Alcohol: No Ordinary Commodity Part I: Establishing the Need for Alcohol Policy

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Alcohol No Ordinary CommodityPart I
Establishing the Need for Alcohol Policy

• Thomas F. Babor, Ph.D., MPH
• University of Connecticut
• School of Medicine
• Farmington, CT USA

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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.

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The Alcohol Public Policy Group

• Co-authors Academic Affiliations
• Thomas Babor University of Connecticut (USA)
• Raul Caetano University of Texas (USA)
• Sally Casswell Massey University (New Zealand)
• Griffith Edwards National Addiction
  Centre (United Kingdom)
• Norman Giesbrecht University of Toronto (Canada)
  
• Kathryn Graham Centre for Addiction and Mental
  Health (Canada)
• Joel Grube University of California (USA)
• Paul Gruenewald University of California (USA)
• Linda Hill University of Auckland (New Zealand)
• Harold Holder University of California (USA)
• Ross Homel Griffith University (Australia)
• Esa Österberg Institute for Social Research
  (Finland)
• Jürgen Rehm University of Toronto (Canada)
• Robin Room Stockholm University (Sweden)
• Ingeborg Rossow National Institute for Alcohol
  and Drug
• Research (Norway)

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Alcohol, No Ordinary CommodityResearch and
Public PolicyOxford 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 policy-related
  strategies and interventions
• New understandings of the policymaking process at
  the local, national and international levels

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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.

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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

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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 alcohols
  ability to cause medical, psychological, and
  social harm
• physical toxicity
• intoxication
• dependence

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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.

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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
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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 cardio-protective 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).

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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.

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Alcohol related injury

• Unintentional injury
• Motor vehicle accidents,
• drowning,
• falls,
• poisonings,
• other unintentional injuries
• Intentional injury
• Self-inflicted injuries,
• homicide,
• other intentional injuries

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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 persons
  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.

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Why alcohol is no ordinary commodity Relations
among alcohol consumption, mediating variables
and consequences
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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.

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Economic development status and alcohol
consumption (based on population weighted
averages of 182 countries)
Level of mortality and category of countries WHO regions Adult consump-tion in litre/year Percent Male Drinker Female Consump-tion per drinker in g/day pure alcohol Average pattern of drinking
Developing countries 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
Developed countries 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
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Patterns of drinking throughout the world
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ALCOHOL CONSUMPTION IN DIFFERENT WORLD REGIONS
population weighted averages 1 low level
of risk, 4 high level of risk associated with a
countrys predominant pattern of drinking
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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).
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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 alcohol-attributable disease burden.

(Murray Lopez, 1996 Ezzati et al., 2002).
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Leading risk factors as causes of disease burden
alcohol, drugs, tobacco
Developed countries
Developing countries
High Mortality
Low Mortality
1 Underweight Alcohol Tobacco 2
Unsafe sex Blood pressure Blood pressure 3
Unsafe water Tobacco Alcohol 4 Indoor
smoke Underweight Cholesterol 5 Zinc
deficiency Body mass index Body
mass index 6 Iron deficiency Cholesterol L
ow fruit veg. intake 7 Vitamin A
deficiency Low fruit veg intake Physical
inactivity 8 Blood pressure Indoor smoke -
solid fuels Illicit drugs 9 Tobacco Iron
deficiency Unsafe sex 10 Cholesterol Unsafe
water Iron deficiency 11 Alcohol Unsafe
sex Lead exposure 12 Low fruit veg intake
Lead exposure Childhood sexual abuse
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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.
• 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.
• 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.

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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)

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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.

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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).

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Alcohol, No Ordinary CommodityPart II
Effective Alcohol PoliciesA Consumers Guide
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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

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Ratings of 32 Policy-relevant Prevention
Strategies and Interventions

• Evidence of Effectiveness the quality of
  scientific information
• Breadth of Research Support quantity and
  consistency of the evidence
• Tested Across Cultures, e.,g. countries, regions,
  subgroups
• Cost to Implement and Sustain monetary and
  other costs
• aRating Scale 0, , , , (?)
• b Rating Scale Low, Moderate, High

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Assumptions Underlying Pricing and Taxation
Policy Options

• Policy
• High taxes, prices

• Assumption
• Reduce demand by increasing economic cost of
  alcohol relative to alternative commodities

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Taxation/Pricing Controls
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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)

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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

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Regulating Physical Availability
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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).

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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

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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

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Modifying the Drinking Context
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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.

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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

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Regulating Alcohol Promotion
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Regulating alcohol promotionIndustry
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.

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Assumptions Underlying Drink-driving Policy
Options

• Policy
• Drink-driving countermeasures

• Assumption
• Reduce drink driving though deterrence,
  punishment and social pressure

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Drinking-Driving Countermeasures
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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.

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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.

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Assumptions Underlying Education and Persuasion
Policy Options

• Policy
• Provide information to adults and young people
  especially through mass media and school-based
  alcohol education programs

• Assumption
• Health information increases knowledge, changes
  attitudes and prevents drinking problems

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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).

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Education and Persuasion
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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.

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Education and Persuasion StrategiesPublic
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
  pro-drinking messages that appear much more
  frequently as paid advertisements in the mass
  media.

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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

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Treatment and Early Intervention
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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

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Other Policies and Policy Issues

• Water rights
• Agriculture
• International trade
• The alcohol beverage industry

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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 65782-793.
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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

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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.
  

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Swimming With CrocodilesWHO 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.