Module 14- Summary and Conclusions Part One- Alcohol Policy and Public Health It is clear that evidence-based policies are capable of reducing the burden of disease and disability associated with alcohol consumption. What is lacking is a convincing and coherent rationale to guide the policymaking process and the resources to implement and sustain it. Given the low to moderate cost of many of the policies reviewed in the previous modules, it now seems possible for communities and nation states to substantially reduce the alcohol-related burden of illness. This module provides a summary of the policy issues that have been reviewed in the previous modules, and provides discussion questions and planning exercises for further work. A series of test questions are appended at the end to test knowledge. Module 14- Summary and Conclusions Pan American Health Organization

Learning Objectives Upon completion of this module you will be able to: Summarize the most effective policies to reduce alcohol related harms Describe cost-effectiveness of combining policies Summarize policies to tackle unrecorded consumption Discuss what to do when there is insufficient evidence Upon completion of this module you will be able to summarize the most effective policies to reduce alcohol related harms, describe the cost-effectiveness of combining policies, summarize policies to tackle unrecorded consumption and discuss what to do when there is insufficient evidence for Pan American Health Organization

Best Practices and their Relative Costs Lower Cost Higher Cost Minimum legal purchase age Government monopoly on alcohol Restriction on hours or days of sale, outlet density Alcohol taxes Lower alcohol strength Random Breath Testing Lowered BAC limits Administrative license suspension Graduated licensing for novice drivers Brief interventions for hazardous drinkers Treatment and detox This table lists 10 “best practices” that represent the most effective, evidence-based policy approaches to reduce alcohol-related harm. Many of the interventions are universal measures that restrict the affordability, availability, and accessibility of alcohol. Alcohol taxes and restrictions limiting the opening hours, locations, and density of alcohol outlets have a considerable amount of research support. The enforcement of a minimum purchase age for alcohol is another very effective strategy. Given their broad reach, the expected impact of these measures on public health is relatively high, especially when the informal market and illegal alcohol production can be controlled. Many drink-driving countermeasures received high ratings as well, especially those that increase the likelihood of apprehension, and are part of a core alcohol policy mix. Alcohol treatment services have good evidence of effectiveness, but they can be expensive to implement and maintain, with the exception of mutual help organizations. At the population level, their impact is limited relative to other policy options, since full treatment for alcohol problems can only benefit those individuals who come to treatment. Nevertheless, these programs have the potential to impact the heaviest drinkers in a society, and could lower population levels of alcohol consumption and harm if they could be widely disseminated. Although the evidence is limited by the relative lack of research, it is likely that a total ban on the full range of marketing practices could affect drinking by young people, particularly if diversion of the promotional spending to other channels were blocked. There is no evidence that the alcohol industry’s favored alternative to marketing restrictions -- voluntary self-regulation -- protects vulnerable populations from exposure to alcohol advertising and other marketing practices. The amount of evidence on the effects of altering the drinking context has been growing, and we now think that strategies in this area can have modest effects. The fact that these strategies are primarily applicable to on-premises drinking in bars and restaurants somewhat limits their public health significance, as a high proportion of alcohol is purchased more cheaply for consumption elsewhere. Many of these policies are relatively inexpensive to implement and sustain, and even the more expensive policies may be cost-effective because they save more money than they cost in terms of health care expenses and social costs. Pan American Health Organization

Summary: What have we learned about how alcohol policies work at the population level? GOAL POLICY Limit economic availability Alcohol taxes, price controls Limit physical availability  State monopolies, age restrictions, controls on time, place, density Social availability constraints Restrictions on drinking context Deterrence and social pressure Drink driving measures, brief interventions, treatment Reduce psychological attractiveness Marketing restrictions What have we learned about how alcohol policies work at the population level? Although the “best practices” found by research to be effective policies have been evaluated as separate entities because they are linked to specific laws and regulations, at a more general level they all translate into one general concept: availability. For the individual drinker, alcohol taxes and price controls place limits on economic availability. State monopolies, age restrictions, and controls on time, place, and density are society’s way of limiting the physical availability of alcohol. Restrictions on the drinking context impose social availability constraints operate through drink driving measures, brief interventions, and treatment operate through social pressures to drink less, and like marketing restrictions, reduce the attractiveness of alcohol, or its psychological availability. What this theory tells us is that in the absence of specific research on a particular policy or intervention, the likelihood that it will be effective increases with its probable impact on the various kinds of alcohol availability. Pan American Health Organization

Cost-Effectiveness of 5 Policy Options in 3 WHO Regions AmrC AurB WprB A Cost per DALY saved (I$, 2005) H Brief interventions for heavy drinkers Drink-driving legislation and enforcement Reduced access to retail outlets Comprehensive advertising ban Increased excise taxation (by 20%) Increased excise taxation (by 50%) Tax enforcement (20% less unrecorded) Tax enforcement (50% less unrecorded) G B C E F D Based on an earlier analysis prepared for the World Health Organization, Anderson et al. (2009) used economic modelling procedures to estimate the cost and cost -effectiveness of seven of the interventions reviewed in Chapters 8 through 14: school-based education, brief interventions for heavy drinkers, mass media campaigns, enforcement of random breath-testing, reduced access to retail outlets, a comprehensive advertising ban, and four levels of tax pricing policies. Population-level costs to implement the interventions included legislation, enforcement, administration, training, and service provision (in the case of treatment). The health benefits of the interventions were expressed in disability-adjusted life-years (DALYs) saved, relative to a hypothetical situation of no alcohol control measures in the population. In addition, non-health effects of the measures, such as reduced property damage and increased work productivity, were added to the model. The findings, presented in this table, are provided for three regions defined by the World Health Organization: the Americas (e.g., Brazil and Mexico), Eastern Europe (e.g., Russia, Ukraine), and the Western Pacific (e.g., China and Vietnam). The following points summarize the findings: 1) two strategies (school-based education and mass-media awareness campaigns) were found not to be cost-effective because they do not affect alcohol consumption or health outcomes; 2) population-level alcohol policies (e.g., pricing and availability policies) are more cost effective than individual-level policies, such as brief interventions for hazardous alcohol use; 3) tax increases represent a highly cost-effective response in regions with a high prevalence of heavy drinking, such as Latin America and Eastern Europe; 4) in countries with high levels of unrecorded production and consumption, increasing the proportion of consumption that is taxed could be more effective than a simple increase in excise taxes; and 5) the impact of reducing access to retail outlets for specified periods of the week and implementing a comprehensive advertising ban have the potential to be cost-effective countermeasures, but only if they are fully enforced. Pan American Health Organization Source: Anderson, Chisholm, Fuhr (Lancet, 2009)

What Works in Mexico? Cost-effective policies: Increase taxes Incremental cost-effectiveness Average cost-effectiveness Cost-effective policies: Increase taxes Reduce availability Ban advertising/ marketing Brief interventions in PHC Random Breath Testing A B C D A. 50% Tax increase alone B. Combination 1: Tax increase + Regulate advertising C. Combination 2: Tax increase + Regulate advertising + Regulate Access + Brief intervention D. Combination 3: Tax increase + Regulate Advertising + Brief Intervention + Regulate Access + Random Breath Testing This study evaluates the most cost-effective interventions developed in Mexico. When implemented alone, increasing taxes proved to be the most cost-effective intervention. The rest (reducing availability, banning advertising, brief interventions, random breath testing, etc.) are more expensive to implement and therefore less cost-effective. Pan American Health Organization

Summary Alcohol problems can be minimized or prevented using a coordinated, systematic policy response. Alcohol policies that limit access to alcoholic beverages, discourage driving under the influence of alcohol, reduce the legal purchasing age for alcoholic beverages, limit marketing exposure and increase the price of alcohol, are likely to reduce the harm linked to drinking. Based on the evidence reviewed in this course, the following conclusions can be drawn: Alcohol problems can be minimized or prevented using a coordinated, systematic policy response. Alcohol policies that limit access to alcoholic beverages, discourage driving under the influence of alcohol, reduce the legal purchasing age for alcoholic beverages, limit marketing exposure and increase the price of alcohol, are likely to reduce the harm linked to drinking. Pan American Health Organization

Summary, cont. In most UN Member States, taxation offers the most cost-effective strategy, but there are exceptions owing to illicit production. The known effective interventions produce a favorable health return for cost incurred in policy implementation. Policy-relevant research is a priority, especially in low- and middle-income countries. In most UN Member States, taxation offers the most cost-effective strategy, but there are exceptions owing to illicit production. The known effective interventions produce a favorable health return for cost incurred in policy implementation. Policy-relevant research is a priority, especially in low- and middle-income countries. Pan American Health Organization

What can be done when there is insufficient evidence? Use theory to guide policy Use the Precautionary Principle: The introduction of new alcohol products, 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 Policy changes should be made with caution and with a sense of experimentation to determine whether they have their intended effects. Some policies have not been investigated systematically, and most policies have only been studied in a few countries. There is therefore a need to strengthen the links between science and policy so that promising research findings are identified, synthesized and effectively communicated to the policymakers and the public. Even in the absence of research, meaningful action can still be taken. First, sound theory can be used as a guide to action, as has been suggested in our review of availability theory. Second, the “precautionary principle” can be applied. The ‘precautionary principle’ is a general public health concept that suggests how to take preventive action even in the face of uncertainty, by shifting the burden of proof to the proponents of a potentially harmful activity, by offering alternatives to harmful actions, and by increasing public involvement in decision-making. When applied to alcohol policy, the precautionary principle implies that decision-making in areas like international trade agreements, the introduction of new alcohol products (high alcohol content malt beverages, for instance), removal of restrictions on hours of sale and the promotion of alcohol through advertising should be guided by the likelihood of risk, rather than the potential for profit. The application of the precautionary principle to alcohol policy will help to increase both public participation in the policymaking process and the transparency of decision-making, currently guided too often by the economic considerations of the few rather than the public health concerns of the many. Pan American Health Organization

We can use the science we have. Pan American Health Organization

“ We need to go beyond the traditional associations implied in the Hippocratic Oath: from doing no harm by errors of commission to avoiding harm by errors of omission. ” William Foege, Senior Fellow, BMG Foundation Given all the evidence from thousands of studies from around the world, it is important to select interventions based on what is known first, and innovate based on the science that already exists. As William Foege said in a recent presentation: we need to go beyond the traditional associations implied in the Hippocratic Oath: from doing no harm by errors of commission to avoiding harm by errors of omission- that is to say, not using the science we have available to us to prevent harm. conclusions Pan American Health Organization

REFLECTION Which policies you think should be prioritized in your country? Why? Pan American Health Organization