Removal of cheap, super-strength beer and cider to address alcohol-related harms: a qualitative study of a local alcohol availability intervention

Abstract Background Increasingly, English local authorities are implementing an intervention called Reducing the Strength whereby off-licences voluntarily stop selling inexpensive super-strength (≥6·5% alcohol by volume) beers and ciders. We conceptualised Reducing the Strength as an event within a complex system and aimed to create a pluralistic account of how the intervention could lead to a range of intended and unintended consequences. Methods In an inner-London borough, we conducted one focus group with alcohol treatment professionals (n=11) and semi-structured interviews with homeless drinkers (9), and professionals working in hostels for homeless people (6), in alcohol services (2), and in outreach teams (2). Participants were recruited through stakeholder contacts and by approaching hostels and services. We asked participants about alcohol and service provision for homeless people, homeless peoples’ drinking behaviours, and the Reducing the Strength intervention. Interviews were audiorecorded and transcribed. One researcher coded the transcripts in NVivo (version 10), using the interview guide to group major themes. The research team suggested further iterations as part of an inductive process of using participant narratives to consider different levels at which the intervention might have impacts, including the levels of the individual, local environment, services, and policy. Ethics approval was obtained from the London School of Hygiene & Tropical Medicine Ethics Committee (reference 6452-02). Findings Individual drinkers attempt to maintain intoxication by adapting to the intervention in different ways, including finding alternative shops, switching drinks, using drugs, or committing crimes to purchase more expensive drinks. Depending on the adaptive response, there were mechanisms for both positive and negative impacts on individuals’ health and on the local environment. Service providers suggested that the present iteration of the intervention is too narrow and misses opportunities to encourage intersectoral working between the council, alcohol services, and hostels. However, several participants believed that small-scale interventions such as Reducing the Strength might contribute to long-term political and cultural changes leading to more effective interventions. Interpretation Evaluators can conceptualise interventions as events in complex systems to explore pathways to impact across multiple levels. Our findings lead us to theorise that R