5. ALCOHOL POLICY AND INTERVENTIONS
6.1 Progress in alcohol consumption, alcohol-related harm and policy
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6. REDUCING THE HARMFUL USE OF ALCOHOL: A PUBLIC HEALTH IMPERATIVE
As WHO sets a course in its Global Programme of Work for 2019–2023 to ensure that 1 billion more people enjoy better health and well-being by the year 2023 and 1 billion more benefit from universal health coverage (WHO, 2018b), it becomes a public health imperative to address effectively the harmful use of alcohol and the need to reduce alcohol-related harm worldwide. As shown in Chapter 1, the harmful use of alcohol has an impact on a wide range of conditions which are among the main areas of action for achieving the SDG health targets by 2030. Notably, a 10% relative reduction in harmful use of alcohol by 2025 in comparison with 2010 is one of nine targets in the NCD Global Monitoring Framework (Chapter 2).
Reviewing the progress achieved since 2010, as well as exploring the major challenges and opportunities for reducing the harmful use of alcohol worldwide, is the focus of this chapter.
6.1 PROGRESS IN ALCOHOL CONSUMPTION, ALCOHOL-
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2010. These figures demonstrate the feasibility of a 10% relative reduction as envisaged by the NCD Global Monitoring Framework, even though it is in the region with the highest baseline level of alcohol consumption. No changes are observed in the African and Eastern Mediterranean regions, but a dramatic increase in alcohol consumption is observed in the South-East Asia Region, with some increase in the Western Pacific Region. The current trends and projections point towards increase of total per capita consumption worldwide in the next 10 years that will make the target of 10% relative reduction by 2025 out of reach unless implementation of effective alcohol control measures will reverse the situation in countries with high and increasing levels of alcohol consumption.
There are positive changes in the estimated prevalence of heavy episodic drinking in all WHO regions, surpassing the target of a 10% relative reduction in four out of six WHO regions for the population aged 15 years and older, and in three regions (Africa, Americas, Europe) among adolescents (15–19 years of age).
Total (recorded and unrecorded) alcohol per capita (APC) (aged 15+ years) consumption within a calendar year in litres
of pure alcohol by WHO Region and the world, 2010 and 2016
Age-standardized prevalence (%) of heavy episodic drinking (HED) among the population by WHO Region and
the world, 2010 and 2016
WHO
Region 2010 95% CI 2016 95% CI
Relative change
(%) 2010 95% CI 2016 95% CI
Relative change (%)
AFR 6.3 5.9-6.8 6.3 5.8-6.8 0 18.7 17.3-20.2 16.8 15.3-18.1 -10.2
AMR 8.2 7.8-8.7 8.0 7.6-8.4 -2.4 25.0 22.1-28.0 22.3 19.6-25.1 -10.8
EMR 0.6 0.4-0.7 0.6 0.4-0.7 0 0.6 0.5-0.7 0.5 0.4-0.6 -16.7
EUR 11.2 10.6-11.8 9.8 9.3-10.3 -12.5 33.8 27.6-38.1 28.9 23.3-33.3 -14.5
SEAR 3.5 3.0-4.0 4.5 3.7-5.4 28.6 14.0 12.4-15.6 13.8 12.2-15.4 -1.4
WPR 7.0 6.5-7.6 7.3 6.7-7.9 4.3 24.2 16.8-31.9 22.6 15.5-30.2 -6.6
World 6.4 6.2-6.6 6.4 6.2-6.6 0 20.6 16.6-24.5 18.5 14.9-22.2 -10.2
Table 6.1 Relative changes (2010–2016) in total alcohol per capita consumption (APC) and age-standardized prevalence of heavy episodic drinking (HED)
Positive changes in levels and patterns of alcohol consumption translate into reductions of alcohol-related mortality exceeding 10% in the African, European and Western Pacific regions and the world, and in reductions of more than 10% in age-standardized alcohol- attributable DALYs in the African and European regions and in the world. However, the global level of per capita alcohol consumption continues to be high, resulting in 3 million deaths in 2016 and 5.1% of the global burden of diseases expressed in DALYs.
Age-standardized alcohol-attributable deaths (all causes) per 100 000 people, by WHO Region and
the world, 2010 and 2016
Age-standardized alcohol-attributable disability-adjusted life years (DALYs) per 100 000 people, by WHO Region and
the world, 2010 and 2016 WHO Region 2010 95% CI 2016 95% CI
Relative change
(%) 2010 95% CI 2016 95% CI
Relative change (%) AFR 79.8 64.9-98.6 70.6 57.1-87.4 -11.5 3438.2 2834.3-4124.5 3043.7 2491.8-3659.6 -11.5
AMR 36.2 26.4-63.9 34.1 27.0-56.4 -5.7 1937.7 1595.7-2294.5 1821.9 1513.2-2158.4 -6.0
EMR 7.0 5.4-11.0 7.0 5.3-10.9 -0.3 327.2 276.2-438.6 322 267.7- 428.6 -1.6
EUR 84.1 78.5-89.0 62.8 58.3-67.1 -25.3 3554.7 3376.4-3723.0 2726.5 2563.3-2878.4 -23.3
SEAR 35.1 29.2-43.2 36.8 28.1-40.9 4.9 1664.4 1311.2-2392.6 1718.3 1335.9-2261.4 3.2
WPR 27.0 20.5-34.6 24.3 17.6-32.2 -10.1 1242.8 1035.6-1507.8 1132.9 929.1-1,390.9 -8.8 World 44.6 39.3-52.2 38.8 33.8-45.8 -13.0 1967.7 1746.6-2270.3 1758.8 1543.5-2039.4 -10.6
Table 6.2 Relative changes (2010–2016) in age-standardized alcohol-attributable deaths and age-standardized alcohol-attributable disability-adjusted life years (DALYs)
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Seen in this light, the global situation regarding alcohol policy development and implementation has improved, but it is still far from accomplishing effective protection of populations from alcohol-related harm, and from the targeted reduction in the global level of alcohol consumption as measured by the main indicator – total per capita consumption.
The good news is that more countries have written national alcohol policies, although these are most common in higher-income countries. Funding for implementation continues to be scarce and insufficient, especially in the WHO African, Americas and Eastern Mediterranean regions. Awareness-raising activities are common, but 30% of countries providing information to WHO indicate that these are funded by the alcohol industry, and there is substantial evidence that industry-funded initiatives are unlikely to be effective (McCambrige, Mialon & Hawkins, 2018; Torjesen, 2011; Esser et al., 2016). Community action projects regarding alcohol are widespread but they most frequently involve simply providing information, which is also unlikely to be effective in changing behaviour.
Laws to discourage or prevent drink–driving are a bright spot, with the majority of countries having set BAC limits for drivers of 0.05% or lower. Policies offering responsible beverage service training and requiring labels to provide alcohol content have also spread widely, but just eight countries require alcohol containers to disclose the number of standard drinks they contain. Most countries also report some kind of tracking system for informal or illegal alcohol, and most countries with written alcohol policies include this in their policy texts. While population-level access to treatment for alcohol dependence remains limited or unknown in much of the world, more than half of responding countries reported having expanded access to alcohol screening and brief intervention. However, this expanded access is mostly limited to higher-income countries. This is a consistent pattern when it comes to other alcohol policies as well, and it is particularly evident with regard to the most effective policies, the “best buys”. The skewed prevalence of effective policies raises issues of global health equity and underscores the need for greater resources and priority to be placed on disseminating effective actions to low- and middle-income countries to reduce alcohol-related harm.
While almost all countries levy some kind of tax on alcohol, fewer than half report adjusting these taxes for inflation or using other price strategies such as minimum unit pricing or bans on low-cost selling and volume discounts. For alcohol marketing, the least restrictive policies continue to be the most common, and countries in the WHO African Region and the Region of the Americas were the most likely to have no restrictions at all. Despite an increase in countries adopting policies that limit alcohol advertising and marketing, restrictions on one of the fastest growing areas for this activity, the Internet and social media, are rare.
The situation is perhaps the worst in terms of the critically important “best buy” of alcohol availability. With the exception of minimum age purchase laws which exist in most of the high- and middle-income countries, but not the lower-income countries, availability restrictions appear to be declining over time. Restrictions on days of sale and alcohol outlet density exist in less than one-third of reporting countries, and barely half of the countries report limiting hours of sale. The number of licences to produce, distribute and sell alcohol – a marker for increased rather than decreased availability – is increasing in much of the world, particularly in lower-income countries.
Considerable challenges for effective alcohol policy development and implementation remain. These are associated, inter alia, with the complexity of the problem and sometimes limited levels of political will and commitment of governments and other stakeholders to supporting and implementing effective measures to reduce the harmful use of alcohol in a context of powerful commercial interests.