World Bank calls for action on youth and alcohol

Raising prices through taxation, comprehensive bans on advertising and product promotions, age restrictions on sales and prominent health warnings on alcohol are called for by the World Bank in its World Development Report 2007*.

The report, Development and the Next Generation, is devoted to the theme of young people, and it says that there has never been a better time to invest in young people in developing countries.

Those who are 12-24 years of age number 1.3 billion and make up the largest youth cohort in history. They are, on average, more educated and healthier than generations before them. They represent a potentially stronger base on which to build in a world that is increasingly demanding more than basic skills.

Today's young people are the next generation of workers, entrepreneurs, parents, active citizens and leaders who have relatively fewer dependents because of lower birth rates. Countries need to seize this window of opportunity to invest in the future before the ageing process closes it.

The report discusses priorities for government action across five youth transitions that shape young people's human capital: learning, working, staying healthy, forming families, and exercising citizenship.

Within these transitions, priorities for investment vary across countries. The Report highlights three lenses that help assess priorities: expanding opportunities, enhancing capabilities, and providing second chances.

• Expanding opportunities focuses on increasing the quality (not just quantity) of education, smoothing the transition to work, and providing young people with a platform for civic engagement.

• Enhancing capabilities involves making young people aware of the consequences of their actions, especially consequences that will affect them much later in life; building their decisionmaking skills; and giving them the right incentives.

• Providing second chances calls for helping young people recover from missed opportunities through remedial education, retraining, treatment, and rehabilitation.

Growing up Healthy
The report says that the best way to avoid the future loss of human productive capital and steep increases in future health care expenditure is to modify health behaviour during youth, when habits are still being learned. Policies to promote better health in young people stand on three legs: the provision of the knowledge and skills necessary to make informed choices and negotiate safe behaviour; an environment that enables healthy behaviour and discourages risky behaviour, and, for young people harmed by poor health decisions or environments, treatment and rehabilitation services.

Alcohol, tobacco and drugs.
Alcohol is the most widely consumed drug in the world: about half of those 15 and older have consumed alcohol in the past year. Patterns are difficult to interpret, because moderate drinking – even by youth – is accepted in many countries. The proportion of young people who report drinking generally exceeds 60 percent, of whom 10 to 30 percent engage in binge drinking. In the United Kingdom, young people between 16 and 24 are the heaviest drinkers in the population, and the least likely to abstain from drinking. Limited data from developing countries suggest that young people are beginning to drink alcohol at earlier ages. Boys are more likely than girls to drink alcohol and to drink heavily, though consumption among girls in some countries (especially in Latin America) has begun to approach or even surpass that of young men.

Early initiation of alcohol use is correlated with a greater likelihood of both alcohol dependence and alcohol-related injury. A study of hospitals in three cities in South Africa found that 61 percent of patients admitted to trauma units in these cities were alcohol-positive, including 74 percent of violence cases, 54 percent of traffic collisions, and 30 percent of trauma from other accidents. Young people who abuse alcohol and drugs are more likely to commit crimes, and substance abuse is a major risk factor in violence. Examination of 960 people arrested in nine police stations in three cities in South Africa found that 22 percent were under the influence of alcohol when the alleged crime took place.

Per capita consumption of tobacco is declining in developed countries, but rising in many developing countries, for both men and women. Between 1970 and 1990, tobacco consumption is estimated to have increased by about 3.4 percent a year in low- and middleincome countries, and people are beginning to smoke at younger ages. Reported use of cigarettes, pipes, and chewing tobacco varies widely. Most smokers in Indonesia consume clove cigarettes, which contain twice the tar, nicotine, and carbon monoxide of American cigarettes, and smoking among 15- to 19-year-olds rose from 32 percent in 1993 to 43 percent in 2000. Fewer girls than boys report tobacco use, though it may be increasing among girls in developing countries.

Few young people experiment with illegal drugs, and an even smaller number go on to develop long-term chronic problems. Even so, measures to prevent experimental use are worthwhile to avoid addiction and the acute and possibly fatal reactions with even limited experimental use. Young people in developed and developing countries experiment with cannabis, amphetamines, cocaine, heroin, and inhaling solvents, glue, and gasoline. Inhaling volatile chemicals, relatively neglected by policy makers, is extremely dangerous, and acute intoxication can be fatal. Young people are more likely to abuse solvents because they are easily available in homes and shops, and street children are especially vulnerable.

Street children abusing drugs:
The prevalence of illegal drug use is highest in developed countries but increasing in developing countries. In many regions, especially Central Asia, prevalence now approaches developed country levels. (Estimates of drug abuse by young people are available only from a few small studies, mainly for school students.) There are an estimated 13 million injecting drug users worldwide, 78 percent of them in developing and transition countries, the majority young. Potentially deadly in itself, injecting drug use increases the risk of acquiring HIV through the sharing of infected needles and the exchange of body fluids.

Changing prices and incentives
Young people’s choices respond to changes in prices and incomes, as well as to the existence of health services. In rural Kenya, a randomized controlled experiment providing free uniforms (along with sex education) significantly reduced risky sex, as evinced by a drop in pregnancy incidence among schoolgirls. General poverty alleviation programs targeted at youth or families with youth can increase the opportunities available to young people, and conditional cash transfers can provide additional incentives for health choices. The Oportunidades program in Mexico provided incentives for young people to remain in school, where they received health information and periodic health services. In addition to the beneficial effects on schooling, the program led to reduced smoking and alcohol consumption for all youth, and an increase in the age of sexual debut among girls.

Most governments levy taxes on tobacco and alcohol, which increases prices. In general, young people are more price-sensitive than adults. If the price of cigarettes rises, they are less likely to take up smoking, and those who have begun smoking are more likely to quit. In Indonesia, where the prevalence of smoking among men is high, 15- to 24-year-old males were more responsive to cigarette prices than older males. Alcohol consumption also declines with increases in price. Among high school students in the United States, a 10 percent increase in the price of alcohol will reduce alcohol consumption by 4-5 percent, and binge drinking by 20 percent. There is similar evidence on the consumption of illicit drugs: a 10 percent increase in the price of marijuana will reduce marijuana use by 5 percent; and price increases in marijuana, cocaine and heroin reduce both arrests and hospital admissions associated with drug consumption. Changes in prices can explain most of the observed changes in binge drinking and marijuana use by high school seniors between 1975 and 2003.

Cigarette smoking tends to be more sensitive to price in low-income countries than in high-income countries. For example, it is estimated that a price rise of 10 percent for a pack of cigarettes reduces demand for cigarettes by 6- 10 percent in China, and only 4 percent in the United States. One reason for the difference could be that low-income countries have a larger share of young people than high-income countries, and young people are more price-sensitive than adults. Poorer people are also more price-sensitive than wealthier.

In addition to raising prices through taxation, comprehensive bans on advertising and product promotions, age restrictions on sales, and prominent health warning labels can reduce the consumption of tobacco and alcohol. Comprehensive bans on cigarette advertising and promotion reduced smoking in some highincome countries, although partial bans had little or no effect. Studies based on cross-country analysis find no link between advertising and sales restrictions and reduced smoking. However, a study of 100 countries comparing consumption trends over time found that consumption fell much more steeply in countries that had nearly complete bans on advertising, compared with countries with no such ban. Health warning labels on cigarette packs, though effective in reducing tobacco consumption among adults, may not discourage youth from smoking, because they are more likely to buy single cigarettes than packs.

Young people are exposed to a wide variety of tobacco control policies, including advertising restrictions, health warnings, and prohibitions on the sale of tobacco to minors. There is little consistency in policies: some countries ban advertising without restricting sales to minors; others ban sales to minors but do not restrict advertising. The independent effect of each policy is difficult to identify. Interventions to reduce the consumption of these potentially harmful substances are more effective if implemented jointly: for example, tobacco control is more effective if it includes both advertising bans and higher taxes.

Policies to reduce consumption of harmful substances can have unintended consequences. In 1985, Russia restricted alcohol sales and raised the legal age for alcohol consumption. This dramatically improved life expectancy among men, but it also increased the use of harmful alcohol substitutes.

Russia limited the sale of alcohol, and deaths and illnesses fell.

* World Development Report 2007: Development and the Next Generation