Alcohol, harm to others and global governance of alcohol Peter Anderson MD, MPH, PhD Professor, Substance Use, Policy and Practice, Institute of Health and Society, Newcastle University, England Professor, Alcohol and Health, Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands Helsinki 12 June 2013

1.Consider harm done by alcohol to others than the drinker 2.Mention six reasons why we need global governance of alcohol 3.Discuss governance options

1.Consider harm done by alcohol to others than the drinker i.Disability adjusted life years ii.Estimates of personal violence iii.Social costs

Source: Rehm et al 2012

Low birth weight Violence Transport injuries Source: Rehm et al 2012

1.Consider harm done by alcohol to others than the drinker i.Disability adjusted life years ii.Estimates of personal violence iii.Social costs

In the European Union, it has been estimated that:  7% - 47% of all crimes  24% - 86% of all violent crimes  19% - 53% of all robberies  29% - 60% of all sex offences  16% - 71% of all domestic violence  40% of all homicides are due to alcohol. Source: Anderson & Baumberg 2006

1.Consider harm done by alcohol to others than the drinker i.Disability adjusted life years ii.Estimates of personal violence iii.Social costs

Costs of alcohol to Australian society (Billions of dollars) Source: Laslett et al 2010

Costs of alcohol to Australian society (Billions of dollars) Source: Laslett et al 2010

1.Consider harm done by alcohol to others than the drinker 2.Mention six reasons why we need global governance of alcohol 3.Discuss governance options

Six reasons for global governance of alcohol 1.Scope of global damage 2.Damage substantial over most of world 3.Damage transcends national borders 4.Countries cannot manage in isolation 5.No legally binding agreement 6.Ready for movement

This does not include all: 1.alcohol use disorders 2.alcohol-related infectious diseases 3.harm to people other than the drinker

Six reasons for global governance of alcohol 1.Scope of global damage 2.Damage substantial over most of world [Despite the fact that 3 out of 5 of the world’s adults do not currently drink alcohol] 3.Damage transcends national borders 4.Countries cannot manage in isolation 5.No legally binding agreement 6.Ready for movement

Six reasons for global governance of alcohol 1.Scope of global damage 2.Damage substantial over most of world 3.Damage transcends national borders 4.Countries cannot manage in isolation 5.No legally binding agreement 6.Ready for movement

Major illegal trade routes for alcohol as documented by alcohol industry

Major illegal trade routes for alcohol as documented by alcohol industry

Damage transcends national borders: It is not just the product and the damage that it carries that crosses borders, but all the forms of commercial communications, and, particularly, those through electronic and social media

Damage transcends national borders:

Six reasons for global governance of alcohol 1.Scope of global damage 2.Damage substantial over most of world 3.Damage transcends national borders 4.Countries cannot manage in isolation 5.No legally binding agreement 6.Ready for movement

Countries cannot manage in isolation: This is not just a matter of illegal trade or communication by digital media, but also a principle of comity between nations, in which countries should honour and support alcohol policies of other countries. 1.No legally binding agreement 2.Ready for movement

Thailand case study: On 21 January 2010, Thailand notified theWTO Committee on Technical Barriers to Trade (‘TBT Committee’) of its intention to introduce a new alcohol warning law (‘Thailand’s Notification’) under s 26(1) of its Alcohol Beverage Control Act.No legally binding agreement 1.Ready for movement

Thailand case study: 1.It prohibits any words on alcoholic beverage packages which would mislead the consumer into believing that (i) alcohol can improve health or (ii) one alcoholic beverage is less ‘toxic’ than another. 2.It requires that all alcohol beverage packages carry the words: ‘Sale of alcohol beverages to persons under 20 years old is prohibited...’. 3.It requires all alcoholic beverage packages (including bottles, cans, boxes or wrapping) to carry one of six graphic warnings of the harm that drinking alcohol can do.

Thailand case study: Argentina, Australia, Canada, Chile, Mexico, New Zealand, Switzerland, United States and European Union have repeatedly expressed concerns that Thailand’s warnings labels are inconsistent with the Agreement on Technical Barriers to Trade.

Thailand case study: The EU, Mexico and Chile have argued that it is not drinking per se, but excessive drinking that is the problem

Six reasons for global governance of alcohol 1.Scope of global damage 2.Damage substantial over most of world 3.Damage transcends national borders 4.Countries cannot manage in isolation 5.No legally binding agreement 6.Ready for movement

No legally binding agreement: This is not because alcohol is any different from or is a special substance compared with tobacco or the illicit drugs. It is simply because at a global level, it has not happened, yet. 1.Ready for movement

No legally binding agreement: The first four reasons that I have mentioned are the very same four reasons that are used to justify the framework convention on tobacco.Ready for movement

No legally binding agreement: In addition, a psychotropic substance, as is alcohol, may be scheduled under the 1971 drugs convention if a WHO Expert Committee finds: that the substance has the capacity to produce a state of dependence and impairs central nervous system functioning/ or produces similar abuse and ill effects as a substance already covered by the Convention

No legally binding agreement: and that there is sufficient evidence that the substance is likely to be abused so as to constitute public health and social problems warranting the placing of the substance under international control.

No legally binding agreement: By these criteria, it would be difficult for an expert committee not to recommend alcohol for scheduling under the convention.

Six reasons for global governance of alcohol 1.Scope of global damage 2.Damage substantial over most of world 3.Damage transcends national borders 4.Countries cannot manage in isolation 5.No legally binding agreement 6.Ready for movement

Ready for movement: 1.There is a growing backlash against the behaviour of the alcohol industry, who are fast positioning themselves as the next tobacco industry 2.Increasingly alcohol is recognized as a problem of the middle aged and middle class, our problem, and we all need help for it 3.Classified as a carcinogen by the International Agency for Research on Cancer, it is recognized that there is no safe level of alcohol consumption 4.Countries are getting more worried and more countries are asking for action.

1.Consider harm done by alcohol to others than the drinker 2.Mention six reasons why we need global governance of alcohol 3.Discuss governance options

Maintaining the status quo: 1.Does not facilitate the institutional, political, financial, or civil society support that have been mobilized in the context of the framework convention on tobacco control; 2.Does not provide the needed resources available to match the scale of the global damage; 3.Allows the alcohol industry space and time to normalize the use of alcohol.

Maintaining the status quo: 4.terminology of the global strategy [to reduce the harmful use of alcohol] can be counter intuitive and confusing to those countries whose policies aim to support non-drinkers to maintain their non-drinking behaviour. Harmful use implies non-harmful use, which does not exist - being a carcinogen, any dose, and even one molecule can cause cancer.

Schedule alcohol in the 1971 Convention on Narcotic Drugs: 1.Alcohol would need to be exempted from articles 5 and 9, which essentially state that use and possession of the substance is to be limited to medical and scientific purposes. 2.There may be substantial obstacles to reframing this particular wording that would counter the scheduling of alcohol within the 1971 Convention, but it is not impossible. 3.Calls from parts of the Americas to open discussions of the drug conventions may contribute to leaning in this direction.

Framework Convention on Alcohol Control:  Provides trade liberalization that is both sustainable in relation to alcohol and respectful of comity of nations.  Provides the needed global governance architecture, resources and institutional policy support to further policy development at the country level, particularly in low and middle income counties  Provides more freedom from the actions of vested interest groups.

Framework Convention on Alcohol Control:  Instead of routing from convention to protocol, as has been done with tobacco, one could route protocol to convention and start with a protocol on commercial communications.

In conclusion 1.The scope, extent and nature of the global damage done by alcohol, particularly harm to others, calls for effective global architecture. 2.A legally binding agreement provides the institutional arrangements that voluntary actions seem not to be able to do. 3.In this sense, a global legal protocol that curbs commercial communications could be a new step forward.