Issue 1 2002

Alcohol industry’ssocial aspect

groups exposed

G l o b a l A l c o h o l P o l i c y A l l i a n c e

GLOBAL ALCOHOL POLICY ALLIANCE

Editor in ChiefDerek Rutherford

EditorAndrew McNeill

Assistant EditorAndrew Varley

Design and production2b Graphic Design

Published by The Global Alcohol Policy Alliance12 Caxton StreetLondon SW1H 0QSTel: 020 7222 4001Fax: 020 7799 2510Email: gapa@ias.org.uk

ISSN 1460-9142

Contents Issue 1, 2002

3. The International Center for Alcohol Policies

Peter Anderson

8. The Amsterdam Group

Derek Rutherford

12. Alcohol policies in EU member states

Esa Österberg and Thomas Karlsson

14. Free alcohol for youth in Israeli clubs

Shoshana Weiss

16. Hard liquor on American TV

18. Cultural aspects of drinking patterns and alcohol

controls in China

Ian Newman

22. Two thirds of Australian alcohol consumption “unsafe”

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3

The International Center for Alcohol Policies:a public health body or a marketing arm ofthe beverage alcohol industry?

An overall strategy for policy on alcohol, anaddictive substance, is to create anenvironment that helps people to makehealthy choices and renders unhealthy choicesmore difficult or expensive2. Alcohol policymust take into account the total drinkingpopulation, in order to define the scope ofpublic health action. Alcohol policy should notbe limited to “alcoholism”, the alcohol addict,or extreme physical illness, but should takeinto account both alcohol-related problemsand alcohol dependence.

It should give attention to acute and accidentproblems, as well as to long-term problems. Itshould deal with social and psychologicalproblems, as well as physical ones. It shouldtackle small and common problems, as well asmajor and less common consequences. Policymust be concerned with the adverse impact ofdrinking on the family and on other people, aswell as on the drinker. Alcohol policy needs totake into account both a population’s generallevel of drinking and its patterns of drinking.Per capita alcohol consumption affects theprevalence of drinking problems. Further,alcohol consumption levels are not set. Theyfluctuate and respond to changes in suchfactors as market controls, politicalliberalization, production, buying power,urbanization, migration, real price, andmarketing and trade.

The International Center forAlcohol PoliciesSearching the Internet for alcohol policyreturns the International Center for Alcohol

Peter Anderson

Alcohol Policy and the harm done byalcoholAccording to its analysis of the globalburden of disease the World HealthOrganization estimates that, worldwide,alcohol related deaths and disability

account for greater costs to life and longevity than thosecaused by tobacco1. The aim of alcohol policy should be toreduce this harm and alcohol policy options must be judgedin the light of their impact on harm.

www.icap.org

Around the world, the beverage alcohol industry, in its detemination to avoidthe fate of the tobacco industry, is making strenuous efforts to influence publicopinion and government policy on alcohol issues. It promotes ‘social aspectgroups’ which purport to address the problems of alcohol abuse. Here, PeterAnderson and Derek Rutherford critically examine the work of the two maininternational groups: ICAP based in Washington DC and the Amsterdam Groupin Europe

Policies (ICAP) http://www.icap.org . Themission of ICAP, which is funded by theinternational beverage alcohol industry, is:� To help reduce the abuse of alcohol

worldwide and promote understanding ofthe role of alcohol in society.

� To encourage dialogue and pursuepartnerships involving the beveragealcohol industry, the public healthcommunity and others interested inalcohol policy”.

ICAP’s President is Marcus Grant, who waspreviously responsible for global activities forthe prevention of substance abuse, includingalcohol, with the World Health Organization(WHO), where he worked for 10 years. In hisown words, Grant, who regards himself as apublic health advocate, has “ seen again and again how much commonground exists between governments, industryand scientists and how willing those of goodfaith are to come together and explore thatcommon ground in working partnerships”.

The Philosophy of ICAPICAP’s philosophy statement is as follows: “As a basis for open dialogue with thescientific and public health communities,and as a contribution to meaningfuldiscourse concerning beverage alcohol's rolein society, the companies sponsoring theInternational Center for Alcohol Policiesbelieve:1. The vast majority of people who consume

beverage alcohol do so responsibly and inorder to enhance the quality of their lives.

2. When consumed moderately and in aresponsible manner by those with goodhealth and dietary habits and who haveno medical reason to refrain fromdrinking, beverage alcohol is associatedwith very few risks of harm and has beenreported to have some beneficial effectson health.

3. Irresponsible consumption of beveragealcohol is associated with a variety ofrisks both to the individual and to thepublic in health, social, economic, andsafety contexts. Irresponsibleconsumption refers to high levels ofintake, either on single occasions orrepeatedly, or to drinking ininappropriate circumstances or by thosewho should not be drinking at all.

4. Alcohol policies need to be based uponan objective understanding of availableresearch on alcohol use and abuse; andshould aim to create a reasonablebalance of government regulation,industry self-regulation and individualresponsibility.”

Is ICAP really interested in public health, or isit really a marketing arm of the beveragealcohol industry? In a recent editorial,McCreanor and colleagues argued that ICAP’srole is the promotion of an industry-favourablealcohol ideology 3. In this paper, I would like togo further and consider whether or not anadditional purpose of ICAP is to mobilisescience to provide the information thebeverage alcohol industry needs to market itsproducts. One way of addressing this questionis to read ICAP’s website and its mainpublications. ICAP has four priorities in itswork, each of which will be discussed in turn.

Forge a More IntegratedApproach to Alcohol PolicyICAP aims to “develop a more integrated approach (toalcohol policy) that reassesses currenttheories with a primary focus on thedifferences between positive and negativepatterns of drinking”.

Through its publications and statements, ICAPattempts to establish the concept of drinkingpatterns as a basis for alcohol policy and topromote elements of alcohol policy, which,according to the evidence base, are largelyineffective.

Drinking patterns and their consequences4 is apublication that attempts to make drinkingpatterns the basis for alcohol policy. It isunbalanced in its review of the literature andat times lacks comprehensiveness andauthority in its analysis. It concludes thatpolicy makers should shift their focus toeliminating negative drinking patterns bytargeted strategies and to promoting beneficialpatterns of drinking. Through its focus inattempting to discredit the single distributionmodel of alcohol consumption, the publicationfails to review and analyse the extensiveliterature on the relationship between percapita alcohol consumption and alcoholrelated harm. There is no doubt that patternsof alcohol consumption are important foralcohol-related harm, but so are societal levelsof alcohol consumption. A very good exampleof this is the post-war experience of alcoholand mortality in the countries of the EuropeanUnion5. In Sweden, for example, there is a veryclear and strong relationship between alcoholconsumption and alcohol related mortality(see figure).

Pooling the experience of a number of differentEuropean countries, time series analysisshows that there is a significant positiverelationship between change in alcoholconsumption and change in both overall andalcohol related death for each age segment ofthe population5. The relationship is stronger innorthern Europe than in southern Europe. Forexample, an extra litre of alcohol per personwould result in a 12.4 per cent increase inhomicides in northern Europe, but only a 5.5per cent increase in southern Europe.However, since consumption levels aregenerally higher in southern Europe, theactual number of deaths attributable to alcoholis roughly equal in the northern and southernregions.

ICAP’s response to a more integrated approachto alcohol policy is to promote those policyoptions generally regarded as ineffective. Thisapproach is evident in the first of ICAP’s twomain policy guidelines, the 1997 DublinPrinciples of Co-operation Among theBeverage Alcohol Industry, Governments,and Scientific Researchers. The DublinPrinciples cover both alcohol and society andalcohol research. Principle C of alcohol andsociety states that: “Consumption of alcohol is associated with a

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The International Center for Alcohol Policies

Sponsors of ICAP

Allied Domecq PLC

Asahi Breweries, Ltd.

Bacardi-Martini

Brown-Forman BeveragesWorldwide

Coors Brewing Company

Diageo PLC

Foster's Brewing Group Limited

Heineken NV

Joseph E. Seagram & Sons

Miller Brewing Company

Molson

South African Breweries

variety of beneficial and adverse health andsocial consequences, both to the individualand to society. Governments,intergovernmental organizations, the publichealth community, and members of thebeverage alcohol industry, individually andin co-operation with others, should takeappropriate measures to combatirresponsible drinking and inducements tosuch drinking. These measures could includeresearch, education, and support ofprograms addressing alcohol-relatedproblems.”

It is difficult to see how education, which mostevidence has shown to be ineffective,particularly when implemented independentlyof other policy measures2, is going to reducethe harm done by alcohol. It is not clear whatprogrammes ICAP would like to implement toreduce alcohol-related problems. Readingother ICAP publications and documentssuggests that they would not include evidencebased measures, such as those that deal withprice or availability that have been shown toreduce harm2.

In forging a more integrated approach toalcohol policy, ICAP aims to reframe thealcohol policy debate away from the point ofview that alcohol consumption matters, to thepoint of view that it is irresponsible drinkingthat matters. ICAP aims to lead science andpolicy away from preventive measures andeffective environmental strategies and towardsan increasing focus on the choices of the

individual drinker, ineffective or marginalinterventions, and beneficial consumption ofalcohol. The process neglects to mention theaddictive properties of the substance, the lackof knowledge about harm amongst consumers,a welfare analysis of alcohol use and theeconomic rationale for governmentintervention in the alcohol market.

The ICAP approach to alcohol policy isselectively to review the evidence for effectivepolicy in its own interests. For a moreintegrated approach to alcohol policy, readmore sales for the alcohol industry. Drinkingpatterns and their consequences can be readas giving the industry good advice on how toincrease the volume of alcohol consumed, andthus marketed, by trying to change the policydebate in the direction that minimises theadverse risks to the industry.

Find a Common LanguageICAP has “set in motion a process of finding a lessemotional and value-laden way ofcommunicating as a basis for a moreeffective partnership”.

This simply means trying to introduce acommon language into alcohol policy andresearch that serves the beverage alcoholindustry’s interests.

ICAP’s second policy statement, The GenevaPartnership on Alcohol – Towards a GlobalCharter, published in 2000, is

“intended as a policy tool to assist in alcoholpolicy development at the international,national and local level”.

The Geneva Partnership on alcoholemphasizes the need to bring people togetherto forge the common language.

Its preamble states: “There is a growing recognition of theimportance of establishing stronger relationsbetween the public and private sectors at theinternational level. In this context, ICAP hastaken the initiative to develop an agenda forpartnership as a contribution to the globaldebate on alcohol policy. This documentbreaks new ground by identifying andpromoting the complementary interests ofthe public health and scientific communities,the beverage alcohol industry, governmentsand the non-governmental sector. It buildsupon the Dublin Principles andacknowledges the efforts of internationalorganizations to develop alcohol policy. In itspreparation, which has involved anextensive process of consultation, includingregional and global meetings, input has beensought from a wide range of people involvedin alcohol policy development, with theobjective of formulating general principlesmutually acceptable to all parties.”

The common language the beverage alcoholindustry would like to promote is pleasure, thetheme of one of its conferences and itsproceedings, published as Alcohol and Pleasure,a Health Perspective6. Alcohol and Pleasure wasalso about partnership building. In its conclusion,Grant says:“It is through partnerships that it will be possibleto build upon the success of the conference andto take forward the remarkably broad range ofideas covered by this volume.”

Alcohol and Pleasure is about establishingICAP’s brand, credibility, and policy influence.This credibility is about giving the beveragealcohol industry good advice on the role ofpleasure in alcohol consumption and how thiscan best be used for marketing its products.

Balance Interests forDeveloping Countries andEmerging MarketsAccording to ICAP: “Emerging markets, especially in developingcountries, provide an opportunity for the

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The International Center for Alcohol Policies

Alcohol consumption (solid line) and male alcohol-related mortality (broken

line) in Sweden

66 68 70 72 74 76 78 80 82 84 86 88 90

7.5

7.0

6.5

6.0

5.5

5.0

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20

18

16

14

12

10

8

6

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Year

industry to work with the public healthcommunity to set new standards for abuseprevention and responsible marketing.Although the social environment may varyenormously from country to country, ICAPidentifies common factors that can be usedpro-actively around the world”.

Some of the ways that ICAP balances theinterests in new markets are through dialoguesand country projects. As an example ofdialogue,“ICAP convened a meeting among publichealth officials from developing countriesand alcohol beverage companyrepresentatives active in emerging marketsin 1999. The purpose of the meeting was todiscuss ways in which meaningfulpartnerships concerning alcohol issues couldbe developed between industry, governmentand the public health sector in thedeveloping world.”

As an example of a country project, “ICAP is working with public healthspecialists in India to develop ongoingconsultation on national alcohol policyissues of mutual concern. It worked with thelocal social aspects organization, SASPI(Society for Alcohol and Social PolicyInitiatives), to begin a dialogue withgovernment, public health, and the alcoholbeverage industry to agree on an alcoholpolicy agenda for India. These discussionswere based on the Asia-Pacific RegionalDraft Charter on Alcohol, which in turninformed discussions of the GenevaPartnership on Alcohol: Towards a GlobalCharter.”

Balancing interests for developing countriesand emerging markets means opening up andexpanding markets in new areas of the worldthat traditionally have had a low level ofalcohol consumption or have been previouslyclosed to the international beverage alcoholindustry. Little mention is made of thedevastation that alcohol can do to theeconomies of already impoverishedindividuals, families, and communities.

In 1998, ICAP published Alcohol andEmerging Markets: Patterns, Problems, andResponses7. This is a descriptive review ofexisting patterns, problems, and responses ofalcohol consumption and alcohol-relatedharm in sub-Saharan Africa, Asia, Eastern

Europe, and South America. Only two policyapproaches are specified: responsiblepromotional and advertising practices andalcohol education and initiatives whichpromote sensible drinking. Effectiveenvironmental strategies are not adequatelyaddressed. Alcohol and Emerging Marketsserves the interests of the internationalbeverage alcohol industry in the developmentand promotion of its products in countrieswith emerging and accessible markets.

As Jernigan and Mosher 8 have written:“Research scientists in the developed worldhave an ethical responsibility not to profitfrom or contribute to the alcohol industry’sdrive for new lucrative markets in countrieswhich lack the infrastructure, resources andexperience to respond effectively to theindustry’s slick sales pitch.”

Promote Responsible LifestylesICAP works “with industry and public health partners topromote responsible lifestyles inindustrialised and developing countries”.

It notes that “the concept of responsibility differs widelydepending on a range of cultural factors. Asconsumption patterns change – especially incountries where drinking is not necessarily atraditional part of the culture – it isimportant to constantly redefineresponsibility in culturally sensitive ways.”

For the international beverage alcohol industry,promoting responsible lifestyles meanspromoting drinking in young people and incountries where drinking is not necessarily atraditional part of the culture.

Learning about Drinking9 attempts to be areview of how young people acquire the skillsto drink alcoholic beverages. It is exclusive inthe topics that are reviewed and neglects theharm that alcohol can do to young people.Learning about Drinking fails to discusslearning about dying - in Europe, for example,one quarter of all male deaths at age 15-29years is attributable to alcohol10. In the book’sindex, neither intoxication nor dependence islisted. Alcohol poisoning is, but it receives oneword under the heading “is the experimentaldrinking of youth a problem?” Binge drinkingis mentioned, but only to be described underthe heading “do negative expectations increase

problems”, as an “emotionally laden word.”Learning About Drinking is another examplewhere good advice has been given to thebeverage alcohol industry on how to market itsproducts, this time to young people.

Drinking Occasions is another example ofpromoting (ir)responsible lifestyles11. It is asingle author publication describing the varietyof drinking occasions that exist around theworld. This book does not describe the harmdone by alcohol related to these drinkingoccasions, or how different cultures mightrespond to harm. As the author writes aboutSpain: “Although most people drink each day,drunkenness is generally discouraged andlooked down upon as a sign of weakness in acountry where men take great pride in theirmasculinity”. The author neglects to mentionthat this same masculinity is a cause of roadtraffic accidents or of domestic violence, forwhich, in Spain, one quarter is alcoholrelated10. Drinking Occasions gives theinternational beverage alcohol industry goodadvice on how to build on existing culturalpractices and market and integrate drinkingwithin a wide range of other human activitiesin diverse cultures, without worrying about(because they are not mentioned) the harmssuch drinking occasions cause.

Going forwardEssentially, ICAP’s mission seems to be toreframe alcohol policy away from policy thatminimises harm towards policy that promotesthe positive aspects of alcohol consumption.Grant might argue that it has been publichealth that has created this space for ICAP tofill. ICAP’s own harm is that it attempts to fillthis space in a disingenuous way.

ICAP’s actions are an affront to the 140 millionpeople throughout the world who aredependent on alcohol, because it does noteven consider them or their families orcolleagues, let alone take any responsibility forthem. ICAP does a disservice to alcohol policyand a disservice to the long term interests ofthe beverage alcohol industry. By failingcomprehensively to discuss the harm done bybeverage alcohol, and by failing to be balancedand comprehensive in its review of thescientific literature, ICAP perpetuates the viewthat the beverage alcohol industry is moreinterested in marketing than being “anindustry with an impressive record of good

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The International Center for Alcohol Policies

corporate citizenship”, as described by Grant.It is an industry that fails to be accountable forthe products that it produces.

ICAP is involved in issues management,similar to the strategies employed by thetobacco industry and baby food manufacturerswho have found it financially advantageous tomanage issues that are perceived to bethreatening to their survival12. If anyone is indoubt of this, remember the tobacco industry.Through internal documents of the industryreleased through litigation in the United States,it is clear that research on ‘safer’ cigarettes(light and ultra light cigarettes) that publichealth scientists pursued in good faith, wasseen by the tobacco industry purely asmarketing research and has had no benefit topublic health, as the industry itself knew itwould not13.

Through its publications, ICAP has recruitedover 80 international scientists to write itsphilosophy and its policy approach. ICAPpublications fail to mention that thesescientists were paid by the beverage alcoholindustry for their work. It should also benoted that four of the five publicationsincluded ICAP staff members as editors. Aswith all declarations of interest (which theseinternational scientists should also state intheir future alcohol-related scientificpublications), this needs to be borne in mindwhen interpreting the evidence. ICAPpublications provide selective evidence; theygive less than half the story; they focus onbenefits, not problems; they do not discussalcohol dependence and the addictiveproperties of alcohol; evidence based policy toreduce the harm done by alcohol is notcomprehensively reviewed or not reviewed atall; the presented evidence is not publichealth driven, and where it is, it is based onan incorrect interpretation of public healthscience; much of the evidence presented isdescriptive and not analytical; and much ofthe evidence aims to confuse, not clarify.Nevertheless, what these publications do,albeit simply, is to provide the internationalbeverage alcohol industry with goodinformation and good practices to find novelways of marketing its products in newmarkets, without worrying about theconsequences (because they are notmentioned or admitted). Through thisdisingenuousness and naivety, science has

done a disservice to the public good. Babor12

has gone so far as to “call for a moratorium on further ‘dialogues’with industry sources until alcohol scientistsand the public health community can agree towhat is in their legitimate interest, and how toavoid compromising our well-earnedintegrity”

To repair the damage, public health and scienceneed to continue to develop, provide anddisseminate the best evidence for effective policythat reduces the harm done by alcohol; publichealth and science need to promote theexpansion of this evidence base to cover a widerange of situations and a wide range of partners;public health and science need to provide acritique and challenge the words of the alcoholindustry, without getting involved in dialogue,debate or partnership; public health and scienceneed to carry out health impact assessments toevaluate the effect of the alcohol industry’ssocial and economic policies and programmeson health, in order to ensure accountability; andpublic health and science need to support non-governmental organisations and networks thathave a specific role to play in informing andmobilising civil society with respect to alcohol-related problems, lobbying for policy change andeffective implementation of policy at governmentlevel, as well as exposing harmful actions of thealcohol industry.

The 2001 Stockholm declaration on Youngpeople and Alcohol of the World HealthOrganization14 explicitly states that:“Public health policies concerningalcohol need to be formulated by publichealth Interests, without interferencefrom commercial interests”.

Reading the website and the publications ofthe International Center for Alcohol Policesleads one to the conclusion that, far frombeing a public health advocate, ICAP is but oneof the marketing arms of the internationalbeverage alcohol industry.

Dr Peter Anderson is an independentconsultant in public health. Between 1992and 2000, he worked with the EuropeanOffice of the World Health Organization,where he was responsible for thedevelopment of the European AlcoholAction plan and the Action Plan for aTobacco Free Europe.

References1. Murray, J.L. and Lopez, A.D. Eds. The

Global Burden of Disease. Harvard,Harvard University Press, 1996.

2. Edwards, G., Anderson P., Babor T.F. etal. Alcohol Policy and the Public Good.Oxford, Oxford University Press, 1994.

3. McCreanor, T., Casswell, C. and Hill, L.ICAP and the perils of partnership.Addiction 2000 95 179-185.

4. Grant, M. and Litvak, J. Eds. Drinkingpatterns and their consequences.Washington, Taylor and Francis, 1998.

5. Norstrom, T. and Skog, O-J. Alcohol andmortality: methodological andanalytical issues in aggregate analysis.Addiction 2001 96(Supplement 1), S5-S17.

6. Peele, S. and Grant, M. Eds. Alcohol andPleasure. A Health perspective.Washington, Taylor and Francis, 1999.

7. Grant, M. Ed. Alcohol and EmergingMarkets. Patterns, problems andresponses. Washington, Taylor andFrancis, 1998.

8. Jernigan, D.H. and Mosher, J.F.Permission for profits. Addiction 200095 190-191.

9. Houghton, E. and Roche, A.M. Eds.Learning about drinking. Washington,Taylor and Francis, 2001.

10. Rehn, N. Alcohol in the European Region– consumption, harm and policies.Copenhagen, World HealthOrganization Regional Office forEurope, 2001.

11. Heath, D.B. Drinking occasions.Comparative perspectives on alcoholand culture. Washington, Taylor andFrancis, 2000.

12. Babor, T.F. Partnerships, profits andpublic health. Addiction 2000 95 190-191.

13. Shopland, D.R. Historical perspective:the low tar lie. Tobacco Control 2001 10Suppl I, i1-i3.

14. World Health Organization. StockholmDeclaration on Young People andAlcohol. Copenhagen, World HealthOrganization Regional Office forEurope, 2001.

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The International Center for Alcohol Policies

The Amsterdam Group (TAG), formed in 1990,is an alliance of Europe’s leading producers ofbeers, wines, and spirits who work together aswell as with governments and other interestedgroups in addressing social problems relatedto the excessive or inappropriate consumptionof alcoholic beverages. TAG lists its objectivesas:“encouraging responsible consumption andcontributing to combating abuse.; promotingunderstanding and tracking research onbiomedical and social issues; andsafeguarding responsible commercialcommunications through effective self-regulation”.

TAG’s member companies at European levelare active in: the Confédération desProducteurs de Spiritueux, which has 35national organisations, and the Confédérationdes Brasseurs du Marché Commun.

TAG’s members are also active in industryactions on alcohol ‘misuse’ and educationcarried out by thirty world wide Social AspectOrganisations.

TAG has published two reports to the EuropeanUnion in 1993 and 2000 which clearly showtheir opposition to the public health model.They state:� Evidence suggests that the prevalence of

alcohol-related problems is not directlyrelated to the average per capitaconsumption, but rather to problematicpatterns of drinking.

� Policies aimed at the reduction of overall percapita consumption (in the form of limitingthe overall sales of alcoholic beveragesthrough marketing and productionrestrictions and high taxation) does notaddress those who abuse the product.

� The notion of individual responsibility fordrinking behaviour needs to be stressedand that no collective regulation can everreplace individual responsibility.

With regard to public policy Anderson andLopez1 point out:“Public policy needs to take into account thatharm is not restricted to heavy drinkers butat the same time recognise that most harmamong those who are low average drinkersof alcohol arises due to episodes ofintoxication or heavy drinking on isolatedoccasions. Policies to strongly discouragesuch behaviour in light drinkers must

therefore also receive sufficient priority inimplementing the public health response toalcohol problems in society”.

The following areas of concern are taken fromthe Amsterdam Group’s report and contrastedwith the actions of their members.

Young people and alcohol TAG will support and participate in educationprogrammes which give balanced and accurateinformation about alcohol and its effects,aimed at:� young people directly;� parents, schools, youth clubs and other

relevant authorities;� ensure that all promotional and

advertising campaigns are effective self-regulation;

� develop and promote materials whicheducate young people about the dangers ofdrinking and driving;

� train people in the HORECA sector (hotels,restaurants and cafes) not to sell tounderage drinkers.

Contrast the above with the fact that membersof TAG launched alcopops and continuallybring new designer drinks onto the marketwhich especially appeal to the young.

Drinking and DrivingTAG says it is fully committed to encourage theindustry to undertake practical steps to helpreduce the number of drink-related drivingaccidents, by, for example:� working with the hotel, restaurant, cafe and

bar (Horeca) sectors to develop anti-drinkdriving initiatives, including encouraging theavailability of alcohol-free products;

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Derek Rutherford

Is there common ground between public health and the industry and together with their socialaspect groups can they be trusted in any form of partnership?

An examination of the words and actions of the industry should provide the answer.

The Amsterdam

TAG: Current members are:

Allied Domecq

Bacardi-Martini

Bass Brewers

Berentzen-Gruppe

Brauerei Beck & Co

Carlsberg

Group Pernod Ricard

Heineken

Interbrew

Kronenburg

Moet Hennessy

Prips Ringnes

Remy Cointreau

Seagram Europe & Africa

United Distillers & Vintners

� developing and supporting educationalprogrammes which teach that drivingwhen impaired by alcoholic beverages isunacceptable and that the law must beobserved;

� support research into issues such as theattitudes of drivers who drink excessivelyand how best to change them;

� support focused activity aimed at thechronic problem of drinkers whopersistently drive whilst over legal limits;

� the industry will continue to collaboratewith road safety organisations,governments and other interested parties.Educational programmes aimed at theyoung should be a priority.

Yet in its actions the Industry shows it is againsteffective legislation. In the early 1990’s CADD,the Campaign Against Drink Driving,approached the industry’s social aspect groupin the UK, the Portman Group, for financial helpand was told that if they dropped theircampaign to reduce the legal limit andintroduce random breath testing, money mightbe forthcoming. Over the years the PortmanGroup has continued to be against such action.In 1997 the British government said it was‘mindful’ to reduce the limit to 50mgs per cent.Despite the EU recommending this limit, the UKremains one of three EU countries above it. ThePortman Group has been implacably opposed tosuch a change. Portugal’s Social Aspect Group,on the day it was launched, requested thePortuguese Government to raise BAC from 0.5per cent to 0.8 per cent.

Commercial Communicationsand Self RegulationTAG considers Commercial Communicationsshould:� be legal, decent, honest and truthful and

conform to accepted principles of faircompetition and good business practice;

9

Group

� be prepared with a due sense of socialresponsibility and be based on principlesof fairness and good faith;

� not in any circumstances be unethical orotherwise impugn human dignity andintegrity.

Contrast this with thefollowing

� should not encourage excessive orirresponsible consumption, nor presentabstinence or moderation in a negative way;

� should not suggest any association withviolent, aggressive behaviour;

� should not be specifically aimed at minorsnor show minors consuming beverages;

� should not be placed in or on printedmedia or broadcast programmes directedprimarily at minors rather than adults;

� should not promote beverages in media,events or programmes at which themajority of the audience are known to beminors;

� should not create the impression thatconsumption of beverages enhancesmental ability or physical performance e.g.when in engaging in sports;

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The Amsterdam Group

� should not create the impression thatconsumption of beverages is a requirementfor social or sexual success.

Policy InitiativesGuinness attempted, in the late eighties, toinfluence the WHO European Alcohol ActionPlan. As a consequence, the first draft of theplan entitled “Conviviality with moderation”which refelected Guinness’s views was rejectedby member states.

The Portman Group has in the past attackedsensible drinking limits in the UK. and wasinstrumental in getting them changed. Inaddition, it challenged the whole basis of theEuropean Alcohol Action Plan (EAAP) and offered“bribes” of £2000 to scientists to attack AlcoholPolicy and Public Good – along with the promiseto publish anonymously. ICAP was critical of boththe EAAP and its theme - ‘Less is Better.’

The Amsterdam Group attempted to influencethe Second WHO European Alcohol Action Planby devising a number of amendments:

“a reduction in the harm that can be done byalcohol is amongst the most important publichealth actions that countries can undertake toimprove the quality of life.” TAG suggested theamendment: “a reduction in alcohol misuseis amongst…”

“risk of alcohol related problems” TAGsuggested it became, “consequences ofalcohol misuse”

The statement that “alcohol is a psychoactivedrug” was deleted - TAG did not like the worddrug.

The sentence, “alcohol use and alcohol relatedharm, such as drunkenness, binge-drinkingand alcohol related social problems arecommon among adolescents and young peoplein Western Europe” disappeared in TAG’sversion.

“Responsibilities of the beverage alcoholindustry and hospitality sector” is rewritten byTAG as “Industry-society partnerships toreduce alcohol misuse”,

“…promote high visibility breath testing on arandom basis” becomes, in TAG’s version:“promote drink driving campaigns”.

“…place restrictions on the sponsorship bythe drinks industry on sports” is,unsurprisingly, deleted by TAG.

The Amsterdam Group did not succeed inchanging the plan, even though it puttremendous pressure on those governmentsover which it has influence. Dr Asfel, the thenDirector of WHO European Region, in theforward to the plan, said:

‘Throughout the preparation of this Plan,relations with the industry have been aparticular concern, raised repeatedly in theStanding Committee of the RegionalCommittee and in the Regional Committee.The Plan contains some references to the roleof industry and commerce. It proposes, forexample, that the industry and the hospitalitysector develop and implement programmes toreduce alcohol-related problems in thedrinking environment. After the RegionalOffice held a meeting with the industry,through the so-called Amsterdam Group, theGroup delivered an extensive critique of thePlan, explaining the industry’s standpoint andoffering suggestions for incorporating this inthe text.

Although some of the proposals made by theAmsterdam Group were in accordance withthe debate, there was no support from theRegional Committee for a global revision ofthe text.

Communication with the Group to promotereciprocal information sharing was, however,encouraged. Although some form ofcooperation with the industry, commerce andthe hospitality sector cannot a priori be ruledout, there was no support for recommendingthat local and national public health alcoholpolicies in general be developed in co-operation with them.”2

The WHO Ministerial Declaration at itsconference in Stockholm issued this caution:

“Public Health Policies concerningalcohol need to be formulated by PublicHealth Interests, without interferencefrom Commercial Interests.”

WHO European Alcohol Action Plan considersit important to:“support non-governmental organisationsand networks that have a specific role to playin informing and mobilising civil societywith respect to alcohol-related problems,lobbying for policy change and effectiveimplementation of policy at governmentlevel, as well as exposing harmful actions ofthe alcohol industry.”

In June 2001 the EU Council of HealthMinisters called for effective mechanisms to:ensure that producers did not producealcoholic beverages specifically targeted at ordesigned or promoted to appeal to childrenand adolescents. The Council furtherrecognised that alcohol is a key healthdeterminant in the European Community.

It is clear that public health authorities andnon governmental organisations, that have aparticular concern in redressing alcoholrelated harm and the promotion of publicpolicy, need to keep the industry and its alliesat arms length. The industry cannot be allowedto set the political agenda on alcohol policy.

1. Peter Anderson and Alan Lopez, Alcoholand Health - implications for publichealth authority, WHO Regional Officefor Europe, Copenhagen, 1995.

2. Foreword to the European AlcoholAction Plan, 2000-2005, WHO RegionalOffice, Europe.

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The Amsterdam Group

Compared to the Nordic countries, special taxeson alcoholic beverages and especially on winewere very low in the Mediterranean countries inthe early 1950s. As wine was in these countriesthe clearly preferred beverage, alcoholconsumers in the Mediterranean countrieshardly paid any alcohol taxes at all. Drinkers inthe Nordic monopoly countries concentrated ondrinking distilled spirits, the most heavily taxedform of alcohol in these countries.

In the Central European member states beerwas the preferred beverage. Many of thesecountries have, however, a history of consumingdistilled spirits, and also a history oftemperance movements. In the early 1950sIreland and the United Kingdom, had a strictand functioning licensing system especially foron-premise retail sales of alcoholic beverages.Belgium and the Netherlands had in forceremnants of an earlier tight alcohol controlsystem.

The Central European beer countries alsocollected special taxes on alcoholic beverages.However, the term Central European beercountries is not very good, as there aresystematic differences in alcohol policies inthese countries on the east-west dimension.

Converging alcohol policiesThe second half of the twentieth century is aperiod of converging alcohol policies in thepresent EU member states (Karlsson &Österberg, 2001). The converging tendencycannot, however, be understood by referring tosimilar trends in groups of countries either onthe basis of the preferred beverage orgeographical location. The converging trendcan, however, be understood when looking attrends in different areas of alcohol control.

In 2000-2001 the level of alcohol excise dutiesstill follows the old distinction made on the basisof the preferred beverage. Alcohol excise dutiesare clearly lowest in the Mediterranean winepreferring countries as well as in other wineproducing countries. They are highest in theNordic countries, the former spirits drinkingcountries, followed by Denmark, Ireland and theUnited Kingdom. Those member states falling inbetween these extremes are all located incontinental Central Europe.

Decrease in the control ofalcohol availabilityThe control of the production, wholesale andretail sale of alcoholic beverages has decreased

during the last fifty years in the present EUmember states meaning that alcohol controlmeasures targeted on alcohol availability andsupply have lost ground. The most importantexplanations of this development are theincreased importance of free marketorientation and the growth of consumerism.

The creation of the single European market in1993 alone has led to the abolition of manyalcohol control measures starting fromproduction, import, export and wholesalemonopolies and ending in new regulationsconcerning licensing of retail sale outlets. In mostEU member states granting of alcohol licences isnowadays a formal procedure where everyapplicant fulfilling some basic requirements, forinstance, having no criminal record, will obtainthe licence.

Also the growth of consumerism has put pressureon alcohol control measures, as consumers arenot any longer willing to be guided bygovernments. Therefore, restrictions on the daysand hours of retail sale of alcoholic beverages, aswell as other obstacles to free consumer choice,have been increasingly criticised, and manyrestrictions have also loosened or been abolished.The legal age limits for buying alcoholic beverageshave, however, been kept and even been madestricter during the last fifty years.

There are also many commercial operationsbeing interested in increasing alcohol availabilityand consumption. Consequently, it is notinfrequent to see contradictory governmentalpolicies related to alcoholic beverages. Theministries of agriculture are trying to safeguardthe interest of wine growers. The ministries ofindustry act in the interests of breweries anddistilleries, while the ministries of social affairsand health aim to prevent the harms caused byalcohol. These conflicting interests have alsoaffected the developments in alcohol availability.

Affecting alcohol demandThe control of alcohol demand is clearly anarea that has gained in importance. In practice

12

Esa Österberg and Thomas Karlsson

Alcohol policies in the 1950s

In the early 1950s there were large differences in alcohol policiesamong the present EU member states. In all Nordic member statesas well as in Iceland and Norway, alcohol policy was built on highexcise duties on alcoholic beverages and, with the exception ofDenmark, on comprehensive state alcohol monopoly systems andstrict personal control. In the Mediterranean EU member statesthere were only few alcohol policy measures in force, and many ofthese were motivated by industrial or commercial interests. In theMediterranean as well as in many Central European countries theterm alcohol policy was not even known.

Alcohol policies in EUmember states

13

this means more alcohol information andeducation as well as new or stricter regulationson alcohol advertisement and sponsorship.There are nowadays also more and harsheralcohol control measures aimed at certainalcohol-related problems like drunk drivingand public drinking both generally and incertain problem-prone situations. Imposed orlower blood alcohol concentration (BAC) limitsreflect the increases of alcohol-relatedproblems in traffic but also the development oftechnical devices able to measure the BACquickly and reliably.

In most EU members states there is nowadayseither a national alcohol prevention or educationprogramme and a responsible agency. Even inthose member states which are lacking thesekinds of programmes, like Greece, there havebeen serious discussions to introduce suchprogrammes. Prevention and educationprogrammes are not of course as suchguarantees of effective action. However, theirexistence means that the alcohol issue has beenincluded, in one way or another, in the nationalpolitical agenda. That these kinds of programmeshave become more prevalent is partly related tothe activities of the World Health Organization asits European office has developed alcohol actionplans agreed on by its member states.

The trends will continueAlcohol policies are nowadays more similar inthe EU member states than they used to be inthe early 1950s. This overall converging trendconsists of two kinds of developments. On theone hand, measures affecting alcoholavailability are nowadays applied to a muchlesser extent than fifty years ago. In otherwords, countries which in the 1950s practisedstrict alcohol control policies targeted onalcohol availability and supply have dismantledthem, while countries that have begun to beinterested in alcohol policies, have not focusedon controlling the availability of alcohol. On theother hand, alcohol control measures targetingcertain alcohol-related problems, or aiming toaffect the demand for alcoholic beverages, havebecome more common in all EU memberstates. At first, it might be a little surprising thatEU member states have at the same timeabolished alcohol control measures affectingalcohol availability and known to be effective,and introduced control measures aiming toaffect alcohol demand even if they are known tobe much less effective at least in the short run.

Our basic explanation for the decreasing controlof alcohol availability is that guaranteeing freemovement of capital, goods, services and labourhas been the leading principle in organising theworld economy in recent decades. Therefore,many alcohol control measures affecting alcoholsupply have been seen as obstacles to free tradein alcoholic beverages, and have been abolished.It is difficult to see that this trend would bediscontinued or turned, even if public health andsocial policy considerations have gainedincreased importance in the EU during the lastdecade. Consequently many of the remainingcontrol measures on alcohol availability will mostcertainly be challenged in the future. In any case,it seems to be impossible that structures like thecomprehensive alcohol monopoly system couldbe rebuilt in any EU member state.

Consumers mostly see alcoholic beverages asordinary commodities satisfying individual needsin many ways. Because of alcohol informationthey are or should be aware of the possibleharmful effects of their drinking. Most alcoholconsumers, however, believe, rightly or wrongly,that they are able to control their own drinkingand do not need any direct guidance from thegovernment. Therefore, it is very difficult tolegitimate measures restricting alcoholavailability by referring to the harmful effects ofdrinking alcohol. We believe that this kind ofsituation will continue in the EU member stateseven in the future. And finally, there are no signsthat the alcohol industry would in the future takea more favourable stand towards restrictions onalcohol availability than at present. In summary,it can be projected that alcohol control measuresaimed at affecting alcohol availability will in thefuture become fewer and weaker.

Alcohol-related problemsDespite the decline in alcohol consumption insome EU member states alcohol-relatedproblems have not disappeared. Besidesaffecting the drinker himself, alcoholconsumption often has negative side-effects onthird parties: the drinker’s family, friends or thelocal community. Therefore, it is quite commonthat drinker’s environment tries to affectdrinking by informal social control, which cantake the form of direct personal control or theform of more or less developed social andcultural norms about where, when and howdrinking should or should not be practised. Insome countries, this traditional way to cope withalcohol-related problems is not any longer

working as it used to. As informal alcohol controlis losing ground, we may in the future see newand more formalised alcohol control measurestrying to restrict alcohol consumption in theworkplace, in educational or public carebuildings, in government offices, in publictransport, in sports or other leisure events aswell as in parks and streets.

This tendency may also be seen in legal orofficial measures aiming to affect certaingroups of alcohol consumers: for instance,higher age limits, more alcohol information forpregnant women, attempts to prevent knowndrunkards or intoxicated persons from buyingalcohol, harsher controls of drinking in sportsarenas or in other problem-prone leisuresituations, increasing the legal responsibility ofon-premise places for the behaviour of theirpatrons, harsher controls of alcohol advertisingand sponsorship, banning alcohol sales ingasoline stations and increased enforcementand lower BAC limits in traffic.

There are also other possibilities for regulatingalcohol-related problems. One way could be totry to define and find alcoholics or problemdrinkers, and then to try to cure them or toeducate, persuade or force them to decrease orstop drinking or change their drinking habits.The other potential way is to use alcohol exciseduties as an instrument for preventive alcoholpolicy. The first way, as well as alcoholinformation and education, is convenient forthe majority of the drinking population and forthe alcohol industry as these measures do notreally affect conventional drinking or alcoholproduction and trade. These measures are,however, costly to governments, and ultimatelyto the taxpayers. Increasing excise duties onalcoholic beverages is politically difficult as itdecreases the amount of alcohol consumption,production and trade but from the point of viewof the government or local authorities it wouldbe cheap to introduce. In most cases it wouldalso be a sure way to collect more tax revenue.

Esa Österberg is an alcohol researcher atthe National Research Centre for Welfareand Health, Stakes, Finland. He was acontributor to the ECAS study - EuropeanComparative Alcohol Study - supported bythe EC which produced Alcohol in PostwarEurope: Consumption, drinking patterns,consequences and policy responses in 15European countries.

While such studies among teenagers appearfrequently, data concerning Israeli armypersonnel are confidential. In spite of this,some findings have been published in thepast and revealed a much higher proportion

of alcohol use among soldiers (18-to-21-year-old youngsters) in comparison to high schoolstudents. In addition, studies amonguniversity students (18+ years old) alsoshowed a higher proportion of alcohol

drinking compared to high school students.Adolescents, soldiers, and college anduniversity students visit pubs and clubs in theweekends (Thursdays- Saturdays). Thoseclubs are open from midnight until six in themorning and nowadays serve as the mainsource of entertainment for Israeli youth.

Alcoholic drinks in supermarkets are notexpensive and the price of beer is the same asor lower than the price of fruit juices.Naturally, the cost of alcoholic beverages inclubs or pubs is more than that insupermarkets or grocery stores. However,

14

Shoshana Weiss

A recent study among Israeli youth aged 14 to 18, carried out inNovember-December 2000 and published in Alcologia, revealedthat about 37 per cent of respondents reported being drunk atleast once in the last year. About 67 per cent of the participantsvisited pubs, bars, or clubs where alcohol was served in theprevious year. Senior high school students visited such placesmore (67 per cent - 10th-11th grades, 80 per cent - 12th grade)than junior high school students (40 per cent). It is clear thatvisiting public drinking places is common among Israeliadolescents, in spite of the fact that the supply of alcoholicbeverages to minors in bars, pubs, and clubs is prohibited by alaw of which there is no serious enforcement.

Free alcohol for youth

Free alcoholic drinks and cocktails all night in ‘Kazu Club’ near Chadera.

(town in the centre of Israel)

local and foreign alcohol producers makeintensive efforts to increase the consumptionof alcohol in Israel, including the offer of freealcoholic beverages to young people in manyclubs and pubs at weekends. It is reasonableto assume that the clubs do not lose moneyand that the alcohol industry supplies theclubs with some brands either free or atreduced prices in order to establish brandloyalty among the young sector of thepopulation.

Whatever the precise financial arrangement,clubs are unlikely to distribute free alcoholicbeverages without the co-operation orpermission of the producers. While alcohol isserved free, mineral water or fruit juice aregenerally expensive in the clubs. In the lightof the difficult economic situation in Israel,and the fact that most adolescents andsoldiers have restricted disposable income, itis inevitable that they choose free beer ratherthan expensive juice. In addition, there areclubs that offer young people alcoholicdrinks such as vodka, tequila, wine, rum,

gin, beer, and champagne for only 2 NIS (40American cents).

Invitation cards to such events are distributedin central stations, trains, near schools, nearmilitary camps, and are also sent by mail tocertain young people that registered as“members” in these clubs or pubs.

Mostly, the names of the alcohol brandsponsors are not mentioned on the cards, butsometimes the brands’ names do appear,such as the local “Goldstar” or the foreign“Tuborg” beer. However, once in the clubs,young people can get free beers from localbreweries such as Tempo Beer Industries aswell as those of foreign origin such asHeineken and Carlsberg, some of which areproduced by licence in Israel, as well asimported distilled spirits and wines of manyforeign brands.

As can be seen, foreign alcohol producers ofbeers, wines, and distilled spirits behave inIsrael in a way that is forbidden in their owncountries, taking advantage of the absence of

local regulations and law enforcement andthe difficult economic condition. As well asthe imported drinks, the foreign brandsproduced in Israel by licence or distributed bythe local industry are marketed in a waywhich is unacceptable in their countries oforigin. Furthermore, as can be seen in theexamples, most invitation cards are aimed at18+ years old youngsters (mainly soldiers),but some are aimed at 17-to-18-year-oldstudents.

Many of the youth clubs that offer free alcoholare located in kibbutzim. The kibbutz is asmall co-operative enterprise, a voluntaryclosed society based on communal property,production (both agricultural and industrial)and labour, and on communal consumptionand living arrangements. Many urbanyoungsters drive to those clubs from townsand cities. This fact makes the “free alcohol”phenomenon even more dangerous, sincemany traffic accidents can be attributed to the“drink as much alcohol as you can” habit.Indeed, a number of recent fatal accidents

15

in Israeli clubs

Free bar in a club near Haifa.

16

Free alcohol for youth in Israeli clubs

The television advertisements will have toobserve a set of conditions. They will only beable to be shown after nine o’clock at nightand the actors who appear in them must all

be at least thirty years old. Before they canrun commercials for their own brands, thedistillers will be obliged to run for fourmonths a series of social-responsibility

messages on such topics as designateddrivers and moderate drinking.

There is, however, considerable concern thatthe commercials could be easily watched byyoungsters. “This is more than the camel'snose under the tent,” said George Hacker,director of the Alcohol Policies Project at theCenter for Science in the Public Interest. “It'sthe first foot forward that will result down theline to opening the door for hard-liquor adslooking like beer ads.”

The decision by NBC is a major victory forliquor marketers who have long been anxiousto gain access to the extremely important

Hard liquor onAmerican TVThe alcohol industry made a big breakthrough in the UnitedStates recently when NBC, one of the four largest nationalbroadcasting networks agreed to begin acceptingadvertisements for hard liquor. It is five years since some localand cable television stations began to air commercials producedby Seagrams and a number of other companies for drinks suchas vodka, gin, and Scotch whiskey – a move which broke aninformal agreement dating back over fifty years.

happened when young people were on theirway home to the city from such “rural” clubs.Thus, thousands of young people are on theroads between midnight and six o’clock in themorning at weekends, after drinking freealcoholic beverages, or very cheap alcoholicdrinks. Police presence on the roads at thesetimes is very limited.

The Israel Society for the Prevention ofAlcoholism is consulting with legal expertsconcerning ways to cope with the free alcoholphenomenon in youth clubs. In addition, theAssociation is having a series of meetings withpolice officers and establishing co-operationin order to increase the enforcement of thelaw concerning the supply of alcohol tominors in clubs on the one hand, and the lawconcerning driving under the influence ofalcohol (BAC – 0.05 per cent) on the other.

Shoshana Weiss is the Director of TheIsrael Society for the Prevention ofAlcoholism

Free cocktails for soldiers in a club in Afek Kibbutz.

(in the north of Israel)

17

Hard liquor on American TV

advertising medium of television. “We're verypleased we have the opportunity to gain theefficiencies in our advertising and marketingprogrammes,” said Gary Galanis, aspokesman for Guinness UDV, the firstcompany to advertise.

Since 1996 several national cable TV networksand over two hundred local TV stations -some owned by the broadcast networks likeNBC – have accepted commercials for vodka,Scotch whiskey, and rum as well as for lower-alcohol products like liqueurs and blendedspecialty drinks such as Baileys Original IrishCream.

“There's a momentum gathering here,” saidRandy Falco, president for the NBC TelevisionNetwork division of NBC in New York. “Wethought we'd get in front of it with a prettystrict set of guidelines.” He went on to saythat this “is obviously a sensitive subject” andadded that “the standards speak forthemselves, particularly as they relate toyoung people.”

Beer and wine advertising has been ontelevision since commercials first appeared.There were no such spots for liquor from1948, when the distilled spirits industryintroduced its voluntary ban, until that banwas lifted in November 1996.

When the ban was lifted, there was a move inCongress and within federal agencies to haveit reinstated or formalised in a law. Theseefforts petered out as the end of the ban didnot immediately lead to a flood of liquorcommercials.

Gary Galanis claimed that the guidelines underwhich Guinness UDV will advertise on NBCought to satisfy the critics because “it's a solid,strict code.” There are nineteen conditions,one of which is a provision that thecommercials may appear only on programmeswhere the audience has at least 85 per cent ofviewers who are 21 or older. In addition, theadvertisements must not promote distilledalcohol products “as a ‘mark of adulthood' or‘rite of passage' “ and may not show orrepresent consumption on camera.

An NBC executive said that they had beenapproached in the past but that untilGuinness UDV began talking to NBC severalmonths ago there were never any seriousdiscussions with a company willing to “workwith us on the protocols and standards”outlined under the guidelines.

However, George Hacker, of the CSPI, saidthat he was concerned about the appearanceof commercials for hard liquor on broadcasttelevision networks “because of their nature,their broad audience, which is very differentfrom running spots on golf matches orequestrian events” shown on cable networks“where the audience can be carefullytargeted.” He also said he would like to see“messages that tell the true story” aboutdrinking “that are approved by public healthagencies” rather than liquor companyexecutives.

The move is also causing apprehensionamong medical professionals. According to Dr

John Slade, a professor specialising inaddiction at the Robert Wood Johnson MedicalSchool at the University of Medicine andDentistry in New Jersey, “The alcoholicbeverage industry seeks to increase its sales inthe name of ‘moderate drinking.’ At the sametime, it continues to make money by sellingalcohol to heavy drinkers, to underageconsumers, and to those whose drinking isacutely dangerous to themselves and others.The industry’s professed interest in publichealth would be less self-serving if it promotedmoderate drinking in parallel with effectiveefforts to reduce immoderate drinking.” Publichealth experts point out that the tragic result isthat many young people feel it is perfectly allright to get drunk, as long as they don’t getbehind the wheel of a car.

As for the three other big broadcast networks,they had similar responses to NBC's decision.Spokesmen for ABC, CBS and FoxBroadcasting all said they had no plans nowto change their policies against acceptingliquor commercials.

George Hacker is in no doubt about thedangerous consequences of theadvertisements for distilled spirits or aboutthe motivation of the alcohol industry:“NBC’s shameful acceptance of liquor adsthat threaten our children’s health and safetyis a clear sign that voluntary advertisingstandards do not work. When they becomeinconvenient or stand in the way of easymoney, they play second fiddle to economicconcerns. Remember, that liquor marketers,until 1996, voluntarily stayed off TV, until theydecided to reverse the steady decline in liquorconsumption and go after the beer industry’scustomers. This latest assault on America’schildren demands official action.”

George Hacker

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Legend tells that Du Kang, living in the Xiadynasty (2100 BC - 1600 BC) invented alcohol.Today some Chinese still use his name toindicate alcohol. Others attribute alcohol’sorigin to Yi Di, the daughter of emperor Yu,who tasted the drink and “felt cheerful” (Lee,1987). In the agricultural communities alongthe Yellow River there is archaeologicalevidence of alcohol production 7000 years ago.In fact some archaeologists argue that theearliest crops were cultivated for the brewing ofalcohol rather than for the purpose of food.

Lessons from history The Chinese have continually regarded jiu asthe representation of happiness and theembodiment of auspiciousness. At the sametime, they regard it as one of the “Four Vices”or disasters. This double view of alcohol isreflected in China’s history.

Early Chinese literature includes manyreferences to alcohol. Dynasties appear to havefallen as a result of alcohol. The historicalrecord clearly suggests that, at different times,governments have acknowledged alcohol-related problems and have used policies toprevent these problems. For example, theEmperor Yu (2205 - 2198 BC) imposed an

alcohol tax to reduce consumption. During theHan Dynasty (220 - 206 BC) a variety of lawswere passed to control consumption. In 206BC a fine of four ounces of silver was imposedif three or more people were found drinkingtogether. The idea was to curtail drinking atfeasts, a practice that encouraged excessivealcohol use. In 147 BC alcohol production wastotally prohibited, but in 98 BC a revision inthe law specified that only government officialscould manufacture and sell alcohol, thusestablishing a government monopoly.

During the Wei regime (220 - 264 A D)infringement on the government’s alcoholmonopoly was punishable by death. At thesame time as these restrictions, intended inpart to prevent public health problems fromalcohol use, there were actions promotingalcohol use for the public good. In 179 B. C.the social welfare legislation provided wine,corn, and meat to all old men.

With time the government alcohol monopolygave way to the private manufacture of alcoholunder licence. By the 5th century alcoholconsumption again was causing problems and itis reported that the Emperor ordered allmanufacturers, sellers, and consumers ofalcohol beheaded. Similar penalties for alcohol

production were again evident in the 11th and12th century when the Mongol leader, KublaKhan, is said to have banished all alcoholmanufacturers from China (Cherrington, 1924).

In the same way Julia Lee (1986) in a review ofChinese poetry showed that heavy drinkingand drunkenness have at times beenfashionable and then fallen out of favour.

The Chinese government today has chosen notto interfere with the traditional patterns ofalcohol use. There are no laws regulating thepurchase, consumption, or selling of alcohol.Instead today alcohol use appears to becontrolled by culture, tradition, socialpressure, and the economy. The few scholarswho have looked at Chinese alcohol use haveconcluded that Chinese may consume lessalcohol than other ethnic groups for a varietyof reasons. � Chinese society is based on strong family

units and people exercise considerableinfluence on one another. Family andcommunity norms effectively shapebehaviour (Fei Ping, 1982).

� Both Confucian and Taoist philosophiesemphasise moderation, a standard widelyapplied to alcohol use in China today (Sue,et al., 1985).

� The Confucian ideal of “moral drinking”that emphasises alcohol’s role instrengthening all that is good in a personmitigates against abuse.

� Chinese are highly “situation-centered,”and therefore unlikely to exhibit recklessbehaviour in a social setting (Hsu, 1981).The avoidance of embarrassment and theconcept of “face” are powerful forcesagainst drunkenness.

� Chinese traditionally drink alcohol onlywhen eating. Drinking with food decreasesthe rate of alcohol absorption and mayalso reduce the amount consumed(Johanson & Schuster, 1981; Kalant,

Cultural aspects of drinkalcohol controls in ChinaIan Newman

Alcohol, ‘jiu’ in Mandarin, is intimately intertwined in almostevery aspect of Chinese culture and has been since earliesttimes. China’s cultural traditions, which have until nowminimised the risks associated with alcohol use, will bechallenged as China opens to the West. There will be atendency for outsiders to encourage the adoption of Western-style policies to address problems from alcohol abuse. Doing sowithout careful consideration of the cultural role of alcoholcould be counter-productive.

19

1971). It is believed that alcohol should beconsumed slowly to enhance its pleasure(Wang, et al., 1992).

� The ceremony associated with eating, mostevident in toasts and other rituals, dictateswhen drinking occurs (Cherrington,1924). The small size of the glasses ordrinking cups also defines use.

� Traditionally, when drinking Chinese playgames requiring cognitive and motorskills, especially at banquets. The goal ofthe game is not to get drunk becausegetting drunk is the penalty for losing(Barnett, 1955; Fei Ping, 1982; Moore,1948). Playing games while drinkingheightens sensitivity to the state ofintoxication (Cicero, 1980).

� Chinese do not typically frequent western-style bars. Banquets and other drinkingoccasions are infrequent (Singer, 1972).Solitary drinking is looked down upon(Williams, 1998).

� For many Chinese, economic conditionsrestrict the use of alcohol to specialoccasions.

� Some believe the physiological flushingresponse—the reddening of the upperbody, especially the face—restricts alcoholuse. There is mixed evidence to supportthis conclusion (Schwitters, et al., 1982;Park, et al., 1984).

� Home production of alcohol dependsupon the availability of grain, the economy,the alcohol makers’ (usually the women)inclination to make the alcohol, and theauspiciousness of the occasion.

China is a large and diverse country. Thesedifferent traditions will vary in importancefrom place to place.

As China continues to open to the West thesetraditional and cultural constraints againstalcohol abuse will be severely tested. Already inthe urban areas and in the special economiczones they are being largely discarded.

ConsumptionIn a country as large and as diverse as China itis difficult to estimate actual alcohol

consumption. WHO estimates that 81 per centof Chinese alcohol consumption is in the formof spirits, 18 per cent as beer and 1 per cent aswine. Per capita alcohol consumption hasincreased 402 per cent between 1970 — 72and 1994 — 1996 making it one of the fastest-growing alcohol markets worldwide.Considering the Chinese population is 1.3billion, a small increase in the percentage ofalcohol users represents large numbers ofpeople and significant profits for the alcoholindustry. Per capita consumption however is asyet low, 5.4 litres of pure alcohol per adult 15years and older compared to 8.9 litres in theUnited States, 9.4 litres in the UK and 12.5litres in Denmark (WHO, 1999).

Making meaning from these numbers isdifficult. Some 80 per cent of China’spopulation lives in rural areas and an evenlarger percent could be considered poor. Theirability to purchase alcohol is limited. They aremuch more likely to produce their own alcoholin quantities that are unrecorded. This meansthe estimated consumption of 5.4 litres perperson actually applies only to the moreaffluent Chinese, who tend to live in the urbanand economic development regions of thecountry. China is one of the world’s largestproducers of alcohol: it will surpass the USA inthe next couple of years to become the world’slargest producer of beer. China is already theworld’s largest producer of spirits; however,the consumption of spirits is declining infavour of wine and beer.

In the 1970’s the government built breweriesin almost every province and semi-autonomous region except Tibet. Thegovernment is reported to have invested some$800 million in brewing technology. It isreported that more than 50 foreign companieshave joint ventures related to alcoholproduction in China. No one companydominates the alcohol production market. One

ing patterns and

20

Cultural aspects of drinking patterns and alcohol controls in Chinaof the largest breweries, Tsingtao, is movingaggressively to increase its market share.

What do we know about adolescent alcoholuse? Not much.

Li et al. (1996) in a study of students in gradesequivalent to U.S. grades 6, 8, and 10 inBeijing reported that 70 per cent of theirsample had consumed alcohol at least onceand that beer was the alcohol of choice. Theaverage age of first use was age 12.

Zhang (1997) studied alcohol use among asample of high school students in Shanghai ingrades equivalent to U.S. grades 10, 11,and 12, and found that, 77 per cent had usedalcohol in the past year, 29.3 per cent hadused alcohol in the past month.

Lifetime use among the Shanghai (males 91per cent; females 89 per cent) and Beijing (78per cent) samples, two cities with considerablewestern exposure, was similar to the lifetimeuse in the USA (80 per cent), while last-30-day-use was significantly higher in the USA (51per cent) compared to Shanghai (males 36 percent; females 23 per cent) and Beijing (20 percent).

Qu, et al., (2000) reported that 59 per cent ofthe students in grades equivalent to U.S. grades11 and 12 in Hohhut, Inner Mongolia, arelatively remote area with limited exposure toWestern influences, had consumed alcohol inthe last year — a rate similar to other areas.Use in the last 30 days was comparable toother Chinese samples (22 per cent)

As in most societies there is a relationshipbetween parental and youth drinking anddifferences in male and female drinking.Adolescents’ drinking patterns tend toresemble their parents’ drinking patterns.Female drinking is relatively rare, at least inpublic. The percentage of female recentdrinkers (last 30 days) is low — in theShanghai sample 23 per cent, Beijing16 percent.

Changing patternsThe increasing consumption of alcohol isassociated with the changing political andeconomic conditions and the opening of Chinato the West. This increased contact with theWest has allowed the sharing of Westernimages of alcohol use — images that are notalways accurate and which tend to encourage

risky drinking. The availability of westernbrands of alcohol has created a special appealthat is cosmopolitan and western, especiallyfor young people. The development of brewpubs, usually joint ventures, has attractedyoung people. Increased competition has ledto lower prices.

Nevertheless the influence of culture as aconstraint against risky drinking is stillapparent. Asked where they usually did theirdrinking the majority of students reported “ atfestivals and at parties,” the time honouredoccasions for drinking. The differences indrinking patterns among Inner Mongolian andHan students also illustrates this point.

Mongolians have a reputation for heavydrinking and consider drinking capacity a signof status among males. Yet our survey datafrom Inner Mongolia suggested that Han(ethnic Chinese) students consume alcoholmuch more frequently than Mongolianstudents. However, when the quantityconsumed at each drinking occasion isexamined Mongolian students report drinkingsignificantly more than Han students. TheMongolian students explained this by sayingthat their drinking was more likely to berestricted to special celebrations when excessuse was more likely to be tolerated. Theirdrinking patterns appear to reflect long-standing indigenous Mongolian culturalpractices. The Han, most of whom recentlymoved to Inner Mongolia, have tended to losetouch with their more traditional culturalpractices and as a consequence appear to bemore open to the acceptance of westerndrinking practices displayed in alcoholadvertising and portrayed in movies, television,and other images from the west. Theirdrinking no longer relates to the traditionaldrinking occasions.

The complicated challenge ofpolicy developmentIf the trend in per capita alcohol consumptioncontinues, alcohol-related problems are likelyto increase and gain more attention. With anincrease in the number of automobiles, theeffect of alcohol on drivers will become morenoticeable. It is estimated that half of all trafficcrashes involve drivers who have beendrinking (China Daily, Feb. 4, 1996). Thedevelopment of technologically sophisticatedworkplaces will mean the effect of alcohol on

employee performance will become moreevident. Similarly, contact with the west willincrease the recognition of alcohol’s role insocial problems such as family break-ups andcrime. It is estimated that one-third of seriouscrimes committed by adolescents involvealcohol (China Business Weekly, June 17,1996). The tolerance for certain drinkingpractices will decrease. As this occurs therewill be a tendency to look to the government tohelp reduce alcohol-related problems.

A natural tendency could be for thegovernment to adopt alcohol control policiesused in other countries, in the West forexample, to address similar problems. Theintroduction of these policies into a verydifferent cultural setting will need to becarefully evaluated. Policies that interfere withtraditional drinking practices are likely to beopenly rejected or thwarted by the public.

A careful analysis of the traditional roles thatalcohol plays in Chinese society illustrates thispoint. Alcohol use is an integral part of religion.Alcohol in various forms is an important part ofChinese medicine. Alcohol is a critical elementin hospitality. Alcohol is important in cookingand as part of the meal. Alcohol has traditionallybeen an important part of special celebrationsand festivals. Accepting these traditional rolesfor alcohol illustrates how difficult it would be toadopt policies like those in the West that arereported to be effective in reducing alcoholrelated harm.

For example, raising the price, restricting thehours of sale, restricting home manufacture,

Confuscius

21

Cultural aspects of drinking patterns and alcohol controls in China

setting a minimum age for purchase anduse, and restricting the place of sale couldall potentially interfere with alcohol’s role inreligion, medicine, hospitality, specialcelebrations, cooking and the ritualsassociated with meals. Policies that supportthe maintenance of traditional Chinesedrinking practices will likely be wellreceived. Policies that support traditionaldrinking practices, even though these carrysome risks, will therefore need to be givenserious consideration. The risks associatedwith traditional drinking appear to besignificantly lower than the risks associatedwith western-style drinking.

If the introduction of policies to controlalcohol itself carries some risks what then isthe alternative? Perhaps attending to themost obvious problems associated withalcohol abuse, such as drunk driving, wouldbe an initial approach. It’s hard to say. At thevery least the focus would then be on the“problem behaviour,” whatever it is, and notautomatically on alcohol itself.

What is important, as this brief paper hasattempted to show, is that policies to preventand reduce alcohol-related risks and harmneed to be in concert with the values and thetraditions of the society. In societies asdifferent to the West as China’s the challengeof policy development will depend first on acareful understanding of local traditions andculture. A first step in policy developmentwould be to encourage traditionalindigenous controls. As societies becomemore like those of the West, western policyoptions may become effective. In themeantime, and in the hope that societiescan maintain something of theiruniqueness, Chinese policymakers andpolicy advisers will need to reflect on theirown cultural traditions for guidance inreducing alcohol related harm and notquickly adopt foreign strategies. And whilethis is a controversial point, they should alsolook to their traditions and cultural valuesfor the basis of low risk patterns of alcoholuse. From a policy perspective, it issignificantly easier to maintain a behaviouralpattern, even if it includes some risks, thanto change it.

Ian Newman is Professor of HealthEducation at the University of Nebraska.

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Cherrington, E. H. (editor-in-chief)(1924). Standard encyclopaedia of thealcohol problem. Westerville, OH:American Issue Publishing Company.

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Cicero, T. J. (1980). Alcoholself-administration, tolerance andwithdrawal in humans and animals:Theoretical and methodological issues.In H. Rigter & J. C. Crabbe, Jr. (Eds.),Alcohol tolerance and dependence.New York: Elsevier/North-HollandBiomedical.

Fei Ping, Z. (1982). Drinking in China.The Drinking and Drug PracticesSurveyor, 18, 14.

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Johanson, C. E., & Schuster, C. R. (1981).Animal models of drugself-administration. In N. K. Mello (Ed.),Advances in substance abuse:Behavioral and biological research, vol.2. Greenwich, CT: JAL.

Kalant, H. (1971). Absorption, diffusion,distribution, and elimination ofethanol: Effects on biologicalmembranes. In B. Kissin & H. Begleiter(Eds.), The biology of alcoholism, vol. I:Biochemistry. New York: Plenum.

Lee, J. A. (1986). Alcohol in Chinesepoems: References to drunkenness,flushing, and drinking. ContemporaryDrug Problems, 13, 303-338.

Lee, J. A. (1987). Chinese, alcohol andflushing: Sociohistorical andbiobehavioral considerations. Journalof Psychoactive Drugs, 19(4), 319-327.

Li, X., Fang, X., Stanton, B., Feigelman,S., & Dong, Q. (1996). The rate andpattern of alcohol consumption amongChinese adolescents. Journal ofAdolescent Health, 19(5), 353-361.

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Bowman, K. S. (1984). The flushingresponse to alcohol use among Koreansand Taiwanese. Journal of Studies onAlcohol, 45, 481-485.

Qu, M., Newman, I.M., Shell, D.F., Li,Y.C., Gao, F.F. (2000, November).Relationship of grade, sex, and alcoholuse to alcohol expectancies amongChinese adolescents. Presented to the128th Annual Meeting of the AmericanPublic Health Association, Boston,Massachusetts, November 12-16.

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22

In the guidance, male drinkers are advised todrink no more than an average of 40 g alcoholper day and females no more than an averageof 20 g of alcohol per day to prevent chronichealth problems (for example, alcoholic livercirrhosis).

It is also recommended that, provided thereare no other situational or individual riskfactors (such as driving or being pregnant),men drink no more than 60 g on any day andwomen no more than 40 g to prevent acuteconditions associated with bouts ofintoxication (for example, alcohol-relatedinjuries).

Unfortunately, Professor Stockwell’scalculations suggest that this guidance is notfollowed by a rather large number ofAustralians. He found that 39 per cent of totalconsumption was being drunk by people whoexceeded the low-risk limits for chronic harm(36 per cent for men, 45 per cent for women).He also found that 51 per cent of totalconsumption occurred on days when thedrinker exceeded low-risk limits for acuteharm (53 per cent for men and 47 per cent forwomen). Drinking that was risky for either

acute or chronic harm was found to comprise67 per cent of total consumption. For youngmen aged 18 -24 years this figure was aremarkable 93 per cent of all alcoholconsumed.

Commenting on the findings, ProfessorStockwell said the figures disproved thepopular perception that alcoholics were theonly ones affected.

“For every alcohol-related death, there’s anaverage of 25 years of life knocked off becausea lot of it involves young people, through roadcrashes or violent offences or suicide,” he said.“We, like many other nations, draw a veil overwhat alcohol is. It’s putting a lot more lives atrisk than people realise.”

Professor Stockwell said the study wasparticularly timely as for the first time for yearsalcohol consumption was on the rise inAustralia. While full-strength beer sales hadfallen, those for pre-mixed drinks – mostpopular in the under-30s market – hadsoared.

“These statistics show that, the way we’re usingalcohol, it’s not a benign product,” Professor

Stockwell said. “We need to regulate it verycarefully.”

He suggested that the recent increase inalcohol sales could be linked to deregulation ofthe market.

“Everywhere there’s longer trading hours,more outlets. It’s more available, it’s regardedas a commodity like breakfast cereal or milk,”he said. “But most of the drinking that’s goingon is not doing people’s health any good – andmuch of it is quite unsafe.”

Professor Stockwell said the problem ofalcohol abuse could be even worse than thestudy suggested because total sales indicatedpeople were under-reporting their drinking byas much as half.

“It doesn’t all get tipped down the sink or soldto tourists,” he said. “It’s just not beingreported. People forget, they under-estimate,they fib.”

With most alcohol consumed after people hadexceeded their safe quota of standard drinksfor one day, the years of life lost to excessivedrinking outweighed those possibly saved bysupposed protective effects of light drinking inrelation to heart disease.

“If (drinkers) could all try and drink withinthe limits, many thousands of lives would besaved in Australia,” Professor Stockwell said.

Letters: How much alcohol is drunk inAustralia in excess of the newAustralian alcohol guidelines?

Tim R Stockwell, Penny Heale, Tanya NChikritzhs, Paul Dietze and PaulCatalano

The Medical Journal of Australia 21January 2002 176 2: 91-92

The Courier-Mail, Australia. 21 January2002

More than two-thirds of the alcohol drunk in Australia is ‘highrisk’, and the cost is estimated at 3300 deaths a year.

According to research by Professor Tim Stockwell and hiscolleagues, Australia’s “heroic binge-drinking culture” regularlypushes consumption beyond safe levels, with 18-24 and 14 to17-year-olds the biggest offenders. The researchers analyseddata provided by the1998 National Drug Strategy Household(NDSH) survey, calculating the volumes of alcohol consumed atthe different risk levels proposed by the National Health andMedical Research Council in its guidance on “sensible drinking”levels designed to help reduce alcohol-caused deaths inAustralia, estimated to have been 3290 in 1997.

Two thirds of Australianalcohol consumption “unsafe”

Further publications available from theInstitute of Alcohol Studies

Counterbalancing the Drinks IndustryCounterbalancing the Drinks Industry: A Report to the European Union on Alcohol PolicyA response to a report published by the European drinks industry and a defence of the WHO Alcohol ActionPlan for Europe.

Alcohol Policy and The Public GoodAlcohol Policy and the Public Good: A Guide for ActionAn easy-to-read summary of the book written by an international team of researchers to present thescientific evidence underpinning the WHO Alcohol Action Plan for Europe

Medical EducationMedical Education in Alcohol and Alcohol Problems: A European PerspectiveA review of educational programmes on alcohol and alcohol problems in European medical schools,identifying gaps in provision and proposing guidelines for a minimal educational level within thenormal curriculum of under- and post-graduate medical students.

Alcohol Problems in the FamilyAlcohol Problems in the Family: A Report to the European Union

A report produced with the financialsupport of the European Commission describing the natureand extent of family alcohol problems in the Member Countries, giving examplesof good practice in policy and service provision, and making recommendations to theEuropean Union and Member Governments.

Marketing Alcohol to Young PeopleChildren are growing up in an environment where they are bombarded with positiveimages of alcohol. The youth sector is a key target of the marketing practices of thealcohol industry. The booklet depicts the marketing strategies of the industry andshows how advertising codes of practice are being breached.

G l o b a l A l c o h o l P o l i c y A l l i a n c e

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