Leadership, awareness and commitment

WHO Member States must demonstrate leadership and generate appropriate awareness of the burden of alcohol use in order to meaningfully and sustainably reduce the harms from alcohol consumption (WHO, 2010). Ideally, Member States should document their commitment with adequately-funded, intersectoral national policies, and these policies should have clear objectives, strategies, targets and divisions of responsibility (WHO, 2010). The Global Survey on Alcohol and Health 2016 reported on two indicators of leadership, awareness and commitment, namely 1) the development of national written alcohol policies and 2) the presence of awareness-raising activities.

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5.1.1.1 Written national policies

The presence of a written national alcohol policy is a key indicator of a country’s commitment to reducing alcohol-related harm (WHO, 2010). National alcohol policies may be either separate documents or part of a broader public health policy – such as on substance abuse, noncommunicable diseases or mental health. Ideally, these policies will be well-funded, will establish clear leadership, will clearly indicate the responsibilities of the sectors involved and will set attainable objectives, strategies and targets (WHO, 2010).

In 2016, 80 responding countries reported having written national alcohol policies (46%;

Figure 5.1). An additional eight countries (5%) had subnational policies and 11 others (6%) had a total ban on alcohol. The Global strategy states that all WHO Member States will benefit from a national alcohol strategy, regardless of their level of resources (WHO, 2010). However, the presence of a written national alcohol policy has risen with national income levels: 34 high-income countries (67%), 23 upper-middle-income countries (43%), 18 lower-middle-income countries (42%) and four low-income countries (15%) reported having a written national policy on alcohol.

Note: The numbers in each coloured bar indicate the number of countries in that category, whereas the length of each coloured bar indicates the percentage of countries in the category.

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Percentage (%) of countries

AFR AMR EMR EUR SEAR WPR World

WHO Region

Yes, written national policy No, but have written or subnational policy/policies No, no national policy Total alcohol ban

Figure 5.1 Presence of a written national alcohol policy by WHO region and percentage (in %) of countries, 2016

(n = 175 reporting countries)

90 80 70 60 50 40 30 20 10 0

11

76

8

80 4

13 1

2

1

5 1

30

2

14

12

3

37 9

5

3 23

2

8

The good news is that most (66%) of the 80 responding countries with a national alcohol policy reported having government funding for national policy implementation. However, the presence of such funding was uneven across the world. Funding was prevalent in the WHO regions of Europe (EUR) (70%), Western Pacific (WPR) (85%) and South-East Asia (SEAR) (100%) but scarce in Africa (AFR) (57%), the Americas (AMR) (38%) and Eastern Mediterranean (EMR) (0%).

Once policies are written, government must formally adopt them in order for them to be implemented. Most of the countries with national written alcohol policies adopted them through the national government (59%) or a national parliament (28%). However, a small minority adopted their policies through the Ministry of Health (11%) or through another ministry (3%). Many (40%) existing national alcohol policies were specific to alcohol.

When a country integrated its national alcohol policy with other areas, it was frequently integrated into substance abuse policies (25%), noncommunicable disease policies (23%) and/or public health policies in general (20%).

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Box 5.1 National alcohol policy in the Russian Federation

Until recently, the Russian Federation had one of the riskiest patterns of drinking in the world (WHO, 2011b). In the 2011 Global status report on alcohol and health, Russia was shown as having a per capita consumption of 15.8 litres per person, which was the fourth highest in the European Region (WHO, 2011b). This harmful consumption pattern contributed substantially to high levels of morbidity and mortality, including alcohol-attributable deaths (Nemtsov, 2002;

Leon et al., 2007), cancer (World Bank, 2005), violence (World Bank, 2005; WHO Regional Office for Europe, 2006), alcohol poisoning (World Bank, 2005) and alcohol use disorders (World Bank, 2005).

To combat these harms, Russia implemented a series of evidence-based national alcohol policies in a stepwise manner within a comprehensive framework (WHO, 2017b). In 2005, Russia implemented a federal alcohol control law and, five years later, adopted a national programme of actions to reduce alcohol-related harm through to 2020 (WHO, 2017b). These two documents formed the backbone for subsequent policy measures (see the figure below).

The new policies spanned many of the action areas outlined in the Global strategy, with a focus on the three “best buys”.

As a result of these coordinated actions, total per capita alcohol consumption in the Russian Federation fell by 3.5 litres over a 9-year period (2007–2016) (WHO, 2017b). In addition, the number of cases of alcohol psychosis dropped from 52.3 to 20.5 per 100 000 population, and the rate of alcohol-attributable deaths declined, particularly among males (WHO, 2017b).

AVAILABILITY 2005

• Strengthened control system for

production, distribution, and retail sales

• Banned alcohol sales at selected spaces

• Banned sales of alcoholic beverages containing more than 15% alcohol by volume (ABV) in selected public places, by individuals, and other places not properly licensed

2011

• Increased enforcement and penalties for sales to minors

• Banned retail alcohol sales at petrol stations

2012

• Prohibited beer sales in selected locations

2014

• Increased fines for sales to minors and added criminal responsibility for repeat violators

2016

• Introduced alcohol registration system at the retail level

MARKETING 2008

• Banned advertising on all

types of public transportation infrastructure

2012

• Banned alcohol advertising on the internet and electronic media

• Relaxed advertising laws for domestic wines and removed some regulations in anticipation of the FIFA World Cup to be held in 2018

PRICE 2005

• Introduced mandatory excise

stamps for all alcohol sales in the domestic market

2008

• Amended tax code to increase alcohol excise taxes by 10% each year

2010

• Established minimum retail price for beverages stronger than 28%

ABV

2014

• Increased alcohol excise taxes by 33%

• Increased minimum retail price for spirits further

2015

• Decreased minimum price of vodka

2016

• Increased minimum price of vodka

DRINK–DRIVING 2010

• Established zero tolerance policy

for drivers and 0.0% blood alcohol concentration limit

2012

• Established a limit of 0.16 mg/l for breathalyzer as a maximum measurement error

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Box 5.2 Thailand’s national alcohol policy

Only a minority of adults in Thailand drink alcohol, yet the country experiences substantial alcohol-attributable harms. Thailand’s per capita alcohol consumption among adults skyrocketed from 0.3 litres per year in 1961 to 8.5 litres per year in 2001 (WHO, 2014b; Institute of Alcohol Studies, 2017). With current per capita consumption at 7.2 litres, Thailand has the highest per capita consumption in WHO’s South-East Asia Region (6.4 litres) (Waleewong, 2017). This consumption leads to consequences such as drink–driving, interpersonal violence, and alcohol consumption during pregnancy (Waleewong, 2017). In addition, 82% of the population report experiencing harm from someone else’s drinking (Waleewong et al., 2015).

In Thailand, the likelihood of domestic violence increases fourfold when one person drinks, and two in five crimes committed by young people involve alcohol (Department of Child and Adolescent Correction and Protection, 2008).

Thailand has managed to slow the rise in alcohol consumption and address the harmful use of alcohol through the “triangle that moves the mountain” (Waleewong, 2017). The three legs of this “triangle” are strong scientific communities, energetic grassroots movements and evidence-based policies.

Thailand has been particularly innovative with regard to alcohol taxation, structuring its taxes to account for problems specific to low- and middle-income settings. Specific taxes are one common type of alcohol excise tax, with the level of these taxes based on the volume of the alcohol content of the beverage. Specific taxes favour consumption of low-alcohol alternatives, an appropriate step in high-income settings with high prevalence of alcohol consumption (Babor, 2010). However, specific taxes may inadvertently encourage drinking initiation among young people in low- and middle-income settings, where young people often start their drinking careers with cheap, low-alcohol beverages. Thailand’s solution to this dilemma was the “two-chosen-one” (or 2C1) taxation design. This taxation method “calculates the excise tax of each alcoholic beverage using both primary taxation methods – specific and ad valorem; the excise tax on the beverage is then determined to be the higher of the two calculations” (Sornpaisarn, Shield & Rehm, 2012).

A timeline of key events in Thailand’s alcohol policy development since 2000 appears below.

2001 2008 2009 2010 2012 2013 2015 2017

Passed Alcohol Beverage Control Act, including:

• ban on direct advertising and promotions

• minimum legal drinking age of 18 years

• new warning labels

• restriction on hours and days of sale Added a 2% surcharge to the alcohol and tobacco excise tax, the proceeds of which fund the ThaiHealth Promotion Foundation (ThaiHealth)

Thai National Health Assembly adopted a national strategic plan and prohibited alcohol sales on Buddhist holidays

Regulations on alcohol logos

Prohibited sales and drinking in factories, public organizations, state enterprises, road/

pavement, and in cars

Prohibited alcohol sales and drinking in public parks

Increased alcohol excise tax by 2% and lowered BAC limit for young drivers to 0.02%

Amendments to Alcohol Beverage Control Act, including:

• prohibiting sales within 300 metres of higher education buildings

•limiting hours of sale to 11 AM – 2:00 PM and 5:00 PM to 12:00 AM

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WHO recommends intersectoral approaches to national policies because alcohol-related harms span multiple sectors (WHO, 2010). Every country with a national alcohol policy described it as multisectoral. Most frequently, countries included the health (99%), law enforcement (83%), finance/taxation (79%), education (78%), criminal justice (75%), and transport and/or road safety sectors (74%). Principal responsibility for the policy lay with the health sector in 69% of countries with a national policy.

Another positive finding is that just over half (55%) of the 76 countries without a national policy, subnational policy or a total alcohol ban reported that they are actively developing a policy. As with the presence of a national policy, development of new policies increased with country income. Fewer low-income (45%) and lower-middle-income countries (40%) without a national alcohol policy were developing one, compared to their upper-middle- income (68%) and high-income counterparts (67%).

5.1.1.2 Nationwide awareness-raising activities

Awareness of alcohol-related harms can demonstrate the need for policy change (WHO, 2010), which is why awareness-raising activities are the second indicator under leadership, awareness and commitment. Most (86%) responding countries reported such activities in the 2016 survey. Among these countries, drink–driving (93%), youth (79%) and health (77%) were the most common topics for awareness-raising activities (Figure 5.2).

Reported funding source: NGO Industry None

Figure 5.2 Nationwide awareness-raising activities in the past three years by topic, number of countries and funding source, 2016

(n = 145 reporting countries, except illegal/surrogate alcohol and other [143]; FAS/FASD [144]; parents, binge drinking and indigenous people [146];

pregnancy [147]; youth, drink–driving and domestic violence [148]; and impact on health [149])

Drink–driving

Topic area

Indigenous peoples Other Elderly

Illegal/surrogate alcohol FAS/F HIV ASD Social harms

Youth Work

Binge drinking Domestic violence Pregnancy

Parents Sports

Health

Number of countries

160 140 120 100 80 60 40 20

137

117 115

97 89 88 84

75 74

60 57

50 45

38 32 28

0

Funding sources probably influenced countries’ choices of awareness-raising topics, because the most commonly-reported topics were also those most often funded by nongovernmental organizations (NGOs) and the alcohol industry. Most responding countries (77%) that reported awareness-raising activities also reported that they received NGO funding for these activities. NGO funding most commonly focused on youth (58%), drink–driving (57%), parents (51%) and health (50%). In addition, 45 countries (30% of responding countries with awareness activities) reported receiving funding from the alcohol industry to raise awareness of alcohol-related harms, and the percentage of countries accepting industry funding for awareness-raising activities increased with

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national income. Six percent of low-income countries, 25% of lower-middle-income countries, 33% of upper-middle-income countries and 40% of high-income countries reported industry-funded activities. Drink–driving (21%) and youth (13%) were the topics most commonly funded by the alcohol industry.

In document Global Status Report on Alcohol and Health 2018 (Sider 110-115)