5. ALCOHOL POLICY AND INTERVENTIONS
6.3 Opportunities for reducing the harmful use of alcohol
Many opportunities on the horizon may provide a path forward for WHO Member States aiming to reduce alcohol-related harms. Specific inclusion of a health goal in the SDGs, with a specific target oriented to the prevention of both narcotic drug abuse and harmful use of alcohol, and inclusion of harmful use of alcohol as one of the key risk factors in the NCD action plan, both help to keep alcohol and alcohol policies on the global agenda.
The bright spots and case studies emphasized throughout this report demonstrate that countries can use policies to achieve reduction in alcohol-related harms. Conducting and disseminating rigorous evaluations of these examples can serve as templates
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and inspiration for other countries. Training, technical assistance, commitment and adequate resourcing to take this research and put it into action through the passage and implementation of the most effective alcohol policies will be crucial to the achievement of WHO’s mission of improving the health and well-being of at least a billion more people over the next five years.
In the next sections several opportunities for reducing the harmful use of alcohol within the context of 2030 Agenda for Sustainable Development will be discussed in detail.
6.3.1 Building on the decrease in youth alcohol consumption in many high- and middle-income countries and increased health consciousness in populations
In recent years, alcohol consumption among young people has been dropping in a wide range of countries where there are regular youth surveys – throughout Europe (though less in Eastern Europe) and in English-speaking high-income societies (de Looze et al., 2015; Pennay et al., 2018). The decline seems to be quite general across subdivisions of the population (e.g. Livingston, 2014). For a few countries for which measures are already available, the decline seems to be continuing into the next age group as the cohort grows older (Livingston, 2015).
The wide distribution of the change suggests that factors which reach beyond specific policies or cultures must be in play, and collaborative research is currently under way to identify contributing factors (e.g. Pennay et al., 2018). Whatever the causes, the fact of the change offers considerable opportunity for public health policies and programming to reduce harms from alcohol. Recent history in such areas as cigarette smoking and drink–driving suggests that it is the combination and mutual support of policy initiatives with shifts in popular sentiment that are most effective in improving public health.
While the decline in youth drinking is occurring in some of the heavier-drinking parts of the world, trends are in the opposite direction in many places, particularly in Asia (see Table 3.6). A better understanding of factors behind the decline where it has occurred will point to avenues for broader positive change.
As demonstrated in Chapter 3, there is a trend towards an increase in the proportion of former drinkers in populations. One of the factors contributing to this phenomenon is an increasing awareness of the health consequences of alcohol consumption, and particularly its causal relationship with some types of cancer, liver and cardiovascular diseases, as well as infectious diseases such as tuberculosis and HIV (Chapter 4).
6.3.2 Building on recognition of the role of alcohol control policies in reducing health and gender inequalities
As WHO has moved to analyse and counter adverse risks to health, alcohol has been increasingly recognized as a factor in health inequality (e.g. Blas & Sivisankara Kurup, 2010). As described in Chapter 1, within a given society, the health and social harm from a given level and pattern of drinking is greater for poorer people than for richer people, and is greater in poorer societies than in richer ones.
On the other hand, rates of abstaining from drinking are generally higher in low-income than in high-income societies and are higher among poorer people within a society than among those who are richer. In addition, levels of drinking in a population often increase
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when a society develops and reaches a higher average income. In the past, economic development has therefore often carried with it increases in alcohol consumption and in harms from drinking. Policies and programmes to promote sustainable development thus need to include sustained attention to policies and programmes that will discourage heavy drinking and reduce harms from drinking.
Economic development in societies where there is no strong religious norm against drinking 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 (Jernigan, 2009; Esser &
Jernigan 2018). However, any economic gain from increased alcohol consumption will be outweighed by the costs and harms in terms of public health. Given the higher “harm per litre” for poorer drinkers, increased alcohol consumption will also tend to increase health and social inequalities – between genders as well as social classes. From the perspective of public health and the public interest, sustainable development requires strengthening rather than loosening of the market controls on the availability, price and marketing of alcohol. In a growing economy, the public health interest is best served by discouraging the initiation of drinking by those who currently abstain, and by discouraging increases in drinkers’ amount of drinking. Social policies should take into account, and work to counteract, the higher “harm per litre” for poorer drinkers and those around them.
Alcohol control measures oriented to reducing levels of drinking in the whole population, such as higher taxes and restrictions on availability – among WHO’s “best buys” for reducing harms from alcohol (WHO, 2017a) – tend to have a greater effect on poorer drinkers than on richer ones. In the conventional language of economists, such measures are referred to as “regressive” because of this differential impact although, in the case of alcohol, this disregards the higher rates of abstention from alcohol among poorer people (Ashton, Casswell & Gilmore, 1989). From a public health perspective, a greater effect on poorer drinkers is a means of reducing health inequality. Measures such as WHO’s
“best buys” for alcohol policies thus contribute to a major goal of the 2030 Agenda for Sustainable Development.
Increasing attention is being paid to the role of alcohol on gender inequality in many societies. In every region of the world, men are more likely to drink, and much more likely to drink heavily, than women; as a result, on the global burden of disease (in DALYs) attributable to men’s drinking is four times greater than the burden for women’s drinking (Chapter 3).
The imbalance between genders in relation to drinking plays out in multiple ways in terms of the interests of women. Expenditures on drinking and behaviours accompanying it (e.g.
gambling) are decided on and made by an adult male in a family, but the amounts spent come from the budget which sustains the family as a whole.
There is a growing recognition of the role of alcohol in violence against women, particularly in the family. As noted in Chapter 1, a United Nations study of male perpetration of intimate partner violence in six low- and middle-income countries in Asia and the Pacific found that men in non-Muslim majority countries who acknowledged “alcohol misuse”
reported higher rates of intimate partner sexual violence (Fulu et al., 2013). WHO’s recent Global Plan of Action on interpersonal violence, in particular against women and girls and against children, notes “ease of access to alcohol” as a risk factor for the occurrence of such violence, and “partner’s harmful use of alcohol” as a risk factor for intimate violence against women (WHO, 2016).
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6.3.3 Building on the evidence of cost-effectiveness of alcohol control measures
During recent years the evidence of high cost-effectiveness for a number of alcohol control measures has been strengthened (Chisholm et al., 2018), and “best buys”
for reducing the harmful use of alcohol include increases in excise taxes on alcoholic beverages, bans or comprehensive restrictions on exposure to alcohol advertising, and restrictions on physical the availability of alcohol via reduced hours of sale (Chapter 2).
The latest economic analysis undertaken under the auspices of WHO demonstrated a high return on investment for “best buys” in alcohol control. According to the results of this analysis, involving calculations of the cost estimates of implementation of “best buys” in 78 low- and middle-income countries, every additional US dollar invested in the most cost-effective interventions per person per year will return US$ 9.1 by 2030. This return is higher than for a similar investment in tobacco control (US$ 7.4) or prevention of physical inactivity (US$ 2.8) (WHO, 2018b).