Reducing the Role of the Global Alcohol Industry in Health Education David H. Jernigan Ph.D. Department of Health, Behavior and Society Johns Hopkins Bloomberg School of Public Health And Director, Center on Alcohol Marketing and Youth

Disclosure and Acknowledgment No financial interests to disclose. Acknowledge Dr. Thomas Babor for his leadership in tracking and evaluating alcohol industry actions that I will discuss.

2010 GBD (% of total burden of disease)

GBD Men 2010 (% of all burden)

GBD women (% of all burden)

Alcohol’s role in the global burden of disease for year- olds Source: Gore et al., Lancet 2011; 377: Leading cause of DALYs for males everywhere but EMRO Leading cause of DALYs for females in high-income and Americas region

Alcohol Producers and Public Health: The conflict of interest Alcohol industry self-regulatory (voluntary) codes: Distilled Spirits Council of the U.S. (“DISCUS”): “DISCUS members encourage responsible decision- making regarding drinking, or not drinking, by adults of legal purchase age, and discourage abusive consumption of their products.” Beer Institute (U.S.): “Brewers strongly oppose abuse or inappropriate consumption of their products.”

What is “abusive consumption”? The alcohol industry will never define this. In the U.S., “binge consumption” is defined as: – More than 5 drinks in two hours for males – More than 4 drinks in two hours for females

Binge drinking dominates the alcohol market More than half of adult consumption in the U.S. is in the form of binge drinking (CDC) 90% of youth consumption in the U.S. is in the form of binge drinking Office of Juvenile Justice and Delinquency Prevention. Drinking in America: Myths, Realities, and Prevention Policy. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, Available at

Even if we limit “abusive consumption” to DSM-IV criteria and underage drinking… The alcohol market in the U.S.: – Value of underage drinking: $22.5 billion – Value of abusive and dependent drinking (DSM-IV criteria): $25.8 billion – Total combined loss to industry if underage and pathological drinking eliminated: $48.3 billion, or 37.5% of sales (Foster et al. 2006)

The Conflict of Interest If everyone drinks in a safe and responsible manner: – Alcohol companies face a market less than half the size of what we have today – Alcohol companies lose at least a third of their profits. – No publicly-traded company can intentionally lose this much of their market and survive. – The alcohol industry has a conflict of industry with safe and responsible drinking.

WHO Global Strategy to Reduce Harmful Use of Alcohol: Role of the Alcohol Industry “Public policies and interventions to prevent and reduce alcohol- related harm should be guided and formulated by public health interests and based on clear public health goals and the best available evidence.” “The appropriate engagement of civil society and economic operators is essential.” “Economic operators in alcohol production and trade are important players in their role as developers, producers, distributors, marketers and sellers of alcoholic beverages. They are especially encouraged to consider effective ways to prevent and reduce harmful use of alcohol within their core roles mentioned above, including self-regulatory actions and initiatives. They could also contribute by making available data on sales and consumption of alcohol beverages.”

WHO Global Strategy to Reduce Harmful Use of Alcohol: Role of the Alcohol Industry The strategy and WHA resolutions leading up to it very clear: collaborate with Member States, but only consult with the economic operators, NGOs, etc. WHO DG Dr. Margaret Chan: – “…member states have a primary responsibility for formulating, implementing, monitoring and evaluating public policies to reduce the harmful use of alcohol. The development of alcohol policies is the sole prerogative of national authorities. In the view of WHO, the alcohol industry has no role in the formulation of alcohol policies, which must be protected from distortion by commercial or vested interests.” (BMJ) ICAP’s interpretation: – “the adoption of the WHO Global Strategy…has legitimized industry’s ongoing efforts and has opened the door to inclusion of producers as equal stakeholders.” (Source: Grant M and Martinic M, Harmful alcohol consumption, NCDs and post-2015 MDGs. ICAP: Washington DC, 2012)

ICAP’s “Global Actions on Harmful Drinking” Focus – Drink-driving – Non-commercial alcohol – Self-regulation Help industry to avoid effective steps – quote from mid-term evaluation: – “Recent calls from some quarters to reduce advertising and increase taxation…show the importance of the Self-Regulation initiative for ICAP members.”

ICAP’s “Global Actions on Harmful Drinking” Evaluators’ recommended response to PAHO refusal to collaborate with the industry: – “Potential opposition in some quarters could be circumvented by the deployment of efforts targeted at areas with greater potential for success, such as possibly turning to different states in Mexico, where WHO/PAHO is less active.”

Fund Junk Science: “Tale of Two Surveys” Compared WHO alcohol policy survey to ICAP- sponsored alcohol policy survey Both surveyed health policy professionals, used similar methodologies ICAP survey conclusions belie its own data: – Claims public education on alcohol favored by 70% of respondents in “emerging” market countries – Re-analysis shows only 38% favor this Source: Babor and Xuan, 2006

“FLACSO” study Surveyed 1800 persons in nine countries: – El Salvador, the Dominican Republic, Costa Rica, Peru, Nicaragua, Venezuela, Mexico, Colombia, Brazil Used WHO protocols and cited WHO and PAHO liberally in its report Funded by Cerveceros Latinoamericanos and brewers in each country

“FLACSO” study Apparently a market research study - no evidence of academic human subjects review Mis-used WHO concepts, e.g. AUDIT Made misleading comparisons across countries, without statistical checks or confidence intervals

“FLACSO” study Reached industry-friendly conclusions – “There is no direct relation between the prevalence of annual alcohol consumption and rates of harmful consumption, especially binge drinking.” – “The data also indicate that countries where alcohol consumption is less prevalent may have higher rates of the population prone to long-term and occasional risk.” Conclusions not supported by study’s own data…

“FLACSO” study Independent statistical analysis finds that numbers in report do not support the conclusion – Correlations between per capita consumption and percentage of binge drinkers all positive and statistically significant for totals, males and females across the 9 countries Conclusions support industry-favored approach to alcohol: target the “high-risk” drinkers with punishments, do NOT take population-level steps “Findings” presented at side meeting at WHA in Geneva, and to LA health ministries

GAPG 5 Commitments (Oct 2012) 1.Reducing underage drinking, via enforcement of current laws and encouraging governments to introduce and enforce minimum purchase ages – To be achieved through increased enforcement and action by the industry “to develop, promote and disseminate educational materials and programmes designed to prevent and reduce underage purchase and consumption…” Evidence base is clear: educational approaches ineffective with young people Doing this is violation of industry role in the Global Strategy 2.Continuing to strengthen and expand marketing codes of practice that are rooted in our resolve not to engage in marketing that could encourage excessive and irresponsible consumption, with a particular focus on digital marketing – Abundant evidence in multiple countries that industry self-regulatory codes are ineffective both in protecting against offensive content and in shielding young people from alcohol advertising

GAPG 5 Commitments (Oct 2012) 3.Making responsible product innovations and developing easily understood symbols or equivalent words to discourage drinking and driving and consumption by pregnant women and underage youth – Industry product innovations: – “We commit not to produce any beverage alcohol products that contain excessive amounts of added stimulants…” No definition of excessive… – There is no evidence that warnings – either in symbols or in words – will reduce harmful use of alcohol.

GAPG 5 Commitments (Oct 2012) 4.Reducing drinking and driving by collaborating with governments and non-governmental organizations to educate and enforce existing laws – Industry has historically opposed effective laws. – American Beverage Institute (begun with seed money from Philip Morris) opposing ignition interlocks for all except “hardcore drinking drivers,” move to.05, etc. 5.Enlisting the support of retailers to reduce harmful drinking and create ‘guiding principles of responsible beverage alcohol retailing’ – Evidence is that “reliance on manager training to promote responsible establishment alcohol policies is not sufficient to prevent illegal alcohol sales to obviously intoxicated patrons and to reduce alcohol-related problems.” (Toomey et al. 2008)

WHO Global Strategy to Reduce Harmful Use of Alcohol: “Best Buys” for alcohol Regulating commercial and public availability of alcohol Using pricing policies such as excise tax increases on alcoholic beverages Restricting or banning alcohol advertising and promotions

Active opposition to the “best buys” Regulating commercial and public availability of alcohol – Brazil – producers lobbied successfully to repeal ban on alcohol sales in sports stadia Using pricing policies such as excise tax increases on alcoholic beverages – Scotland – producers lobbying against minimum pricing Restricting or banning alcohol advertising and promotions – South Africa, Lithuania – producers lobby against bans on alcohol advertising

The opposition Alcohol: $1 trillion globally At least $4 billion per year on marketing in the U.S. alone Primarily in hands of small number of large global companies U.S. – one lobbyist for every two members of Congress (2009) U.S. states - $150 million in political donations to state legislatures from 2000 to 2010 WHO: GAPG spent >$1 million lobbying WHO since 2005

Public health intervention: “Global Statement of Concern” Drafted by an international coalition of 17 public health professionals, health scientists and NGO representatives, send under the auspices of GAPA In the form of public letter to WHO Director General Dr. Margaret Chan In less than a month received endorsements from more than 500 academics, health professionals, and NGO representatives from over 60 countries.

Recommendations Refrain from all marketing including sponsorship and product design (e.g., caffeinated alcohols, alcopops, sweetened alcohol beverages) in order to protect children, young persons, high risk alcohol users and females in their child bearing years Refrain from further lobbying against effective public health measures Refrain from further engagement in health-related prevention, treatment, and traffic safety activities, as these tend to be ineffective, self-serving and competitive with the activities of the public health community

Recommendations Refrain from direct funding of alcohol research because of the potential for agenda setting and Cease political activities designed to reduce or eliminated evidence-based alcohol control policies Respect the rules of science and the integrity of researchers and research organizations, e.g. quote and use the research in appropriate ways, and not use sponsorship of scientific research for marketing or political lobbying purposes Review and otherwise meet the standards of academic publishers

Recommendations Secure its own supply chains and cooperate with all aspects of the law when it comes to preventing the diversion of commercially produced alcohols to the informal market Further recommendations for WHO, Member States and the public health community Full Statement of Concern is available at concern pdf. concern pdf

Thank you very much!