Third Edition of “Alcohol: No Ordinary Commodity”: Opportunities for Preventing Alcohol Harm Are Clearer Than Ever

Alcohol: No Ordinary Commodity—a summary of the third edition

Book summary

Overview

The third edition of the book Alcohol: No Ordinary Commodity is soon to be released. The two previous editions have contributed to a remarkable advancement in the evidence base on alcohol policy issues. The first edition was published in 2003, the second edition in 2010, and the third edition is much anticipated.

Earlier this year, a summary of the book was published in Addiction. The article summarizes the findings and conclusions of the third edition, with special attention to three developments:

1. Epidemiological trends showing increasing consumption and alcohol-related problems in many of the world’s emerging economies,
2. The growing economic and political power of the alcohol industry, and
3. New scientific evidence on the effectiveness of alcohol policies to more effectively inform policymakers.

The authors describe the emergence of a “new public health” approach to alcohol issues during the last three decades of the 20th century. Earlier focus on the heaviest alcohol users and on the treatment and prevention of a unitary disease (“alcoholism”) has to a large extent been replaced by a more effective, broader approach covering a wide range of alcohol harms, utilizing broad population-based measures.

The majority of [alcohol users] in a society are part of this approach, not only because they occasionally experience direct harms associated with acute intoxication or regular consumption of as little as one drink a day, but also because they contribute indirectly to the social climate that facilitates heavy [alcohol use].”

Babor, TF, Casswell, S, Graham, K, Huckle, T, Livingston, M, Rehm, J, et al. Alcohol: No Ordinary Commodity—a summary of the third edition. Addiction. 2022; 117( 12): 3024– 3036. https://doi.org/10.1111/add.16003

Evidence shows that the effects of population approaches in conjunction with individual-level approaches can be dramatic. The authors specifically mention policy changes and related positive health outcomes in Russia and Lithuania as relevant examples.

No ordinary commodity

Alcohol products are sold in the marketplace, like many other products. However, alcohol is also a drug with toxic effects that causes harm on many levels. Up to 3 million deaths per year could be avoided.

The latest evidence on alcohol-attributable burden of disease indicates that alcohol plays a causal role in a wide range of health conditions and social problems, including coronary heart disease, breast and other cancers, liver disease, HIV/AIDS, suicide and interpersonal violence.”

Babor, TF, Casswell, S, Graham, K, Huckle, T, Livingston, M, Rehm, J, et al. Alcohol: No Ordinary Commodity—a summary of the third edition. Addiction. 2022; 117( 12): 3024– 3036. https://doi.org/10.1111/add.16003

The authors also note that harm caused by alcohol extends far beyond damage to the individual alcohol user, also affecting others regarding deaths, injury and violence, injuries in traffic, fetal alcohol spectrum disorder, prenatal exposure to alcohol and child maltreatment.

That’s why alcohol is no ordinary commodity.

Evidence shows that people living in low- and middle-income countries are hit disproportionally hard by the products and practices of the alcohol industry. The alcohol harm per litre of alcohol consumed is higher compared to high-income countries. Among the underlying reasons are higher overall mortality and interactions between alcohol and poverty and other risk-factors.

Relatively low current levels of aggregate consumption in these areas reflect higher levels of abstention, but among [alcohol users] in many LMICs a pattern of heavy episodic consumption is associated with injuries and other acute alcohol problems. This places a heavy burden on the limited resources available to protect health, welfare and public safety.”

Babor, TF, Casswell, S, Graham, K, Huckle, T, Livingston, M, Rehm, J, et al. Alcohol: No Ordinary Commodity—a summary of the third edition. Addiction. 2022; 117( 12): 3024– 3036. https://doi.org/10.1111/add.16003

The alcohol industry

The third edition of Alcohol: No ordinary commodity contains a chapter devoted entirely to the alcohol industry. The authors describe the growing corporate power of the alcohol industry, leading to limited ability of public health authorities and policymakers to minimize harm.

Some key findings from the summary are:

• The growing corporate power is partly facilitated by the concentration of alcohol producers into a very small number of very large transnational corporations (TNACs).
• To a large extent the profits of the alcohol industry are generated by the heaviest alcohol consumption occasions.
  • In order to maximize profits TNACs rely on heavy alcohol use and seek to increase the number of alcohol consumers in so called emerging markets (low- and middle-income countries).
    • Therefore, the alcohol industry is in opposition to effective, evidence-based alcohol policy.
• International trade and investment agreements have contributed to the globalization of the alcohol industry during the past four decades, limiting the authority national governments have over these TNACs.
• Through investments, mergers and acquisitions, TNACs have expanded into low- and middle-income countries in Latin America, Asia Pacific and Africa – parts of the world that are becoming increasingly important for the alcohol industry.

The authors also describe the role of alcohol marketing:

The industry nexus also includes digital platforms and other marketing actors, such as owners of global sporting events and the industry’s public relations agencies. Marketing to consumers and to society as a whole is a necessary part of industry activity to recruit [alcohol users], build brand loyalty, normalize alcohol products and legitimize the industry’s role in the policy arena.”

Babor, TF, Casswell, S, Graham, K, Huckle, T, Livingston, M, Rehm, J, et al. Alcohol: No Ordinary Commodity—a summary of the third edition. Addiction. 2022; 117( 12): 3024– 3036. https://doi.org/10.1111/add.16003

When it comes to the alcohol policy process, the authors emphazise the fact that alcohol industry interests “diverge considerably from those of public health, non-governmental organizations and community response agencies such as emergency departments, police and social workers”, and that partnering with the industry will lead to poor outcomes:

Given the divergence of interests and the industry’s well-documented influence tactics, working in partnership with the alcohol industry is likely to lead to ineffective policy in terms of public health and welfare.”

Babor, TF, Casswell, S, Graham, K, Huckle, T, Livingston, M, Rehm, J, et al. Alcohol: No Ordinary Commodity—a summary of the third edition. Addiction. 2022; 117( 12): 3024– 3036. https://doi.org/10.1111/add.16003

Interventions to reduce alcohol related harm

The third part of the book describes strategies and interventions to prevent and reduce alcohol harm.

The authors describe this part as “the core of the book”.

When it comes to methodology the authors favored the findings published in peer-reviewed journals that were based on controlled and natural experiments, population surveys and time–series analyses. Findings in systematic reviews and meta-analyses were given special attention.

The authors describe seven major approaches to reduce alcohol harm, some with very good effect, some with limited effect.

Controlling affordability: pricing and taxation

• Evidence shows that taxation and other pricing policies have substantial potential to reduce alcohol harm.
  • Reducing alcohol affordability is one of the most cost-effective ways for a government to do so.
  • Furthermore, alcohol taxes generate direct revenue for the government.
• The potential downsides of alcohol taxation – the risk of illegal smuggling and illegal production – is often overstated. The net effects of tax and price increases tend to be a reduction in alcohol consumption and related problems, without a significant expansion of the illegal market.

Limiting physical availability

• Studies of retail availability, especially reductions in the hours and days of sale and limits on the number of alcohol outlets, consistently show that availability limits are linked to reductions in both alcohol use and alcohol problems.
• There is also strong scientific support for limiting access to alcohol of young people through the implementation of a minimum legal purchase age.

Restrictions on marketing

• Extensive research shows that exposure to and engagement with alcohol marketing affects beliefs, norms, consumption and heavy alcohol use.
• Evidence indicates that alcohol industry voluntary codes, so called “self-regulation”, is ineffective.
• A complete ban of alcohol advertising, sponsorship, and promotion would reduce alcohol consumption both in the short term but also over a longer time-period by contributing to a de-normalization of alcohol.

Education and persuasion strategies

• Studies of these approaches find that their effectiveness in changing alcohol use behavior or alcohol harms is generally limited, with some targeted programs showing more success.

Drinking-driving: prevention and countermeasures

• The most effective measures in deterring driving under the influence of alcohol (DUI) are low maximum BAC levels for drivers (0.00–0.05%), zero tolerance for youth drivers and random breath testing.
• When punishment for DUI is swift, the deterrent effect is increased. Well-executed, high-intensity, media campaigns can also increase the deterrent effect by increasing the perception of getting caught.

Modifying the alcohol consumption context

• Some of the individual- and venue-focused approaches (e.g. peer interventions, training in preventing aggression) have a modest impact upon alcohol-related problems.
• Policing approaches (enhanced enforcement and targeted policing) have shown positive impacts.
• Comprehensive community approaches that include training and licensing of security personnel and other bar staff are the only interventions that have shown large effects, but these approaches can only succeed if they involve community leaders and other stakeholders.

Treatment and early intervention services

• A major policy issue with regard to brief intervention and specialist treatment services is their cost-effectiveness. Brief intervention for alcohol use disorder has been found to be cost-effective in emergency departments and outpatient settings.
• There is suggestive evidence that treatment, early intervention and mutual help programs can reduce the prevalence of alcohol-related problems, but the costs of most treatment services are high relative to other types of intervention.

Alcohol policies: A consumer’s guide

The main message from the authors under this section is one of opportunity.

All in all, this is an excellent guide for governments and advocates for effective, protective alcohol policies based on evidence.

Some of the main messages in this section are:

• The ‘best practices’ are limits on affordability, availability and accessibility, as well as marketing regulations and DUI deterrence measures.
  • There is also a number of ‘good practices’, such as outlet density restriction and minimum unit price.
• Some of the evaluated policy options are attractive to the alcohol industry because they are unlikely to interfere with their markets (e.g. education programs, marketing self-regulation). However, these tend to be the least effective alcohol policy options.
• There is no single way to address the broad spectrum of harms caused by alcohol. A combination of the most effective strategies and interventions to address multiple aspects of the alcohol policy environment comprehensively is therefore needed.
• There are considerable opportunities to strengthen international collaboration in this area. The research findings make a strong case for strengthened WHO initiatives on alcohol and public health, including a Framework Convention on Alcohol Control.

Abstract

Background and Aims

This article summarizes the findings and conclusions of the third edition of Alcohol: No Ordinary Commodity. The latest revision of this book is part of a series of monographs designed to provide a critical review of the scientific evidence related to alcohol control policy from a public health perspective.

Design

A narrative summary of the contents of the book according to five major issues.

Findings

An extensive amount of epidemiological evidence shows that alcohol is a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. Trends in alcohol products and marketing are described, indicating that a large part of the global industry has been consolidated into a small number of transnational corporations that are expanding their operations in Asia, Africa and Latin America.

The main part of the book is devoted to a review of strategies and interventions designed to prevent or minimize alcohol-related harm. Overall, the most effective strategies to protect public health are taxation that decreases affordability and limits on the physical availability of alcohol. A total ban on alcohol marketing is also an effective strategy to reduce consumption. In addition, driving under the influence of alcohol counter-measures, brief interventions with at-risk alcohol users and treatment of alcohol users with alcohol dependence are effective in preventing harm in high-risk contexts and groups of hazardous alcohol users.

Conclusion

Alcohol policy is often the product of competing interests, values and ideologies, with the evidence suggesting that the conflicting interests between profit and health mean that working in partnership with the alcohol industry is likely to lead to ineffective policy.

Opportunities for implementation of evidence-based alcohol policies that better serve the public good are clearer than ever before as a result of accumulating knowledge on which strategies work best.

Source Website: Wiley Online Library