By Dr. Marjana Martinic, Consultation Event Alcohol Panel Presenter and Deputy President, International Center for Alcohol Policies (ICAP) Washington DC.
Problems and diseases related to the harmful use of alcohol are high on the agenda of global public health policy. Alcohol ranks fifth among risk factors for disease and disability, according to the most recent calculations from the Global Burden of Disease study1, and has become the focus of considerable political attention. In 2010, the 63rd World Health Assembly adopted the WHO Global Strategy to Reduce the Harmful Use of Alcohol,2 and the Global Action Plan for the Prevention and Control of NCDs 2013-20203 identifies the harmful use of alcohol as one of the main areas for action. Yet alcohol stands apart from other risk factors for health, making it a unique challenge for prevention and policy.
Due to its dual nature, alcohol is implicated in outcomes that sit on a continuum from benefit to harm. The relationship between drinking and its consequences is influenced by many individual, societal and cultural factors.4 At a political level, efforts to address alcohol-related harm may be impeded by tensions between local needs and priorities, and politicised global imperatives. The ability to effectively address alcohol-related harm both at the micro and the macro level requires an understanding of the role that drinking (and alcohol itself) plays in society, and how that role affects the relationship with outcomes. This allows a crafting of responses that are appropriate and flexible enough to meet particular needs and circumstances. Most importantly, policy and prevention must not be driven by ideology or moralistic positions, but by pragmatic considerations aimed at maximising benefits and minimising harm. They must be inclusive of opportunities, resources, and a broad range of stakeholders.
From drinking patterns to outcomes
While most people who drink do so with few problems, many experience a range of harmful social and health outcomes in the three domains identified in WHO’s definition of health as a “state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity”.5
Alcohol is inextricably linked with each of these three areas, and also plays a role in how they relate to each other. The detrimental impact of chronic heavy drinking, for example, has been well described,6 as has the relationship with acute outcomes, which include accidents, injuries, and mental health problems.7 The involvement of alcohol in certain social issues, such as violence and public order has also been studied extensively.8 At the same time, moderate drinking confers both somatic and mental health benefits9, and has an impact on the intangible dimensions of quality of life (Table 1).
Yet the outcomes of drinking do not depend solely on how much people drink, but also on where, when, by whom, and for which purpose alcohol is consumed.10 These so-called ‘drinking patterns’ describe three distinct but interrelated aspects of alcohol consumption and are powerful predictors of both negative and positive outcomes. As a point of departure, the crafting of responses requires a thorough understanding of these often complex relationships.
The first component describes individuals and groups whose common practices or traits affect drinking and its likely outcomes. For example, the physiological response to alcohol is quicker in women than in men, and occurs at lower levels of consumption. Women are also at risk for particular diseases in which alcohol plays a role, including breast cancer,11 and the impact of heavy drinking on pregnancy and fetal development has been well described.12 As a result, women generally drink less than men, and are also advised to do so where official recommendations on drinking exist.13 Young people’s inexperience with alcohol, their propensity for risk-taking, and certain physiological and developmental factors place them at higher risk than adults for adverse outcomes.14 Appropriate interventions aimed at these groups, therefore, require a nuanced approach. Similarly, those individuals with particular health conditions or a genetic predisposition for alcohol dependence require tailored measures, including advice on whether to drink at all.
Table 1. The relationship between drinking patterns and outcomes for physical, mental, and social health. Beneficial and harmful effects have been described in research studies for the various diseases and conditions listed. Adapted from Stimson et al.15
The second facet of drinking patterns includes culture-bound factors, such as norms and perceptions around the acceptability of drinking,16 and societal views on drunkenness. Drinking cultures have been dichotomised into “wet” and “dry”.17 At one end of the spectrum lies the Mediterranean-style pattern, which is regular and well integrated into daily life, but with little tolerance for intoxication and drunken behaviour. On the other end lies the Nordic-style pattern, with its concentrated episodes of heavy drinking and general acceptance of drunkenness as a normative outcome. While many drinking cultures lie somewhere in between these two extremes, they serve as a useful illustration of the role played by cultural norms. They also exemplify the values and constraints that society places on drinking and how problems might be viewed.
Finally, behaviours also have an important bearing on consequences. The risks inherent in drinking and driving, for example, are all too familiar, as are its consequences, and the impact of “extreme”18 drinking that has as its goal intoxication can easily be predicted. It is important to recognise that the implications of the relationship between drinking patterns and outcomes reach far beyond the individual. They also have a profound bearing on families and communities, social and public order, productivity, and social equity.
The cultural dimensions of drinking
It is clear that culture plays a pivotal role in the relationship between drinking and outcomes. Yet culture is hardly static. Globalisation, urbanisation, migration and social integration have a profound impact on drinking styles and patterns. One example is the shift that has occurred over past decades in some European countries with regard to beverage preferences that were previously closely tied to national and cultural identify. In Italy, for example, the traditional consumption of wine has declined significantly; Russia, where spirits were once considered the beverage of choice, has experienced a shift towards beer, especially among younger consumers (Figure 1).
Figure 1. Changing trends in alcohol beverage preferences Italy and Russia, 1990-2008.
Source: World Health Organisation (2013). Global Information System on Alcohol and Health (GISAH).
Changing beverage preferences are at times also accompanied by changes in total levels of alcohol consumption. Once widely disparate across the countries of Europe, country-level consumption has been gradually converging, a reflection of evolving preferences, homogenisation of cultures, and, in some cases, changes in alcohol regulation within the EU (Figure 2).
Figure 2. Recorded total adult (15+ years) consumption of alcohol (per capita), 1991-2010.
Source: World Health Organisation (2013). Global Information System on Alcohol and Health (GISAH).
Cultural shifts have also been observed in other aspects of drinking. One notable example is the trend of increasing alcohol consumption among women in both developed and developing countries. There has been an increase in the numbers of women who drink, including in countries where this has traditionally been frowned upon. Some have blamed the globalisation of the alcohol market. However, changing gender roles, greater gender equality, the presence of more women in the workforce, and greater economic power surely play a sizeable role in this trend. However, these shifts have also been associated with heavier drinking among some women, with implications for problematic outcomes.
According to the European School Survey Project on Alcohol and Other Drugs (ESPAD),19 a longitudinal survey of students, girls are not only increasingly keeping up with boys, but in some cases, such as in the UK, are out-drinking them. These developments suggest the need for new approaches that are responsive to the ongoing societal changes and that can help minimise harm.
Changing consumption trends and patterns have also been observed across the developing world, and with them new challenges. Increases in economic prosperity and the emergence of a more affluent middle class have resulted in changes from traditional drinking styles to more “western” patterns of consumption. At the same time, a higher prevalence of alcohol-related chronic diseases and alcohol dependence has also been reported in these countries, particularly among urban populations.
The impact of changing drinking patterns in developing countries is further complicated by continued high levels of consumption of unrecorded alcohol. This segment, which does not figure in official government statistics, includes home-produced traditional beverages, illicit and counterfeit products, and surrogates (e.g., cleaning fluids, colognes),20 and is conservatively estimated at around 30% of total global consumption. In some regions, the figures are significantly higher: 90% of all consumption in Eastern Africa; two thirds of all alcohol on the Indian Subcontinent; and a third in Europe and Latin America.21 There is also wide variation at country level in the proportion of the unrecorded alcohol market (Figure 3). While some of these beverages are of reportedly high quality, others are high in alcohol content, contaminated, or adulterated with potentially toxic substances. There is also evidence, particularly in some regions, that locations where unrecorded alcohol is sold may also serve as settings for the sex trade and contribute to the spread of HIV/AIDS.22
Figure 3. The proportion of recorded and unrecorded alcohol in select countries.
Source: International Center for Alcohol Policies (ICAP).23
The complexity of the alcohol market in developing countries shows the challenges in unravelling the relationship between drinking patterns and harm. While regulators might be tempted to curtail access to branded products in an effort to reduce consumption, unrecorded alcohol remains outside the reach of government. From the standpoint of interventions, therefore, it is clear that approaches to addressing alcohol-related harm in developing countries, from both a public health and a social perspective, require measures that take into account the full cultural context and the reality of consumption among the population, as well as the potential for unintended consequences.
Policies aimed at alcohol beverages, like most other health and social policies, should have as their primary goal the minimisation of harm while maximising benefit. This applies to individuals as much as to populations, and requires realistic, responsive and culturally appropriate approaches that can balance the rights and responsibilities of the individual with those of society.
Traditional public policy responses to alcohol problems have largely ignored the wide array of idiosyncratic drinking cultures and the diversity in drinking patterns that exist around the world. The mainstay of policy measures has been a focus on regulation to reduce levels of consumption, on the assumption that this will also reduce problems. Restricting the availability of alcohol, most commonly by increasing price, curtailing hours of trade and licensing, and instituting government monopolies for the sale of alcohol beverages (e.g., in Nordic countries, US and Canada), and in some cases its production, form the pillars of alcohol control policies. Additional measures are aimed at restricting marketing and advertising, at limiting access by groups at particular risk for harm, notably young people, for whom legal purchase age limits apply,24 and at reducing drinking combined with other activities, such as while driving25 or in the workplace.
There is no question, given alcohol’s potential for abuse and the risk for negative outcomes, that regulatory measures to prevent unfettered availability and access are needed. Indeed, alcohol is one of the world’s most heavily regulated commodities. However, while the simplicity of population-level approaches holds obvious appeal for governments, they are blunt instruments, insensitive to the diversity of drinking patterns and problems that are of relevance to particular target populations. It has been shown, for example, that heavier drinkers are actually less responsive to pricing policies than are moderate drinkers,26 and require a more targeted and specific approach. Similarly, while marketing restrictions are often hailed as a panacea to reducing drinking among young people, in reality, parents and peers are significantly more influential in shaping drinking patterns.27
The application of a one-size-fits-all approach is also unsatisfactory in addressing the world’s many drinking cultures and myriad political, social and economic contexts, and can result in unintended outcomes.28 These may create new problems without necessarily solving old ones. For example, pricing policies that aim to reduce consumption by making alcohol beverages less affordable have encouraged consumers to simply switch to cheaper alcohol, which may be of poor quality.29 This includes a shift to the unrecorded sector, often associated with organised crime. Other measures, such as restrictions on the trade of alcohol, for example through alcohol retail monopolies in Nordic countries, has in part been responsible for high rates of smuggling and cross-border traffic.30
The appeal of regulation for governments is understandable. It is quick, demonstrates action, and brings in revenue. However, the reality is that in many countries, particularly in the developing world, regulatory measures are poorly enforced. The infrastructure that allows policing and controls in high-income countries is lacking in the world’s poorer ones. There is also a tendency to ignore the social, political, and economic context within which alcohol policy measures must be applied. Social and health harms in developing countries, from the harmful use of alcohol to other areas, are also the product of a lack of resources for healthcare, public services, treatment options, and infrastructure. It is unrealistic to expect that policies that can be applied in Sweden or Australia can equally be applied, enforced, or are even appropriate in Nigeria or Colombia.
Engagement for prevention and policy
What, then, is the solution? First, there is a need for a strong regulatory framework around the production, sale and consumption of alcohol. Yet there is a danger in assuming that, by itself, regulation can provide an adequate response. Feasible and sustainable interventions for reducing alcohol-related harm are not the ones that offer simple solutions. Rather, they must involve a pragmatic approach to alcohol problems. People will drink as long as alcohol products are legal and will continue to do so even when they are not. People will also continue to take risks, to drink too much, and to ignore common sense. The imperative, therefore, is to strive to make sure that drinking, when it occurs, is as safe as it possibly can be.
Setting aside the prerequisite of a balanced regulatory framework, workable solutions are those that recognise this challenge. They include measures aimed specifically at reaching young people through education and changes in social norms to defer the onset of drinking or to prevent intoxication. Special measures that include screening, brief interventions, and treatment are needed to address the particular needs of problem drinkers. Changes to the drinking environment, and attention to the quality and integrity of beverages are, similarly, measures that can reduce the likelihood of harm. Education and awareness-raising among consumers, encouraging them to avoid harmful drinking patterns and to make informed and responsible choices, are also included in this array of measures.31 The selection of the right mix needs to be made while bearing in mind the role that alcohol plays in a particular society, its cultural value and context, and the degree to which particular interventions are likely both to be appropriate and to enjoy public support.
Workable solutions are also those that build on the strengths of different stakeholders, allowing them to contribute to reducing harmful outcomes according to their individual competencies.32 Regulation and the setting of policies is the realm of governments, but at national level, bearing in mind local context, challenges and culture. Educators, health professionals, and prevention specialists have a role in crafting interventions that can raise awareness and encourage safe and responsible drinking behaviours. Community leaders and civil society have a particularly important role in responding to immediate needs and in setting priorities. Those who produce, sell and serve alcohol beverages also have a role to play within their respective competencies. And, finally, the average consumer, almost universally ignored, has a role in making decisions and in voicing dissent when measures unreasonably infringe upon individual rights.
Encouragingly, WHO’s Global Alcohol Strategy, at least in theory, offers an approach that has the potential to touch upon these various criteria for success, offers a flexible menu of prevention and policy approaches, and proposes a seat at the table for all relevant parties. However, whether it will live up to the complexities of drinking and culture, be inclusive and implemented in an appropriate and responsive way, or be usurped by ideology and moralistic positions remains to be seen.
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