Despite the existence of cost effective interventions to reduce alcohol harm, many countries are not giving it the attention it deserves, say Dag Rekve and colleagues…


Dag Rekve, Nicholas Banatvala, Adam Karpati, Dudley Tarlton, Lucinda Westerman, Kristina Sperkova, Sally Casswell, Maik Duennbier, Ariella Rojhani, Øystein Bakke, Maristela Monteiro, Natalia Linou, Alexey Kulikov, Vladimir B Poznyak


Rekve Dag, Banatvala Nicholas, Karpati Adam, Tarlton Dudley, Westerman Lucinda, Sperkova Kristina et al. Prioritising action on alcohol for health and development BMJ 2019; 367 :l6162

British Medical Journal
Release date

Prioritising action on alcohol for health and development


Solutions for Prevention and Control of Non-communicable Diseases

Key point

Despite the existence of cost effective interventions to reduce alcohol harm, many countries are not giving it the attention it deserves, say Dag Rekve and colleagues.

Key messages

  • Alcohol use is among the leading risk factors for the global burden of disease;
  • Cost effective strategies to reduce alcohol harm exist and should be more widely used, with an equity focus,
  • Global and regional policy frameworks and guidance can help countries to develop national and local alcohol policies and programmes,
  • The alcohol industry should not be allowed to influence public health policy,
  • Civil society can advocate for action and hold policy makers and government agencies to account.

Summary of main points

Need for action on alcohol

Scientific consensus is growing that there is a robust public health case for policy makers to implement WHO’s recommended interventions to prevent and reduce alcohol harm.

Alcohol related harm affects all countries. Although the European region has the highest total per capita consumption of alcohol and the highest share of all deaths attributable to alcohol compared with other risk factors for the global burden of disease, low and middle income countries, and especially Africa, have the highest age standardised attributable deaths per 100,000 people, indicating greater harm per litre of alcohol consumed than in wealthier countries.

Recent modelling forecasts that global targets to reduce harmful use of alcohol will not be met.

Without action Africa could see an increase in both the absolute number and proportion of people consuming alcohol, the amount consumed per capita, and heavy episodic alcohol use. There are similar challenges in other parts of the world – for example, South East Asia has seen a 29% increase in alcohol consumption per capita since 2010.

The WHO global alcohol strategy, endorsed by the World Health Assembly in 2010, provides guidance on formulating and implementing effective national alcohol policies. In 2017, the World Health Assembly endorsed three effective interventions that cost ≤$100 (£78; €90) per disability adjusted life year (DALY) averted in low and middle income countries. These so called “best buys” are:

  1. Increasing excise taxes on alcoholic beverages,
  2. Comprehensive restrictions on alcohol advertising, and r
  3. Restrictions on sales of alcohol.

Implementation of the three best buys would result in a return on investment of $9 for every $1 invested. Over 50 years, a 20% global increase in alcohol taxes alone could avert nine million premature deaths. Revenues from excise tax, alcohol company taxes, and licensing fees could also help cover, or even meet, the costs of a comprehensive alcohol control programme, the prevention and treatment of disorders caused by alcohol use, as well as contributing to the funding of other health and development priorities. A 20% increase in the price of alcohol through higher taxes could accumulate as much as $9tn in increased revenues globally over 50 years.

To support countries in scaling up implementation of best buys interventions, a new WHO led initiative called SAFER was launched in 2018.

Lack of implementation

Some countries have shown the benefits of implementing evidence based, cost effective, and high impact policies. Nevertheless, most countries, particularly low and middle income countries, have not implemented a comprehensive set of alcohol policies. No low income country has reported increasing the resources for implementing alcohol policy since the WHO global alcohol strategy was adopted in 2010. In addition, many countries are failing to implement the best buys, with low and middle income countries more likely to have weaker policies.

Barriers to implementation

Several of the most cost effective interventions require legislative or regulatory action – for example, taxes, marketing restrictions, regulations on availability, including sale to minors and licensing, and road traffic laws. An effective programme requires broad political commitment and dedicated and sustained financing at national and local level. Regulatory approaches need to be supported by effective enforcement.

Policy coherence across government is crucial, and implementation of these comprehensive measures requires multisectoral collaboration. For example, tax policy requires leadership from ministries of finance, and driving under the influence prevention requires transportation and law enforcement authorities. Civil society also has an important role, acting as advocates, allies, and independent monitors of policy implementation and interference by vested interests.

Strong monitoring and evaluation is important to track progress and ensure accountability. Indicators need to be further refined or developed to cover sales, consumption, health and social harms, economic impact, policy implementation, and industry practices.

Since all the most cost effective interventions restrict commercial activity, governments have and will face opposition from vested interests. In this regard, any involvement of the alcohol industry in public health decisions has substantial risks. Alcohol industry activities related to marketing, education, corporate political activities, and funding of research can undermine public health efforts by hedging them against more effective interventions and distorting the research agenda.

The SAFER initiative

The objective of the WHO led SAFER initiative is to provide support for countries in preventing and reducing alcohol harm by enhancing the ongoing implementation of the global alcohol strategy and other WHO and UN instruments. SAFER is based on the accumulated evidence of cost effectiveness of different alcohol control measures and recognises the need to protect public health oriented policy making from alcohol industry interference as well as strong monitoring systems to ensure accountability and track progress in the implementation of the SAFER interventions.

SAFER is an acronym for the five most cost effective interventions to reduce alcohol related harm:

  • Strengthen restrictions on alcohol availability
  • Advance and enforce drink driving countermeasures
  • Facilitate access to screening, brief interventions, and treatment
  • Enforce bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion
  • Raise prices on alcohol through excise taxes and pricing policies

WHO, the secretariat of the UN Interagency Task Force on the Prevention and Control of NCDs, and the UN Development Programme together with IOGT International, the NCD Alliance, the Global Alcohol Policy Alliance, and Vital Strategies have been working together to initiate and develop SAFER, engage more partners in the initiative, raise resources, and implement SAFER at country level.

Countries and development partners from governments, philanthropy, civil society, and selected private sector entities are now armed with an evidence based, action oriented programme to rally around.


Effective alcohol control policies have important economic and public health benefits, but their development and execution is uneven and not proportional to the harm from alcohol. Effective action will require a coordinated approach across government. In light of this, all countries will benefit from a periodic review, adjustment, and strengthening of their policies and programmes. Civil society can advocate for action, catalyse political will, and hold policy makers and government agencies to account. The alcohol industry should not be involved in the development of public health oriented government policy to reduce the harmful use of alcohol.

Over the past decade, significant progress has been made in tobacco control, largely as a result of political pressure and catalytic funding from national and international development partners. Now that countries have cost effective and feasible interventions for controlling alcohol, it is time to accelerate action, through initiatives such as SAFER, to reduce the health and development burden from alcohol: people and societies everywhere will benefit.

Source Website: BMJ