3. What do social aspects organizations stand for?

Social aspects organizations advance five main standpoints, which have been most clearly articulated by the International Center for Alcohol Policies (4):

Patterns of drinking are the best basis for alcohol policies;
Responsible drinking can be learned;
Public/private partnerships will increasingly influence alcohol policy development;
The beverage alcohol industry will strengthen self-regulatory mechanisms; and
Alcohol – despite its potential for abuse – confers a net benefit to society.

Each of these standpoints will be described and the difficulties associated with them outlined.

3.1 Standpoint 1
Patterns of drinking are the best basis for alcohol policies

Although it can include levels of drinking, the term patterns of drinking is usually taken to refer to how people drink and the circumstances in which they drink. The first volume in the International Center for Alcohol Policies Series' on Alcohol and Society is Drinking Patterns and their Consequences (5). This publication advanced the standpoint that patterns of drinking are the best predictor of whether an individual will experience positive or negative consequences of alcohol consumption.

The standpoint led to the view of the Amsterdam Group (6) that:

"The prevalence of alcohol-related problems is not directly related to the average per capita consumption, but rather to problematic patterns of drinking."

and to the view of the International Center for Alcohol (7) policies that:

"Policy makers should shift their focus to the elimination of negative drinking patterns by targeted strategies and to the promotion of beneficial patterns of drinking".

The Amsterdam Group continued:

"Policies aimed at the reduction of overall per capita consumption (in the form of limiting the overall sales of alcoholic beverages through marketing and production restrictions and high taxation) do not address those who abuse the product. The notion of individual responsibility for drinking behaviour needs to be stressed and that no collective regulation can ever replace individual responsibility".

The standpoint that patterns of drinking are the best basis for alcohol policies fails on three main counts: the purpose of alcohol policy is to reduce the harm done by alcohol and the effectiveness of alcohol policy needs to be judged in the light of its impact on harm; alcohol related harm is determined by the volume of alcohol consumption, as well as by how it is drunk; and the notion that alcohol policy should be a matter of individual responsibility alone is a false choice.

Count one
The purpose of alcohol policy is to reduce harm and the effectiveness of alcohol policy needs to be judged in the light of its impact on harm

The purpose of alcohol policy is to reduce the harm done by alcohol. The European Alcohol Action Plan of the World Health Organization, which has been endorsed by its Member States, has been criticized by the beverage alcohol industry for being a prohibitionist document. However, the Action Plan is specific in its aim (8):

"to prevent and reduce the harm that can be done by alcohol throughout the European region"

The Action Plan supports the achievement of Target 12 of the health for all policy framework for the WHO European region, also endorsed by its Member States, which states that (9):

"By the year 2015, the adverse health effects from the consumption of addictive substances such as tobacco, alcohol and psychoactive drugs should have been significantly reduced in all Member States."

Alcohol policy should be judged by its impact in reducing harm. And the evidence is that those policy options that address the economic and physical availability of alcoholic products are effective in reducing harm, whereas those policy options that address the responsibility of the individual, through programmes such as education, are largely ineffective (10). (This is discussed in more detail in standpoint 3 below).

Count two
Alcohol related harm is determined by the volume of alcohol consumption, as well as by how it is drunk

For the individual drinker, the harm done by alcohol is related to both the volume of alcohol consumed and to how the alcohol is consumed (11). For almost all of the physical conditions related to alcohol, including cirrhosis of the liver and alcohol-related cancers, the level of alcohol consumption is a more important determinant of harm than how the alcohol is consumed. The risk of these conditions increases with increasing levels of alcohol consumption, and there is no clear cut off point between use, hazardous use and harmful use. For conditions related to alcohol intoxication, (including accidents, road traffic accidents, intentional violence both towards self and others, suicide, family violence, violent crime, engaging in criminal behaviour, and victimization, including robbery and rape) both the level of alcohol consumed and how it is consumed are related to the risk of harm. For these conditions, the risk increases with increasing levels of alcohol consumption and is influenced by different patterns of drinking.

At the societal level, there is a direct relationship between levels of per capita consumption and alcohol related harm. The European Comparative Alcohol Study reviewed the post-war experience of alcohol and mortality in the countries of the European Union (12). Time series analysis demonstrated that there is a positive and significant relationship between changes in alcohol consumption and changes in both overall and alcohol related death for both men and women. The relationship applies to all types of alcohol related harm, and is stronger in countries with lower overall alcohol consumption than in countries with higher overall alcohol consumption. For example, an extra litre of alcohol per person would result in a 12.4% increase in homicides in northern Europe, but only a 5.5% 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.

The drinking population in general has been found to behave as a collectivity. Increases or decreases in overall consumption are likely to result in shifts across the entire spectrum of drinkers, except when alcohol is rationed (13). To be effective, policy that reduces the harm done by alcohol will have an impact on both the volume of alcohol consumed as well as on how the alcohol is consumed.

Count three
The notion that alcohol policy should be a matter of individual responsibility alone is a false choice

Social aspects organizations imply that individual responsibility should be at the core of alcohol policy. Social aspects organizations use the term abuse, implying that this is an irresponsible use of the beverage alcohol industry's product and is the cause of harm. Social aspects organizations imply that it is the individual drinker who is responsible for whether or not the product is abused. The World Health Organization has considered the term abuse as potentially pejorative and emotionally laden, and because of its ambiguity no longer uses it in its ICD 10 classification of mental and behavioural disorders when referring to drugs of dependence (14). The terms intoxication, harmful use and dependence take preference. Harmful use is a pattern of alcohol use that is causing damage to health. The damage may be physical (as in cases of liver cirrhosis) or mental (for example, episodes of depressive disorder secondary to heavy consumption of alcohol). Alcohol is classified by the World Health Organization as a dependence producing drug, with dependence on alcohol being a recognized disorder.

Approaches centred on individual responsibility and individual change fail to consider the social factors governing behaviour, including the various environmental constraints and pressures that limit individual choice. Individual based strategies are far less effective than strategies aimed at controlling or altering relevant factors within the individual's immediate environment, such as the physical and economic availability of alcohol, formal social controls on alcohol-related behaviour and initiatives aimed at changing alcohol-related practices in the drinking environment through broad-based community action. Effective policy to reduce the harm done by alcohol is about shaping the individual's drinking environment to enable the healthy choices to be the easy choices.

3.2 Standpoint 2
Responsible drinking can be learned

The fifth book in the International Center for Alcohol Policy's Series on Alcohol and Society is Learning about Drinking (15). The publication advanced the standpoint that drinking is a learned behaviour, much like learning to drive. It is proposed that, if what influences this learning is better understood, programs that seek to reduce harm are likely to be more effective.

This standpoint led to the view of the Portman Group in the United Kingdom that (16) "Education is the key to tackling alcohol abuse and that responsible attitudes should be encouraged at a young age."

The International Center for Alcohol Policies has emphasized the importance of responsibility and stated that (17) it "Works with industry and public health partners to promote responsible lifestyles in industrialized and developing countries", [noting 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."

Social aspects organizations implement and fund a number of programmes to support their understanding of responsible lifestyles, including, for example, educational programmes at school and designated driver campaigns to reduce drink driving.

In the field of education, the United Kingdom based Portman Group, for example, has published resource materials for use in schools (18). 'We've Seen People Drinking' is a publication for use in primary schools and 'Finding Out About Drinking Alcohol' is for use by pupils in secondary schools. The Portman group states that 'Discussing Drinking With Your Children' is its most popular leaflet. It is promoted as a general guide for parents who would like information on talking to their children about alcohol. The Portman Group states that although it is mainly aimed at parents of teenagers, much of it is also relevant for parents of younger children.

In low income countries, the International Center for Alcohol Policies has promoted learning about drinking through its Growing Up Life Skills Education programme (19), which was developed for all seven grades of selected primary schools in South Africa and Botswana, during the period from 1996-1999. Rather than providing health education by pointing out the dangers of certain behaviours, Life Skills Education introduces children to a number of skills such as decision-making skills, communication skills and how to handle emotions. The program included, but did not focus primarily upon, issues related to beverage alcohol. The International Center for Alcohol Policies took the view (although provided no evidence for this) that:

"It is unlikely that primary school children will be applying these skills immediately to drinking alcohol beverages. Nevertheless a Life Skills Education programme at this early age will provide the necessary foundation skills in ways that will enable them, as they get older, to apply the skills in situations that do involve drinking".

Designated driver campaigns, such as the Arnoldus Group's Bob campaign are common initiatives (20). The United Kingdom Portman Group's designated driver campaign promotes the message 'If you drink, let others drive' (21). The campaign is aimed particularly at 18-40 year old male drivers who are the group most at risk of being involved, injured or killed in a drink-drive accident. The campaign was launched with support from professional football, supported by a series of regional promotions delivered in partnership with local communities, and supported by radio and bus advertising. In the Netherlands, the beverage alcohol industry itself partnered with the Ministry of Transport to launch a designated driver campaign which was criticized because the non-drivers were clearly intoxicated and there was no scientific research on the effectiveness of the campaign.

These initiatives are wrongly conceived on two counts: the educational initiatives proposed by the social aspects organizations have minimal or no impact in reducing the harm done by alcohol and there is little or no evidence for the effectiveness of designated driver campaigns, the cornerstone of social aspects organizations' policy to reduce alcohol-related traffic accidents and; learning responsible drinking as promoted by social aspects organizations can be interpreted as a marketing tool in all societies and as a way to influence the beliefs about alcohol in those societies where drinking is not necessarily a traditional part of the culture.

Count one
The educational initiatives proposed by the social aspects organizations have minimal or no impact in reducing the harm done by alcohol and there is little or no evidence for the effectiveness of designated driver campaigns, the cornerstone of social aspects organizations' policy to reduce alcohol-related traffic accidents

The evidence is that whilst school-based educational initiatives can change knowledge and attitudes about alcohol, they are generally ineffective in changing behaviour in the use of alcohol or preventing the harm done by alcohol (22). This is hardly surprising since school-based education competes against a barrage of messages that promote the use of alcohol. The primary source of pro-alcohol messages is social reality itself, the widespread and visible availability of alcoholic beverages, and the presence and acceptability of alcohol in a variety of everyday situations and contexts. The influence of experience on people's conceptions of alcohol issues tends to be more powerful than that of any alcohol information provided.

Unfortunately, there has been very little research to test the effectiveness of the designated driver campaigns that are supported by social aspects organizations to reduce alcohol-related traffic accidents. From the limited evidence that is available, it appears that designated driver campaigns are largely ineffective and certainly not as effective as a measure to prevent alcohol-related traffic accidents as originally envisioned (23). Whilst the public may be aware of the designated driver concept and there is an increased use of designated drivers, a large proportion of those familiar with the term do not require a designated driver to be identified before the planned drinking event or to avoid consuming alcohol during the event. Many who agree to serve as designated drivers renege after drinking, even though it means becoming an intoxicated driver. Further, there is some evidence that the presence of a designated driver encourages the non-drivers to drink more than they would otherwise, making them a greater danger if either they or the designated drivers changed their minds. Unfortunately, the social aspects organizations are generally opposed to those initiatives, such as reducing blood alcohol concentration (BAC) levels permitted for driving or high visibility random breath testing that have been demonstrated to be effective in saving deaths from alcohol related road traffic accidents. Norway reduced its legal blood alcohol concentration limit to 0.2g/L in 2001. Police data from road side tests showed a 22% drop in violations of the limit compared with the year 2000, with the decrease across the entire range of illegal blood alcohol levels (24).

Count two
Learning responsible drinking as promoted by social aspects organizations can be interpreted as a marketing tool in all societies and as a way to influence the beliefs about alcohol in those societies where drinking is not necessarily a traditional part of the culture

Education on alcohol is one aspect of public communication, which is connected with alcohol advertising and other media representations of alcohol (25). Although education as a means of reducing the harm done by alcohol has limited success, this does not mean, however, that communication about alcohol plays no role in shaping people's beliefs and perceptions. As the range of most people's direct experience with alcohol is limited, many of people's views and notions are based on what is learnt from other people or from the mass media. The media convey a steady flow of images and views on alcohol and drinking. These images mainly represent alcohol consumption as a harmless practice, playing down the potential health risks and other negative consequences. When the media do depict negative social, economic or health consequences, they tend to present these as occasional afflictions rather than as risks inherent in alcohol use. It is not surprising, therefore, that educational initiatives rarely succeed in bringing about behavioural change in the direction of reducing the harm done by alcohol. They are simply swamped by the massive flow of messages conveying the social acceptability and high level of prevalence of alcohol use. A large part of these messages are commercial advertisements that portray the use of alcohol as an essential component of desirable lifestyles. When alcohol education funded and implemented by the beverage alcohol industry is viewed within this context, it is very difficult to avoid the blurring between education, advertising and the media portrayal of the use of alcohol. In other words, it is very easy for such alcohol education to be interpreted as a part of a marketing strategy by the beverage alcohol industry.

It is estimated that the growth areas for the use of alcoholic beverages are the same emerging markets that are considered in the second volume of the International Center for Alcohol Policies' Series on Alcohol and Society, Alcohol and Emerging Markets (26), that is Asia, Central and Eastern Europe, Latin America and sub-Saharan Africa. The International Center for Alcohol Policies (27) is actively promoting what it calls 'balanced alcohol policies based on partnerships between the public and private sectors' in a number of low income countries and emerging markets, introducing the 'concepts of responsible drinking in countries where drinking is not necessarily a traditional part of the culture'. The balanced alcohol policies that the International Center for Alcohol Policies proposes are responsible promotional and advertising practices and alcohol education to promote sensible drinking, both of which are known to lack effectiveness. The effective environmental strategies are not adequately addressed. The involvement of social aspects organizations in emerging markets and low income countries can be understood as a marketing tool which shows little respect for the vast majority of individuals in such countries who choose not to consume alcohol, and with little regard for the harm that alcohol can add to the problems of already impoverished individuals, families and communities (28).

3.3 Standpoint 3
Public/private partnerships will increasingly influence alcohol policy development

Social aspects organizations were set up and funded by the beverage alcohol industry to represent the industry in policy debate. Therefore, it is no surprise, that social aspects organizations regard themselves as having an equal place at the policy table.

The International Center for Alcohol Policies (29) believes that social aspects organizations are:

"Public health organizations that should be partners in influencing alcohol policy development."

In promoting its role in policy development, the International Center for Alcohol Policies 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."

The common language the International Center for Alcohol Policies promotes is pleasure, the social aspects organizations' brand and means of policy influence, and the theme of the Center's third book in its Series on Alcohol and Society, Alcohol and Pleasure: a Health perspective (30).

There is simply one problem with this approach: social aspects organizations are neither public health bodies nor scientific organizations, but beverage alcohol industry organizations which misrepresent the evidence base for effective policy to reduce the harm done by alcohol.

Problem one
Social aspects organizations are beverage alcohol industry organizations which misrepresent the evidence base for effective policy to reduce the harm done by alcohol

The social aspects organizations' misrepresentation of alcohol policy is demonstrated in the table, which summarizes the evidence for the impact of policy options in reducing the harm done by alcohol (classified as effective or ineffective), based on scientific reviews of the evidence, and the positions taken by the social aspects organizations (classified as not supportive or supportive), based on their publications and web-sites.

It is clear that there is a mismatch between the evidence for effective alcohol policy and the policy options supported by the social aspects organizations. In general, policy options that have been demonstrated to be effective in reducing the harm done by alcohol are not supported by the social aspects organizations, whereas policy options that have been demonstrated to be ineffective in reducing the harm done by alcohol (or policy options for which there is no evidence either way) are supported by the social aspects organizations.

3.4 Standpoint 4
The drinks industry will strengthen self-regulatory mechanisms

The social aspects organizations take the view that there is insufficient evidence to support an association between advertising and levels or patterns of drinking. They are opposed to legislative marketing restrictions and believe that the marketing of alcoholic products should be regulated by the beverage alcohol industry itself.

The International Center for Alcohol Policies summarizes the view of social aspects organizations in the following way (31):

"the right [of beverage alcohol industry organizations] to advertise their brands is a most important commercial freedom, but [beverage alcohol industry organizations] recognize that they must safeguard this freedom by advertising in a responsible manner. [Beverage alcohol industry organizations] believe that industry self-regulation through voluntary codes of practice is the most efficient means of regulating drinks advertising and promotional activities, while at the same time protecting the rights of individual companies to communicate with their consumers and to compete for market share"

The International Center for Alcohol Policies also takes the view that self-regulation applies to all markets, including that of low income countries:

"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, the International Center for Alcohol Policies identifies common factors that can be used pro-actively around the world".

Table. (Click to view four sections in pdf format). The impact of alcohol policy options to reduce the harm done by alcohol (effective or ineffective) and the position of social aspects organizations (not supportive or supportive)

Thus, the International Center for Alcohol Policies encourages:

"Strict industry compliance with all existing legislation or self-regulatory codes of practice relating to the advertising and promotion of alcohol beverages;
Initiatives aimed at establishing self-regulatory codes in countries where they do not already exist;
Efforts to ensure that such codes of practice adequately reflect local culture and values; and.
The development of appropriate enforcement mechanisms to ensure that such codes are adhered to."

With the assistance of the European Advertising Standards Alliance, the International Center for Alcohol Policies has prepared a toolkit on self-regulation and alcohol for emerging markets and the developing world, which includes a model Code of Practice for the marketing and promotion of alcoholic beverages(32).

Some social aspects organizations were set up specifically to deal with self-regulation. For example, the Dutch organization, STIVA was founded in response to alcohol policy developments. The first task of STIVA was to manage the new self-regulation system as part of a political compromise to prevent an advertising ban. In subsequent years, its function was reformulated to broader issues.

There are two arguments against self-regulation as a response to the marketing of alcoholic beverages: the beverage alcohol industry is unable to regulate itself and its self-regulatory codes are persistently and consistently broken; and advertising of alcoholic products does have a small but contributory effect to individual drinking and levels of alcohol-related harm

Argument one
The beverage alcohol industry is unable to regulate itself and its self-regulatory codes are persistently and consistently broken

The beverage alcohol industry members of the social aspects organizations have blatantly, consistently and extensively broken their own advertising codes in all areas of the world (33) and there is no evidence that this has changed over recent years.

The Amsterdam Group produced its first set of Guidelines for Commercial Communications on Alcoholic Beverages in 1994 (34), which were updated in 2002 (35). There are very many examples in which the member organizations of the Amsterdam have broken and continue to break the Group's self-regulatory codes, including for example, Bacardi and Heineken (36). Diageo, a member organization of the Amsterdam Group, has its own code to define responsible marketing activities, which according to Diageo has "proved to be particularly helpful in countries where national laws or self-regulatory codes are not sufficiently detailed to give an effective framework for the regulation of alcohol beverages" (37). The Diageo code, like many of the national and international codes, states that the "packaging of alcoholic products should not suggest sexual success or prowess", and "advertising and promotional activities should not give the impression that social acceptance or sexual success cannot be achieved without consuming alcohol beverages". Yet despite this code, and despite an emphasis expressed by the beverage alcohol industry at a joint meeting of the Member States Working Group on Alcohol and Health of the European Commission and representatives of interest groups that was held in June 2001 that it can regulate itself, the launch of Diageo's brand, Archers Aqua, clearly uses sexual words and sexual imagery that is difficult to interpret other than an association between the use of the product and sexual success. This is illustrated with its "Come out to Play" "Moist theme" in the United Kingdom and through its club promotions in, for example, South Africa.

Self-regulation is inherently unlikely to work, since the essence of self-regulation in most countries and in most media is that compliance with codes is voluntary, and subject to changes and revision by the beverage alcohol industry itself (38). In theory, a voluntary code can be monitored by the public and non-governmental organizations, but the effectiveness of this will depend on widespread knowledge of the code, a sufficiently independent complaints body with powers of sanction, and sufficient funds to monitor marketing practices and implement litigation if necessary. Most advertising campaigns are designed as short bursts to avoid saturation effects, so complaints decisions must be fast. "Pre-vetting" may increase effectiveness, but beverage alcohol industry self-regulation against its own interests not infrequently leads to under-regulation and under-enforcement. Bodies that judge adherence to the codes tend to restrict their judgements to the intentions of the advertisers, rather than to the real effects of the advertisements on, for example, young people, even when the evidence shows that young people perceive the advertisements as being directed at them. (39)

Most self-regulatory codes also do not account in their content for the way successful advertising actually works (40). For example, codes on advertising standards commonly state that actors in alcohol advertisements must be adults.

This part of the content of the codes has little meaning, since studies of advertising for other products show that children generally desire what they see being enjoyed by an older person. Similarly, while codes explicitly prohibit the portrayal of intoxication, research suggests that advertisements do communicate the concept of intoxication and young recipients perceive intoxication as a beneficial effect.

Argument two
Advertising of alcoholic products does have a small but contributory effect to individual drinking and levels of alcohol-related harm

In a number of European countries, about 10% of drinkers drink between one third to two thirds of the total alcohol consumed; it is this sector that contributes most to the alcohol producers' markets (41). Young males are most likely to be recruited to be these heavy drinkers and are disproportionately represented in the statistics for the harm done by alcohol, including intentional and unintentional injuries and premature death. As young males age, the levels of alcohol consumption reduce. The logical implication is that the beverage alcohol industry continually needs to recruit new generations of young heavy drinkers in order to maintain its profitability. The beverage alcohol industry spends heavily on advertising. Seven alcohol companies rank amongst the world's 100 leading advertisers, and their total advertising expenditures exceeded US$4.5 billion in 2000 (42). Probably this same sum is spent again on forms of promotion other than direct advertising. Most effective among these is marketing through sporting activities that attract young males, the group most likely to be heavier drinkers.

A considerable body of research has attempted, using a variety of methodologies, to investigate whether there is a discernible link between advertising and consumption at either the aggregate or the individual level (43). A comparison of 17 high income countries for the period 1970-1983 found, for example, that the countries with a ban on spirits advertising had 16% lower consumption and 10% lower motor vehicle fatalities than countries with no such ban (44). Broadening the analysis to 20 OECD countries over the years from 1970 to 1995, including prohibitions on print as well as radio and television broadcasting, and studying all classes of alcoholic beverages concluded that an advertising ban would lead to a reduction in alcohol consumption of between 5% and 8%. A comparison of local data from 75 metropolitan areas in the United States using quarterly data from 1986-1989 and controlling for numerous other relevant variables, found an impact of advertising on motor vehicle fatalities which was significant, although smaller than the impact of increasing the price of alcoholic products.

At the individual level, two analyses of longitudinal data have found an impact of response to advertising on consumption in New Zealand (45). In the first, the numbers of alcohol advertisements recalled at age 15 years in response to a question about the portrayal of alcohol in the media significantly predicted heavier drinking among young men aged 18 years. In the second analysis, liking for advertising measured at age 18 years predicted heavier drinking and experience of more alcohol-related problems at age 21 years.

An Irish study found that that alcohol advertising has a strong attraction for teenagers, as it portrays lifestyles and images which are part of their social setting (46). Most believed that the alcohol advertisements were targeted at young people as the advertisements depicted dancing, clubbing, lively music and wild risqué activities which they consider synonymous with their social activities. The younger age group (12-14 years) perceived the advertising messages as saying that alcohol can help them have fun, make friends and become popular and those that don't drink are missing out. The message from the alcohol advertisements for the older age group (15-17 years) was that social success and a good time results from alcohol use.

A basic strategy of alcohol promotion is not to rely on a single message or a single campaign, but on a synergy created by a variety of messages and channels. Direct advertising through mass media channels is only one example of the range of promotional activities. Other methods used to secure the visibility of alcohol products include sponsorship of cultural and sports events, on-site promotion in alcohol outlets, drinking paraphernalia and other products carrying brand names or symbols, and product placement in the entertainment media.

Marketing of beverage alcohol products is not just about recruiting new drinkers, but also about promoting a public discourse in which alcohol is "normalized" as part of everyday life and drinking is seen as a matter of individual choice and responsibility (47). This choice is informed and created by direct and indirect means: not only advertisements and promotions but the unproblematic portrayal of drinking in television, radio, film and print. In these ways the beverage alcohol industry acts as a "drug educator", reaffirming drinking cultures and creating an environment supportive of the beverage alcohol industry when policy decisions are taken on the regulation of beverage alcohol products and on public health strategies.

3.5 Standpoint 5
Alcohol – despite its potential for abuse – confers a net benefit to society

Alcohol and Pleasure: a Health perspective, the third book in the International Center for Alcohol Policies' Series on Alcohol and Society, promoted the view that for most people most of the time alcohol can confer considerable benefits, although it carries some risks (48). The fourth book in the Series, Drinking occasions: Comparative Perspectives on Alcohol and Culture, an anthropological review of global drinking habits, put forward the view that most drinking occasions are normal parts of daily life and not associated with problems or excess (49).

Both of these publications are part of the International Center for Alcohol Policies' strategy (50) to:

"demonstrate that moderate drinking is likely to provide a net gain to society and thus rehabilitate pleasure so that it can take its legitimate place in human affairs"

arguing that alcohol is an essential component of a productive life:

"as quality of life indicators will be increasingly used to determine health status, a balanced lifestyle – which can for most people include moderate drinking – will probably prove the best predictor of a long and healthy life. Both for developed and developing countries, the key issue may be the redefinition of what constitutes a productive life and alcohol's place in it".

There are three problems with this approach: despite what the beverage alcohol industry states, it is not in its economical interests to promote what it terms responsible drinking; alcohol ranks as one of the highest causes of disease burden in the world; and drinking alcoholic products is neither a pre-requisite, nor a necessity for a balanced lifestyle or a long and healthy life.

Problem one
Despite what the beverage alcohol industry states, it is not in its economical interests to promote what it terms responsible drinking

Whilst the social aspects organizations propose that their objectives are to promote moderate and responsible drinking, it should be remembered that alcohol is essentially an intoxicating and dependence producing drug (51). It is drunk for its intoxicating effects, even by those who are light or moderate consumers of wine. Many drinkers, and in particular younger men, deliberately and self-consciously use alcohol to pursue intoxication, i.e. to get drunk. Thus the pleasures of moderate or responsible drinking occur in spite of, not because of, the basic nature of the substance. The beverage alcohol industry is aware of alcohol's intoxicating effects. An examination of alcohol advertising especially that aimed at young people shows that its ability to intoxicate, and the glamour and excitement with which intoxication is associated is the product's main selling point. A small percentage of the population is responsible for a greatly disproportionate amount of the total alcohol consumed. Ten per cent of the population may consume between 30% and 60% of the total amount consumed in a society (52). In the United States, hazardous drinking, defined as 5 drinks or more per day, accounts for more than half the beverage alcohol industry's market and 76 per cent of the beer market (53). Thus if all hazardous drinkers and drinkers currently drinking above medically recommended levels were somehow transformed into moderate or responsible drinkers, the beverage alcohol industry's profits would be considerably minimized.

Problem two
Alcohol ranks as one of the highest causes of disease burden in the world

Alcohol use causes significant harm to the physical, psychological and social health of individuals, families and communities in both high and low income countries. It was estimated to account for 3.5% of the disability-adjusted life years (DALYs) lost in 1990, more than tobacco at 2.6% (54). It is a risk factor to global health on the same level as measles, tuberculosis and malaria combined. Twenty five per cent of all deaths of young people aged between 15 and 29 years are attributable to alcohol, with 55,000 alcohol-related deaths occurring among young people in Europe in 1999. Alcohol use can cause or contribute to physical, psychological and social harm for both drinkers and non-drinkers, and can damage nearly every tissue and system in the body (55). Harm to the drinker includes alcoholic psychosis, alcohol dependence syndrome, alcoholic polyneuropathy, alcoholic cardiomyopathy, alcoholic gastritis, alcoholic liver cirrhosis, ethanol toxicity and methanol toxicity. The risk of dependence increases with increasing levels of alcohol consumption (56) and its prevalence is considerable. It is estimated that globally there are 140 million people suffering from alcohol dependence at anyone time (57). In the United States (a middle ranking country in terms of worldwide per capita alcohol consumption) it has been estimated that 1 in 4 men and 1 in 20 women will experience at least one episode of alcohol dependence in their lifetime (58). Alcohol use increases the risk of cancers of the oral cavity, pharynx, larynx, oesophagus, liver and breast, as well as certain types of heart disease, high blood pressure and stroke and pancreatic inflammation, atrophy and fibrosis. For non-drinkers, the harm from alcohol use may begin prenatally in the form of foetal alcohol syndrome and foetal alcohol effects. Both drinkers and non-drinkers may suffer from the consequences of alcohol use, for example by traffic crashes, burns, drowning and suicide. While the causal connection of alcohol to criminal behaviour is complex, crimes of violence consistently show strong relationships with alcohol use. Alcohol use may also be related to a variety of other social problems including marital breakdown, loss of productivity and high rates of absenteeism, family violence and child abuse, and homelessness.

Alcohol imposes a high economic cost to society (59). One estimate puts the yearly economic cost of the harm done by alcohol in the United States at US$148 billion, including US$19 billion for health care expenditure. In Canada, the economic costs of alcohol amount to approximately US$18.4 billion, representing 2.7% of the gross domestic product. In European countries, the total costs arising from the harm done by alcohol lie between 2% and 5% of gross domestic product. In a research study in The Netherlands, it was estimated that 9% of the adult population drink at hazardous levels – a total of 1.1 million problem drinkers. These drinkers cost the economy 2.6 billion.

Problem three
Drinking alcoholic products is neither a pre-requisite nor a necessity for a balanced lifestyle or a long and healthy life as proposed by social aspects organizations

In the estimates of pleasure and a long and healthy life, much emphasis is placed on the cardio-protective effects of alcohol. Although there is evidence that alcohol use at levels as low as one drink per week may offer some degree of protection against coronary heart disease and ischaemic stroke, it is an effect reported mostly from high income countries, where there has been considerable debate on the size of the reduction in risk (60). Since coronary heart disease primarily affects men aged over 35 years and postmenopausal women, the effect has been primarily confined to older age groups. However, while numerous studies have found an effect, several have not, and the former may have had methodological failings. Any protective effect of drinking is likely to be very small in the many cultures in low income countries with low rates of coronary heart disease. In terms of years of life lost the adverse effects of drinking outweigh any protection against coronary heart disease, even in the most vulnerable national populations. Globally, the estimate of 3.5% of disability-adjusted life years lost is a net figure allowing for the possible protective effects of alcohol consumption. A long and healthy life amongst those who consume small amounts of alcohol may well be due to other factors, such as a healthier diet, greater physical activity and less cigarette smoking (61).

References:

4 Grant, M. A New Force for Health. International Center for Alcohol Policies. http://www.icap.org/.

5 Grant, M. & Litvak, J. Eds. Drinking Patterns and their Consequences London, Taylor & Francis. 1998.

6 The Amsterdam Group Report 2001. www.amsterdamgroup.org.

7 Grant, M. A New Force for Health. International Center for Alcohol Policies. http://www.icap.org/.

8 European Alcohol Action Plan 200-2005. Copenhagen, World Health Organization Regional Office for Europe.

9 Health 21 – health for all in the 21st century. Copenhagen, World Health Organization Regional Office for Europe.

10 Edwards G., et al. Alcohol Policy and the Public Good. Oxford, Oxford University Press, 1994.

11 Edwards G., et al. Alcohol Policy and the Public Good. Oxford, Oxford University Press, 1994.

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

13 World Health Organization. Alcohol and Health - implications for public health policy. Report of a WHO working Group, Oslo October 1995. Copenhagen; World Health Organization Regional Office for Europe.

14 World Health Organization. The ICD-10 Classification of mental and behavioral disorders. Geneva, World Health Organization, 1992.

15 Houghton, E. & Roche, A.M. Eds. Learning about Drinking London, Taylor & Francis, 2001.

16 The Portman Group www.portmangroup.org.uk.

17 Grant, M. A New Force for Health. International Center for Alcohol Policies. http://www.icap.org/.

18 The Portman Group www.portmangroup.org.uk .

19 International Center for Alcohol Policies. Life skills education in South Africa and Botswana 2000. www.icap.org.

20 The Arnoldus Group. belgian.brewers@beerparadise.be.

21 The Portman Group www.portmangroup.org.uk.

22 Midford, R. & McBride, N. Alcohol education in school. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 785-804, 2001.

23 McKnight, A.J. & Voas, R.B. Prevention of alcohol-related road crashes. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 741-770, 2001.

24 Eurocare Newsletter. June 2002. www.eurocare.org

25 Hill, L. & Caswell, S. Alcohol advertising and sponsorship: commercial freedom or control in the public interest. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 823-846, 2001.

26 Grant, M. Ed. Alcohol and Emerging Markets London, Taylor & Francis, 1998.

27 Grant, M. A New Force for Health. International Center for Alcohol Policies. http://www.icap.org/.

28 Saxena, S. Alcohol, Europe and the developing countries. Copenhagen, WHO Regional Office for Europe, 1995 (document EUR/ICP/ALDT 94 03/CN 01/32).

29 Grant, M. A New Force for Health. International Center for Alcohol Policies. http://www.icap.org/.

30 Peele, S. & Grant, M. Alcohol and Pleasure: a Health perspective London, Taylor & Francis, 1999.

31 International Centre for Alcohol Policies. A suggested Framework for responsibility, 1998 www.icap.org.

32 International Centre for Alcohol Policies. Self-regulation and alcohol. A toolkit for emerging markets And the developing world May 2002 www.icap.org.

33 Marketing alcohol to young people; Eurocare, London, 2001.

34 The Amsterdam Group. Guidelines for Commercial Communications on Alcoholic Beverages. 1994.

35 Commercial Standards for Commercial Communication 2002 www.amsterdamgroup.org.

36 www.alcoholreclame.nl

37 Code of marketing practice for alcohol beverages. www.diageo.com.

38 Hill, L. & Caswell, S. Alcohol advertising and sponsorship: commercial freedom or control in the public interest. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 823-846, 2001.

39 Van Dalen, W. Alcohol marketing in the Netherlands. Paper prepared for the WHO international technical meeting on Marketing and Promotion of Alcohol to Young People, Valencia, Spain, 7-9 May 2002.

40 Hill, L. & Caswell, S. Alcohol advertising and sponsorship: commercial freedom or control in the public interest. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 823-846, 2001.

41 Hill, L. & Caswell, S. Alcohol advertising and sponsorship: commercial freedom or control in the public interest. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 823-846, 2001.

42 Jernigan, D.H. Marketing alcohol to young people: Effects, responses, evaluations and prospects Paper prepared for the WHO international technical meeting on Marketing and Promotion of Alcohol to Young People, Valencia, Spain, 7-9 May 2002.

43 Wagenaar, A.C. & Komro, K.A. Marketing Alcoholic Beverages to Youth: Study Designs and Research Needs. Paper prepared for the WHO international technical meeting on Marketing and Promotion of Alcohol to Young People, Valencia, Spain, 7-9 May 2002.

44 See Jernigan, D.H. Marketing alcohol to young people: Effects, responses, evaluations and prospects Paper prepared for the WHO international technical meeting on Marketing and Promotion of Alcohol to Young People, Valencia, Spain, 7-9 May 2002.

45 Hill, L. & Caswell, S. Alcohol advertising and sponsorship: commercial freedom or control in the public interest. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 823-846, 2001.

46 Dring, C & Hope, A. (2001). The Impact of Alcohol Advertising on Teenagers in Ireland. Department of Health and Children, Dublin.

47 Hill, L. & Caswell, S. Alcohol advertising and sponsorship: commercial freedom or control in the public interest. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 823-846, 2001.

48 Peele, S. & Grant, M. Alcohol and Pleasure: a Health perspective London, Taylor & Francis, 1999.

49 Heath, D.B. Drinking occasions: Comparative Perspectives on Alcohol and Culture London, Taylor & Francis, 2000.

50 Grant, M. A New Force for Health. International Center for Alcohol Policies. http://www.icap.org/.

51 Heather, N. Pleasures and pains. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 5-14, 2001.

52 Lemmens, P. Relationship of alcohol consumption and alcohol problems at the population level. In Eds. Heather, N., Peters, T.J. & Stockwell, T. International Handbook of alcohol dependence and problems. Chichester: John Wiley & Sons Ltd. pp 395-412, 2001.

53 Rogers, J. & Greenfield, T. Beer drinking accounts for most of the hazardous alcohol consumption reported in the United States. Journal of Studies on Alcohol 60(6): 732-739. 1999.

54 Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996 (Global Burden of Disease and Injury Series, Vol. I).

55 Towards a global alcohol policy: alcohol, public health and the role of WHO Jernigan D.H., Monteiro M., Room, R. & Saxena S. Bulletin of the World Health Organization, 2000, 78 491-499.

56 Midanik L.T. et al (1996). Risk functions for alcohol-related problems in a 1988 US national sample. Addiction 91 1427-1437.

57 Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996 (Global Burden of Disease and Injury Series, Vol. I).

58 Edwards G et al. Alcohol policy and the public good. Oxford, Oxford University Press, 1994.

59 World Health Organization. New Understanding New Hope. The World Health Report. Geneva, 2001.

60 Towards a global alcohol policy: alcohol, public health and the role of WHO Jernigan D.H., Monteiro M., Room, R. & Saxena S. Bulletin of the World Health Organization, 2000, 78 491-499.

61 Barefoot, J.C., Grønbæk, M., Feaganes, J.R., McPherson, R.S., Williams, R.B. & Siegler, I.C. Alcoholic beverage preference, diet, and health habits in the UNC Alumni Heart Study Am J Clin Nutr 2002;76:466–7