 · see citing works
‘Sweet talk’: framing the merits of a sugar tax in Australia
Anaf, J., Fisher, M., Handsley, E., Baum, F. E., & Friel, S. (2020) · Health Promotion International · doi:10.1093/heapro/daaa152 · Cited by 7 · see citing works
“examples of polarized views on the efficacy of a sugar tax reflect the findings of other research highlighting the diverse and contradictory ways that evidence can be used within a policy context, and how policy actors frame policy issues in very different ways (Katikireddi et al., 2014).”
BackgroundThe Health of People: How the social sciences can improve population health
Science, C. F. S. (2017) · SAGE Publications Ltd eBooks · doi:10.4135/9781473998889 · Cited by 6 · see citing works
Lesch, M., & McCambridge, J. (2023) · Globalization and Health · doi:10.1186/s12992-023-00923-y · Cited by 7 · see citing works
Katikireddi, S. V., Beeston, C., Millard, A. D., Forsyth, R., Deluca, P., Drummond, C., Eadie, D. R., Graham, L., Hilton, S., Ludbrook, A., et al. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-028482 · Cited by 6 · see citing works
“A number of potential risks arising from the introduction of MUP have been identified by policymakers, the alcohol industry and public health professionals.(54) 1.”
Self-citationA Political Economy Analysis of Health Taxes
Babor, T. F., Collin, J., & Monteiro, M. G. (2023) · WORLD SCIENTIFIC (EUROPE) eBooks · doi:10.1142/9781800612396_0015 · Cited by 6 · see citing works
Craig, P., Campbell, M., Deidda, M., Dundas, R., Green, J., Katikireddi, S. V., Lewsey, J., Ogilvie, D., de Vocht, F., & White, M. J. (2025) · Public Health Research · doi:10.3310/jtyw6582 · Cited by 5 · see citing works
Self-citationLesch, M., & McCambridge, J. (2024) · Globalization and Health · doi:10.1186/s12992-024-01034-y · Cited by 6 · see citing works
Embrett, M. G., & Randall, G. E. (2021) · Health Care Analysis · doi:10.1007/s10728-020-00426-6 · Cited by 4 · see citing works
“Without controversy, there is little opportunity for opposing frames to be presented [38].”
BackgroundThe Influence of Commercial Industries on Public Discourse
Hilton, S. (2022) · Oxford University Press eBooks · doi:10.1093/oso/9780197578742.003.0027 · Cited by 4 · see citing works
Self-citationJoseph, A., Lasimbang, H. B., James, S., & Seok, C. B. (2020) · Borneo Journal of Medical Sciences (BJMS) · doi:10.51200/bjms.v14i2.2002 · Cited by 4 · see citing works
Counting the cost of alcohol: what you measure will shape the policy response
Katikireddi, S. V. (2016) · Addiction · doi:10.1111/add.13674 · Cited by 3 · see citing works
Self-citationBrook, A., Körner, K., van Schalkwyk, M. C., Barnes, A., & Petticrew, M. P. (2024) · Health Promotion International · doi:10.1093/heapro/daae166 · Cited by 3 · see citing works
“…the public, which could draw on developments in areas such as climate communications (van der Linden et al ., 2017; Farrell et al. , 2019), framing (Katikireddi et al. , 2014; Rowbotham et al ., 2019; Maani et al ., 2022) and other rhe-torical practices and storytelling (Lillie et al ., 2024).”
Lee, J. G. L., Cristello, J. V., Buckton, C. H., Carey, R., Trucco, E. M., Schenk, P. M., Ikegwuonu, T., Hilton, S., Golden, S. D., & Conway, D. I. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-041324 · Cited by 3 · see citing works
Self-citationO’Donnell, R., Mohan, A., Purves, R. S., Maani, N., Angus, C., Egan, M., & Fitzgerald, N. (2023) · Drugs Education Prevention and Policy · doi:10.1080/09687637.2023.2205991 · Cited by 3 · see citing works
“…a compelling case to local licensing authorities. clear, convincing stories (‘narratives’) for policymakers are considered an effective strategy used by advocates seeking policy change, in theory (McBeth et al., 2014), and in practice, e.g. in relation to MUP for alcohol (Katikireddi et al., 2014).”
Klingemann, H., & Lesch, M. (2024) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2024.104333 · Cited by 3 · see citing works
4. Community-Based Interventions
McDermott, R. J., Bryant, C. A., Mayer, A. B., Martinasek, M. P., Baldwin, J. A., & Vamos, S. (2016) · American Public Health Association eBooks · doi:10.2105/9780875532783ch04 · Cited by 3 · see citing works
Severi, K., & Hawkins, B. (2024) · International Journal of Health Policy and Management · doi:10.34172/ijhpm.2024.8068 · Cited by 2 · see citing works
Regulatory capture in UK alcohol licensing policy: The 2025 ‘licensing taskforce’ report
Nicholls, J. Q., & Fitzgerald, N. (2025) · Addiction · doi:10.1111/add.70241 · Cited by 2 · see citing works
Modelling the case for alcohol pricing policy in the USA
Robinson, M., & Veerman, L. J. (2025) · The Lancet Public Health · doi:10.1016/s2468-2667(25)00189-6 · Cited by 1 · see citing works
B, F. P. O. M. H. (2015) · Journal of Alcoholism and Drug Dependence · doi:10.4172/2329-6488.1000186 · Cited by 1 · see citing works
“An account of the Act’s development and the policy context can be found in [11].”
BackgroundDomestic Violence against Women: Higher Tax on Alcohol Could Protect Women
Simister, J. G. (2016) · Open Journal of Social Sciences · doi:10.4236/jss.2016.45015 · Cited by 1 · see citing works
“But Katikireddi, Bond & Hilton [8] recommend raising the minimum price of alcohol, to achieve various health improvements; they claim a minimum alcohol price is more effective than general taxes on alcohol, as a way to discourage excessive alcohol consumption.”
Wayenberg, E. (2017) · Beleidsonderzoek Online · doi:10.5553/bo/221335502017000008001 · Cited by 1 · see citing works
15. Lessons From Scotland’s Experience of Minimum Unit Pricing of Alcohol
Katikireddi, S. V., Rice, P. M., Holmes, J., & Meier, P. S. (2017) · American Public Health Association eBooks · doi:10.2105/9780875532929ch15 · Cited by 1 · see citing works
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‘Intervening early’: agendas and rationalisations for children’s developmental health
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Alcohol consumption, wealth, and health – Authors' reply
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“1 The man whom many credit with this victory, political strategist James Carville, reportedly hung a sign in Clinton’s campaign headquarters making 3 points: (1) the importance of emphasizing change versus the status quo, (2) the even greater importance of health care reform, and (3) the centrality of the economy.”
BackgroundRESPONSIBLE ALCOHOL CONSUMPTION AND EUROPEAN PUBLIC POLICY
Buţiu, C. A. (2019) · Social Research Reports · doi:10.33788/srr11.3.11
More Evidence to Support Increasing Alcohol Taxes: A Commentary on Jiang et al. (2022)
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Nuo blaivybės judėjimų iki įrodymais grįstos alkoholio politikos : Lietuvos atvejo vertinimas
Tamutienė, I., Civinskas, R., Stumbrys, D., Peištarė, B., & Auglytė, V. (2022) · doi:10.7220/9786094675287
VISUOMENĖS SVEIKATOS KOALICIJA ALKOHOLIO POLITIKOS ĮGYVENDINIMO PROCESE 2007–2011 METAIS
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Reframing the Wicked Problem of Pre-Harvest Sugarcane Burning Through Participatory ModelingPreprint
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Alcohol lobbying in Canada: a quantitative analysis of the federal registry of lobbyists
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“Similar to public outreach efforts, these coordinated lobbying messages often centre around distracting from the issue at hand by framing alcohol as problematic for only certain segments of the population (e.g. young or heavy drinkers) (Katikireddi et al. 2014, Kypri et al. 2014).”
Lesch, M., & McCambridge, J. (2022) · Figshare · doi:10.6084/m9.figshare.19750739
Parnham, J. C., Chang, K., Essman, M., Smith, D., Etkind, M. P., McKenzie, M., Shah, P., Vasiljevic, M., Petticrew, M. P., White, M. J., et al. (2026) · Food Policy · doi:10.1016/j.foodpol.2026.103160
Abbas, H. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1885569
“…as a problem of social disorder caused by a minority of young or problematic drinkers, thereby promoting targeted rather than population-wide interventions, however, public-health advocates, by contrast, framed alcohol as a population-level health problem requiring population-wide action (32).”
- Authors
- KATIKIREDDI, S. V., BOND, L., & HILTON, S.
- Affiliations
- NHS Lothian (GB)
- MRC/CSO Social and Public Health Sciences Unit (GB)
- Corresponding author
- KATIKIREDDI, SRINIVASA VITTAL
- Venue
- The Milbank Quarterly
- Publisher
- Wiley
- Published
- 2014-06
- Volume
- 92
- Issue
- 2
- Pages
- 250-283
- ISSN
- 0887-378X (ISSN-L)
- 1468-0009
- PMC
- PMC4089371
- OpenAlex
- W2148516002
- Cited by
- 95
- References
- 74
- Citations by year
- 2026: 2 · 2025: 5 · 2024: 9 · 2023: 8 · 2022: 7 · 2021: 12 · 2020: 7 · 2019: 12 · 2018: 4 · 2017: 10 · 2016: 12 · 2015: 3 · 2014: 4
- FWCI
- 21.26
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Milbank Quarterly (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Strathprints: The University of Strathclyde institutional repository (University of Strathclyde) (acceptedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion)
- Victoria University Research Repository (Victoria University) (submittedVersion, cc-by)
- Funders
- Chief Scientist Office (MC_U130059812 and MC_UU_12017/4)
- Medical Research Council (MC_U130085862 and MC_UU_12017/6)
- Topics
- Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Global Public Health Policies and Epidemiology
- Health Sciences › Health Professions › General Health Professions › Public Health Policies and Education
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Keywords
- minimum unit pricing, alcohol policy, policy framing, public health advocacy, alcohol consumption, alcohol industry, policy stakeholders, population-level interventions, Scotland, alcohol harm, social disorder
- MeSH terms
- Administrative Personnel, Alcoholic Beverages, Costs and Cost Analysis, Health Policy, Humans, Interviews as Topic, Legislation as Topic, Scotland, Qualitative Research
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