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The International Center for Alcohol Policies:

a public health body or a marketing arm of the beverage alcohol industry?

Around the world, the beverage alcohol industry, in its determination to avoid the fate of the tobacco industry, is making strenuous efforts to influence public opinion and government policy on alcohol issues. It promotes 'social aspect groups' which purport to address the problems of alcohol abuse. Here, Peter Anderson and Derek Rutherford critically examine the work of the two main international groups: ICAP based in Washington DC and the Amsterdam Group in Europe

Alcohol Policy and the harm done by alcohol

According to its analysis of the global burden of disease the World Health Organization estimates that, worldwide, alcohol related deaths and disability account for greater costs to life and longevity than those caused by tobacco1. The aim of alcohol policy should be to reduce this harm and alcohol policy options must be judged in the light of their impact on harm.

An overall strategy for policy on alcohol, an addictive substance, is to create an environment that helps people to make healthy choices and renders unhealthy choices more difficult or expensive2. Alcohol policy must take into account the total drinking population, in order to define the scope of public health action. Alcohol policy should not be limited to "alcoholism", the alcohol addict, or extreme physical illness, but should take into account both alcohol-related problems and alcohol dependence.

It should give attention to acute and accident problems, as well as to long-term problems. It should deal with social and psychological problems, as well as physical ones. It should tackle small and common problems, as well as major and less common consequences. Policy must be concerned with the adverse impact of drinking on the family and on other people, as well as on the drinker. Alcohol policy needs to take into account both a population's general level of drinking and its patterns of drinking. Per capita alcohol consumption affects the prevalence of drinking problems. Further, alcohol consumption levels are not set. They fluctuate and respond to changes in such factors as market controls, political liberalization, production, buying power, urbanization, migration, real price, and marketing and trade.

The International Center for Alcohol Policies

Searching the Internet for alcohol policy returns the International Center for Alcohol Policies (ICAP) http://www.icap.org . The mission of ICAP, which is funded by the international beverage alcohol industry, is:

  • To help reduce the abuse of alcohol worldwide and promote understanding of the role of alcohol in society.

  • To encourage dialogue and pursue partnerships involving the beverage alcohol industry, the public health community and others interested in alcohol policy".

ICAP's President is Marcus Grant, who was previously responsible for global activities for the prevention of substance abuse, including alcohol, with the World Health Organization (WHO), where he worked for 10 years. In his own words, Grant, who regards himself as a public health advocate, has " seen again and again how much common ground exists between governments, industry and scientists and how willing those of good faith are to come together and explore that common ground in working partnerships".

The Philosophy of ICAP

ICAP's philosophy statement is as follows:

"As a basis for open dialogue with the scientific and public health communities, and as a contribution to meaningful discourse concerning beverage alcohol's role in society, the companies sponsoring the International Center for Alcohol Policies believe:

  1. The vast majority of people who consume beverage alcohol do so responsibly and in order to enhance the quality of their lives.

  2. When consumed moderately and in a responsible manner by those with good health and dietary habits and who have no medical reason to refrain from drinking, beverage alcohol is associated with very few risks of harm and has been reported to have some beneficial effects on health.

  3. Irresponsible consumption of beverage alcohol is associated with a variety of risks both to the individual and to the public in health, social, economic, and safety contexts. Irresponsible consumption refers to high levels of intake, either on single occasions or repeatedly, or to drinking in inappropriate circumstances or by those who should not be drinking at all.

  4. Alcohol policies need to be based upon an objective understanding of available research on alcohol use and abuse; and should aim to create a reasonable balance of government regulation, industry self-regulation and individual responsibility."

Is ICAP really interested in public health, or is it really a marketing arm of the beverage alcohol industry? In a recent editorial, McCreanor and colleagues argued that ICAP's role is the promotion of an industry-favourable alcohol ideology3. In this paper, I would like to go further and consider whether or not an additional purpose of ICAP is to mobilise science to provide the information the beverage alcohol industry needs to market its products. One way of addressing this question is to read ICAP's website and its main publications. ICAP has four priorities in its work, each of which will be discussed in turn.

Forge a More Integrated Approach to Alcohol Policy

ICAP aims to

"develop a more integrated approach (to alcohol policy) that reassesses current theories with a primary focus on the differences between positive and negative patterns of drinking".

Through its publications and statements, ICAP attempts to establish the concept of drinking patterns as a basis for alcohol policy and to promote elements of alcohol policy, which, according to the evidence base, are largely ineffective.

Drinking patterns and their consequences4 is a publication that attempts to make drinking patterns the basis for alcohol policy. It is unbalanced in its review of the literature and at times lacks comprehensiveness and authority in its analysis. It concludes that policy makers should shift their focus to eliminating negative drinking patterns by targeted strategies and to promoting beneficial patterns of drinking. Through its focus in attempting to discredit the single distribution model of alcohol consumption, the publication fails to review and analyse the extensive literature on the relationship between per capita alcohol consumption and alcohol related harm. There is no doubt that patterns of alcohol consumption are important for alcohol-related harm, but so are societal levels of alcohol consumption. A very good example of this is the post-war experience of alcohol and mortality in the countries of the European Union5. In Sweden, for example, there is a very clear and strong relationship between alcohol consumption and alcohol related mortality (see figure).

 

 

Pooling the experience of a number of different European countries, time series analysis shows that there is a significant positive relationship between change in alcohol consumption and change in both overall and alcohol related death for each age segment of the population. The relationship is stronger in northern Europe than in southern Europe. For example, an extra litre of alcohol per person would result in a 12.4 per cent increase in homicides in northern Europe, but only a 5.5 per cent increase in southern Europe. However, since consumption levels are generally higher in southern Europe, the actual number of deaths attributable to alcohol is roughly equal in the northern and southern regions.5

ICAP's response to a more integrated approach to alcohol policy is to promote those policy options generally regarded as ineffective. This approach is evident in the first of ICAP's two main policy guidelines, the 1997 Dublin Principles of Co-operation Among the Beverage Alcohol Industry, Governments, and Scientific Researchers. The Dublin Principles cover both alcohol and society and alcohol research. Principle C of alcohol and society states that:

"Consumption of alcohol is associated with a variety of beneficial and adverse health and social consequences, both to the individual and to society. Governments, intergovernmental organizations, the public health community, and members of the beverage alcohol industry, individually and in co-operation with others, should take appropriate measures to combat irresponsible drinking and inducements to such drinking. These measures could include research, education, and support of programs addressing alcohol-related problems."

It is difficult to see how education, which most evidence has shown to be ineffective, particularly when implemented independently of other policy measures2, is going to reduce the harm done by alcohol. It is not clear what programmes ICAP would like to implement to reduce alcohol-related problems. Reading other ICAP publications and documents suggests that they would not include evidence based measures, such as those that deal with price or availability that have been shown to reduce harm2.

In forging a more integrated approach to alcohol policy, ICAP aims to reframe the alcohol policy debate away from the point of view that alcohol consumption matters, to the point of view that it is irresponsible drinking that matters. ICAP aims to lead science and policy away from preventive measures and effective environmental strategies and towards an increasing focus on the choices of the individual drinker, ineffective or marginal interventions, and beneficial consumption of alcohol. The process neglects to mention the addictive properties of the substance, the lack of knowledge about harm amongst consumers, a welfare analysis of alcohol use and the economic rationale for government intervention in the alcohol market.

The ICAP approach to alcohol policy is selectively to review the evidence for effective policy in its own interests. For a more integrated approach to alcohol policy, read more sales for the alcohol industry. Drinking patterns and their consequences can be read as giving the industry good advice on how to increase the volume of alcohol consumed, and thus marketed, by trying to change the policy debate in the direction that minimises the adverse risks to the industry.

Find a Common Language

ICAP has

"set in motion a process of finding a less emotional and value-laden way of communicating as a basis for a more effective partnership".

This simply means trying to introduce a common language into alcohol policy and research that serves the beverage alcohol industry's interests.

ICAP's second policy statement, The Geneva Partnership on Alcohol – Towards a Global Charter, published in 2000, is

"intended as a policy tool to assist in alcohol policy development at the international, national and local level".

The Geneva Partnership on alcohol emphasizes the need to bring people together to forge the common language.

Its preamble states:

"There is a growing recognition of the importance of establishing stronger relations between the public and private sectors at the international level. In this context, ICAP has taken the initiative to develop an agenda for partnership as a contribution to the global debate on alcohol policy. This document breaks new ground by identifying and promoting the complementary interests of the public health and scientific communities, the beverage alcohol industry, governments and the non-governmental sector. It builds upon the Dublin Principles and acknowledges the efforts of international organizations to develop alcohol policy. In its preparation, which has involved an extensive process of consultation, including regional and global meetings, input has been sought from a wide range of people involved in alcohol policy development, with the objective of formulating general principles mutually acceptable to all parties."

The common language the beverage alcohol industry would like to promote is pleasure, the theme of one of its conferences and its proceedings, published as Alcohol and Pleasure, a Health Perspective6. Alcohol and Pleasure was also about partnership building. In its conclusion, Grant says:

"It is through partnerships that it will be possible to build upon the success of the conference and to take forward the remarkably broad range of ideas covered by this volume."

Alcohol and Pleasure is about establishing ICAP's brand, credibility, and policy influence. This credibility is about giving the beverage alcohol industry good advice on the role of pleasure in alcohol consumption and how this can best be used for marketing its products.

Balance Interests for Developing Countries and Emerging Markets

According to ICAP:

"Emerging markets, especially in developing countries, provide an opportunity for the industry to work with the public health community to set new standards for abuse prevention and responsible marketing. Although the social environment may vary enormously from country to country, ICAP identifies common factors that can be used pro-actively around the world".

Some of the ways that ICAP balances the interests in new markets are through dialogues and country projects. As an example of dialogue, "ICAP convened a meeting among public health officials from developing countries and alcohol beverage company representatives active in emerging markets in 1999. The purpose of the meeting was to discuss ways in which meaningful partnerships concerning alcohol issues could be developed between industry, government and the public health sector in the developing world."

As an example of a country project, "ICAP is working with public health specialists in India to develop ongoing consultation on national alcohol policy issues of mutual concern. It worked with the local social aspects organization, SASPI (Society for Alcohol and Social Policy Initiatives), to begin a dialogue with government, public health, and the alcohol beverage industry to agree on an alcohol policy agenda for India. These discussions were based on the Asia-Pacific Regional Draft Charter on Alcohol, which in turn informed discussions of the Geneva Partnership on Alcohol: Towards a Global Charter."

Balancing interests for developing countries and emerging markets means opening up and expanding markets in new areas of the world that traditionally have had a low level of alcohol consumption or have been previously closed to the international beverage alcohol industry. Little mention is made of the devastation that alcohol can do to the economies of already impoverished individuals, families, and communities.

In 1998, ICAP published Alcohol and Emerging Markets: Patterns, Problems, and Responses7. This is a descriptive review of existing patterns, problems, and responses of alcohol consumption and alcohol-related harm in sub-Saharan Africa, Asia, Eastern Europe, and South America. Only two policy approaches are specified: responsible promotional and advertising practices and alcohol education and initiatives which promote sensible drinking. Effective environmental strategies are not adequately addressed. Alcohol and Emerging Markets serves the interests of the international beverage alcohol industry in the development and promotion of its products in countries with emerging and accessible markets.

As Jernigan and Mosher8 have written:

"Research scientists in the developed world have an ethical responsibility not to profit from or contribute to the alcohol industry's drive for new lucrative markets in countries which lack the infrastructure, resources and experience to respond effectively to the industry's slick sales pitch."

Promote Responsible Lifestyles

ICAP works

"with industry and public health partners to promote responsible lifestyles in industrialised and developing countries".

It notes that

"the concept of responsibility differs widely depending on a range of cultural factors. As consumption patterns change – especially in countries where drinking is not necessarily a traditional part of the culture – it is important to constantly redefine responsibility in culturally sensitive ways."

For the international beverage alcohol industry, promoting responsible lifestyles means promoting drinking in young people and in countries where drinking is not necessarily a traditional part of the culture.

Learning about Drinking9 attempts to be a review of how young people acquire the skills to drink alcoholic beverages. It is exclusive in the topics that are reviewed and neglects the harm that alcohol can do to young people. Learning about Drinking fails to discuss learning about dying - in Europe, for example, one quarter of all male deaths at age 15-29 years is attributable to alcohol10. In the book's index, neither intoxication nor dependence is listed. Alcohol poisoning is, but it receives one word under the heading "is the experimental drinking of youth a problem?" Binge drinking is mentioned, but only to be described under the heading "do negative expectations increase problems", as an "emotionally laden word." Learning About Drinking is another example where good advice has been given to the beverage alcohol industry on how to market its products, this time to young people.

Drinking Occasions is another example of promoting (ir)responsible lifestyles11. It is a single author publication describing the variety of drinking occasions that exist around the world. This book does not describe the harm done by alcohol related to these drinking occasions, or how different cultures might respond to harm. As the author writes about Spain: "Although most people drink each day, drunkenness is generally discouraged and looked down upon as a sign of weakness in a country where men take great pride in their masculinity". The author neglects to mention that this same masculinity is a cause of road traffic accidents or of domestic violence, for which, in Spain, one quarter is alcohol related10. Drinking Occasions gives the international beverage alcohol industry good advice on how to build on existing cultural practices and market and integrate drinking within a wide range of other human activities in diverse cultures, without worrying about (because they are not mentioned) the harms such drinking occasions cause.

Going forward

Essentially, ICAP's mission seems to be to reframe alcohol policy away from policy that minimises harm towards policy that promotes the positive aspects of alcohol consumption. Grant might argue that it has been public health that has created this space for ICAP to fill. ICAP's own harm is that it attempts to fill this space in a disingenuous way.

ICAP's actions are an affront to the 140 million people throughout the world who are dependent on alcohol, because it does not even consider them or their families or colleagues, let alone take any responsibility for them. ICAP does a disservice to alcohol policy and a disservice to the long term interests of the beverage alcohol industry. By failing comprehensively to discuss the harm done by beverage alcohol, and by failing to be balanced and comprehensive in its review of the scientific literature, ICAP perpetuates the view that the beverage alcohol industry is more interested in marketing than being "an industry with an impressive record of good corporate citizenship", as described by Grant. It is an industry that fails to be accountable for the products that it produces.

ICAP is involved in issues management, similar to the strategies employed by the tobacco industry and baby food manufacturers who have found it financially advantageous to manage issues that are perceived to be threatening to their survival12. If anyone is in doubt of this, remember the tobacco industry. Through internal documents of the industry released through litigation in the United States, it is clear that research on 'safer' cigarettes (light and ultra light cigarettes) that public health scientists pursued in good faith, was seen by the tobacco industry purely as marketing research and has had no benefit to public health, as the industry itself knew it would not13.

Through its publications, ICAP has recruited over 80 international scientists to write its philosophy and its policy approach. ICAP publications fail to mention that these scientists were paid by the beverage alcohol industry for their work. It should also be noted that four of the five publications included ICAP staff members as editors. As with all declarations of interest (which these international scientists should also state in their future alcohol-related scientific publications), this needs to be borne in mind when interpreting the evidence. ICAP publications provide selective evidence; they give less than half the story; they focus on benefits, not problems; they do not discuss alcohol dependence and the addictive properties of alcohol; evidence based policy to reduce the harm done by alcohol is not comprehensively reviewed or not reviewed at all; the presented evidence is not public health driven, and where it is, it is based on an incorrect interpretation of public health science; much of the evidence presented is descriptive and not analytical; and much of the evidence aims to confuse, not clarify. Nevertheless, what these publications do, albeit simply, is to provide the international beverage alcohol industry with good information and good practices to find novel ways of marketing its products in new markets, without worrying about the consequences (because they are not mentioned or admitted). Through this disingenuousness and naivety, science has done a disservice to the public good. Babor12 has gone so far as to

"call for a moratorium on further 'dialogues' with industry sources until alcohol scientists and the public health community can agree to what is in their legitimate interest, and how to avoid compromising our well-earned integrity"

To repair the damage, public health and science need to continue to develop, provide and disseminate the best evidence for effective policy that reduces the harm done by alcohol; public health and science need to promote the expansion of this evidence base to cover a wide range of situations and a wide range of partners; public health and science need to provide a critique and challenge the words of the alcohol industry, without getting involved in dialogue, debate or partnership; public health and science need to carry out health impact assessments to evaluate the effect of the alcohol industry's social and economic policies and programmes on health, in order to ensure accountability; and public health and science need to support non-governmental organisations and networks that have a specific role to play in informing and mobilising civil society with respect to alcohol-related problems, lobbying for policy change and effective implementation of policy at government level, as well as exposing harmful actions of the alcohol industry.

The 2001 Stockholm declaration on Young people and Alcohol of the World Health Organization14 explicitly states that:

"Public health policies concerning alcohol need to be formulated by public health Interests, without interference from commercial interests".

Reading the website and the publications of the International Center for Alcohol Polices leads one to the conclusion that, far from being a public health advocate, ICAP is but one of the marketing arms of the international beverage alcohol industry.

Dr Peter Anderson is an independent consultant in public health. Between 1992 and 2000, he worked with the European Office of the World Health Organization, where he was responsible for the development of the European Alcohol Action plan and the Action Plan for a Tobacco Free Europe.

References

1. Murray, J.L. and Lopez, A.D. Eds. The Global Burden of Disease. Harvard, Harvard University Press, 1996.

2. Edwards, G., Anderson P., Babor T.F. et al. Alcohol Policy and the Public Good. Oxford, Oxford University Press, 1994.

3. McCreanor, T., Casswell, C. and Hill, L. ICAP and the perils of partnership. Addiction 2000 95 179-185.

4. Grant, M. and Litvak, J. Eds. Drinking patterns and their consequences. Washington, Taylor and Francis, 1998.

5. Norstrom, T. and Skog, O-J. Alcohol and mortality: methodological and analytical issues in aggregate analysis. Addiction 2001 96(Supplement 1), S5-S17.

6. Peele, S. and Grant, M. Eds. Alcohol and Pleasure. A Health perspective. Washington, Taylor and Francis, 1999.

7. Grant, M. Ed. Alcohol and Emerging Markets. Patterns, problems and responses. Washington, Taylor and Francis, 1998.

8. Jernigan, D.H. and Mosher, J.F. Permission for profits. Addiction 2000 95 190-191.

9. Houghton, E. and Roche, A.M. Eds. Learning about drinking. Washington, Taylor and Francis, 2001.

10.Rehn, N. Alcohol in the European Region – consumption, harm and policies. Copenhagen, World Health Organization Regional Office for Europe, 2001.

11.Heath, D.B. Drinking occasions. Comparative perspectives on alcohol and culture. Washington, Taylor and Francis, 2000.

12.Babor, T.F. Partnerships, profits and public health. Addiction 2000 95 190-191.

13. Shopland, D.R. Historical perspective: the low tar lie. Tobacco Control 2001 10 Suppl I, i1-i3.

14. World Health Organization. Stockholm Declaration on Young People and Alcohol. Copenhagen, World Health Organization Regional Office for Europe, 2001.