Alcohol and public health policies in India
K S Jacob

India is one of the major growth markets for alcohol and there is increasing concern about any commensurate increase in alcohol harm.

Here, K S Jacob argues that both prohibition and the current permissive strategies are counter productive, and he calls instead for a nuanced public health approach to the issue. This paper first appeared in the National Medical Journal of India Vol. 23, No. 4, 2010. Pages 224–5

There is increasing recognition that consumption of alcohol is a major contributor to the burden of disease in India and the developing world, and is indeed a major public health concern.^1,2 The complex relationships between policies, economics and politics of alcohol and public health and between governments, industry and individuals call for a thorough review of the current situation. While public health implications of policies concerning alcohol have long been accepted, the failure to implement many of these policies demands a more balanced and nuanced approach to the problem.

India has experienced social and economic changes since the 1990s. Current trends suggest a steady increase in the production and use of alcohol; these are supported by available data from the organized sector in India.² However, a large proportion of alcohol produced in India is illicit and its manufacturing is a ‘cottage’ industry outside governmental control.³ Noncommercial alcohol includes traditional beverages brewed using local produce (e.g. rice, wheat, potatoes, molasses and sap from palms and trees) and illicit alcohol spiked with chemicals such as battery acid, urea, ammonium chloride and pharmaceutical medication. The low cost makes it an attractive option for low income groups. The lack of regulation and quality control also leads to mortality and blindness due to methanol poisoning in addition to harmful use and physical morbidity.

The pattern of consumption of alcohol in India has changed from occasional and ritualistic use to social drinking, and has become an acceptable leisure activity for men.⁴ A recent study from Bangalore reported that one-fourth of adult men consumed alcohol.⁵ The increase in consumption in urban and semi-urban areas is mainly due to increased and easy availability of commercially produced alcohol. Hazardous drinking has been recorded in subjects from higher educational status and income levels as well as in those from lower socioeconomic backgrounds. Variations in the preference for any particular type of alcohol were related to the socioeconomic indices.⁵

Hazardous patterns of drinking, with excessive and regular use despite major impact on health and functioning, have been linked not only to acute health outcomes (e.g. intentional and unintentional injury, suicide) but also to chronic diseases (e.g. chronic liver disease, neuropsychiatric morbidity, cardiovascular and cerebrovascular disorders and malignancies).² Harmful alcohol use also contributes to road traffic injuries and fatalities, violence, occupational, marital and social problems including financial debt.⁵ Moreover, harmful use also results in loss of productivity, income and trained manpower. The effects of alcohol aggravate the causes of poverty (e.g. by increasing malnutrition, absenteeism at work, road traffic accidents and loss of productivity).¹

On the other hand, the production and sale of alcohol results in substantial excise and sales taxes, which is a major source of revenue for governments. Duties on alcohol constitute nearly one fourth of the budget of some states in India, making it a seemingly attractive revenue-generating option.⁶ In addition to the generation of legal revenue for the government, the industry also provides large amounts of nontaxed income (black money) to the economy.

While drinking is portrayed as a consequence of poverty, a detailed study of global consumption suggests that it is also associated with relative affluence.¹ The patterns of drinking are changing rapidly with major changes in economic policies, liberalization, the market economy and growing consumerism in India. The break-up of the traditional joint family system, changes in values and attitudes, including those towards consuming alcohol, have also had an impact on its pattern of use.⁵ Cultural and religious controls, which prevented people from drinking alcohol, have been weakening and alcohol use is now seen in all sections of society. Alcohol use is also increasing among groups who were traditionally abstainers such as women, teenagers and the rural rich. The changing economy has brought with it changes in lifestyles and culture.

Election campaigns of political parties often include restrictions on alcohol—a vote winner among women. But these promises are usually not implemented after the formation of government because a complete ban will have a major impact on revenue. High taxation strategies and high cost of alcohol result in the mushrooming of moonshine markets, which lack regulation and quality control and sometimes result in methanol poisoning in addition to loss of revenue to the exchequer. Low taxes, on the other hand, while reducing the demand and supply of illicit alcohol, increase consumption from the organized sector and are associated with increased health risks. The complete ban on the production and sale of alcohol (e.g. prohibition in Gujarat) has resulted in reduced consumption.⁷ Though it does not imply that alcohol is not available in the region.⁸ The rich and the powerful have easy access while the poor rely on a thriving illicit industry. While the ease of availability is reduced, those who are dependent on the substance will find ways of obtaining it. Extreme policies of prohibition and the current permissive strategies are both counterproductive.

The policies on licensing and restrictions on availability of alcohol, dry days, restricted locations and timings of sales outlets, also have an impact on consumption. Recent trends in sponsorship by the alcohol industry and its sophisticated advertising campaigns, which project successful lifestyles, aim to recruit untapped segments of society. While the alcohol industry is a legitimate operation, its functioning (with minimal checks) results in major health consequences to individuals at risk. The media and mass education campaigns, with their limited budgets, are no match for industry-sponsored promotion.

The statute books have many laws related to alcohol. However, many regulations including those related to drink driving are observed more in the breech with alcohol outlets freely advertising their wares even on national highways. A review of national road safety suggests an increase in road traffic fatalities and the lack of enforcement of drink driving laws and the absence of audits related to new roads and highways.⁹ The strict enforcement of laws related to drink driving in the West has led to responsible drinking and responsible driving, which argues for the need for similar implementation in India. Similarly, work-related accidents and absenteeism due to the use of alcohol should be tackled with firm implementation of rules to reduce the loss of productivity and manage alcoholrelated problems at an early and reversible stage. There is also a need to support employees who misuse alcohol, and implement policies for prevention of use and promotion of alternative healthy lifestyles.

While psychiatric treatment and rehabilitation do help individuals in quitting the habit, the delay in referral results in seeking help at the end stages of the problem when family, social and financial supports are low and the motivation to quit limited. Early identification of problem drinking at the workplace and by general physicians will pay greater dividends in breaking the cycle of poor choices.

The only systematic study from India on expenditure related to alcohol, using conservative costs, estimated that while the government spent more every year to manage the direct and indirect consequences of alcohol use than it gained in terms of taxes from the sale of alcohol.⁵ While revenue from alcohol appears to help in social and economic development in the short term, it does result in huge costs in the medium and long term.

To view alcohol-related problems as a medical or an individual’s issue is to fail to understand the complex dynamics related to policies and politics of alcohol and their impact on individual health and on the consequences of alcohol use. Population and public health interventions have a greater impact on alcohol-related morbidity and mortality than on individual therapy. While holding individuals responsible for their lifestyle choices is crucial, the government cannot abdicate its responsibility and fail to use public health perspectives and approaches, which have a greater impact on the population rates of use, abuse and consequences of excess consumption of alcohol. The enforcement of laws related to alcohol (e.g. drinking and driving) and monitoring alcohol intoxication at work will have a major impact on the consumption of alcohol and on individual health. In addition, personnel and legal departments at the workplace need to implement rules and labour courts should support their enforcement.

India should review policies and support legislation that promote health, prevent harm and address the many social problems associated with the use of alcohol.¹⁰ These should include a broad range of policies and approaches including those related to licensing, taxation, restrictions on availability and purchasing, education and media information campaigns, advertising and sponsorship, laws on drink driving and alcoholrelated offences and those related to treatment and rehabilitation. Serious attempts should be made at achieving a balance between economic and political issues related to alcohol current ad hoc policy-making should change to a long term intersectoral perspective and policy. Health perspectives demand increased advocacy to implement public health approaches to reduce alcohol consumption. There is a need to balance regulation by governments, industry and individuals.

The goal of a sustainable and effective alcohol policy can only be achieved by coordinated action by multiple stakeholders. The divergent frameworks used result in confusion and inaction. Multiple agencies including the Ministries of Law, Industry, Agriculture, Revenue, Health, Home, Customs and Enforcement, non-governmental organizations, and medical associations should be involved. Indian society and governments need to take a longer term view of issues and plan a coordinated, comprehensive and balanced approach. While complete prohibition has been shown to be a failure, the current permissiveness without the enforcement of regulations also represents a lack of responsibility from a public health perspective. The WHO’s global strategy for alcohol¹¹ and governmental and non-governmental efforts¹² can be used synergistically to produce sustained action.

CONFLICT OF INTEREST
None declared.

Reprinted by kind permission of Professor K S Jacob, Department of Psychiatry, Christian Medical College, Vallore, Tamil Nadu, India and The National Medical Journal of India, AIMS, New Delhi, Vol 23, No 4 2010 pages 224-225

(A similar article appeared in the lay press. It can be accessed at Jacob KS. Alcohol politics, policies and public health. The Hindu 03.11.09 Available at http://www. hindu.com/2009/11/03/stories/ 2009110356060800.htm).