To investigate how interventions may work we will look at the effects of alcohol consumption on individuals and populations, and draw attention to the search for policies that protect health, prevent health problems such as liver cirrhosis, cardiovascular disease and disability, and address the social problems associated with the misuse of alcohol consumption. What alcohol policy is why it is needed, which interventions are effective, how policy is made, and how scientific evidence can inform the policy-making process? Also looking at why the higher the average amount of alcohol consumed in a society, the greater the incidence of problems experienced by that society.
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We will access the policy responses that are considered to reduce alcohol consumption: alcohol taxation, legislative controls on alcohol availability, and age restrictions on alcohol purchasing, media information campaigns, school-based education, community action programs, and treatment interventions. Considering the influence of environments that people live in, effects of cultures and social norms that define the appropriate uses of alcohol.
The value of population thinking in alcohol policy, and its ability to identify health risks and suggest appropriate interventions comparing different intervention strategies in terms of their effectiveness, and the ever-changing process that needs to constantly adapt to the evidence of new research results and tested intervention if it is to serve the interests of public health. One of the biggest determinants to alcohol consumption is the advertising and marketing of alcohol products by the drinks industry.
The extent and the nature of alcohol marketing will be examined to illustrate its effects on consumption, cultures and social norms. We will show that more evidence is needed to progress education as a viable intervention. Showing evidence that the majority of the population, alter their damaging drinking through the phenomenon of spontaneous remission, maturing out or self change.
It is good practice to learn from the past to plan for the future, the control of alcohol production, distribution, and consumption, has been around for thousands of years, such as requiring that all wine be diluted with water before being sold, these were devised by monarchs, governments, and the clergy to prevent alcohol-related problems.
But it was not until the rise of modern medicine and the emergence of the world Temperance Movement in the 19th century that alcohol policy was first seen as a potential instrument of public health. Between 1914 and 1921, laws prohibiting the manufacture and sale of all or most forms of beverage alcohol were adopted in the United States, Canada, Norway, Iceland, Finland, and Russia (Paulson 1973). Most of these laws were repealed during the 1920s and 1930s, and replaced by less extreme regulatory policies.
To view alcohol policies through the narrowly focused perspective of prohibition, however, is to ignore the fact that most policy-making during the past century has been incremental, deliberate, and respectful of people’s right to drink in moderation.: Alcohol control policies in public health perspective (Bruun et al. 1975), Sponsored by the World Health Organization (WHO), the monograph drew attention to the preventable nature of alcohol problems and to the role of national governments and international agencies in the formulation of rational and effective alcohol policies.
Alcohol control policies stimulated a heated debate not just among academics, but also among policy-makers. The most significant aspect of the book was its main thesis: the higher the average amount of alcohol consumed in a society, the greater the incidence of problems experienced by that society. Consequently, one way to prevent alcohol problems is through policies directed at the reduction of average alcohol consumption, particularly those policies that limit the availability of alcohol.
In the early 1990s, a new project was commissioned by WHO to review the development of the world literature pertaining to alcohol policy. The new study produced Alcohol policy and the public good, a book that proved to be as thought-provoking as its predecessor (Edwards et al. 1994). The book concluded that public health policies on alcohol had come of age because of the strong evidential underpinnings derived from the scientific research that had grown in breadth and sophistication since 1975.
After reviewing the evidence on taxation of alcohol, restrictions on alcohol availability, drinking and driving countermeasures, school-based education, community action programs, and treatment interventions, it was concluded that: The research establishes beyond doubt that public health measures of proven effectiveness are available to serve the public good by reducing the widespread costs and pain related to alcohol use.
To that end, it is appropriate to deploy responses that influence both the total amount of alcohol consumed by a population and the high-risk contexts and drinking behaviours that are so often associated with alcohol-related problems. During the past decade there have been major improvements in the way alcohol problems are studied in relation to alcohol policies. With the growth of the knowledge base and the maturation of alcohol science, there is now a real opportunity to invest in evidence-based alcohol policies as an instrument of public health.
In 1994, Edwards and his colleagues provided a broader view of alcohol policy, considering it as a public health response dictated in part by national and historical concerns. Though there was not an explicit definition of the nature of alcohol policy, its meaning could be inferred from the wealth of policy responses that were considered: alcohol taxation, legislative controls on alcohol availability, and age restrictions on alcohol purchasing, media information campaigns, and school-based education, to name a few.
Public policies are authoritative decisions made by governments through laws, rules, and regulations (Longest 1998). The word ‘authoritative’ indicates that the decisions come from the legitimate scope of legislators and other public interest group officials, not from private industry or related advocacy groups. Based on their nature and purpose, alcohol polices can be classified into two categories: allocative and regulatory (Longest 1998).
Allocative policies are intended to provide a net benefit to a distinct group or type of organization (sometimes at the expense of other groups or organizations) in order to achieve some public objective. The provision of treatment for alcohol-dependent persons is an example of a policy that seeks to reduce the harm caused by alcohol or to increase access to services for certain population groups.
In contrast to allocative policies, regulatory policies seek to influence the actions, behaviours, and decisions of others through direct control of individuals or organizations. Economic regulation through price controls and taxation is often applied to alcoholic beverages to reduce demand and to generate tax revenues. Laws that impose a minimum purchasing age and limit hours of sale have long been used to restrict access to alcohol for reasons of health and safety.
From the perspective of this paper, the central purpose of alcohol interventions is to serve the interests of public health and social well-being through their impact on health and social determinants, such as drinking patterns, the drinking environment, and the health services available to treat problem drinkers. Drinking patterns and behaviours that lead to intoxication, which leads to accidents, injuries, and violence.
Similarly, drinking patterns that promote frequent and heavy alcohol consumption are associated with chronic health problems such as liver cirrhosis, cardiovascular disease, and depression. Alcohol is causally related to more than 60 International Classification of Diseases codes (Rehm, Room, Graham, and others 2003); disease outcomes are among the most important alcohol-related problems.
4 percent of the global burden of disease is attributable to alcohol, or about as much death and disability globally as is attributable to tobacco and hypertension (Ezzati and others 2002; WHO 2002). The conclusions for alcohol policy are the same, whether alcohol is the sole causal factor for or consequence, a causal factor among many others or a factor mediating the influence of another causal factor.
In all cases alcohol contributes to social burden, and public policy must strive to reduce this burden, as well as the alcohol-related burden of disease. While there may be some offsetting psychological benefits from drinking (Peele and Brodsky 2000), from the point of view of minimizing the social harm from drinking, the general conclusion is that the lower the consumption, the better.
The environmental determinants of alcohol-related harm include the physical availability of the product, the social norms that define the appropriate uses of alcohol (e.g., as a beverage, as an intoxicant, as a medicine), and the economic incentives that promote its use. Health and social policies that influence the availability of alcohol, the social circumstances of its use, and its retail price are likely to reduce the harm caused by alcohol in a society.
Overall, the conclusion must be that alcohol consumption levels affect the health of a population as a whole. In addition to this, the predominant pattern of drinking in a population can have a major influence on the extent of damage from alcohol consumption. Patterns that seem to add to the damage are drinking to intoxication, and recurrent binge drinking. Another important determinant of health in relation to alcohol is the availability of and access to health services, particularly those designed to deal with alcohol dependence and alcohol-related disabilities.
Alcohol-related health services can be preventive, acute, and rehabilitative, and can be either voluntary or coercive. Health policies have a major impact on the alcohol treatment and preventive services available in people within a country through health care financing and the organization of the health care system. Bondy S.J. (1996) Public health is concerned with the management and prevention of diseases and injuries in human populations. Unlike clinical medicine, which focuses on the care and cure of disease in individual cases, public health deals with groups of individuals, called populations.
The value of population thinking in alcohol policy is in its ability to identify health risks and suggest appropriate interventions that are most likely to benefit the greatest number of people. The concept of ‘population’ is based on the assumption that groups of individuals exhibit certain commonalities by virtue of their shared characteristics (e.g., gender), shared environment (e.g., towns, countries) or shared occupations (e.g., alcoholic beverage service workers) that increase their risk of disease and disability, including alcohol-related problems (Fos and Fine 2000).
They also provide epidemiological data to monitor trends, design better interventions, and evaluate programs and services. In the context of the “public good” served by effective alcohol policy refers to those things that benefit most for a given society. One such public good would be effective intervention that would reduce alcohol related harm. Just as the eradication of malaria or (HIV) infections globally are seen as “global public goods” (Smith et al 2003).
By locating alcohol policy within the realm of public health and social policy, rather than economics, criminal justice, or social welfare, Authorities tend to approach alcohol as a major determinant of ill health. Health is viewed not only as the absence of disease and injury, but also as a state in which the biological, psychological, and social functioning of a person are maximized in everyday life (Brook and McGlynn 1991).
The way in which health is defined and valued within a society has important implications for alcohol policy. If it is defined narrowly as the absence of disease, then the focus is often placed on the treatment of alcohol dependence and the clinical management of alcohol-related disabilities, such as cirrhosis of the liver and traumatic injuries. If health is defined more broadly, then alcohol policy can be directed at proactive interventions that help many more people attain optimal levels of health.
Health is influenced by a variety of factors, including the physical, social, and economic environments that people live in, and by their genetic make-up, their personal lifestyles, and the health services that they have access to. An attempt is made to synthesize what is known about evidence-based interventions that can be translated into policy. By comparing different intervention strategies in terms of their effectiveness, scientific support, generalism, and cost, it becomes possible to evaluate the relative appropriateness of different strategies, both alone and in combination, to present problems and future needs.
As the scientific basis for alcohol policy begins to take shape, it is becoming apparent that there is no single definitive, much less politically acceptable, approach to the prevention of alcohol problems; a combination of strategies and policies is needed. If this realization is sobering, so too is the conviction, argued in this paper, that alcohol policy is an ever-changing process that needs to constantly adapt to the evidence of new research results and tested intervention if it is to serve the interests of public health. It will require extraordinary measures, some of them relatively painless to implement, others more demanding in terms of resources, ingenuity, and public support.
Another important factor is the “social norms” of a society where there are important differences in the cultural meaning of drinking for men and women. Societies’ normative expectations regarding the use of alcohol vary across age groups and between men and women. In some societies, drinking has been almost exclusively a province of men (Roizen 1981), In many societies, abstention rates increase in the later stages of life for both men and woman (Demers et al. 2001; Taylor et al. 2007).
This reflects social norms as older people are not suppose to get intoxicated and party as is common amongst young people. Most societies use taxation of alcoholic beverages to bring in revenue in larger or smaller quantities to relevant budgets. Alcoholic beverages are, by any reckoning, important, economically.
The benefits connected with the production, sale, and use of alcohol come at an enormous cost to society. Public health specialists and policy-makers who forget this fact do so only at their peril (Edwards and Holder 2000). Also social customs and economic interests should not blind us to the fact that alcohol is a toxic substance. It has the potential to adversely affect nearly every organ and system of the body. No other commodity sold for ingestion, not even tobacco, has such wide-ranging adverse physical effects.
Taking account of alcohol’s potential for toxicity is therefore an important task for public health policy. Especially the past decade, it can be said that remarkable progress was made in the scientific understanding of alcohol’s harmful effects, as scientists discovered biological, chemical, and psychological explanations for humans’ propensity to consume what has been called ‘the ambiguous molecule’ (Edwards 2000).
One of the biggest determinants to alcohol consumption is the advertising and marketing of alcohol products by the drinks industry. The extent and the nature of alcohol marketing have changed globally in the last decade, and the research has also expanded considerably to better understand its effects. Most of the new research is directed to the measurement of the impact of marketing on youth.
More is now known about the effects of marketing on younger people’s beliefs and intentions to drink as well as on their drinking behaviour. Research has investigated the impact of marketing other than the broadcast and print media advertising, although some of the new media and marketing approaches being used by the alcohol industry remain unmeasured and under-researched.
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The first examination is the current state of alcohol marketing and what is known about the way in which marketing has its impact. Second, two different policy approaches codes of content and restrictions to reduce exposure are assessed for their likely impact on consumption and harm. Interventions that change exposure to advertising have often been limited and evaluations have mixed findings.
More effort has gone into the establishment of codes aimed to affect the content of the advertising. Conclusions regarding the likely effects of these approaches can be made based on theoretical understanding and empirical evidence about the way in which marketing has its effects and its measured impacts. Conclusions may also be informed by research on tobacco advertising where the impacts are established and widely accepted (Lovato et al. 2004; Henriksen et al. 2008).
The alcohol industry insists that they only advertise to promote their own particular brands, and that the advertising does not affect any rise in the consumption of alcoholic beverages. Research and evidence shows that the commodity chain analysis highlights the importance of advertising, sponsorship and other forms of marketing to a globalized alcohol industry (Jernigan 2006). The marketing of the products and brand(s) produced is essential for the profit-making enterprise.
Marketing now involves much more than advertising using traditional media outlets such as print, television, and radio. Marketing exploits the possibilities provided by the design of products. New products and packaging have been developed to meet the needs and wants of different sectors of the market (Brain 2000). Pre-mixed drinks in which spirits or beer are made more palatable by the addition of a soft drink base or fruit flavourings have expanded in sales very rapidly and have become associated in some contexts, but not all, with heavier consumption (Huckle et al. 2008b).
Packaging has increased acceptability and palatability of alcoholic beverages among young people (Copeland et al. 2007; Gates et al. 2007). It utilizes a range of new media opportunities including electronic means, and a key element is the sponsorship of sporting and cultural events. The measured media (usually broadcast and print) is known to be an underestimation of the marketing effort by a factor of two to four (Anderson et al. 2009b). Marketing at the place of sale has become increasingly important with an expansion of alcohol sales into more retail outlets.
This often goes hand in hand with pricing promotions. For example buy-some-get-some-free (Jones and Lynch 2007). Promotion of alcohol brands in electronic media is a major part of marketing. Advertising is also shown in cinemas and this is increasingly supplemented by product placement in movies and television. Newer forms of electronic communication such as internet networking sites e-mail and cell phones have also provided new opportunities for alcohol promotion which are popular with young people (Jernigan and O’Hara 2004).
Sports and cultural events, particularly those with appeal to young people, are widely sponsored by alcohol brands. They also provide opportunities for direct marketing through free gifts and exclusive ‘pourage’ rights (Hill and Casswell 2004). Carlsberg’s sponsorship of the EURO 2004 football/soccer championship was reported to grow the brand by about 6% worldwide; Carlsberg told shareholders that its signage had appeared in the background of television sport coverage for an average of 16 minutes per game (Carlsberg 2006).
Much of marketing, including that based on sponsorship, crosses national boundaries. (Breen 2008). The theology is that the first stage is liking alcohol advertisements, followed by a desire to emulate the featured characters (including those that depict the lifestyle of young adults), and then the belief expressed that acting this way will result in positive benefits (Austin et al. 2006). Much of the marketing that targets young people is driven by an understanding of the importance of alcohol consumption for identity formation.
The advertising is designed to provide humour, attractive ideas, images, phrases, and other resources that are used in the process of peer-to-peer interaction as identity is formed and communicated (McCreanor et al. 2005). The longitudinal studies have been subjected to systematic reviews. The strength of the association, the consistency of the findings, the temporal relationship, the dose-response relationship and the theoretical plausibility of the effect have led to the conclusion that alcohol advertising increases the likelihood that young people will start to use alcohol and will drink more if they are already using alcohol (Jernigan 2006; Smith and Foxcroft 2009; Anderson et al 2009b).
Experience with policies to restrict the negative impacts of marketing is less well developed than with other areas of alcohol policy. In part this reflects the rapid developments and financial investment in marketing and media over the last four decades and a failure of policy developments to keep abreast of marketing practices. Research has suggested that voluntary codes are subject to under-interpretation and under-enforcement (Rearck Research 1991; Saunders and Yap 1991; Sheldon 2000; Dring and Hope 2001; Jones et al. 2008); including a bias in favour of the corporations represented on the decision-making board (Marin Institute 2008a).
There are also documented cases of the instability of such voluntary codes in response to changing market conditions (Martin et al. 2002; Hill and Casswell 2004). Following the introduction of a ‘co-regulatory’ approach in the UK, in which a government agency was delegated the handling of broadcast complaints to the Advertising Standards Authority (funded by the Alcohol industry), a code change was introduced.
Research demonstrated that advertisements continued to contain attributes that appealed to young people and the data showed a link between exposure to advertisements and consumption of specific beverages (Gunter et al. 2008). This substantial body of research has shown that, even if alcohol marketing remains in line with codes on alcohol advertising content, it nevertheless encourages drinking and has an impact on younger people’s beliefs and alcohol consumption levels.
A recent analysis of self-regulation by the alcohol industry in the UK concluded it was not an effective driver of change towards good practice (KPMG 2008b). Overall there is no evidence to support the effectiveness of industry self-regulatory codes, either as a means of limiting advertisements deemed unacceptable or as a way of limiting alcohol consumption (Booth et al 2008). Research has also suggested that the effects of marketing on beliefs about alcohol counteract any possible effect from health promotion activities (Wallack 1983; Centre on Alcohol Marketing and Youth 2003).
Recipients, who bring their own cultural and social experiences to their interpretation of the marketing, may perceive heavy drinking or intoxication as represented within the advertising even when it is not shown directly (Duff 2003; McCreanor et al 2008). This is particularly likely to have an impact on efforts to reduce heavier drinking as a cultural norm.
Direct effect on exposed individuals is not the only concern which underpins restrictions on marketing, however. It is possible that widespread marketing, which promotes alcohol as a positive and commonplace element of everyday life, has an impact on social norms around alcohol which may, in turn, affect the acceptability of more restrictive policies and practice. In effect, marketing is a force for ensuring that alcohol is dealt with as if it were an ordinary commodity (Casswell 1997).
There is clearly a need for an independent review of the evidence, with a view to impose restrictions that can meet public health goals. In some jurisdictions there are restrictions, typically by regulation, on exposure to alcohol marketing by media type, beverage type, time of broadcast or composition of media audiences (particularly of younger people). Most research has focused on exposure of young people to the measured media. This varies by country.
In the USA, young people aged 15-26 years on average reported seeing the equivalent of almost 360 advertisements per year, the majority on television. Restrictions imposed by agreement among industry actors are inherently unstable. In the context of the EU and other trade agreements, they may be subject to legal attack as an illegal restraint of trade. They may also be easily breached or dropped. The effect of partial bans was also reported not to have affected consumption in seventeen countries over 26 years (Nelson 2008a), in a study with material that included at least fifteen consequential changes in bans.
A comprehensive regulation of alcohol marketing, and one which has maintained political support for more than a decade, one of the key elements of the Loi Evin (relevant to the need to control the current ongoing proliferation of marketing approaches) is that advertising of alcohol is prohibited in all media unless the law provides for an exemption; there is a complete ban on sponsorship and on advertising in many media, including television and cinema.
Such advertising regulation has been challenged. However, restrictions on alcohol advertising to meet public health goals have been upheld by the courts, although sometimes with some modification. However, the findings of an effect of exposure to marketing put the question of controls on advertising high on the policy agenda.
The extent to which effective restrictions would reduce consumption and related harm in younger age groups must remain somewhat of an open question. The most probable scenario, based on the theoretical and empirical evidence available, is that extensive restriction of marketing would have an impact.
The evidence suggests there can be other effective restrictions other than advertising, strategies such as availability can have an effect studies of restriction on alcohol availability support the conclusion that such strategies can contribute to the reduction of alcohol problems. The best available evidence comes from studies of changes in retail availability, including reduction in hours and days of sale, limits on the number of outlets and restriction on retail access to alcohol.
For young people, laws that raise the minimum legal drinking age reduce alcohol sales and problems. This strategy has the strongest empirical support (Shults et al 2001; Wagenaar and Toomey 2002), with dozens of studies finding substantial impact on traffic and other casualties from change of the drinking age. The cost of raising the drinking age is low, and as the evidence shows that in the USA they estimated that thousands of lives have been saved over the last decade (Wagenaar et al. 1998).
A WHO analysis of the relative cost of a “restricted access” option estimated that Saturday closing would have considerable societal benefits in most parts of the world, though that would still be less than the result from a substantial price rise in alcohol via taxation.(Chisholm et al. 2006; Anderson et al. 2009a) This provides evidence that regulations backed up with enforcement can be effective in reducing alcohol consumption and problems; this is also used to force all sellers to hold a specific license to sell alcohol beverages, if there is any sales infringements the license can be suspended or revoked.
As well as restrictions and regulation strategies, measures to reduce the harm in drinking situations are thus a useful option in the mix of strategies for preventing, alcohol-related problems. The less the political process is willing to support general alcohol control and tax measures the more important local harm reduction measures become. Alcohol policies are primarily the concern of local, regional, and national governments, which often view the provision of treatment as part of a comprehensive approach to alcohol-related problems.
In addition to its value in the reduction of human suffering, treatment can be considered as a form of prevention. When it occurs soon after the onset of alcohol problems, it is called secondary prevention; when it is initiated to control the damage associated with chronic drinking, it is called tertiary prevention. As one of the first societal responses to alcohol problems, treatment interventions have not been critically examined as policy options, despite the resources they consume and the scientific evidence that is available concerning their effectiveness and costs.
To what extent are alcohol treatment and early intervention services effective in reducing population rates of alcohol-related harm? Other questions relevant to treatment policy include the following: Should people with these conditions be managed within the general health care system, specialized addiction services, social welfare agencies, psychiatric facilities, the criminal justice system, or a combination of these entities? What is the optimal amount and best combination of services needed to serve the needs of a country or a geographic area? What kinds of ‘ treatment systems are best suited to prevent the marginalization of people with chronic alcohol problems? How can treatment services best be organized to provide the most effective treatment at the lowest cost?
Treatment for alcohol problems typically involves a set of services, ranging from diagnostic assessment to therapeutic interventions and continuing care. Researchers have identified more than 40 therapeutic approaches, called treatment modalities, which have been evaluated by means of randomized clinical trials (Miller et al. 1995). Examples include motivational counselling, relapse prevention training, marital and family therapy, aversion therapy, cognitive-behavioural therapy, pharmacotherapy, and interventions based on the Twelve Steps of Alcoholics Anonymous.
These modalities are delivered in a variety of settings, including residential facilities, psychiatric and general hospital settings, outpatient programmes, and primary care. More recently, treatment services in some countries have been organized into systems that are defined by linkages between different facilities and levels of care, and by the extent of integration with other types of services, such as mental health, drug dependence treatment, and mutual help organizations (Klingemann et al. 1993; Klingemann and Klingemann 1999).
Most treatment research and the scientific evidence derived from it are component-based, focusing on a single intervention or episode of care. In general, the research, evidence can be organized according to three types of intervention within the emerging treatment systems of countries where information on efficacy and effectiveness is available, interventions for non-dependent high-risk drinkers, formal treatment) for problem drinking and alcohol dependence, and mutual help interventions.
Harmful drinking typically precedes the development of alcohol dependence, and by definition it can cause serious medical and psychological: problems in the absence of dependence. With the increased interest in clinical preventive services in both developed and developing countries, early intervention programmes have been developed by WHO and national agencies to facilitate the management of harmful drinking in primary health care and other settings
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