1. Alcohol: No Ordinary Commodity Part 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-authorsAcademic Affiliations Thomas BaborUniversity of Connecticut (USA) Raul CaetanoUniversity of Texas (USA) Sally Casswell Massey University (New Zealand) Griffith Edwards National Addiction Centre (United Kingdom) Norman Giesbrecht University of Toronto (Canada) Kathryn GrahamCentre for Addiction and Mental Health (Canada) Joel Grube University of California (USA) Paul Gruenewald University of California (USA) Linda HillUniversity of Auckland (New Zealand) Harold HolderUniversity of California (USA) Ross HomelGriffith University (Australia) Esa ÖsterbergInstitute for Social Research (Finland) Jürgen Rehm University of Toronto (Canada) Robin RoomStockholm University (Sweden) Ingeborg RossowNational Institute for Alcohol and Drug Research (Norway)

4. Alcohol, No Ordinary Commodity: Research and Public Policy Oxford 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: 1)physical toxicity 2)intoxication 3)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 1.7192332.9 Very high or high mortality AFR-D AFR-E AMR-D 7.14732413.0 Low mortality AMR-B EMR-B SEAR-B WPR-B 5.76736252.5 Developed countries Very low mortality AMR-A EUR-A WPR-A 10.78165321.8 Low child and low or high adult mortality EUR-B EUR-C 11.77759373.5

17. Patterns of drinking throughout the world Patterns of drinking 1.00 to 2.00 2.00 to 2.50 2.50 to 3.00 3.00 to 4.00

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 Developed countriesDeveloping countries High Mortality Low Mortality = alcohol, drugs, tobacco 1 UnderweightAlcoholTobacco 2 Unsafe sexBlood pressure Blood pressure 3 Unsafe waterTobacco Alcohol 4 Indoor smokeUnderweightCholesterol 5 Zinc deficiencyBody mass index Body mass index 6 Iron deficiencyCholesterolLow fruit & veg. intake 7 Vitamin A deficiencyLow fruit & veg intake Physical inactivity 8 Blood pressureIndoor smoke - solid fuels Illicit drugs 9 TobaccoIron deficiency Unsafe sex 10 CholesterolUnsafe waterIron deficiency 11 AlcoholUnsafe sexLead exposure 12 Low fruit & veg intake Lead exposureChildhood 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. 1)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. 2)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).

31. Alcohol, No Ordinary Commodity: Part II Effective Alcohol Policies: A 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 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

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 4:06 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

47. Regulating Alcohol Promotion

48. 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.

50. 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 Strategies Public 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

64. 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 65:782-793. Cost Effectiveness of 5 Effective Policy Options in 5 WHO Regions

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 Crocodiles WHO 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.