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

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


1
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

2
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.

3
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)

4
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

5
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.

6
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

7
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

8
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.

9
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
10
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).

11
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.

12
Alcohol related injury
  • Unintentional injury
  • Motor vehicle accidents,
  • drowning,
  • falls,
  • poisonings,
  • other unintentional injuries
  • Intentional injury
  • Self-inflicted injuries,
  • homicide,
  • other intentional injuries

13
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.

14
Why alcohol is no ordinary commodity Relations
among alcohol consumption, mediating variables
and consequences
15
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.

16
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
17
Patterns of drinking throughout the world
18
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
19
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).
20
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).
21
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
22
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.

23
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)

24
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.

25
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
32
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

33
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

34
Assumptions Underlying Pricing and Taxation
Policy Options
  • Policy
  • High taxes, prices
  • Assumption
  • Reduce demand by increasing economic cost of
    alcohol relative to alternative commodities

35
Taxation/Pricing Controls
36
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)

37
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

38
Regulating Physical Availability
39
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).

40
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

41
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

42
Modifying the Drinking Context
43
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.

44
Stamp of Approval
406 A.M. WE GET PAST OUR SIXTH DOORMAN OF THE
EVENING
SEE WHERE IT TAKES YOU
45
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
48
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

51
Drinking-Driving Countermeasures
52
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.

53
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.

54
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

55
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).

56
Education and Persuasion
57
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.

58
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.

59
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

60
Treatment and Early Intervention
61
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

62
Other Policies and Policy Issues
  • Water rights
  • Agriculture
  • International trade
  • The alcohol beverage industry

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64
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.
65
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

66
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.

67
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.
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