Transcript Alcohol Research and the Alcoholic Beverage Industry

Alcohol: No Ordinary Commodity
Part I: Establishing the Need
for Alcohol Policy
Thomas F. Babor, Ph.D., MPH
University of Connecticut
School of Medicine
Farmington, CT USA
Alcohol, No Ordinary
Commodity: Research and
Public Policy
Sponsored by:
The World Health Organization
and
The Society for the Study of Addiction (UK)
All royalties from book sales go to the SSA.
Authors received no financial support for their work on the book.
Authors had no financial conflicts of interest to declare.
The Alcohol Public Policy Group*
Co-authors
Academic Affiliations
Thomas Babor
Raul Caetano
Sally Casswell
Griffith Edwards
Norman Giesbrecht
Kathryn Graham
Joel Grube
Paul Gruenewald
Linda Hill
Harold Holder
Ross Homel
Esa Österberg
Jürgen Rehm
Robin Room
Ingeborg Rossow
University of Connecticut (USA)
University of Texas (USA)
Massey University (New Zealand)
National Addiction Centre (United Kingdom)
University of Toronto (Canada)
Centre for Addiction and Mental Health (Canada)
University of California (USA)
University of California (USA)
University of Auckland (New Zealand)
University of California (USA)
Griffith University (Australia)
Institute for Social Research (Finland)
University of Toronto (Canada)
Stockholm University (Sweden)
National Institute for Alcohol and Drug
Research (Norway)
Alcohol, No Ordinary Commodity:
Research and Public Policy
Oxford University Press (2003)
An integrative review of epidemiological data
and prevention literature, based on:
– International research on alcohol consumption
trends and the global burden of disease
attributable to alcohol
– Growth of the knowledge base on policyrelated strategies and interventions
– New understandings of the policymaking
process at the local, national and international
levels
Alcohol policy and alcohol science
in developing societies
•
•
•
As economic development occurs, alcohol consumption and resulting
problems are likely to rise with rising incomes, confronting developing
nations with greater levels of alcohol-related problems, and new
challenges to develop effective alcohol policies.
With the growing emphasis on free trade and free markets,
international institutions such as the World Trade Organization have
pushed to dismantle effective alcohol control measures, including state
alcohol monopolies and other restrictions on the supply of alcoholic
beverages.
Developing countries badly need their own assessments of their own
alcohol policy experiences and their own alcohol science. The world
research community in partnership with international agencies has a
special responsibility to rectify this situation.
ALCOHOL IS A COMMODITY
• Alcoholic beverages are an important, economically
embedded commodity
• The production and sale of commercial alcoholic
beverages generates:
– profits for farmers, manufacturers, advertisers, and
investors
– employment for people in bars and restaurants
– tax revenues for the government.
• Non-commercial alcohol in developing societies has
a traditional role in the local economy
ALCOHOL: NO ORDINARY COMMODITY
•
The benefits connected with the production,
sale, and use of this commodity come at an
enormous cost to society.
•
Three important mechanisms explain alcohol’s
ability to cause medical, psychological, and
social harm:
1) physical toxicity
2) intoxication
3) dependence
Physical Toxicity
•
•
Alcohol is a toxic substance in terms of its direct
and indirect effects on a wide range of body
organs and systems. Non-commercial alcohol can
have additional toxic effects because of additives.
Drinking patterns that promote frequent and heavy
alcohol consumption are associated with chronic
health problems such as liver cirrhosis,
cardiovascular disease, and depression.
Alcohol related chronic disease
Cancer: Mouth & oropharyngeal cancer, Esophageal
cancer, Liver cancer, Female breast cancer
Neuropsychiatric diseases: Alcohol use disorders,
unipolar major depression, epilepsy
Diabetes
Cardiovascular diseases: Hypertensive diseases,
coronary heart disease, stroke
Gastrointestinal diseases: Liver cirrhosis
Conditions arising during perinatal period: Low birth
weight, fetal alcohol spectrum disorder
Moderate Drinking:
Positive and Negative Effects
•
•
•
•
Moderate drinking is linked to an increased risk of cancer and other
disease conditions.
Regular, light, and moderate alcohol consumption has a
cardioprotective effect at the level of the individual drinker. This effect
applies mainly to the age group of 40 years and older, where the
overwhelming majority of coronary heart disease occurs
But at the population level, there may be no net protective effect from
an increase in alcohol consumption, and even a detrimental effect in
societies with heavy episodic drinking patterns.
While there may be some offsetting psychological and cardioprotective benefits from drinking, alcohol accounts for a significant
disease burden worldwide and is related to many negative social
consequences.
(Murray & Lopez, 1996; Rehm and Sempos 1995a, 1995b).
INTOXICATION
•
•
The main cause of alcohol-related harm in the
general population is alcohol intoxication.
Drinking patterns that lead to rapidly elevated
blood alcohol levels result in problems associated
with acute intoxication, such as accidents, injuries,
and violence.
Alcohol related injury
Unintentional injury:
•Motor vehicle accidents,
•drowning,
•falls,
•poisonings,
•other unintentional injuries
Intentional injury:
•Self-inflicted injuries,
•homicide,
•other intentional injuries
ALCOHOL DEPENDENCE
•
•
•
Sustained drinking may result in alcohol dependence, a
syndrome characterized by impaired control over drinking,
high alcohol tolerance, and physical withdrawal symptoms.
Once dependence is present, it impairs a person’s ability to
control the frequency and amount of drinking.
Alcohol dependence has many different contributory
causes including genetic vulnerability, but it is a condition
that is contracted by repeated exposure to alcohol: the
heavier the drinking, the greater the risk.
Why alcohol is no ordinary commodity:
Relations among alcohol consumption,
mediating variables and consequences
Patterns of drinking
Average volume
Intoxication
Toxic
effects*
Chronic
Disease
Dependence
Accidents/Injuries
(acute disease)
Acute
Social
Problems
Chronic
Social
Problems
NO ORDINARY COMMODITY
• Because of its physical toxicity, intoxicating
effects, and dependence potential, alcohol is
not a run-of-the-mill consumer substance.
• Public health responses must be matched to
this complex vision of the dangers of
alcohol as they seek better ways to respond
to population-level harms.
Economic development status and alcohol consumption
(based on population weighted averages of 182 countries)
Level of
mortality
and
category of
countries
Developing
countries
Developed
countries
WHO
regions
Adult
consumption in
litre/year
Percent
Drinker
Female
Consumption per
drinker in
g/day pure
alcohol
Average
pattern of
drinking
Male
High
mortality
EMR-D
SEAR-D
1.7
19
2
33
2.9
Very high
or high
mortality
AFR-D
AFR-E
AMR-D
7.1
47
32
41
3.0
Low
mortality
AMR-B
EMR-B
SEAR-B
WPR-B
5.7
67
36
25
2.5
Very low
mortality
AMR-A
EUR-A
WPR-A
10.7
81
65
32
1.8
Low child
and low or
high adult
mortality
EUR-B
EUR-C
11.7
77
59
37
3.5
Patterns of drinking throughout the world
Patterns of drinking
1.00 to 2.00
2.00 to 2.50
2.50 to 3.00
3.00 to 4.00
ALCOHOL CONSUMPTION IN DIFFERENT WORLD
REGIONS*
WHO Region
(See definitions below)
Predominant
Beverage type
Average
Recorded Total Drinkers Drinkers Consump drinking % alcohol
consump- consump- among among tion per pattern dependent
tion
tion
**
males females drinker
Mainly fermented
Africa D
(e.g. Nigeria, Algeria) beverages
2.3
4.9
47.0
27.0
13.3
2.5
0.7
Mainly other
Africa E
(e.g. Ethiopia, South fermented beverages
and beer
Africa)
3.8
7.1
55.0
30.0
16.6
3.1
1.6
> 50% beer, about
Americas A
(Canada, Cuba, US) 25% spirits
8.3
9.3
73.0
58.0
14.3
2.0
5.1
Beer, followed by
Americas B
(e.g. Brazil, Mexico) spirits
6.3
9.0
75.0
53.0
14.1
3.1
3.5
3.3
5.1
74.0
60.0
7.6
3.1
3.2
Americas D
(e.g. Bolivia, Peru)
Spirits, followed by
beer
* population weighted averages
** 1= low level of risk, 4= high level of risk associated with a country’s predominant pattern of drinking
Adult per capita consumption in selected WHO Regions:
Africa D (e.g., Nigeria, Algeria), Africa E (e.g., Ethiopia, South
Africa), Eastern Mediterranean B (e.g., Iran, Saudia Arabia).
7
6
Litres of pure alcohol
5
Africa D
4
Africa E
3
Eastern Mediterranean B
Eastern Mediterranean D
2
1
0
1961
1971
1981
YEAR
1991
THE GLOBAL BURDEN OF ALCOHOL
CONSUMPTION
•
•
•
•
Alcohol-related death and disability accounted for 4.0% of the global
burden of disease, quantified according to the impact of premature
deaths and disability in a population.
Alcohol was ranked as the fifth most detrimental risk factor of 26
examined; alcohol accounted for about the same amount of disease as
tobacco.
In developed countries, alcohol was the third most detrimental risk
factor, accounting for 9.2% of all burden of disease. In emerging
economies like China, alcohol was the most detrimental risk factor.
Overall, injuries accounted for the largest portion of alcoholattributable disease burden.
(Murray & Lopez, 1996; Ezzati et al., 2002).
Leading risk factors as causes of disease burden
= alcohol, drugs, tobacco
Developing countries
Developed countries
High Mortality
Low Mortality
1 Underweight
Alcohol
2 Unsafe sex
Blood pressure
3 Unsafe water
Tobacco
4 Indoor smoke
Underweight
5 Zinc deficiency
Body mass index
6 Iron deficiency
Cholesterol
7 Vitamin A deficiency
Low fruit & veg intake
8 Blood pressure
Indoor smoke - solid fuels
9 Tobacco
Iron deficiency
10 Cholesterol
Unsafe water
11 Alcohol
Unsafe sex
12 Low fruit & veg intake Lead exposure
Tobacco
Blood pressure
Alcohol
Cholesterol
Body mass index
Low fruit & veg. intake
Physical inactivity
Illicit drugs
Unsafe sex
Iron deficiency
Lead exposure
Childhood sexual
abuse
ALCOHOL CONSUMPTION TRENDS
AND PATTERNS OF DRINKING
Alcohol consumption varies enormously, not only among countries, but
also over time and between different population groups. Two aspects of
alcohol consumption are of particular importance for comparisons
across populations and across time.
1)
Total alcohol consumption in a population is an indicator of the number of
individuals exposed to high amounts of alcohol. Adult per capita
consumption is related to the prevalence of heavy use, which in turn is
associated with the occurrence of negative effects.
2)
Variations in drinking patterns (the quantity, frequency and timing of
alcohol use) affect rates of alcohol-related problems, and have implications
for the choice of alcohol policy measures.
ALCOHOL CONSUMPTION TRENDS
•
•
•
Recorded alcohol consumption is highest in the economically
developed regions of the world. Western Europe, Russia and other
(non-Moslem) parts of the former USSR now have the highest per
capita consumption levels, but Latin American levels are not far behind
Recorded consumption is generally lower in Africa and parts of Asia,
and is particularly low in Moslem states and the Indian subcontinent.
Sales data from established market economies show a slight overall
decrease in alcohol consumption in recent years, as well as converging
trends in traditional high consumption and low consumption countries.
(WHO, 1999)
Population Group Differences
•
•
•
•
•
There are striking gender differences in whether a person drinks,
with men more likely to be drinkers and women abstainers.
Among drinkers, men drink ‘heavily’ (i.e., to intoxication, or large
quantities per occasion) much more often than women.
Abstinence and infrequent drinking are more prevalent in older
age groups, and frequent intoxication is more prevalent among
young adults. Abstinence is the norm in most African countries.
Most of the alcohol in a society is consumed by a relatively small
minority of drinkers.
When alcohol consumption levels increase in a country, there
tends to be an increase in the prevalence of heavy drinkers.
DRINKING PATTERNS
• Countries and population groups vary in the extent to
which drinking to intoxication is a characteristic of the
drinking pattern. They also differ in how intoxicated
people get, and how people behave while intoxicated.
• In the southern European countries, approximately one out
of ten drinking occasions lead to a state of intoxication
among adolescents, whereas the majority of drinking
occasions in the most northern European countries result in
intoxication (Hibell et al., 1997, 2000).
Alcohol, No Ordinary
Commodity:
Part II
Effective Alcohol Policies:
A Consumer’s Guide
Prevention Strategies
Reviewed and Evaluated
•
•
•
•
•
•
•
Pricing and Taxation
Regulating Physical Availability
Altering the Drinking Context
Education and Persuasion
Regulating Alcohol Promotion
Drinking-Driving Countermeasures
Treatment and Early Intervention
Ratings of 32 Policy-relevant Prevention
Strategies and Interventions
1) Evidence of Effectiveness – the quality of
scientific information
2) Breadth of Research Support – quantity and
consistency of the evidence
3) Tested Across Cultures, e.,g. countries, regions,
subgroups
4) Cost to Implement and Sustain – monetary and
other costs
aRating
Scale: 0, +, ++, +++, (?)
b Rating Scale: Low, Moderate, High
Assumptions Underlying Pricing and
Taxation Policy Options
Policy
High taxes, prices
Assumption
Reduce demand by increasing
economic cost of alcohol
relative to alternative
commodities
Taxation/Pricing Controls
Strategy or
Intervention
Alcohol
Taxes
XEffective- Research Cultural
ness
Support Testing
+++
+++
+++
Cost
Low
Pricing and Taxation
Evidence suggests that:
• People increase their drinking when prices are lowered, and decrease
their consumption when prices rise.
• Adolescents and problem drinkers are no exception to this rule.
• Increased alcoholic beverage taxes and prices are related to reductions
in alcohol-related problems.
• Alcohol taxes are thus an attractive instrument of alcohol policy
because they can be used both to generate direct revenue and to reduce
alcohol-related harm.
• The most important downside to raising alcohol taxes is smuggling and
illegal in-country alcohol production.
• Behavioral economic principles apply to discount drink policies, price
advertising, differential taxes on different alcohol products (e.g.,
alcolpops)
Assumptions Underlying Restrictions
on Alcohol Availability
Policy
Restrictions on time,
place, and density of
alcohol outlets
Assumption
Reduce demand by restricting
physical availability –
increase effort to obtain
alcohol
Regulating Physical Availability
Strategy or
Intervention
Total ban on sales
Minimum legal
purchase age
Rationing
Government
monopoly of retail
sales
Hours and days of
sale restrictions
Restrictions on
density of outlets
Different
availability by
alcohol strength
XEffectiveness Research Cultural
Support Testing
+++
+++
++
+++
+++
++
Cost
High
Low
++
+++
++
+++
++
++
High
Low
++
++
++
Low
++
+++
++
Low
++
++
+
Low
Regulating Alcohol Availability
•
•
•
Changes in availability can have large effects in
nations or communities where there is popular
support for these measures.
The cost of restricting alcohol availability is cheap
relative to the costs of health consequences related
to drinking, especially heavy drinking.
The most notable adverse effects of availability
restrictions include increases in informal market
activities (e.g., cross-border purchases; home
production, illegal imports).
Regulating Alcohol Availability Through
Minimum Legal Purchase Age (MPLA)
• In 1984 the US Congress passed the
•
National Minimum Purchase Age Act,
which encouraged states to adopt the age 21
purchase standard
The number of young people who died in a
crash when an intoxicated young driver was
involved has declined by almost 63%
Modifying the Drinking Context
Many prevention measures seek to re-define the
contexts or change the environments where
alcohol is typically sold and consumed (e.g., bars
and restaurants), under the assumption that such
changes can reduce alcohol-related aggression and
intoxication
.
Options include training bar staff, imposing
voluntary house policies to refuse service,
enforcement of regulations, community
mobilization to influence problem establishments
Modifying the Drinking Context
Strategy or
Intervention
Outlet policy to not
serve intoxicated
patrons
Training bar staff
and managers to
prevent and better
manage aggression
Voluntary codes of
bar practice
Enforcement of onpremise
regulations and
legal requirements
Community
mobilization
Effectiveness
+
XResearch Cultural
Support
Testing
+++
++
Cost
Moderate
+
+
+
Moderate
O
+
+
Low
++
+
++
High
++
++
+
High
Regulating alcohol promotion
• The marketing of alcohol is a global industry.
• Alcohol brands are advertised through television, radio,
print, point-of-sale promotions, and the Internet.
• Exposure to repeated high-level alcohol promotion
inculcates pro-drinking attitudes and increases the
likelihood of heavier drinking.
• Alcohol advertising predisposes minors to drinking well
before legal age of purchase.
• Advertising has been found to promote and reinforce
perceptions of drinking as positive, glamorous, and
relatively risk-free.
Stamp of Approval
4:06 A.M. WE GET PAST
OUR SIXTH DOORMAN OF
THE EVENING
SEE WHERE IT TAKES YOU
Assumption Underlying Regulation of
Alcohol Marketing Policy Options
Policy
Regulating alcohol
marketing and
advertising
Assumption
Reducing exposure to social
modeling of excessive
drinking will prevent
underage drinking
Regulating Alcohol Promotion
Strategy or EffectiveIntervention
ness
Advertising
+
bans
Voluntary
controls by
0
alcohol industry
Research
Support
+
XCultural
Testing
++
+
++
Cost
Low
Low
Regulating alcohol promotion
Industry Self-regulation Codes
• Self-regulation tends to be fragile and largely
ineffective.
• These codes may work best where the media,
advertising, and alcohol industries are all
involved, and an independent body has powers to
approve or veto advertisements, rule on
complaints, and impose sanctions.
• Few countries currently have all these
components.
Assumptions Underlying Drinkdriving Policy Options
Policy
Drink-driving
countermeasures
Assumption
Reduce drink driving though
deterrence, punishment and
social pressure
Drinking-Driving Countermeasures
Strategy or
Intervention
Sobriety check
points
Random breath
testing (RBT)
Lowered BAC
Limits
Administrative
license
suspension
Low BAC for
young drivers
(“zero
tolerance”)
Graduated
licensing for
novice drivers
Designated
drivers and ride
services
Effectiveness
++
Research
Support
+++
XCultural
Testing
+++
+++
++
+
Moderate
+++
+++
++
Low
++
++
++
Moderate
+++
++
+
Low
++
++
++
Low
O
+
+
Moderate
Cost
Moderate
Random Breath Testing (RBT)
• Motorists are stopped at random by police and
required to take a preliminary breath test, even if
they are in no way suspected of having committed
an offence or been involved in an accident.
• Highly visible, non-selective testing can have a
sustained effect in reducing drinking-driving and
the associated crashes, injuries, and deaths.
Summary: Drinking-Driving
Countermeasures
• Consistently produce long-term problem
reductions of between 5% and 30%.
• Deterrence-based approaches, using innovations
such as Random Breath Testing, yield few arrests
but substantial accident reductions.
• Another effective measure is the use of graduated
licensing for novice drivers, which limits the
conditions of driving during the first few years of
licensing.
Assumptions Underlying Education
and Persuasion Policy Options
Policy
Assumption
Provide information to
Health information increases
adults and young people knowledge, changes attitudes
especially through mass
and prevents drinking
media and school-based
problems
alcohol education
programs
Education Strategies
• School-based alcohol education programs
are among the most popular types of
prevention programs for policymakers.
• Approaches include giving information,
values clarification, building self-esteem,
teaching general social skills, and
“alternatives” approaches that provide
activities inconsistent with alcohol use (e.g.,
sports).
Education and Persuasion
Strategy or
Intervention
Alcohol
education in
schools
College
student
education
Public service
messages
Warning
labels
Effectiveness
O
Research
Support
+++
XCultural
Testing
++
O
+
+
High
O
+++
++
Moderate
O
+
+
Low
Cost
High
Summary: Education Strategies
• The impact of education and persuasion programs tends to
be small at best.
• When positive effects are found, they do not persist.
• Among the hundreds of studies, only a few show lasting
effects (after 3 years) (Foxcroft et al. 2003).
• The time is past for arguments on behalf of substituting
education for other, more effective approaches.
• If educational approaches are to be used, they should be
implemented within the framework of broader
environmental interventions that address availability of
alcohol.
Education and Persuasion Strategies
Public service announcements (PSAs)
• Messages prepared by nongovernmental
organizations, health agencies, and media
organizations that deal with responsible drinking,
the hazards of drinking-driving, and related topics.
Despite their good intentions, PSAs are an
ineffective antidote to the high-quality prodrinking messages that appear much more
frequently as paid advertisements in the mass
media.
Assumptions Underlying Treatment
and Early Intervrention
Policy
Increase availability of
treatment programs
Conduct screening and
brief intervention in
health care settings
Assumption
Problem drinking is responsive
to various therapeutic
interventions
Heavy drinkers can be
motivated to drink
moderately before they
acquire alcohol dependence
Treatment and Early Intervention
Strategy or
Intervention
Brief
intervention
with at-risk
drinkers
Alcohol
problems
treatment
Mutual
help/selfhelp
attendance
Mandatory
treatment of
repeat
drinkingdrivers
Effectiveness
++
Research
Support
+++
XCultural
Testing
+++
+
+++
+++
High
+
+
++
Low
+
++
+
Moderate
Cost
Moderate
Best Practices
• Minimum legal
purchase age
• Government
monopoly of retail
sales
• Restriction on hours or
days of sale
• Outlet density
restrictions
• Alcohol taxes
• Random Breath
Testing
• Lowered BAC limits
• Administrative license
suspension
• Graduated licensing
for novice drivers
• Brief interventions for
hazardous drinkers
Other Policies and Policy Issues
•
•
•
•
Water rights
Agriculture
International trade
The alcohol beverage industry
Cost Effectiveness of 5 Effective
Policy Options in 5 WHO Regions
From: Chisholm, D., Rehm, J., Van Ommeren, M. & Monteiro, M. (2004) Reducing the global burden of hazardous
alcohol use: A comparative cost-effectiveness Analysis. Journal of the Studies on Alcohol 65:782-793.
What can be done when there is
insufficient evidence?
•
•
•
•
Policy changes should be made with caution and with a sense of
experimentation to determine whether they have their intended effects.
Strengthen the links between science and policy so that promising
research findings are identified, synthesized and effectively
communicated to the policymakers and the public.
Use the Precautionary Principle: the introduction of new alcohol
products (e.g., high alcohol content malt beverages), removal of
restrictions on hours of sale, and the promotion of alcohol through
marketing and advertising should be guided by likely risk, rather than
by potential profit. Shift the burden of proof to the alcohol industry
asking them to demonstrate that their policies are NOT harmful.
Use theory to guide policy
Conclusions
• Opportunities for effective, evidence-based
alcohol policies are more available than ever to
better serve the public good.
• Alcohol policies that limit access to alcoholic
beverages, discourage driving under the influence
of alcohol, reduce the legal purchasing age for
alcoholic beverages, and increase the price of
alcohol, are likely to reduce the harm linked to
underage drinking
• Alcohol problems can be minimized or prevented
using a coordinated, systematic policy response.
Swimming With Crocodiles
WHO Expert Committee on Problems Related to
Alcohol Consumption
The committee recommends that WHO continue its
practice of no collaboration with the various
sectors of the alcohol industry. Any interaction
should be confined to discussion of the
contribution the alcohol industry can make to the
reduction of alcohol-related harm only in the
context of their roles as producers, distributors and
marketers of alcohol, and not in terms of alcohol
policy development or health promotion.