1 Alcohol, No Ordinary Commodity: Research and Public Policy Sponsored by: The World Health Organization and The Society for the Study of Addiction (UK)
2 The Alcohol Public Policy Group Co-authors 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 Academic Affiliations 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)
3 ALCOHOL IS A COMMODITY Alcoholic beverages are an important, economically embedded commodity The production and sale of alcoholic beverages generates: profits for farmers, manufacturers, advertisers, and investors employment for people in bars and restaurants tax revenues for the government.
4 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
5 Why alcohol is no ordinary commodity: Relations among alcohol consumption, mediating variables and consequences Patterns of drinking Average volume Toxic effects* Intoxication Dependence Chronic Disease Accidents/Injuries (acute disease) Acute Social Problems Chronic Social Problems
6 Alcohol-related global burden of disease Alcohol-attributable mortality 0.35 to to to to to 20.00
7 Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS) High mortality Developing countries Low mortality Developed countries Underweight 14.9% Alcohol 6.2 % Tobacco 12.2 % Unsafe sex 10.2 % Blood pressure 5.0 % Blood pressure 10.9 % Unsafe water & sanitation Indoor smoke (solid fuels) 5.5 % Tobacco 4.0 % Alcohol 9.2 % 3.6 % Underweight 3.1 % Cholesterol 7.6 % Zinc deficiency 3.2 % Body mass index 2.7 % Body mass index 7.4 % Iron deficiency 3.1 % Cholesterol 2.1 % Low fruit & vegetable intake 3.9 % Vitamin A deficiency 3.0 % Low fruit & vegetable intake 1.9 % Physical inactivity 3.3 % Blood pressure 2.5 % Indoor smoke from solid fuels 1.9 % Illicit drugs 1.8 % Tobacco 2.0 % Iron deficiency 1.8 % Unsafe sex 0.8 % Cholesterol 1.9 % Unsafe water & sanitation 1.8 % Iron deficiency 0.7 %
8 THE INTERNATIONAL CONTEXT OF ALCOHOL POLICY National and local alcohol policies have increasingly come under pressure at the international level. There has been a gradual decline in alcohol control in most jurisdictions in recent decades, with changes such as privatization of alcohol retail sales. Alcohol taxes have not been raised to match inflation. The collapse of the communist system in the former Soviet Union and Eastern Europe has meant that the control of alcohol availability has lost much of its effect in these countries. In many countries, general alcohol policies affecting the whole population have been weakened or dismantled, often under pressure from international trade organizations and the alcohol industry.
9 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
10 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 a Rating Scale: 0, +, ++, +++, (?) b Rating Scale: Low, Moderate, High
11 Assumptions Underlying Pricing and Taxation Policy Options Policy Assumption High taxes, prices Reduce demand by increasing economic cost of alcohol relative to alternative commodities
12 Taxation Strategy or Intervention Effectiveness Research Support X- Cultural Testing Cost Alcohol Taxes Low
13 Pricing and Taxation Evidence suggests that: People increase their drinking when prices are lowered, and decrease their consumption when prices rise. Heavy or 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.
14 Assumptions Underlying Restrictions on Alcohol Availability Policy Assumption Restrictions on time, place, and density of alcohol outlets Reduce demand by restricting physical availability increase effort to obtain alcohol
15 Regulating Physical Availability Strategy or Effectiveness Research X- Cultural Cost Intervention Support Testing Total ban on sales High Minimum legal Low purchase age Rationing High Government Low monopoly of retail sales Hours and days of Low sale restrictions Restrictions on Low density of outlets Server liability Low Different availability by alcohol strength Low
16 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., home production, illegal imports).
17 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
18 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 Research Support X- Cultural Testing Cost Moderate Moderate O + + Low High High
19 Assumptions Underlying Drinkdriving Policy Options Policy Assumption Drink-driving countermeasures Reduce drink driving though deterrence, punishment and social pressure
20 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 X- Cultural Testing Cost Moderate Moderate Low Moderate Low Low O + + Moderate
21 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. The persistent delinquency of some impaired drivers should not detract from the enormous achievements of recent decades.
22 Assumptions Underlying Education and Persuasion Policy Options Policy Assumption Provide information to adults and young people especially through mass media and school-based alcohol education programs Health information increases knowledge, changes attitudes and prevents drinking problems
23 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).
24 Education and Persuasion Strategy or Intervention Alcohol education in schools College student education Public service messages Warning labels Effectiveness Research Support X- Cultural Testing Cost O High O + + High O Moderate O + + Low
25 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 two show significant lasting effects (after 3 years), and the significance of these is questionable when reanalyzed (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.
26 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.
27 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
28 Regulating Alcohol Promotion Strategy or Intervention Advertising bans Advertising content controls Effectiveness Research Support X- Cultural Testing Cost Low? O O Moderate
29 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.
30 Assumptions Underlying Treatment and Early Intervrention Policy Assumption Increase availability of treatment programs Conduct screening and brief intervention in health care settings Problem drinking is responsive to various therapeutic interventions Heavy drinkers can be motivated to drink moderately before they acquire alcohol dependence
31 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 X- Cultural Testing Cost Moderate High Low Moderate
32 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
33 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 specific drinking patterns and per capita consumption. Alcohol problems can be minimized or prevented using a coordinated, systematic policy response.
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