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Investigating local policy drivers for alcohol harm prevention: a comparative case study of two local authorities in England
© The Author(s). 2017
Received: 24 January 2017
Accepted: 6 October 2017
Published: 18 October 2017
The considerable challenges associated with implementing national level alcohol policies have encouraged a renewed focus on the prospects for local-level policies in the UK and elsewhere. We adopted a case study approach to identify the major characteristics and drivers of differences in the patterns of local alcohol policies and services in two contrasting local authority (LA) areas in England.
Data were collected via thirteen semi-structured interviews with key informants (including public health, licensing and trading standards) and documentary analysis, including harm reduction strategies and statements of licensing policy. A two-stage thematic analysis was used to categorize all relevant statements into seven over-arching themes, by which document sources were then also analysed.
Three of the seven over-arching themes (drink environment, treatment services and barriers and facilitators), provided for the most explanatory detail informing the contrasting policy responses of the two LAs: LA1 pursued a risk-informed strategy via a specialist police team working proactively with problem premises and screening systematically to identify riskier drinking. LA2 adopted a more upstream regulatory approach around restrictions on availability with less emphasis on co-ordinated screening and treatment measures.
New powers over alcohol policy for LAs in England can produce markedly different policies for reducing alcohol-related harm. These difference are rooted in economic, opportunistic, organisational and personnel factors particular to the LAs themselves and may lead to closely tailored solutions in some policy areas and poorer co-ordination and attention in others.
Prioritisation of alcohol harm prevention policies can vary substantially between English local authorities due to differences in local circumstances and conditions. Awareness of how these differences can arise may help guard against imbalances in strategy.
The often considerable political challenges inherent in pursuing national level public health policies to reduce alcohol harm has prompted policy makers in a number of countries to explore locally tailored approaches [1–3]. Such measures have particular relevance in England following two recent policy shifts: Firstly, the transfer of public health teams from the National Health Service to 152 upper tier local authorities (LAs) and, secondly, the designation of local Directors of Public Health as responsible authorities able to challenge applications for alcohol retail licenses . These changes offer considerable scope for intervention as they effectively serve to co-locate within LAs increased powers to regulate alcohol availability alongside commissioning responsibilities for alcohol treatment and early intervention services . Their scope for radical policy formulation however is potentially constrained by competing concerns, most notably the need to foster a vibrant local economy . For many post-industrial UK towns and cities where development of a night-time economy played a key role in urban regeneration, a tension may be present between regulating and supporting business for whom alcohol sales play a major role .
The response of LAs to their new statutory responsibilities around alcohol policy has been highly variable and strongly informed by their differential prioritisation of the immediate socially disruptive effects of alcohol and its longer term chronic health impacts . Research to date suggests a tendency for decisions to be informed by local experiential evidence rather than formal evidence sources such as peer reviewed studies or external expertise . Although the variability of LAs’ new approaches to alcohol policy has been noted, the processes which drive this variability are less well explored [6, 7]. This includes how particular policies and combinations (or suites) of policies are chosen and how decision-making is variously informed by the identified or perceived needs of their local populations, the prioritisation of alcohol-related harm as well as resource constraints and competing priorities.
Within the context of this new policy environment, this paper aims to identify and examine the most significant policy drivers that have led to different suites of alcohol policies being adopted in two LAs in Northern England. Using a qualitative comparative case study approach, involving interviews with key informants and documentary analysis, we seek to understand the considerations that have informed differences in policy and strategy around alcohol licensing and availability, as well as approaches to the provision and availability of targeted screening and brief intervention programmes.
LA1: A post-industrial and ethnically diverse city with high rates of alcohol-related hospital admissions. The city has high levels of deprivation and limited employment opportunities for professionals. Prior to this research, there was significant investment by the city in dedicated alcohol treatment services. A relatively widely dispersed population and proximity to another larger urban conurbation has contributed to a limited ‘night-time economy’.
LA2: A large post-industrial city with a vibrant night time economy serving an economically diverse population. Premature mortality rates were high, particularly from liver disease and the city had developed and pioneered significant local initiatives to tackle alcohol-related crime and disorder, primarily around ‘on-trade’ restrictions on the types of premises associated with such disorder.
Interviewees from each case study Local Authority
Semi-structured interviews followed a topic guide which focused on the characteristics and development processes through which the current mix of alcohol harm prevention policy had come about. Advice was sought from two alcohol policy leads in separate local authorities (outside of the case study areas selected for this study) and with whom the topic guides were piloted. Included questions related to the respondents perceived level of importance which they attributed to the prioritisation of reducing alcohol-related harm, the LA’s general strategic approach within a local context and what had worked well and not so well. Interviewees were invited by email for a 1-h semi-structured interview , although interview length ranged between 26 and 93 min. Eleven of the thirteen interviews were conducted face to face and two by telephone. While interviews sought to cover a broad range of local alcohol policies and programmes, interviewees were free to expand on those aspects most relevant to their own area of experience or expertise.
Interviews were recorded and transcribed verbatim. Thematic analysis was used with a particular focus on (1) identifying key themes informing and driving the development of local alcohol policies and (2) addessing the proposition that recent policy changes described above may facilitate the tailoring of approaches to tackling alcohol-related harm to local contexts. Initial primary coding was undertaken by the first author with all statements of relevance to the research objectives assigned a primary code. Primary codes were then grouped into secondary overarching themes which were discussed and agreed with collaborators on the broader project from which this paper emerged. NVivo version 10 for windows (QSR International) was used to analyse transcripts.
The documentary sources used were the current statement of licensing policy (a statutory requirement for each LA), along with their respective alcohol harm reduction strategies. Other significant documentary sources for background context and between LA comparisons were the Alcohol Needs Assessment Research Project (England) ; a third sector published report highlighting some examples of good practice (not cited for disclosure protection) and Home Office Licensing Statistics  which provided summary totals for licensing applications, challenges, outcomes and appeals. The needs assessment and the third sector report were independently highlighted by at least two interview respondents when prompted about other publications which covered their strategic approaches. Documentary sources were thematically analysed using the agreed secondary themes derived from interview primary codes.
The two participating LAs were situated in cities of comparable population size: LA1 was significantly further south than LA2 (though not in the south of England) and was less centralised around a large city centre. Both were three hours or more travelling time by train from London and both were university cities within commuting distance of academic departments with significant interests in alcohol related research. Both case study LAs also cited alcohol and drug misuse within their top three public health priorities within their respective community safety strategies. From the thematic analysis of interview transcripts, seven second level themes were identified: drinking environment; treatment and intervention; available evidence; planning and strategy; public health burden; targeting risk groups and wider impact. Given the predominant focus in one LA on upstream interventions around the drink environment and availability, contrasting with a focus of the other LA on treatment approaches and risk group targeting, we chose to structure our findings around just three over-arching themes: namely (1) drinking environment, (2) treatment and intervention and (3) barriers and facilitators, which were materially relevant to both these approaches. The third newly introduced over-arching theme subsumed the remaining five themes in that their component topics effectively served either as barriers or facilitators. The three over-arching or ‘third level themes’ therefore provided for the greatest contrast between the comparison LAs, as well as pertaining directly to the overall aims of the study.
LA1 and LA2 contrasted in their approach to the drinking environment with LA1 taking a largely non-regulatory approach and focusing on negotiated agreements while LA2 focused efforts more on proactively exercising its regulatory powers.
…although there are no ‘all inclusive deals’ now, they still stick to ‘gentleman’s agreement’ arrangements that they won’t (for example) go under £1.20/£1.30 for a bottle of beer [LA1; Police].
…So you can agree relatively stringent operating conditions (by negotiation) on licences even though we don’t have cumulative impact [LA1; Police].
…the trading sector don’t generally like those (CIPs), because they are perceived as limiting to local business investment and the local economy [LA1; Trading Standards].
there (was) a view in this city which I think is now diminishing a little bit that our late night economy or image as a ‘party city’ were out of control [LA2; Licensing].
as long as the licensees see transparency between collection and spend they haven’t got that much of a problem really and that’s where we are with it [LA2; Licensing].
The first impression of LA1’s approach to minimizing any adverse impact of alcohol misuse might therefore be seen as more ‘lighter touch” that than of LA2, with an apparent reluctance to place area based statutory restrictions on commercial alcohol trading. On closer reflection, the less formal regulatory environment of LA1 however was not without relatively well developed local procedures for the close scrutiny of licensing arrangements, dependent on specialist police officers and the cultivation of personal relationships with licensees and other stakeholders:
…it’s all about trying to drive up the quality and the diversity of the offer [LA2; Licensing and also highlighted by Police].
I tend to I work with everybody be it solicitors, licence trade consultants or the premises licence holders/the owners the door staff and everybody …and if they have got a problem I put them on an action plan so it’s all highlighted [LA1: Police].
Treatment and Intervention
Anecdotally we’ve known there is an issue with alcohol in the South-East Asian community and following on from work undertaken as part of the needs assessment, we’ve been able to engage community leaders such as Imams [LA1; Public Health]
The comprehensive needs assessment also helped identify defined population sub-groups for whom drinking was associated with adverse life circumstances, such as unemployment, insecure residency status, enabling a joint services approach to treatment provision and not tackling drinking in isolation [LA1; Commissioning]
…the health needs assessment was a massive boon and the start of being able to demonstrate what the likely benefits of investment would be, which persuaded the powers that be [LA1; Public Health].
…there has not been a needs assessment to inform how best to adopt a preventative or treatment-based approach particularly for binge drinkers and those drinking excessively at home [LA2; Alcohol Harm Reduction Strategy].
..(the) longer term objective is to reduce the numbers of people that need to come through to expensive in-patient detox services [LA1; Commissioning].
The response to these concerns has been two fold and has involved a community delivered programme of screening and brief interventions, which has included extensive training and awareness-raising for all front-line health care professionals and a two year pilot of alcohol specialist nurses based within secondary care entirely funded by the CCG.
Public health are conscious of hospital admission indicator, NI39 (the only one that people ever look at), but at present nobody is really monitoring it but, in the new set of core performance indicators, currently under development, we will include NI39, although it is no longer a statutory requirement [LA2; Public Health].
Yes I mean they’re looking at very much (those patients) who have been red-flagged as high risk, very high risk or dependent drinkers [LA2: Treatment Services].
so they’ve taken on doing ABI with all of the patients that they see prior to surgical intervention, when they’re having a pre-assessment. [LA2: Treatment Services].
…it has happened for some time on an ad-hoc basis (so although) many practices are already doing it, it hasn’t been implemented in a strategic way [LA2: Treatment Services].
Barriers & Facilitators
Summary of identified policy drivers from interviews & document sources (Number of times independently referred to by an interview or document source in parenthesis – see abbreviation key below for source initials)
LA SITE 1
LA SITE 2
Resource constraints leading to a decision to focus on over-riding priorities and limited local police resources (×3: PC; PH; CM).
Comprehensive Health Needs Assessment which identified unmet needs in defined sub-populations (×3: CM; PH; DC).
Large metropolitan area leading to problems planning ‘joined up’ services in providing treatment options and pathways (x2: CT; PH).
Successful application for extra funds specifically for tackling alcohol fuelled violence and disorder (×4: PH; LT; PC; DC)
Not wanting to discourage commerce (×2 PH; LT).
Alcohol commissioning co-located with Public Health within organisational structure (×2: CM; PH).
No comprehensive area alcohol needs assessment (×2: PH; DC).
Access to specialist legal expertise making legal team less risk averse about implementing novel policy measures likely to be challenged by the industry (×3: PH; LT; PC)
Information sharing difficulties/IT compatibility issues (×4: CM; PH; IT; TP).
Informal close working: police & licensees (×2: PC; LT).
Under-provision and patchwork nature of alcohol specialist treatment services (×3: CL; CM; DC).
Pro-active police around licensing, strongly motivated to tackle poor public image of the city in relation to drinking (×3: PC; LT; DC)
Necessity of tackling high admissions – restricting capacity for a wider approach (×3 PH; CM).
Enlightened CCG willing to fund Hospital ABIs (×4: CM; CT; PH; DC)
Little apparent engagement from CCGs (×2: CT; TP).
Capacity to diversify large and vibrant night-time economy (×3: LT; PC; TP).
“We have brought the alcohol [treatment] commissioning team into public health as part of the department – (which) has been a big thing as well they work with us and take the lead on lots of commissioning projects” [LA1; Public Health]
Our clinical lead for alcohol is a local GP. And he's great. You know, really, really interested in pushing the (ABI) agenda and encouraging wider provision and take-up… [LA1; Commissioning].
[The funding] helped. [The funding]…got recognition. It wasn’t just about recognition, but I think that brought about a lot of communal working, which I think previously there wouldn’t have been funding to do… [LA1; Commissioning].
the council’s statement of licensing policy is an outstanding document which assists us hugely in being able to effectively deal with two things in particular: one being the control and the regulation of the existing night time economy and two being restricting the proliferation of retail outlets for alcohol off licences [LA2: Police]
..while there were many in the trade who were trying to prevent it, the skill of the legal team was such that they were unable to do so [LA2: Licensing].
Some hospital trusts are doing it (ABIs) and financing it themselves – so no resources forthcoming at present from CCG or LA. [LA2: Treatment Services].
One of the biggest barriers has in fact been IT issues (which) hamper real-time recording/data- sharing efforts (around alcohol) – an adequate IT infra-structure is definitely lacking – often means going to lots of different systems to pull out related information such as localised health and incident data... [LA1; Public Health (also highlighted by Commissioning)].
While genuine population health needs analysis alongside the likely acceptability of regulatory interventions have therefore together informed the different emphases in policy responses, there are clearly a wide range of LA specific organisational enabling or discouraging factors, that can influence policy choices.
The two case study LAs expressed similar levels of perceived commitment to reducing alcohol harm and both clearly saw alcohol as a public health priority; however, this commitment translated into very contrasting approaches to alcohol policy. LA1 exhibited a strategy targeting risk-premises and risk groups which addressed both licensing and healthcare interventions, with the former focusing on negotiated relationships with license holders and applicants. In contrast, LA2’s response was characterised by a less well developed programme of access to screening and healthcare interventions, alongside a substantive suite of regulatory measures aimed at transforming the night-time economy. These were not absolute or static differences (e.g. LA1 did establish working relationships with licensees and LA2 commissioned healthcare interventions in a fragmented fashion while anticipating more work in this area in future), but they served to highlight clear differences in concerns, priorities and resource availability. These differences appeared rooted in four factors: (i) differences in the relative importance and profile of the respective night-time economies; (ii) organisational/structural components, such as the proximity of public health with treatment commissioning (co-located in LA1); (iii) the availability of dedicated additional resources (in LA1 for treatment/screening by the CCG and in LA2 from a charitable fund for tackling crime and disorder) and the ready availability of specialist advice (legal expertise in LA2) or clinical champions (e.g. proactive clinicians in LA1, with a significant interest in alcohol treatment).
A major strength of the case study in descriptive exploratory research is its capacity to draw upon and compare content and emergent findings from a range of different sources . The findings above are strengthened by using extensive cross-corroboration between interviewees, documentary sources and independent third party interviews (see Table 2). This minimises, although does not eliminate, the possibility that interviewees perspectives are selective and based on individual beliefs or preferences, a risk that could have been exacerbated by the relatively low numbers of informants in each LA. Although pro-actively seeking divergent views is an established strategy for validating the coherence of higher order themes in qualitative research , the high degree of convergence (as evident in Table 2) and the ability to explain differing emphasis through appreciating participants' different professional perspectives, indicated early on in this study that such an approach would be unlikely to add any further useful insights.
Although the comparison of two case study sites does not provide a generalisable picture of contemporary local authority-level alcohol policy in England and may therefore be seen as a limitation of the current approach, it does facilitate a focus in this instance on contrasting strategic priorities with regard to reducing alcohol harm and the processes and factors which can contribute to that. Of course, the restriction to just two sites in this study and at one particular point in time, can only hint at the complexities involved in the development of local policy responses to alcohol and we would see this environment as a perfect illustration of recent calls for a ‘complex systems approach’ in the development and appraisal of solutions to modern public health problems . Studies with larger numbers of LAs are likely to lend themselves well to such approaches using established socio-ecological frameworks such as the ANGELO framework used in obesity policy analysis , which would encompass the different ‘policy domains’ that impact on alcohol at both macro and micro-level settings.
The capacity for local government to develop locally responsive alcohol harm reduction measures has received renewed attention in recent years, which in the UK has been facilitated by changes to the public health and licensing infrastructure [6, 19]. Internationally also, there is recognition that locally derived policies benefit from a democratic legitimacy when supported by local populations  and their dispersion and variability present a challenge for alcohol industry efforts to influence policy  (although legal challenges against licensing regulation are common). The results above highlight both that localism in alcohol policy can produce responses tailored to local contexts (e.g. utilising the strong legal team in LA2 to take advantage of regulatory powers and focusing on challenges particular to minority ethnic groups in LA2), but also that uneven strategic responses to alcohol policy can emerge (e.g. some local authorities not having the legal resources available to LA2 and LA2 also being slower to develop a comprehensive alcohol-related healthcare policy and sevice model). Given substantially different starting points in terms of their respective alcohol harm profile, it is hazardous to compare changes over time between the two case study LAs, although LA2, which emphasised availability and the drinking environment, has seen marginally greater reductions in morbidity and mortality indicators over the course of the study and since its completion.
The importance of organisational factors in the viability of and access to alcohol treatment services has previously been highlighted from both a management perspective  and that of service users . Concerns have also been expressed that a form of the “inverse care law” may be emerging in England that is partly attributable to the recent structural changes in the commissioning of preventative public health services . LA2’s intentions and published plans to improve its alcohol-related healthcare services may suggest it is simply at an earlier stage in the implementation process described by Simpson . A key implication of our findings therefore is that from the point of view of individual LAs, support for a broad-based and comprehensive LA policy response aimed at redressing alcohol health harms is to be recommended, whatever the focus of their current priorities. Encouraging CCGs such as that in LA1 for example, to publicise the benefits of investment in treatment services, at a time when many may not see the benefits, is also likely to help foster an understanding of the wider advantages of maintaining or increasing such investments.
Recent encouraging findings on the likely beneficial impact of more pro-active regulatory policy approaches on the part of LAs on alcohol harm statistics such as hospital admission rates  and on the more traditional indices of crime and disorder , help strengthen the evidence case for public health teams in particular to make good use of their recently acquired ‘responsible authority’ status. Experience of the more pioneering LAs in this area also highlights that the way policies such as cumulative impact zones  and reducing the availability of cheap high alcohol content beverages  are implemented are likely to exhibit considerable variability according to local circumstances. A degree of heterogeneity therefore in LA alcohol policy responses and structures is therefore to be expected and it is unsurprising that this extends across the full spectrum of LA influence on treatment and prevention. While the current study has documented some of the more significant barriers and facilitators that might influence the particular combination of policies seen in any particular LA, it is clear that the prospects for maintaining a comprehensive response will be enhanced by ensuring an appropriate mix of treatment and prevention approaches and by spreading effective innovations and good practice between LAs.
New powers over alcohol policy for LAs in England can produce markedly different local policy mixes for reducing alcohol-related harm. These differences are rooted in economic, organisational and personal factors particular to the LAs concerned and may lead to closely tailored solutions in some policy areas with less than may be optimal attention paid to others. Those working in public health need to be vigilant of where and how these imbalances might arise, so that they can work towards proactively addressing them.
Clinical Commissioning Groups are collaborative local groups of primary care practices who in England now hold the health service budgets for their local populations.
We are extremely grateful to members of the wider collaborative work group, in particular Dr. Matt Egan of London School of Hygiene and Tropical Medicine for his comprehensive feedback on the draft submission and to Dr. Emma Halliday and Dr. Vivien Holt at the University of Lancaster for their advice and help in finalising the interview schedule and initial grouping of interview themes. We are also indebted to the two participating local authority areas, who gave unselfishly of their staff time for the duration of the investigation phase.
This work was funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR). NIHR SPHR is a partnership between the Universities of Sheffield, Bristol, Cambridge, Exeter, UCL; The London School for Hygiene and Tropical Medicine; the LiLaC collaboration between the Universities of Liverpool and Lancaster and Fuse: the Centre for Translational Research in Public Health, a collaboration between Newcastle, Durham, Northumbria, Sunderland and Teesside Universities.
Availability of data and materials
The data that support the findings of this study are available from the corresponding author but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of participating local authority areas.
JDM co-designed the case-study, conducted all interviews, undertook initial analysis and wrote the manuscript, JH advised on policy context and provided extensive feedback on the manuscript, LG advised on methodology and interpretation of findings; FdV assisted with policy context and comparability with other LAs; KL and MH provided guidance on site recruitment and overall methodology and AB oversaw project management throughout as well as interpretation of findings at each stage. All authors have read and approved the final manuscript.
Ethics approval and consent to participate
Ethical approval for the study was obtained from the University of Sheffield (Reference number 0025/2013) and written consent was obtained from each interviewee.
Consent for publication
The authors declare that they have no competing interests.
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