Alcohol Advocacy - Lessons to be learned from tobacco

Monika Arora, Director, HRIDAY (Health Related Information Dissemination Amongst Youth), New Delhi, India. Like tobacco, alcohol is also a public health hazard. Tobacco has adverse effects on social, economic, health and environmental factors. Alcohol too has adverse medical, psychological, social and economic impacts. Other similar characteristics between alcohol and tobacco are its increasing social acceptability, dependence on the product, aggressive marketing of the product particularly to recruit youth as its consumers.

Tobacco and Public Health

Tobacco is the second major common cause of death and the fourth leading risk factor for disease. It is responsible for the death of one in ten adults - 5 million deaths a year worldwide. (WHO, Tobacco Free Initiative. Available at www.who.int/tobacco/en/.

By 2030, if present trends continue unchecked, the figure will have increased to 10 million deaths per year, with 70% of these deaths taking place in developing countries. (FCTC, WHO at www.fctc.org).

Alcohol and Public Health

Worldwide, 1.8 million deaths in 2000 were attributable to alcohol use causing 3.2% of all global deaths and contributing to 4% of the disease burden. (World Health Report, WHO, 2002).

Alcohol is the leading risk factor related to the major burden of disease in low mortality developing countries and the third most prevalent risk factor for leading diseases and injuries in developed countries (WHO, 2002). While alcohol consumption is decreasing in some developed countries, it is on the rise in developing nations Significant proportion of the student population drink at hazardous level. The burden from alcohol exceeds that from tobacco because alcohol problems tend to take their toll earlier in life. The physiological and social consequences of alcohol use also negatively affect school performance, attendance and productivity at work and relations within the family.

Direct and Indirect Impact of Alcohol and Tobacco

Second Hand Smoke from a smoker’s cigarette is harmful to a non-smoker in his/her vicinity. Harmful drinking of alcohol is an underlying cause of injury, violence (especially domestic violence against women and children), disability, social problems and premature deaths (mental ill health affecting individuals, families, communities and society). The consequences of drinking and driving impacts on innocent third parties.

Trends in Consumption

Alcohol consumption is declining in most of the developed countries, and rising in many of the developing countries and the countries of Central and Eastern Europe.

Males do most of the drinking in these countries, and evidence available regarding patterns of drinking suggests that large amounts of heavy drinking are occurring.

Patterns, context and overall levels of alcohol consumption influence the health of the population as a whole.

Alcohol transnationals are shifting their focus to Asia and other developing countries (young population and a growing economy) as the American and European markets are saturated. With an increase in per capita incomes, trade barriers falling, and alcoholic beverages advancing into new markets in developing countries, alcohol consumption is likely to increase.

Both beer and spirits consumption in India have been rising, possibly due to economic liberalisation of the Indian market. Privatisation and opening up the market to foreign companies dramatically changes the advertising and marketing of alcohol and most countries (such as in Asia) lack alcohol control national policies and strategies.

Alcohol Consumption Among Young in India

In contemporary India, tendency of alcohol consumption has percolated down to youth. Media has played a leading role in encouraging the use of alcohol among the youth through portrayalof alcohol in congenial social settings, association of alcohol use with glamour and celebrity status and by using direct and indirect advertising.

Age of initiation for alcohol use has progressively reduced in Kerala (India). In 1986, the age was 19. This was reduced to 17 in 1990 and further to 14 in 1994.

Alcohol Industry is following exactly the same marketing and promotion tactics and strategies as were employed by the Tobacco Industry globally and especially in developing countries.

Trends in Tobacco Advertising and Promotion before the enforcement of tobacco control legislations in India

Direct advertising of tobacco products was rampant before the enforcement of tobacco control legislation in India. Billboard advertising of international and domestic brands of cigarettes and chewable forms of tobacco was a common sight. Surrogate Advertising (Brand Stretching) was also common.

Sponsorship of sports events and cultural events by tobacco companies were methods of promoting tobacco brand names. e.g. ‘Wills’ (brand of Indian Tobacco Company - ITC, a subsidiary of British American Tobacco) used to sponsor Indian cricket team/matches. Tennis tournaments were sponsored by ‘Gold Flake’ cigarette (brand of Godfrey Phillips India Ltd.- GPI, a subsidiary of Phillip Morris). Boat racing was sponsored by ‘Four Square’ cigarettes (brand of GPI). Polo events and golf were sponsored by ‘Classic’ (cigarette brand of ITC). ‘Charms’, a cigarette brand sponsored the ‘Spirit of freedom concert’, a musical event. ‘Manikchand’, manufacturers of gutkha (chewing tobacco), patronized the Filmfare awards ceremony.

Advertising and Promotion after theenforcement of tobacco control legislations in India

All direct advertising of tobacco products in all media has been prohibited with the enforcement of National Legislation. Surrogate advertising through brand stretching is a common practice being employed by some tobacco companies. “502 Pataka” a popular beedi (local Indian cigarette) brand is now being advertised as 502 Pataka chai (tea).

Advertising paan masala/ mouth fresheners bearing the same brand name as tobacco products is a common practice. The “Red and White” Bravery Awards are organized by GPI to advertise and promote ‘Red & White” brand of their cigarettes.

Tobacco Brand Promotions:

International Experience
‘Marlboro’ and ‘Benson & Hedges’ (international cigarette brands) extensively advertise by sponsoring Formula 1 race in many countries. British American Tobacco (BAT), sponsored the telecast of the World Cup to Malaysians through the Dunhill brand. BAT offered athletes and sportsmen bicycles and t-shirts. They also give sportsmen shirts imprinted with their product name/logo, e.g. TOBACCO CONGO or EMBASSY.“Bristol” used to sponsor the football matches, in Sri Lanka. The series was called the Bristol Cup. At the same time, Bristol also organized and sponsored a cycle race.

Trends in Alcohol

Billboard advertising of international and domestic brands of alcohol through surrogate means is widely being employed by alcohol industry worldwide. Sponsorship of sports and cultural events is widely being undertaken by alcohol companies in India. “Royal stag” sponsors Indian cricket matches and cricket players. “Shaw Wallace” sponsored the Indian open golfing event as the Royal Challenge Indian open and the Kenya cricket team. “Seagram” sponsors events such as “Chivas Regal Polo championships” and “Chivas Regal Invitational golf challenge” for corporates.

Indirect Advertising

Teacher’s whiskey has launched the Teacher’s Achievement Awards. Other sponsored awards and events
include: “Smirnoff international fashion award”. “Lakme India Fashion Week” was sponsored by Seagram’s Blenders pride.

Surrogate Advertising

“Aristocrat” a popular whisky brand is being advertised as Aristocrat Apple Juice. “Mc. Dowell’s” is advertised as sodas, “Kingfisher” has packaged water bottles. Some alcohol brands have introduced brand promotional items such as: “Haywards 5000” has darting kits, “Bacardi” advertises through its Bacardi blast album and also advertises through parties tied up with rediff.com .

Path to alcohol control

Regulatory strategies for alcohol control thus will have to be formulated on same lines as Tobacco Control. This will require initiating efforts for alcohol control at national, regional and international levels.

Factors Contributing to Global Support for Tobacco Control
Public Outrage

Till the time tobacco use was viewed as an individual’s problem, people and policy makers maintained a luke warm attitude towards introducing any regulatory measures. International research confirming ill effects of second hand smoke helped in influencing people’s and policy makers’ opinion related to tobacco control. Impact on legislation in India included initiatives such as: the Supreme Court of India banned smoking in public places.

NGOs played a crucial role in creating a supportive environment. Youth led campaigns appealing the government for a comprehensive ban on tobacco advertising through NGOs such as HRIDAY (Health Related Information Dissemination Amongst Youth)-SHAN (Student Health Action Network), created a supportive environment to enforce tobacco control measures.

Community support mobilized through advocacy groups such as TAT-Teachers Against Tobacco; PAT - Parents Against Tobacco and SAT - Students Against Tobacco, generated immense awareness among people to support tobacco control initiatives.

Tobacco industry documents

Revelations that tobacco companies knew all facts related to ill effects of tobacco; tobacco industry’s deceptive marketing practices and their efforts orchestrated to lure the youth into getting addicted to their products, helped in highlighting the hidden profit motives of tobacco transnationals. People and government lost confidence in the tobacco industry and their false claims were not given due importance.

Exposure of Documents targeting Women and Young People United States Tobacco Journal stated:

“A massive potential market still exists among women and young adults, cigarette industry leaders agreed, acknowledging that recruitment of these millions of prospective smokers comprises the major objective for theimmediate future and on a long term basis as well”.

‘Marlboro’ document says: The Marlboro Cowboy is chosen to advertise Marlboro cigarettes, “because he is close to the earth.He’s an authentic American hero. Probably the only one. And it worked”.The advertising agent responsible said “We asked ourselves what was the most generally accepted symbol of masculinity in America.” “Younger adult smokers have been the critical factor in the growth and decline of every major brand and company over the last 50 years…Younger adult smokers are the only source of replacing smokers…If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle”. — (R.J. Reynolds Tobacco Company internal memorandum, 29 February 1984)

Litigation

Success in litigation against the tobacco industry was a landmark achievement by government and tobacco control experts.

Lawsuits

Minnesota was the first state in the USA to file an antitrust and consumer fraud lawsuit against the tobacco industry.

The Grounds for the Minnesota Tobacco Lawsuit were:

• Tobacco companies mislead the public about smoking and health in violation of Minnesota’s laws against consumer fraud, false advertising and deceptive trade practices.

• Tobacco companies conspired to suppress medical research and to prevent competitors from developing safer cigarettes in violation of Minnesota’s antitrust laws.

• Tobacco companies intentionally targeted children and concealed the addictive nature of cigarettes.

Minnesota’s Tobacco Settlement achieved:

• $6.1 billion settlement - four and one-half times the $1.7 billion the state had sought for extra costs state programs had paid to treat sick smokers. Most of the settlement money was a sanction against the tobacco industry for what it did to addict kids and mislead the public.

• Permanent ban on tobacco marketing that targets children, enforceable with money penalties, injunctions and fines.

• $202 million fund (3 percent of settlement) to help adults quit smoking and conduct research (called the Minnesota Partnership for Action Against Tobacco).

• Over 33 million pages of secret industry documents opened to the public, including the industry-funded Minnesota Document Depository for public use.

The settlement proposed a permanent endowment to reduce youth smoking through counter-advertising, classroom education, community partnerships, advocacy, research and evaluation in a comprehensive program to reduce tobacco use in Minnesota.

Texas Law suit Against Tobacco

Texas was the third state in USA to settle a lawsuit against the tobacco industry, reportedly accepting at least $14 billion over 25 years to reimburse the state for Medicaid money it spent treating smokers

Iowa Lawsuit Against Tobacco Industry

The State of Iowa has filed a lawsuit seeking to recover millions of dollars in restitution and damages from tobacco companies and their research associations. The suit seeks restitution and civil penalties on the consumer fraud count. The suit also asks the court to order the defendants to pay the State millions of dollars in restitution for costs the State paid to provide health care and other services to citizens and employees as a result of tobaccorelated diseases, illnesses and injuries resulting from “the defendants’ wrongful conduct and unlawful activities.”

Law Suit Against Tobacco Industry by Attorney General Dennis C. Vacco

He filed suit against the nation’s tobacco companies, claiming that the industry deceived New Yorkers about the health effects of smoking, and illegally lured millions of teenagers to take up the deadly smoking habit. This lawsuit seeks to recoup the billions of dollars spent to treat smoking-related illnesses, including expenditures by private insurers and the taxpayer-funded Medicaid program.

In the 1988 lawsuit by the relatives of Nathan Horton who had died of lung cancer after smoking Pall Malls for thirty years, the American Tobacco Company argued, “cigarette smoking is not injurious to health. Customers are justified in relying on that statement” (Robert Heimann). And a person should not “expect to get lung cancer” or “expect to get emphysema” from smoking Pall Mall cigarettes (Preston Leake). Also: “the Surgeon General’s dead wrong” (Robert Heimann).

The New South Wales Supreme Court awarded $450,000 to a nonsmoking bartender after she developed throat cancer after years of heavy exposure to passive smoke. This was the first successful litigation of the kind in Australia.

Legal Law suits in India

PIL filed in the Supreme court of India (1999) by Murli Deora, a former member of the Indian Parliament on account of inaction of the state in regulating the use of tobacco.

Voluntary Organization in Interest of Consumer Education (VOICE) filed a complaint in 1984 against the Indian tobacco Company (ITC), with the Monopolies and Restrictive Trade Practices Commission (MRTPC) for promoting cigarette smoking using contest programme.

Voluntary Health Association of India (VHAI) filed a petition in 1999 before the High court of Delhi, raising the issue of surrogate advertising by cigarette manufacturing companies by way of sponsorship of sports events.

A petition was filed by Consumer Education and Research Centre (CERC) in the High Court of Gujrat related to treatment of cancer patients recommending compensation for patients with oral cancer.

Consumer Education and Research Society (CERS) has initiated a class action suits for compensation on behalf of some patients with oral cancer, who developed the illness after being addicted to the chewing of gutkha.

Generation Saviour Association (Mohali, Punjab) filed PIL in 1996 in Punjab and Haryana High court to ban smoking in public places.

Advocacy

Efforts by national and international health bodies and NGOs influenced government nationally and internationally. International support letters and congratulatory letters mobilized through the international NGO network were well received by national government. WHO’s intervention through Framework Convention on Tobacco Control (FCTC) was a landmark public health treaty negotiated by government of member states.

Global effort related to Tobacco Control

World Health Organization’s Framework Convention on Tobacco Control (FCTC) is the first global public health treaty developed in response to the increasing tobacco epidemic. Adopted by World Health Assembly on May 21, 2003 and came into force on February 27, 2005.

The number of countries who have signed FCTC till December, 2005 are 168 and 114 countries have ratified the Convention.

Role of NGOs in Framework Convention

An international Alliance of nongovernmental organizations from around the world was formed to support the development of FCTC and combat tobacco industry disinformation. FCA now comprises of more than 200 groups from more than 90 countries. Role of FCA during FCTC negotiations of educating policymakers on various issues related to tobacco control is an excellent example of how NGOs can play a crucial role in strengthening international policies that address cross border issues.

FCA’s ‘Orchid Award’ and ‘Dirty Ash Tray Award’ were a powerful advocacy tool.

Global Link

Managed by the International Union Against Cancer, GLOBALink is the leading international tobacco control network serving all those active in tobacco-control, and public health.

GLOBALink members range from individuals to international organizations worldwide, and include information centers, news editors, cancer societies, health educators, project officers and congress organizers. Membership to GLOBALink is free of charge.

GLOBALink offers opportunities for Electronic Conferences: This allows users to exchange views on a broad range of issues. Electronic conferences are also designed to help members get national and international support when requested.

Full-text databases: helps find appropriate information or references (news, legislation, directories); hence, a user-friendly document retrieval system provides instant access to many publications, guidelines, calendars and reports.

Home-page service: GLOBALink offers free web/list-hosting to tobacco-control organizations.

Alcohol Marketing in Asia

Transnational alcohol companies use unethical advertising and marketing tactics to get customers particularly the poor. Alcoholic drinks are advertised as products which will bring sexual prowess, success and power. Adverts blatantly make misleading claims about health such as Guiness Stout which suggests it is good for male fertility and virility. Sponsorship and philanthropic activities e.g. Guinness and Carlsberg sponsor cultural, musical and sporting events. Offering scholarships to poor students, and buying computers for rural schools.

Surrogate Advertising

There is a surrogate approach towards liquor advertising in India.

“There is not much that we can do except market ourselves through promotions with the latest being the birthday. Hollywood films like Scent of a Woman have helped in brand endorsement”. - Dr. Amrit Kiran Singh, Vice President and Area Director, South Asia, Brown Forman Spirits Worldwide. The Asian Age, New Delhi, Sep 26, 2005

Alcohol Control Policies in Asia

Bangladesh
Law prohibits production, sale and consumption of alcoholic beverages. Importation is allowed for consumption by foreign nationals and tourists.

Bhutan
Selling alcohol under the age of 18 and driving while intoxicated are punishable offences. Fixed limits on brewing to prevent food scarcities.

Indonesia
The Food and Drug Directorate General in the Ministry of Health controls the production and distribution of alcoholic beverages.

Maldives
Law prohibits consumption of alcohol by citizens .Consumption of imported alcoholic beverages by tourists in specified resorts is permitted.

India
Cable Television Network (Regulation) Amendment Bill, 2000, completely prohibits cigarette and alcohol advertisements, which directly and indirectly promote sale of these products (enacted from September 8, 2000).

Nepal
Hotel business and liquor sale and distribution Act (1966) prohibits sale of liquor to anyone under 16 years of age.

No policy to curb the production or sale. Licence to be obtained under the liquor Act (1971) for producing, selling, importing and exporting liquor. Clause 7 of the act allows anyone to produce a small amount of liquor without licence.

Sri Lanka
Alcohol advertising is not permitted on television or radio.

Adverts are freely allowed in print media and on billboards.

Legal minimum drinking age was changed from 20 to 18 in 1993. Special licences for alcohol sales forsporting events.

Licences available for hotels with only 5 rooms.

Thailand
Banning sales to under 18. Warning labels on alcoholic beverage containers and advertising “alcohol decreases driving ability”. Restriction on alcohol advertising for beverages containing alcohol more than 15 degrees that is banned on radio and television during the period 05.00 – 22.00. Blood alcohol concentration limits for drivers (0.05G percent).

What is needed to reduce the impact of alcohol on health and society:

There is need to advocate for comprehensive national and subnational policies. Measures to educate the public about dangers of unhealthy use of alcohol. Regulate consumption through legal interventions. A comprehensive ban on alcohol advertising needs to be effectively enforced. Measures that restrict access to Youth need to be introduced. Regulating cross border issues through a Framework Convention on Alcohol control.

Alcohol to be treated as an extraordinary commodity and measures affecting the supply, distribution, sale, advertising, promotion or investment in alcoholic beverages be excluded from international trade agreements.

Regional and International efforts needed for alcohol control

Different countries have alcohol policies with varying degrees of emphasis on control of production, distribution and promotion on health education and treatment. Very few countries (especially developing countries) have a comprehensive alcohol control policy.

Global leadership is required to combat the alcohol problem at global level. With the globalization of alcohol markets, alcohol control measures also need to have global inter governmental focal point on alcohol and public health. Though action is required at national level, international bodies and agreements play a crucial role indealing with issues such as tobacco and alcohol.

Learnings from best practices

Sharing evidence from both developed and developing countries that demonstrates that there are effective policy tools that can be used and recommended to individual governments to reduce alcohol related problems at country level and globally.

Subsequently promote national and sub-national policies that follows ‘best practices’ from the developed countries that can be adapted by developing countries with appropriate modifications. International trade agreements need to be closely monitored and advocacy needs to focus unanimously on treating alcohol as an extra –ordinary commodity and should be excluded from these trade agreements.

National and international policies and partnerships are needed to empower communities and to protect them from dangers of alcohol addiction both directly and indirectly. Balanced policies and programmes with regards to the consumption and production of alcohol need to be advocated to national government at all levels and in different sectors.

Effective legislative measures should be recommended to government for inclusion in comprehensive National Alcohol Control Policies. These should include: minimum drinking age, price and taxation mechanisms and controls on marketing and availability.

Multidisciplinary stakeholders (NGOs, youth groups, women organizations, partners interested in avoiding road accidents, scientists, medical societies and health professionals) need to be brought together at each country level to work collectively on alcohol control that requires a multi-sectoral response. It is also important to train people in these sectors about alcohol issues and to provide specialized training in initiating appropriate advocacy with the government at national level and motivate government to connect at regional and international level for comprehensive global policy on alcohol control.