The Need for Policy
The health, safety and socioeconomic problems attributable to alcohol can be effectively reduced through evidence-based policies and prevention programs.
WHO’s 2010 Global Strategy to Reduce the Harmful Use of Alcohol is a policy framework with 10 key areas of policy options and interventions. Further WHO instruments such as the Global Action Plan for the Prevention and Control of NCDs have reinforced them, yet implementation remains uneven and insufficient. Illustrative of the lack of action is that as of 2017, 48 countries still did not have national alcohol strategies or policies. [16]
A Public Health Approach to Alcohol Harms
The most effective strategies seek to change the social norms and environment that cultivate long-established harmful alcohol use habits. [17] Further, fiscal alcohol policies, such as a tax on alcohol, are cost-neutral or cost-saving, while individual interventions are expensive. [17]
In addition, it is important to make the case for broad-based strategies when the societal consequences of harmful alcohol use are widespread. [1] In an Australian survey, two-thirds of people reported that they had been adversely affected by another person’s alcohol use in the past year. A survey in Europe suggests that women suffer more from the alcohol consumption of those around them, than men do. [17]
Prioritizing Policy: WHO Best Buys and Recommended Interventions
The WHO “Best Buys” for NCDs represent the most effective, evidence-based policy actions for controlling alcohol use globally, with an emphasis on which of them are most viable and cost-effective to enact. There is strong evidence that these policies reduce the harmful use of alcohol, prevent disease and save lives across populations— ultimately reducing the health and social burden of alcohol on society. [1, 16]
The three WHO Best Buys for reducing the harmful use of alcohol:
1. Increase excise taxes on alcoholic beverages;
2. Enact and enforce restrictions on the physical availability of retailed alcohol; and
3. Comprehensively restrict exposure to alcohol advertising.
Further effective evidence-based recommendations include:
4. Drink-driving laws and blood alcohol concentration limits, and
5. Providing brief psychosocial interventions
Taxes on Alcoholic Beverages
Fiscal policies, especially taxation but also including minimum pricing, can result in reduced consumption of alcohol.
Alcohol taxes can improve population health and have the potential to reduce deaths and the economic cost to society, as well as to increase productivity. [17] All consumer types, from occasional to heavy users, and even those with alcohol use disorders, respond to changes in alcohol prices. [63] As with taxes applied to other unhealthy products, another advantage of taxation is that it can raise much-needed revenue for governments.
Evidence
Studies show that tax increases influence purchase and consumption patterns across age groups and populations, delaying initiation of alcohol use, reducing consumption and harm, and raising revenue.[64] Alcohol taxes have been shown to reduce liver disease mortality among the heaviest users, while also reducing alcohol-related traffic deaths among youth.[15] In Chile, an increase in alcohol taxes reduced use overall, including among adolescents, while raising resources for the government. Minimum pricing policies in both high and lower-income countries reduce consumption and alcohol-related harms.[64]
Increasing the price of alcohol has not only been shown to reduce alcohol harms. The positive results are also quantifiable—for example, a 10 percent increase in the average minimum price of all alcoholic beverages was associated with a 32 percent reduction in alcohol-attributable deaths in British Columbia, Canada. [17, 65-67].
Challenges
Where alcohol excise taxes are in place, they are generally set as revenue generators only, too low to affect consumption. Moreover, they often fail to keep up with inflation, thereby allowing alcohol to become more affordable over time.
As with tobacco taxes, governments are often reluctant to increase alcohol prices and taxes, citing concerns about increased smuggling or the substitution of illicit alcohol. These concerns are often used by the alcohol industry—just as they are by the tobacco industry.[68] Countermeasures and provisions to reduce smuggling and the use of illicit alcohol must be part of any plan to increase taxes. Increased law enforcement, prosecution, strong penalties and harmonized tax increases across regions can be effective.[15, 17] Smuggling and illicit alcohol production need to be addressed, but neither should be allowed to derail tax increases. Moreover, tax revenue should be used to counter tax avoidance and illicit alcohol, as well as to support public health initiatives that mitigate alcohol-related harm.
Restricting Alcohol’s Availability
Enacting and enforcing regulations on the availability of retail alcohol has been shown to reduce alcohol-related harms and injuries.
This includes setting rules on who can sell alcohol, who can buy it, the days and times it can be sold, and the locations and density of outlets where alcohol is available.
Evidence
Numerous research studies from many countries have shown links between the number of outlets allowed to sell alcohol and the number of hours they are open, on the one hand, and incidents of violence, alcohol-related traffic injuries, self-reported injuries and suicide, sexually transmitted infections and child abuse, on the other. [20]
In Germany, studies found that regulating the hours alcohol is sold has the potential to prevent 54,000 injuries a year. [17]
In the United States, states that increased the legal alcohol consumption age to 21 saw a 16 percent median decline in motor vehicle crashes. [18]
In Brazil, closing bars at 11 p.m., rather than permitting them to remain open for 24 hours, led to a 44 percent drop in homicides. [69]
Challenges
While research demonstrates the effectiveness of regulating access to alcohol, trends indicate that alcohol consumption is expanding in precisely those countries that lack the regulatory and enforcement capacities to restrict harmful use.[1]
Informal alcohol production is a major source of consumption in Africa and among low-income countries globally. Moreover, such unregulated production, while generating income for poor populations, risks generating products with toxic adulterants and often contributes to substantial occupational health risks and environmental contamination. Efforts to regulate informal production and sales need to be implemented carefully so as not to be influenced by the interests of the corporatized alcohol industry.
Bans and Restrictions on Alcohol Advertising
Alcohol advertising, sponsorship and promotion increases the likelihood of use and the amount of alcohol consumed.
Marketing restrictions must be comprehensive and up to date to protect young people. Bans and restrictions should include not only traditional media such as TV, print and billboards, but also cultural, sporting and promotional events, internet sites, social media, apps, cinemas, points of sale and product placement.
Evidence
Exposure to alcohol advertisements increases the likelihood that young people who do not use alcohol will begin to do so and increases the volume, frequency and risky alcohol use among young people who already consume alcohol.[1, 20] For heavy users and those with alcohol dependency, advertisements also increase cravings or the urge to consume alcohol. [17, 63]
Challenges
The alcohol industry markets and advertises alcohol through a broad range of channels, many of which are completely unregulated.
Additional Recommended Interventions
4. Drink-Driving Laws and Blood Alcohol Concentration Limits
Drink-driving laws and blood alcohol concentration limits can contribute to alleviating the burden of alcohol-related harms by reducing driving under the influence (DUI), when effectively implemented and enforced. Not only do blood alcohol limits prevent and reduce DUI incidences and significantly reduce the risk of road traffic crashes, but they also lower overall alcohol use. [70]
5. Brief Psychosocial Interventions
Brief psychosocial interventions, screenings and treatment for people with alcohol use disorders can produce clinically significant reductions in alcohol use and alcohol-related harm at both individual and population levels. [71] The U.S. Centers for Disease Control and Prevention reports that screening and brief interventions can reduce the amount of alcohol consumed on an occasion by 25 percent among people who consume harmful or hazardous amounts of alcohol. Nevertheless, a vast treatment gap exists. Only one in six adults in the United States have had conversations about their alcohol use with their doctor, nurse or other health professional. [72]
Comprehensive Policies:
Greater Than the Sum of its Parts
Implementation of the WHO Best Buys is an underutilized opportunity to reduce alcohol use and harm
Key prevention policies have the best chance of being effective when they are implemented in a systematic and complementary way, as part of a coherent strategy. Policies designed to be part of a long-term reduction plan can also contribute to changing the environment and social norms around alcohol. [15, 17]
In a 2015 report, the Organisation for Economic Co-operation and Development (OECD), noted that strategies combining multiple alcohol policies multiply/reinforce the impact of each intervention. OECD models also found that packages of fiscal, regulatory and health care interventions had the potential to reduce alcohol-related disability by up to 10 percent. [17]
There may also be an important role for population-wide media campaigns. They have been a critical measure for reducing the prevalence of harmful behaviors in tobacco control, and are recognized as such by WHO, but they have not been shown to be effective for alcohol.
Recent studies comparing the outcomes of communication campaigns that target risky health behaviors around alcohol found that there are clear explanations for this discrepancy as well as viable solutions for increasing future efficacy. [73, 74] Among the reasons cited by experts for the difference:
Inadequate reach, frequency and duration of media campaigns concerning alcohol harms;
A failure to integrate mass media campaigns with alcohol policy initiatives; and
Immense alcohol industry budgets with sophisticated marketing and advertising campaigns that dwarf public health’s alcohol harm messaging.
Researchers surmise that media campaigns that address these impediments have the potential to reach the same level of success experienced in tobacco control.
The economic case for investing in a comprehensive set of alcohol policies is strong too, particularly in low- and middle-income countries. For every U.S. dollar invested in reducing harmful use of alcohol through the most cost-effective alcohol policies, the return on investment is more than ninefold. [1]
Unfortunately, implementation of Best Buy measures around the world is insufficient and highly uneven, and progress on reducing alcohol use and harm will not be achieved without significant global and national commitment, investment and coordinated regulatory action.
Country Guidance on Alcohol
There is a need for clarity on the most important interventions and implementation strategies to reduce alcohol-related harm and WHO, as the primary norm-setting health agency, should lead this initiative. Using the Best Buys as the basis, a resource on the most effective, high-impact interventions in a clear, concise document would benefit countries and advocates.