WHO’s schizophrenic approach to the alcohol industry
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.
Despite overwhelming scientific evidence about Big Alcohol’s conflicting interests, the approach of the Word Health Organization (WHO) to the alcohol industry appears riddled with contradictions.
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.”
While the WHO Global Alcohol Strategy limits the role of the alcohol industry to their core business and excludes them from engagement in public health policy-making, it still advances the problematic concept of self-regulation and of the overall role of Big Alcohol for preventing and reducing the harm their products and practices are causing. I’ll get back to this topic below.
The schizophrenic elements of the WHO Global Alcohol Strategy are also apparent when the strategy talks about the challenge in alcohol control to “balance different interests” on the one hand but recommends “reducing or stopping subsidies to economic operators in the area of alcohol” on the other hand.
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, but is still invited to “dialogue” meetings with the WHO.
WHO Global Alcohol Status Report Discloses Big Alcohol’s Unethical Practices – An Overview
The WHO global alcohol status report – the most authoritative source of evidence about alcohol from the world’s premier norm-setting agency in public health – is a key tool to inform and support the implementation of the Global Alcohol Strategy, with the help of state of the art evidence about worldwide alcohol consumption trends, the global alcohol burden and high-impact, cost-effective alcohol policy solutions.
The WHO global alcohol status report explicitly delineates alcohol industry practices and their harmful consequences worldwide. I’m summarizing nine of them to create a comprehensive overview of what the WHO Global Alcohol Status report contains in this regard.
1. Big Alcohol undermines the economic development of low-income countries
Throughout the history of the existence of the alcohol industry, we can observe similarly aggressive marketing strategies that are being employed still today to capture the market in developing countries and new markets – even though the tools might have changed.
Evidence shows, for example from ethnographic studies, that the commercialization of alcohol in developing countries plays a major role in driving economic inequality.
Developing societies are transformed into consumer markets where new forms of alcoholic beverages become symbols of elite social status. This dynamic typically brings more [alcohol use] and thus a greater burden of alcohol-related problems on the population.” (p.18)
This way the alcohol industry foments power structures, gender stereotypes and high-risk alcohol use patters, creating a perfect storm that results in “high levels of violence and public disruption.”
The report goes on to explain:
… changes in alcohol production play a direct role in generating economic disparities, as in cases where industrialized alcohol production takes over control of alcohol production from local communities and indigenous groups.”
The changes in alcohol production, driven by transnational alcohol industry giants, lead to “greater availability of alcohol around the clock.”
Already vulnerable communities are disproportionately affected, as alcohol problems rise, due to increased availability and consumption.
When the poor become a consumer market, purchasing commercial brands of alcohol takes a larger toll on personal and family income than it does in other social classes.”
Poorer societies, communities and families are more vulnerable to the consequences of alcohol consumption, such as public disruption, violence, loss of income or health problems.
There is no doubt that the establishing of alcohol industries in the global south has resulted in these economies to suffer:
- Poverty is becoming entrenched and perpetuated,
- Access to nutritious food and eduction for the children is jeopardized as household resources are diverted to increasing alcohol consumption (often) by the breadwinner in the family,
- This way financial stability and resilience are threatened.
This vicious cycle can further increase the pressure on poorer communities to find income and thus to get exposed to exploitative labour conditions.
By illustrating these processes with the example of the alcohol industry entering rural Zambia, the WHO explains how the livelihood of rural women and the resilience of families and communities in Zambia was devastated when Big Alcohol took over alcohol production. Alcohol availability increased, and with it alcohol harm rose while the ability to tackle harm eroded.
… beer brewing used to be an important source of income for local women, the increased availability of commercial brands of beer added to the economic burden on village families as men spent their wages on bottled beer. The women, in turn, lacked any independent income to make up the difference for their families, having lost their income from producing beer. As the men [consumed alcohol] more frequently and heavily, the local community experienced more violence towards women and more health problems… Local authorities failed to respond with alcohol control policies, in part because of their institutionalized dependency on alcohol revenue.”
This is just one of the thousands of examples we can observe throughout the developing world, where the alcohol industry acts as a strong inhibitor for (rural) economic and social development.
The report outlines the conflict of interest that emerges from increasing alcohol industry activity in societies, especially in the developing world:
Economic development in societies where there is no strong religious norm against [alcohol use] is usually accompanied by strong efforts to “build the market” for alcoholic beverages, both from entrepreneurs within the society and from the transnational firms which now increasingly dominate the alcohol industry.” (p.133)
This shows the flaw of the alcohol industry describing themselves as committed to eradicating poverty and empowering rural women. In reality, their products and practices are exploiting economies for new profits but leaving them to pay for the costs that result from rising alcohol harm.
The WHO explains that any economic gain from increased alcohol consumption is outweighed by the costs for alcohol harms across society. Especially poorer communities are adversely affected, as increased alcohol consumption leads to rising health and social inequalities.
The World Health Organization writes:
From the perspective of … the public interest, sustainable development requires strengthening rather than loosening of the market controls on the availability, price and marketing of alcohol.”
This means that growing economies best protect the public interest by preventing the initiation of alcohol consumption of people who are alcohol abstainers and by supporting alcohol users to reduce their alcohol consumption.
Alcohol availability increases, harm grows, and development is impeded
Increasing alcohol availability is, however, a major problem. WHO reports that most countries with an alcohol licensing system, reported INCREASING numbers of licences to distribute and sell alcohol, particularly in the African and South-East Asia regions. In countries with the highest prevalence of alcohol abstainers, with the weakest alcohol control systems and with the lowest income and development levels, alcohol is becoming more and more available. (p.xvi)
- Two in every five countries reported growth in the number of licences to produce alcohol.
- Increases in the number of licences for alcohol production and distribution is concentrated in low-income countries.
This is one reason why 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.
2. Does Big Alcohol really mean “responsible”, when say responsible?
The WHO global alcohol status report makes an affirmation about the contradiction of cultural norms propagated by the alcohol industry to what public health experts advocate for health promotion.
The cultural acceptance and normalization of alcohol use and the frequency of alcohol consumption of more than one or two drinks per occassion is promptly promoted by the alcohol industry and their “social aspects” organizations as elements of the concept of so-called “Responsible Drinking”. One example of how Big Alcohol is promoting the normalization of alcohol consumption in their “responsibility” campaigns comes from Diageo’s “Drink Positive”.
This so-called “responsible drinking” concept and the way of delivering its messages aims to shift the RESPONSIBILITY of harm caused by alcohol to the alcohol user AWAY FROM the alcohol producers and promoters themselves. The message is that alcohol is harmless and belongs to all social events as long as the consumer uses it “responsibly”. Big Alcohol shifts the burden to the consumer and frames the issue of alcohol as a matter of the responsibility of an individual to have a mechanism on their own to prevent harm caused by alcohol use.
Different forms of responsibility message – often combined with branding or other product promotion – are ambiguous in terms of any concrete meaning, failing for instance to define when to stop [using alcohol], or to suggest the option of not [using alcohol], and reinforcing the notion that decisions to [use alcohol] responsibly (or not) lie with the consumer and not with the policy, social and marketing environments.” (p.131)
WHO emphasizes that public health experts look at this concept vividly and consider it to be strategically ambiguous and against the public health interest. The report presents studies that underline the moralizing approach that is central to Big Alcohol’s “responsibility” message.
As attention is diverted from risks inherent in the product, the alcohol industry instead directs the focus to deficiencies in the alcohol consumer as the cause of any health or social problems related to alcohol.
Therefore, I would say, that Big Alcohol hides behind the concept of “responsible drinking”. The promotion campaigns with the “personal responsibility” message are embedded in their corporate social responsibility and marketing strategies and remain superficial, ineffective and often even harmful when it comes to preventing and reducing the real harm of alcohol. I’ll get back to this once more below.
3. Big Alcohol’s attack on independent science
The knowledge creation process of any individual or organization depends on the information they receive and seek out on a daily basis through different media and from different sources. Among the high flow of information we receive daily, we give significant importance to the scientifically proven, evidence-based concepts or facts which are considered to be universally acceptable depending on their weight of reliability and accuracy. Thus, beyond the shadow of a doubt, the value of scientific, evidence-based research and its outcomes is crucial for decision-making processes on individual, community and societal levels; for example informing fruitful policy-making processes with regards to the public health of a country.
However, corporate capture of policy-making and scientific knowledge production is a reality also in the fields of alcohol epidemiology and politics. Big Alcohol buys science, subverts independent science, sows doubt about scientific results and seeks to manipulate the public understanding of alcohol harm and attempts to mislead policymakers.
The WHO global alcohol status report attests that although the global situation on alcohol policy development and implementation has shown improvements, still it is not enough to effectively protect populations around the world from alcohol-related harm.
The countries which have developed and implemented alcohol control policies so far are mostly developed countries while the WHO has identified that even developing countries have made a significant effort to identify and measure basic indicators such as “total per capita alcohol consumption” – which is considered a significant achievement.
But there is and remains the major challenge of corporate influence on the scientific and research community through the financial power of the alcohol industry. The subsequent concern is “who is ready to fund?” In a global crisis situation concerning available funding for independent public health research, when other funding priorities rapidly overtake public health concerns, the influence of the alcohol industry on alcohol-related research is becoming stronger and more pervasive. Despite the fact of conflicting interests that affect the research outcomes, there is no mechanism established so far to protect against alcohol industry interference and intimidation.
Alcohol producers may also influence public health and welfare perspectives in research.” (p.130)
The WHO admits that the alcohol industry is influencing public health and welfare perspectives in scientific research. It provides the following examples from the timeline of alcohol research:
- In the post-repeal era in the United States in the late 1930s – The most of very few resources available for research into alcohol problems, came from the the alcohol industry funding research which was only concerned with the causes of “alcoholism” conceptualizing it as a disease stemming from the individual predisposition of the alcohol user.
- Recently, a study of potential health benefits of light alcohol use (one drink per day) versus abstention, with alcohol industry multinationals and alliances as the main sources of the US$ 100 million funding was discontinued after a government review group concluded that the interactions of the study’s investigators and the alcohol industry appear to have intentionally biased the framing of the scientific premise of the study in the direction of focusing on possible benefits of alcohol.
At the time, the New York Times reported that a National Institute of Health (NIH) report had revealed disturbing details about coordination between scientists and the alcohol industry concerning a study that could have changed America’s alcohol consumption habits. The New York Times wrote:
It Was Supposed to Be an Unbiased Study of [Alcohol Consumption]. They Wanted to Call It ‘Cheers.’”
The WHO cites strong evidence documenting that similar unethical efforts to bias research and public health policies to benefit the alcohol industry’s interests can be identified in other countries and situations, too. Often the ambition is to leave no traces of interferences and have as little record of the influence as possible.
What I cannot fathom is that the report goes on to advocate continued WHO dialogue with the alcohol industry. Given their destructive influence on the very foundation of the public discourse about alcohol, how can a dialogue in good faith be even possible? After all, the WHO writes itself that awareness of alcohol-related harms can demonstrate the need for policy change (p.92)
4. Big Alcohol’s vested interests in alcohol control policies
The WHO global alcohol status report repeatedly records instances where the alcohol industry interfered in the formulation and implementation of alcohol control policies despite the fact of their effectiveness. These kinds of vested interest activities have caused negative outcomes in countries’ alcohol policy-making.
WHO illustrates, for example, that when conducting national awareness-raising activities,
Funding sources have influenced in choosing the theme for awareness raising activities since most commonly reported topics were also those mostly funded by NGOs and alcohol industry”.
The report highlights that 30% of reporting countries which conducted awareness-raising activities, reported receiving funds from the alcohol industry.
Alcohol industry funding clearly skews towards avoiding awareness raising about alcohol’s health and social harms, including for example domestic violence or HIV/ AIDS. This matters greatly, as the example from Botswana below will show.
Instead, alcohol industry funding supports campaigns to address driving under the influence of alcohol (21%), youth (13%), parents and heavy episodic (binge) alcohol consumption. (p.93)
In this way, the WHO exposes the strategy of the alcohol industry. They are not only using the concept of “responsible drinking” in their marketing and CSR efforts, but also focus on shifting the burden to parents, or drivers.
Independent science has revealed the conflicting interests in this area, too. While the alcohol industry uses awareness raising campaigns to promote their brands and image – for example reaching children and youth that way – they also promote ineffective and even harmful solutions.
For instance, Big Alcohol’s CSR activities against driving under the influence lack the evidence base for impact, are ineffective or even harmful – such as designated driver programs, which may encourage non-drivers to consume even more alcohol.
5. Big Alcohol’s interference in alcohol (taxation) policies
Increasing alcohol prices through evidence-based taxation was found to be one of the most effective strategies to reduce the harm caused by alcohol.
The WHO reports many positive spillover effects of increased alcohol taxes. And it explains the main challenge for effective implementation of taxation policies: alcohol industry interference.
In the example of Botswana’s alcohol excise tax debate, WHO shows how alcohol industry interference can play out. Between 2005 and 2008 Botswana reacted to pervasive alcohol harm in the country by introducing alcohol taxation:
After a long history without formal alcohol policies at the national level, the Ministry of Trade and Industry in Botswana prepared a regulatory framework referred to as Liquor Regulations in 2005. Three years later, tax levies were introduced in the Control of Goods (Intoxicating Liquor Levy) Regulations, 2008. These regulations proposed a 70% alcohol levy on all domestically produced intoxicating liquors, with the aim of reducing consumption specifically among young people. At the same time, revenue collected from the levy would be invested in efforts to reduce [alcohol consumption and related harm].” (p.109)
Historically, Botswana had an alcohol consumption pattern marked by high levels of both alcohol abstention and heavy episodic alcohol use. The HIV/AIDS prevalence rates were as high as 18% so that in 2002 the National AIDS Coordinating Agency developed a position paper identifying alcohol’s key role as risk factor for HIV infection. Subsequently, national frameworks were developed that highlighted alcohol as a risk factor for exposure to HIV. To this date, alcohol continues to be an obstacle to effective HIV prevention efforts.
However, the alcohol industry responded to the alcohol excise tax increase by advancing their own private interests. Alcohol industry lobbyists argued that increased prices as a result of the tax increment would harmfully affect domestic alcohol production and cause job losses.
As a result, the levy was reduced to 30%.
But two years later, after the tax reduction, the subsequent market failure was apparent and the persistent alcohol burden lead the government to increase taxes again by 40%.
Botswana is not the only country where alcohol industry interference in attempts to raise alcohol taxation (and other alcohol policy best buys) was exposed. It is also well documented that the alcohol industry manipulates policymakers with the very same arguments around the world.
6. Big Alcohol promotions and the targeting of youth
Although there are many recent improvements in the control of alcohol promotions in many traditional forms of media such as television, and print media – according to the WHO, there is a significant rise in alcohol promotions in many less explicit media such as sports sponsorships, alcohol-branded merchandise and increasingly in new forms of media such as social media platforms. With the scientifically proven impacts of alcohol marketing on young people, leading them to initiate alcohol use earlier or use more if they have already started, the WHO emphasizes:
Marketing restrictions are one of the three best buys and the Global strategy recommends setting up regulatory or co-regulatory frameworks, preferably with a legislative basis, to regulate the content and volume of direct or indirect marketing, sponsorships and promotions in connection with activities targeting young people and new alcohol marketing techniques such as social media.” (p.104)
This report further analyses the case example of Finland’s ban on alcohol-branded social media communication. After implementing the social media ban of alcohol advertisements and promotions, transnational alcohol industry marketing activities were significantly limited. Since Finland enacted this ban, several other countries in the Nordic-Baltic region have followed suit. In 2018, Lithuania enacted a comprehensive alcohol advertising ban that included digital media (Law on Alcohol Control, 2018).
Finland’s social media ban prohibits advertisements and promotions that 1) involve games, lotteries or contests or 2) involve information networking service activity of textual or visual content produced by consumers or any such content produced by a commercial actor and intended to be shared by consumers. For example, competitions and prizes on Facebook, allowing people to share posts on their Facebook page, or producing viral videos intended to be shared on social media sites are all banned. In the context of a transnational alcohol industry, the Finnish regulations prohibit commercial actors from targeting Finnish persons with interactive alcohol advertisements even from outside Finland. However, these regulations permit conventional alcohol advertising online and do not apply to consumers’ personal social media pages.” (p.105)
The WHO reports that many countries in the African and the Americas regions have no regulations on any media type. In fact, out of 35 countries (28%) that had no alcohol marketing regulations on any media type, 17 responding countries were in Africa and 11 responding countries were in the Americas.
7. WHO contradicts itself regarding alcohol industry self-regulation
In the context of regulations of alcohol product placement, the report divulges the global situation that the majority of WHO member state countries have some type of restriction on product placement on television, meanwhile 20% (17 countries) reported alcohol industry self-regulation.
Of the 87 countries with some type of restriction, 47% (41 responding countries) had implemented a total ban on product placement of beer on television, 33% (29 countries) had a partial ban, and 20% (17 countries) reported industry self-regulation.” (p.107)
When it comes to alcohol industry sponsorship of sporting events still 16% (25 countries) relied upon industry self-regulation and 51% (81 countries) have no regulation at all.
When it comes to the appropriateness, effectiveness and the ethical background of alcohol industry self-regulation, WHO has made contradicting statements:
- As a part of the dialogue meetings, WHO claims that the alcohol industry as developers, producers and distributors can contribute to reducing harm caused by alcohol through self-regulation of marketing within co-regulatory frameworks, labelling and consumer information, alcohol content on alcoholic beverages and through the provision of data useful for improving estimates of alcohol consumption in populations. (p.135)
- At the same time, WHO emphasizes the fact that regulatory controls on the market must be decided and enforced by the governments, with public health interests as the primary goals while keeping such regulations and their enforcement protected from alcohol industry interferences.
This remains a major flaw of the WHO Global Alcohol Strategy and WHO’s overall approach to the alcohol industry: how can they be involved, through self-regulation in a co-regulatory approach, while safeguarding against interference and accepting the wide array of unethical and deeply harmful practices – some of which are even depicted in the WHO global alcohol status report itself?
8. State-owned retail monopolies for sustainable alcohol control
The WHO global alcohol status report presents evidence of state-owned retail monopolies as a viable option to provide effective solutions for the problem of inadequate funding for the prevention, reduction, and treatment of alcohol harm, including alcohol use disorders and related conditions.
Alcohol retail monopolies operated by governments in the interest of the public and free from commercial pressures to maximize profits are an unimpeachable model for effective alcohol control.
It is worthwhile to note that these state-owned alcohol retail monopolies should be public health-oriented, for example as it is implemented in Sweden, and not like the profit-oriented state-owned monopolies as implemented in Canada.
Removing the profit interest from the alcohol market remains one of the most important corner stones of successful alcohol control models. This is effective not only in high-income but also in low- and middle-income countries:
Early evaluations of availability policies focused exclusively on high-income countries, but recent analyses have confirmed that regulating the physical availability of alcohol (in particular, restricting business hours, government monopolies and government licensing) is also associated with lower alcohol consumption in low- and middle-income countries.” (p.99)
Government monopolies to regulate the alcohol trade are not uncommon around the world.
The WHO writes:
Alcohol monopolies exist when governments exercise exclusive control over the alcohol market or some aspect of it; such monopolies may occur at the level of the import, production, distribution, retail sales and/or export.” (p.100)
Reporting shows that fifty countries (30%) use control over the alcohol market for at least one level.
- Monopolies over imports (36 responding countries) and retail sales (35 countries) were most common for spirits;
- Monopolies for imports (33 responding countries), production (32 countries) and distribution (31 countries) were most common for beer.
- The number of reporting countries with a monopoly over exports (26) did not differ by beverage type.
- Of the countries with monopoly control of at least one level of the alcohol market, 19 (38%) had a monopoly at all levels.
9. The need for a Global Binding Instrument on Alcohol
In consonance with the above discussed examples, arguments and evidence, the WHO global alcohol status report itself underlines the need for an evidence-based global instrument that reaffirms the right of people to have protection from alcohol harm.
Given the increasing encroachment of international trade and investment on the ability of national and subnational governments to control their alcohol markets, and the increasingly consolidated global alcohol producers, a strong public health case for considering the negotiation of a Framework Convention on Alcohol Control, or alternatively for including alcohol within other international control systems, has been repeatedly presented and discussed by public health entities, experts and advocates.” (p.24)
The WHO asserts that alcohol is now the ONLY psychoactive and dependence-producing substance with significant global impact on the health and development of entire populations that is NOT controlled at the international level by a legally binding instrument. (p.xii)
And alcohol harm is indeed an industrial epidemic. Alcohol is a risk factor for over 200 different health conditions across all categories of the disease burden, affecting both the incidence and progression of infectious diseases, non-communicable diseases, and injuries.
- Alcohol adversely affects 14 of 17 Sustainable Development Goals.
- Globally, alcohol is implicated in 3 million deaths – one person every 10 seconds dies due to alcohol.
- Alcohol is responsible for more than 25% of global deaths in people aged 20–39 years.
- In 2016, Public Health England found that alcohol is the UK’s leading cause of death in people aged 15–49 years.
And yet, global alcohol consumption is projected to be rapidly expanding and to increase by more than 10% by 2030.
The WHO Global Alcohol Strategy continues to be the most comprehensive international policy document providing guidance on reducing alcohol consumption and related harm at all levels.
But two facts show its insufficiencies and flaws:
- The importance of alcohol as a risk factor for disease and injury has been increasing since 1990, both in absolute terms and relative to other risk factors. The WHO Global Alcohol Strategy was not able to generate commitment and action to turn the tide on alcohol harm.
- The alcohol industry – as WHO’s own report highlights – is NOT a responsible actor in the effort to protect people from alcohol harm; alcohol availability is in fact increasing, children and youth are targeted by and exposed to alcohol promotions; WHO-recommended policy solutions and WHO-generated knowledge about alcohol harm are being systematically undermined and attacked by the alcohol industry; and still dialogue and engagement with Big Alcohol continues.
Therefore, a global binding instrument should aim to tackle the causes of the alcohol epidemic, such as trade liberalization and cross-border issues, direct foreign investments, subsidies for Big Alcohol, and alcohol advertising, promotion and sponsorship beyond national borders. Establishing such international legal instrument will be the pinnacle of the global, regional and national response to tackle harm caused by alcohol.