Global Status Report: Alcohol Policy
World Health Organisation 2004

Alcohol has been identified by the World Health Organization as the fifth largest risk factor for the global burden of injury and disease. It is the third largest risk factor in industrialised countries. In developing countries with low general mortality – mainly countries with growing prosperity – it is now the highest risk factor.

Alcohol policy is a response toalcohol-related harm in the interests of public health and social wel lbeing. Government measures to control supply and demand, minimise harm and promote public health are important to achieve this, says the report. Alcohol policies can be grouped as

(i) Population-based policies that can shape drinking behaviour across the whole population, e.g. taxation, availability restrictions, minimum drinking age;

(ii) Policies targeted at particular problems, such as drink-driving or offences like sales to minors;

(iii) Policies to help individual drinkers, such as brief interventions or rehabilitation programmes.

The report notes a trend away from policies to reduce drinking by the whole population towards focusing on harmful drinking by certain groups or in particular settings. In many countries, policy choices may be influenced by economic and commercial interests. WHO recognises that alcohol-related harm is not confined to small numbers of heavy drinkers or alcoholics, however. Even non-drinkers may be victims of alcohol-related aggression. The largest share of harm is associated with light and moderate drinkers, because they may occasionally drink hazardously and because their numbers are higher.

A world survey
The Global Status Report: Alcohol Policy aims to raise international awareness about the need for alcohol policies, and provides a benchmark for the further encouragement of effective policymaking by member countries. The report builds on the Global Status Report on Alcohol, 1999, a global survey of consumption data on alcohol, and the Global Status Report: Young People & Alcohol, 2001, as part of WHO’s Global Alcohol Database project.

A four-page questionnaire was sent to WHO representatives or key contact people working in the alcohol field in each country. The choice of questions – on price and taxation, restrictions on availability, drink driving and advertising – was based partly on earlier data and partly on research about the effectiveness of different policies. The survey does not capture the full variety and detail of countries’ policies and it was acknowledged that relying on the knowledge and assessments of contact people may affect accuracy. The report provides a first snapshot, as at May 2002, of alcohol policies in 118 countries with around 86 per cent of the world’s population. Each policy area is reviewed and comparisons made between countries and WHO regions. Tables provide individual country profiles.

Findings
The survey is intended as a starting point for developing a minimum set of essential policies. Suggested policies are listed in the discussion section of the report, which provide a useful framework for highlighting some of the report’s findings.

Defining alcohol in law
Defining alcoholic beverages in law provides the basis for other policies. Definitions in different countries range from 0.1 per cent to 12.0 per cent alcohol by volume, with around 1.2 per cent the most usual level. Definitions of 4.5 or more were considered high because this would not cover many traditional beverages. High definition in law might also be be exploited. For example, Sweden allows advertising of products with less than 2.2 per cent alcohol, so companies advertise low alcohol beer in order to promote higher strength beer with the same brand name and packaging.

Government control over the sale of alcohol
Retail sales for drinking off the premises were reported on, because this is the cheapest source of commercial alcohol. Only 13 countries had no government restrictions on takeaway alcohol sales. There was a government monopoly in 15 per cent of countries, which could allow higher prices and availability restrictions such as fewer outlets and limiting hours of sale. There were licensing systems in 73 per cent of countries, for at least one but usually all alcoholic beverages.

This allows control over the suitability of the licence holder and/or the premises, and over impacts on the neighbourhood. Licences can be suspended or cancelled, so monitoring and enforcement is a key issue. A substantial fee could fund treatment, prevention or policy activities. Licensing may be more difficult to achieve in countries where home-brewing or smuggling is common.

Sales restrictions by time and place
Alcohol availability can be restrictedby limiting hours, days and places of sale, and the density and location of outlets. Restriction by beverage is usually for spirits. Restrictions on place of sale is most common (56 per cent) followed by hours (45 per cent), days (26 per cent) and density (16-22 per cent). A quarter of countries had high levels of restrictions (particularly in the Americas Region), while 59 per cent had few or none (particularly in the African Region).

However, in countries with restrictions, these were rarely enforced in 23 per cent and not
enforced in 10 per cent. This leaves much room for improvement through governmental or local action, the report concluded.

A minimum age, effectivelyenforced
The age reported was for purchasing beer to drink on the premises and for purchase bee to take away. Eighteen was by far the most common age. There was no age limit in 15 per cent of countries for drinking beer on the premises and no age for purchasing takeaway beer in 12 per cent. The age limit was 15-16 in 12 per cent and 13 per cent of countries for on- and off-sales respectively. Around 9 per cent of countries had a minimum age of 19 or higher. Most countries had the same minimum age for all outlets and all beverages.

The age at which young people start drinking has been linked to higher levels of harm, such as injury, and heavy drinking later in life. Research shows that introducing a minimum age or raising the minimum age can reduce harm to young people. The survey did not ask about enforcement, although the report noted research showing that even a small increase in enforcement can reduce sales to people below the legal age.

Blood alcohol limit for drivers
In most countries, general laws against drink-driving have been replaced by specific limits on blood alcohol content (BAC). A successful drink-drive strategy requires highly visible, frequent, random road checks, to test both breath and blood.

Only 7 countries (excluding the Eastern Mediterranean Region) did not have legislation and a BAC limit. In almost 40 per cent of countries with a BAC limit, this was set at around 0.5/100m. The limit was lower in a further 30 per cent of countries. Nearly a third did not do random testing. A quarter did so frequently and these were more likely to be countries with a low BAC level.

Taxation affecting price
Alcohol taxes affect price levels, which influence consumptions levels. Different tax rates are sometimes used to balance up the lower production costs of spirits (per litre of pure alcohol) or encourage people to drink lower alcohol beers or wine. The report compares the price of beer, wine and spirits, the price of any traditional beverages, and looks at alcohol taxes as a proportion of retail price.

In 16 countries, a beer cost less than a cola. In most countries, 1-3 soft drinks could be bought for the price of a beer. Alcohol is sold cheaper in developing countries. Relative to national wealth, one beer in Europe costs the same as nine beers in Africa.

There is good evidence that that higher taxes and higher prices can reduce alcohol related harm. The tax rate may need to be weighed against any risk of illegal production, but many countries put tax stamps on bottle labels. The report recommends that traditional brews be included in alcohol tax systems to keep all consumption and harm down. In some countries the real price of alcohol has been falling, in part because the tax has not been increased in line with inflation. It was noted that industrialised countries are not using alcohol tax to its full potential as a public health measure. The report ranks tax high on the list of possible policy measures, as it is effective, cost-effective, easy to implement and can generate government revenue.

Controlling alcohol advertising and sponsorship
Alcohol advertising portrays drinking as socially desirable, while ignoring risks to individuals and to public health. Advertising can potentially promote pro-alcohol attitudes, recruit new drinkers and increase consumption among current drinkers. Although its effects on total consumption levels and on alcohol related harm may be limited and long-term, the report considers restrictions on alcohol advertising and sponsorship to be an appropriate part of a comprehensive alcohol policy.

A considerable proportion of countries reported no restrictions on advertising, particularly for print media and billboards. Broadcast media were more commonly restricted, particularly for spirits. Less than a third of countries that had laws restricting advertising considered that they were fully enforced. Those countries that reported fully enforced laws were more likely to have more and stronger restrictions. About 15 per cent of countries rely on industry agreements, which appear difficult to enforce effectively because of their ambiguous and voluntary nature.

Sponsorships are becoming increasing important in alcohol marketing. Only a quarter of countries have laws controlling sponsorship of youth and sports events. Alcohol marketing on the internet is also on the increase, often targeting young people.

Alcohol free environments
Restrictions on drinking alcohol in public settings has two aims: to ensure a safe public environment for leisure and sports, and to minimise injury and loss of productivity. There is limited research in this area. Some restrictions may be set by local governments rather than nationally. The survey asked about places and settings in which the drinking of alcohol was restricted.

These included educational and healthcare institutions, government offices, workplaces, public transport, parks and streets, sporting and leisure events. Alcohol was most commonly restricted in official settings, Half the countries had total bans. There was less control over drinking in parks, streets and sports or leisure events. For this approach to be credible, alcohol free environments need to be supported by local communities and properly enforced.

Conclusion
The Global Status Report: Alcohol Policy emphasises that single policies are less likely to impact on drinking and alcohol related-harm than several policies working together. This is particularly important if all government policies are not necessarily working in the same direction. Global marketing and trade agreements may make more effective control measures difficult to achieve. To be effective, says the report, alcohol policy should include regulatory and other environmental supports that promote the health of the population as a whole.