Hiding in plain sight

Recently, a member of Movendi International send me a WhatsApp text, saying: “We cannot in any way work with the devil to drive demons out of our homes.” It was another example for me that people from different cultures, religions and origins have a profound understanding of and sensitivity to situations of conflicting goals and interests.

In the world of public and global health and development the alcohol industry’s conflict of interest is, however, still hiding in plain sight.

In general, we observe that recognition is growing of the influence of corporate activity on the health and development of populations. Corporations of substantial size and scope – such as multinational alcohol giants – influence population health and development in many different and interconnected ways, often across national borders.

The alcohol industry is a perfect example.

Therefore, the understanding of the transnational alcohol industry as commercial determinants of health and development is important. Big Alcohol is producing, promoting, distributing and selling products that have direct negative effects on the health and development of people, communities and populations. Moreover, the alcohol industry – consisting of producers, distributors, retailers and marketers of alcohol products, and a network of front groups, law firms and PR agencies – is impeding health and development through a much broader range of activities that promote their profit interests at the expense of the public interest, such as lobbying to reduce corporate taxation, or diluting or delaying measures that protect health and development at national, regional, and global levels.

Scientific analysis also shows that different corporations use the same methods, for example the alcohol industry is employing Big Tobacco’s playbook.

Despite some important differences, the extensive similarities which exist between the tobacco and alcohol industries in terms of market structure and strategy, and political strategy, call into question the rationale for both the relatively weak regulatory approach taken towards alcohol, and the continued participation of alcohol corporations in policy-making processes,” concluded Hawkins, Holden, Eckhardt and Lee in their study comparing the global tobacco and alcohol industries, in 2016.

But while people in communities around the world, like Movendi members, are sensitive to interests that are at odds with each other, the opinion leaders and decision-makers in global health and development have so far allowed the alcohol industry to play a role that it clearly exploits to its advantage and to the disadvantage of the greater public good.

the alcohol industry has largely avoided the stigma associated with the tobacco industry, write Marten, Casswell and Herrera Amul in The Lancet.

WHO, UN approach to Big Alcohol: Not evidence-based

Despite overwhelming scientific evidence about Big Alcohol’s conflicting interests, the approach of the UN in general and WHO in particular to the alcohol industry remains a serious concern.

For example, the WHO Global Alcohol Strategy is equating civil society engagement with the engagement of economic operators in the alcohol industry – to reduce alcohol harm. This is specified under the strategy’s headline of “Global action: key role and components,” where it says:

45. International nongovernmental organizations, professional associations, research institutions and economic operators in the area of alcohol, all have important roles in enhancing the global action, as follows.”

Under point 45. d) the strategy goes on to say:

Economic operators in alcohol production and trade are important players in their role as developers, producers, distributors, marketers and sellers of alcoholic beverages. They are especially encouraged to consider effective ways to prevent and reduce harmful use of alcohol within their core roles mentioned above, including self-regulatory actions and initiatives. They could also contribute by making available data on sales and consumption of alcohol beverages.”

While the WHO Global Alcohol Strategy limits the role of the alcohol industry to their core business and excludes them thus from engagement in public health policy-making, it still advances the problematic concept of self-regulation and of the overall role they play for preventing and reducing the harm their products and business practices are causing.

The schizophrenic elements of the WHO Global Alcohol Strategy are apparent when the strategy talks about the challenge in alcohol control to be “balancing different interests” on the one hand but then also recommends “reducing or stopping subsidies to economic operators in the area of alcohol.” under the section of pricing policies.

This has created a reality where the alcohol industry is actively promoting doubt and confusion about WHO-recommended policy solutions and WHO-established evidence about the health harm of alcohol, and is still invited to “dialogue” meetings with the WHO.

Another example where the fundamental conflict of interest has been disregarded comes from the United Nations. In 2018, the UN General Assembly adopted the “Political declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases” (PDF).

In operating paragraph 44, the declaration invites “the private sector to strengthen its commitment and contribution to the implementation of national responses to prevent, control and treat non-communicable diseases to reach health and development objectives by:

44. b) Encouraging economic operators in the area of alcohol production and trade, as appropriate, to contribute to reducing harmful use of alcohol in their core areas, taking into account national religious and cultural contexts;

44. c) Taking concrete steps, where relevant, towards eliminating the marketing, advertising and sale of alcoholic products to minors.”

But the evidence-base of scientific studies is by now clear: children and youth are exposed – and often targeted – to an avalanche of alcohol promotions, advertising and sponsorship.

Investing in alcohol marketing is good business for Big Alcohol, but harmful for children, youth and society. For example:

  • Youth who saw more alcohol advertisements on average consumed more alcohol; each additional advertisement seen increased the number of alcoholic drinks consumed by 1%.
  • Youth in markets with greater alcohol advertising expenditures consumed more; each additional dollar spent per capita raised the number of alcoholic drinks consumed by 3%.
  • In the United States, for example, every day, 4,750 young people under age 16 have their first full alcoholic drink of alcohol. This is a problem because the earlier young people start consuming alcohol, the bigger the likelihood that they will suffer alcohol-related health and social problems later in life.
  • Compared to those who wait until they are 21 to start consuming alcohol, young people who begin alcohol use before the age of 15 are four times more likely to become alcohol dependent, seven times more likely to be in a motor vehicle crash because of alcohol and 11 times more likely to be in a physical fight after alcohol use.

Exposure to alcohol marketing increases the likelihood that young people will start consuming alcohol, or that they will consume more alcohol if they are already consuming. A wide range of studies has established the association between exposure to alcohol marketing and youth alcohol consumption, even after controlling for a variety of variables such as parental monitoring or socioeconomic status.

Already in 2003, a comprehensive study showed that underage alcohol users and adult heavy alcohol users in the United States were responsible for 50.1% of alcohol consumption and 48.9% of consumer expenditure.

Alcohol harm of epidemic proportions

But alcohol harm is an industrial epidemic – as it is a risk factor for over 200 different health conditions across all categories of disease burden, affecting both the incidence and progression of infectious diseases, non-communicable diseases, and injuries.

And yet, global alcohol consumption is projected to be rapidly expanding and to increase by more than 10% by 2030 – despite governments’ voluntary commitment to reduce per capita alcohol use by 10% until 2025.

Fundamental conflict of interest

While increased alcohol consumption leads to increased negative health and development impacts, it also leads to increased sales for the alcohol industry, placing public health and development interests in an inherent and direct conflict with corporate interests.

There are four key examples from around the world illustrating the obvious conflict of interest between the private profit interests of the alcohol industry and the public interest in health and development for all:

Middle-income countries: Big Alcohol Relies on Heavy Users For Their Profits

Analysis of data collected in the International Alcohol Control study and used to estimate how much heavier alcohol consumption occasions contribute to the alcohol market in five different countries shows the alcohol industry’s reliance on the heavy use of alcohol.

  • In higher income countries heavier alcohol consumption occasions make up approximately 50% of sales.
  • 76% of sales in middle-income countries are resulting from alcohol consumption in excess of the WHO heavy episodic alcohol intake definition.

Big Alcohol Relies on Heavy Users For Their Profits

Study: How Dependent is the Alcohol Industry on Heavy Alcohol Use in England?

Those using alcohol above guideline levels are estimated to account for 68% of total alcohol sales revenue in 2013/14. This represents 77% of beer, 70% of cider, 66% of wine and 50% of spirits sales value.

The heaviest alcohol using 4% of the population account for 30% of all consumption and 23% of all industry revenue. If all consumers reduced their alcohol use to within guideline levels, alcohol sales revenue could decline by 38% (£13 billion).

In England, the alcohol industry appears to be highly financially dependent upon heavy alcohol use, and might face significant financial losses were consumers to use alcohol within guideline levels.

Despite claims to promote “moderate” alcohol use, the alcohol industry actually gains much of their profits from heavy alcohol users and people who are addicted to or dependent on alcohol. The study highlights the conflict of interest in involving the alcohol industry in public health policy-making regarding alcohol control.

The Economist reports about the study and writes:

The alcohol industry has pitched itself as part of the solution. In Britain more than 100 producers and retailers have signed a ‘responsibility deal‘ and promised to ‘help people to drink within guidelines’, mostly by buying ads promoting ‘moderation’.

However, if these campaigns were effective, they would ruin their sponsors’ finances.”

How Dependent is the Alcohol Industry on Heavy Alcohol Use in England?

Australia: Big Alcohol Targets ‘Super Consumers’

The alcohol industry depends for its profits on those consumers that use alcohol in heavy amounts, regularly exceeding the recommended daily intake of alcohol, a 2016 report from Australia shows.

More than 3.8 million Australians average more than four standard alcoholic drinks per day, twice the recommended amount of the health guidelines. These alcohol users are targeted by the alcohol industry and branded as “super consumers”, according to the latest report from the Foundation for Alcohol Research and Education.

  • The concentration of alcohol consumption among the heaviest alcohol users has increased in recent years. The top 10% of consumers accounted for 49% of the consumption in 2001, and this had increased to 53% in 2013.

Those in the business of selling alcohol have long known about the skewed distribution of alcohol consumption in the population. In meetings among people in the industry, those at the top end of the distribution are called “super consumers“, and they are vital to maintaining or increasing sales.

  • If all the “super consumers” reduced their alcohol use to the two-drinks-a-day average recommended by the NHMRC as an upper limit, alcohol sales would fall by 39%.

If all [alcohol users] in Australia were to [consume] within the government guidelines for low-risk [alcohol use], the alcohol market would shrink substantially,” wrote Robin Room and Michael Livingston in The Conversation.

If governments want to reduce alcohol-related harms, they can’t rely on the industry’s commitment to responsible [alcohol use]. It’s directly against the industry’s interests for the heaviest [alcohol users] (who make up the majority of their sales) to [consume] less.”

Big Alcohol Targets ‘Super Consumers’

USA: Big Alcohol Dependent on Heavy Users

Analysis shows how heavily dependent the alcohol industry is on heavy alcohol users. If the top 10% of alcohol consumers would be induced to curb their consumption level – for example through alcohol taxation and other price policy measures – to that of the next lower group (the ninth decile), the total alcohol sales would fall by 60%.

While 30% of the American population live free from any alcohol consumption and another 30% consume less than one alcoholic drink per week, on average, the top 10% of alcohol users – 24 million adults over age 18 – account for more than 50% of the alcohol consumed in any given year.

Clearly Big Alcohol is heavily dependent on heavy alcohol consumers for their profits.

One consequence is that the heaviest [alcohol users] are of greatly disproportionate importance to the sales and profitability of the alcoholic-beverage industry,” writes Philip J. Cook, author of “Paying the Tab”.

USA: Big Alcohol Dependent on Heavy Users

Alcohol industry, alcohol profits, alcohol harm

There is a direct link between alcohol industry products and practices, their profits and population-level alcohol harm.

A few years after the adoption of the WHO Global Alcohol Strategy, alcohol industry-favorable propaganda was increasing with the posting of over 3500 ‘Industry Actions to Reduce Harmful Drinking’ that were designed to demonstrate Big Alcohol’s support of the strategy. The problem is that not only are these actions mostly trivial, but in some cases potentially harmful to public health – as research demonstrated.

Since Big Alcohol is dependent on under-age alcohol consumers as well as adult heavy alcohol users for the majority of their total profits, they cannot support the most effective, evidence-based alcohol policy interventions, and not even the public’s understanding of the real effects and harm of alcohol. This would affect their bottom line at a massive scale.

In fact, the alcohol industry wants more alcohol use, not less.

But the core part of the WHO Global Alcohol Strategy is five cost-effective, high-impact interventions directed at reducing the availability and sale of alcohol, either overall or to particular vulnerable groups, and at building up management, leadership and information systems to direct and support these interventions. The success of these evidence-based public health strategies is therefore a direct threat to the alcohol industry’s interest in maintaining and increasing sales.

In four waves of market concentration over the last decades, Big Alcohol has accumulated extensive market, financial and political power. A few major corporations, operating transnationally, dominate the alcohol market, especially the beer but also the liquor and wine market. They have the financial and political power to derail, delay, obstruct or undermine public policies that protect Human Rights and that promote sustainable development, social justice and public health; they can undermine the public discourse about the real harm of alcohol; and they can buy the science they prefer.

9 Strategies to protect profits, sway public opinion and influence public policy

The alcohol industry, similar to Big Tobacco, utilizes an array of tactics and strategies to promote their products in order to maximize profits for their shareholders. Therefore, there is necessarily an inherent conflict of interest between their goals of promoting health damaging products and the goals of public health.

In the battle between public health and private profits there is now a vast track record of the alcohol industry obstructing, derailing, delaying or watering down cost-effective, high-impact, and evidence-based public health policies – such as in the WHO SAFER technical package – that are antithetical to their economic interests.

In Movendi International we categorize the strategies of the alcohol industry in the following way, to illustrate in 9 categories how the conflict of interest plays.

  1. Promotion of “healthier” and “safer” products
  2. Corporate Social Responsibility (CSR) and public relations
  3. Self-regulation
  4. Pervasive marketing
  5. Aggressive lobbying and political interference
  6. Shifting the focus and manufacturefalse debate
  7. Attack legitimate science and intimidate scientists
  8. Fund and run disinformation campaigns
  9. Frame the issue in highly “creative”ways

Through CSR activities, industry actors and SAPROs are promoting interventions against specific alcohol harms, such as driving under the influence, for which there is no evidence base for impact, or where the evidence shows that these interventions are ineffective or even harmful – such as designated driver programs, which may encourage non-drivers to consume even more alcohol.

Additionally, the various interventions promoted through public relations campaigns in the mass media are frequently used as opportunities for branding and marketing, allowing the alcohol industry to cultivate a positive public image as a responsible actor while promoting the sales of their products.

At the same time, Big Alcohol is funding research and engaging in broad public relations campaigns, including the use of social media, to mislead the public, for example regarding links between alcohol and cancer. The alcohol industry misrepresents evidence and sows doubt about scientific findings of alcohol harm.

But if denying the association between alcohol consumption and negative health and development outcomes does not work, alcohol industry actors revert to reframing the issue as one of personal responsibility rather than public health, directing the focus on alcohol consumers instead of the supply of alcohol. This puts blame on “others” than alcohol industry actors (e.g. heavy alcohol users) and foments stigma around alcohol problems, perpetuating the myth that a majority of alcohol users are “moderate and responsible”.

Big Alcohol crafts narratives that highlight the undesirability of alcohol control policies. Framing the issues in highly “creative” and questionable ways means that evidence-based public health interventions such as alcohol taxation, banning alcohol advertising or limiting the number of alcohol retail outlets, are mischaracterized as prohibition, an infringement on the personal choices and freedoms of the “moderate drinking majority”, and a threat to the economic activity created by the alcohol industry.

Using this multitude of strategies, the alcohol industry attempts to develop strategic partnerships and manage its reputation as a “good corporate citizen” by supporting, funding, and implementing non-evidence-based alcohol harm reduction interventions, for example in the area of road safety, that will not limit or affect alcohol sales, while at the same time marketing its products and undermining alcohol policy solutions recommended by WHO.

Inevitable, inextricable, inherent

The fundamental conflict of interest is inherent in the products, in the business model and practices and in the strategies chosen by Big Alcohol executives and shareholders to pursue and maximise its profits.

They target and rely on under-age alcohol users as well as people with heavy alcohol use and alcohol use disorders for their profit thirst and thus ruthlessly put them in harms way.

The conflict of interest is therefore not just hiding in plain sight but is in fact inevitable, inextricable and inescapable from the alcohol trade.

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