Challenges to reducing drinking-related harm through social policies

Dr Norman Giesbrecht

In 1960 John Seeley, the then Director of Research at the Addiction Research Foundation in Toronto, published a paper which demonstrated that, as real price of alcohol dropped in Canada, alcohol consumption rates and liver cirrhosis mortality rates increased. At a seminar in December 2002 researchers showed that a rise in total consumption in Canada was associated with an increase in total mortality, alcohol-specific mortality, liver cirrhosis deaths, traffic fatalities, suicide and violent deaths.

Their focus was on five decades between 1950 and 2000. Despite differences in methods and time frame there is nevertheless a striking similarity in conclusions reached almost 40 years apart. Total consumption and drinking patterns do have a significant bearing on rates of drinking-related damage, and the evidence is becoming stronger.

There may be some methodological comfort in the consistency of the findings stretching over several decades. However, what is particularly troubling is that the lessons emerging from research in Canada in the 1960s and 1970s has had so little bearing on policy-making in this country in recent decades. Not only were the policy implications of this work often ignored, but more recent developments with regard to alcohol policy seem to run contrary to the public health and safety messages emerging from this research. It is feasible that several decades from now, another research team will examine associations between alcohol promotion and access to alcohol, consumption rates and indicators of damage, focusing, for example, on the period 2000 and 2035. Will they again find evidence of such associations? Will they also find that the burden of disease, violence, social problems and death from alcohol in Canada was unnecessarily elevated by policy decisions? A critical first step to proposing more effective and appropriate policies is to consider several challenges.

Alcohol control systems

Although all Canadian provinces, except Alberta, have liquor boards that manage a large share of retail alcohol sales, there is a gradual and persistent drift toward privatization, sometimes by stealth, In Ontario, British Columbia, Nova Scotia and Saskatchewan there have been consideration of this option. In principle, a private alcohol retailing system can serve harm reduction and control agendas as effectively as a public one. In practice, however, it is likely that a change to privatization will include much higher outlet density, longer hours of sale and lower vested interest among low-paid staff to curtail sales to minors or intoxicated patrons. Furthermore, a powerful lobby group, namely an alcohol retailers association, will enter the policy arena and will very likely place commerce and marketing agenda above harm reduction and public health considerations.

However, the government run liquor management systems have also shown remarkable innovations on the marketing front in recent years. With the threat of privatization, and the mandate to generate revenues for their provincial governments, they have also become more customer-oriented using highly sophisticated measures to promote themselves, their outlets and their products through on-site innovations and multi-media advertisements.

The goals appear to be that of offering excellent service to their best customers, introducing new customers to their products and encouraging consumers to link alcohol use with many social events and occasions. While social responsibility is a mandate, there appears little official concern about the impact of state-of-the-art marketing on the drinking rates and possible risks associated with a rising rate of consumption.

Therefore, a major challenge in this domain is that of making the policy-makers and public aware of the risks associated with privatization. Also, there needs to be increased vigilance of both the unintended and intended consequences of alcohol management decisions where revenue generation and increased sales seem to be more important than controlling damage at the population level.

Alcohol marketing and promotion

The most important developments with regard to alcohol marketing, sponsorship and promotion appear to mirror those in Europe and the United States. There are several signals that controls of a few decades ago have been eroded. Alcohol sponsorship is extensively linked with events -- such as car races, rock concerts, skiing to mention a few -- where many under-age adolescents are participants. The federal committee associated with Canadian Radio and Television Commission (CRTC) no longer directly oversees proposed alcohol advertisements. This is now handled by a private group. Spirits advertising has been allowed on television and radio since the late 1990s. Despite several attempts, efforts to place warning labels on alcoholic products have been successfully blocked. Alcohol can be ordered by telephone or arranged for home delivery, and recently it became feasible to have Canada Post deliver alcohol. There are occasional counter-advertisement campaigns. However, in contrast to the many sophisticated and attractive messages that promote alcoholic beverages and drinking events, these health and safety messages are significantly under-funded and strongly overshadowed by those promoting alcohol and drinking.

There are at least three challenges with regard to alcohol promotion and marketing. Stronger guidelines about alcohol marketing and sponsorship need to be developed which have significant input from health and safety personnel and include effective mechanisms for their monitoring and enforcement. Curtailing the extensive promotion of alcohol by private and government-run systems is another challenge. Attention should be given to piloting warning labels and other forms of counter-advertising in order to determine which combinations, if any, are likely to have the greatest impact in raising awareness of the risks associated with alcohol. Finally, there needs to be attention to raising public awareness about how alcohol marketing techniques influence public views of drinking and decisions about alcohol use.

Popular perspectives on alcohol problems and prevention

There is growing awareness of the range of risks of drinking and extensive awareness of certain problems, such as alcohol dependence and drinking and driving, to mention two. However, it is uncommon to see media coverage that takes a population-based perspective and associates alcohol promotion, drinking rates and drinking-related damage. The media stories tend to focus on the deviant individual or the high-risk user, and seldom do they consider the potential role of alcohol management at the societal level with regard to problem enhancement or harm reduction.

This narrow focus is in line with other aspects of the current popular framing of alcohol problems and their prevention. By dividing the world into problem drinkers and normal drinkers, it is easier for retailers, alcohol system managers or alcohol industries to conclude that extensive marketing of alcohol is not inconsistent with prevention agendas. The marketing of alcohol is framed as intended for those who do not have a problem with alcohol. Furthermore, the alcohol industries are assumed to be legitimate players in prevention. However, estimates that up to 50% of their products are consumed by the 10% that drink the most suggest that they are not likely to be supportive of the most effective control interventions. Social responsibility is mainly and narrowly defined as offering education and information and generally, given lower priority in contrast to marketing and promotion agendas. It appears, also, that the recent rise in the rates of alcohol consumption in several Canadian provinces is not of concern among those who manage alcohol distribution.

The main challenge here is that of making policy-makers more aware of the association between policy decisions and their impacts on drinking rates and damage at the population level. This population-based orientation is now widely accepted in other domains, for example, with regard to environmental pollution. However, in the alcohol arena there is still a long way to go to raise awareness that how alcohol is distributed and sold has a bearing on drinking rates and risks for populations, communities and populations. Among the many players that need to rise to this challenge, the media has special potential to present this message in a way that is both clear and convincing, to point out, for example, that what is reported on the business page has a bearing on health and crime stories related to alcohol, and vice versa.

An evidence-based perspective

A noteworthy finding by Babor et al. is that some of the more popular prevention strategies are the least effective. They noted that informational and educational campaigns seldom demonstrated any impact on drinking rates among those who were the foci of such campaigns. Some of the more effective measures, such as raising the price of alcohol or having government-run liquor systems oriented to controlling problems, or having a ceiling on the density of outlets, are often unpopular. The term “evidence-based” may be a popular one but it does not typically influence practice. Unevaluated measures are promoted, and attempts to evaluate them, such as server intervention measures, are at times thwarted. With the exception of campaigns to prevent drinking and driving, there is not a strong current pattern to use demonstrated effectiveness as a basis for implementing a policy or prevention strategy. Furthermore, changes such as higher density of outlets, longer hours of sale, more extensive promotion of alcohol, to mention a few, are driven by commercial and revenue-generating agendas, and evidence of their benefits in reducing drinking-related harm.

A first challenge is to promote greater awareness of what types of policies and prevention strategies have the greatest potential to reduce the harm from alcohol. Second, there needs to be a better match between the scale of the problem that is addressed and the harm reduction potential of the intervention that is used to reduce it. Finally, their needs to be a greater willingness to using evidence to inform decisions and assess their impact.

Policy-making protocols

How are alcohol policy decisions made? There is considerable variation on this topic, and in some instances, such as with regard to drinking-driving arena, there are cases of careful assessment of the options, consultation with a wide range of knowledgeable players and consideration of the costs and benefits. On other topics, the health and safety advocates might be consulted literally just a few days before a decision is finalized, and with insufficient time to offer a detailed response that has much hope of influencing the outcome.

There are at least three challenges with regard to using alcohol policy to manage alcohol problems. First, deliberations on alcohol policy are typically not transparent and public debate and input is uncommon, even though a decision will have implications for their health and safety. Second, the alcohol industry is a central player in deliberations leading up to many decisions and the outcome, not surprisingly, is often very close to their interests and agendas. The challenge for public health and safety advocates is to get a place at the table, as an equal partner, and at a stage in deliberations when there is still enough time to influence the outcome. Third, social and health impact assessments are uncommon prior to the policy change. This tradition, common when it comes to proposed changes in transportation, land-use or the environment, needs to become that standard approach in the alcohol arena as well.

Public health and safety response

A final topic is that of the challenges faced by the public health and safety communities that devote some time to alcohol issues. Some of their challenges are similar to those noted earlier, including, for example, a media that is not oriented to thinking about alcohol issues in global terms, control systems that place product promotion above harm reduction, and policy-makers that are often strongly influenced by commercial interests.

They also have unique challenges. Their resources are limited and they are often over-extended with regard to seeking to tackle multiple agendas in the health area. There are constraints related to funding. If some resources come from government then advocacy may be considered out-of-order or unwise. If some resources come from the alcohol industry, then this might influence their stated views on which interventions to support or be cool towards.

Finally, in the hope of demonstrating some progress, there may be a tendency to focus on interventions that are popular and flashy, such as information campaigns, but where there is little evidence of impact in reducing drinking or harm associated with alcohol consumption.

This report has summarized challenges to reducing drinking-related harm. While the focus has been on Canada, it is likely that some experiences are not dissimilar from those in other places. A future report will focus on current activities and options to address these challenges.

Dr Norman Giesbrecht is a Senior Scientist with the Centre for Addiction and Mental Health, Toronto, Canada.