Alcohol and social marketing
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3646 (Published 08 September 2009) Cite this as: BMJ 2009;339:b3646
All rapid responses
I would agree with Ian Gillmore’s opening statement; “The use and
abuse of alcohol in society is complex.” After reading the report you
still get the feeling that we haven’t got to the bottom of what has led to
the development of a binge drinking culture in Britain, and high rates of
alcohol dependence. Although the report has 9 recommendations, a ban on
marketing is their main focus. Will this be the answer? In many countries
in Europe advertising is also all pervasive, but the attitude to alcohol
there still seems healthier overall. Having a glass of wine with lunch is
accepted in a lot of businesses there and this may be what is encouraging
a ‘drinking in moderation’ culture that we are striving for here. In this
country there is a strong attitude in youth culture that there is no point
in drinking unless you are going to get drunk. Will advertising change
that?
I wonder if it may be some of the other recommendations from the
report that have more impact on adolescent consumption, for example
relating the pricing of alcohol to it's units, to try and eliminate the
availability of high strength, low cost alcopops. The report does say that
evidence shows price more than anything else influences the amount of
alcohol that young people buy.
I also wonder if it is price and licensing law changes that will make
a difference to alcohol abuse and dependence in all age groups. These
people, who are dependent on alcohol, should also be a focus for any plan
to decrease alcohol consumption nationally, and are probably even less
likely to take into account advertising and brands of alcohol, just buying
what they can afford. In the case of this group, could it also be more
beneficial to tackle some of the causative factors for their dependence,
for example unemployment, poor education, homelessness.
I had the opportunity to conduct a secret ballot of 26 colleagues in
psychiatry, consisting of F1 trainees through to Consultants, at our
weekly academic meeting. I asked them to vote for or against a ban on
alcohol advertising. The vote was surprisingly split, 10 against a ban and
16 for – maybe reflecting that there are concerns an advertising ban will
not be the straightforward answer to the complex problem of alcohol abuse.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Ian Gilmore eloquently covers much of the past, present and future of
alcohol-related marketing in his editorial.1 He identifies the need to
consider the demographics of the population, such as adolescent drinkers.
We would like to highlight another key issue in the alcohol-related harm
debate – that of ethnic minority group health.
In the UK, certain ethnic groups such as people born in Ireland and
Scotland have historically been known to drink more heavily than the
general population, and die of alcohol-related causes.2 What is less
known is that people born in India may also be more likely to die of these
alcohol-related harms.3 We need to take care as country of birth is not
ethnicity per se, but some subsets of this heterogenous ethnic group
clearly drink heavily, for example, in a previous observational study, 80%
of Indian men in the West Midlands who died of alcoholic liver disease
were Sikh.4 Given the limitations of previous national ethnicity
statistics, it can be difficult to ascertain exact drinking patterns in
these groups, although these patterns are likely to be amenable to social
and cultural interventions.3
As well as lessons from gender influences, there are also positives
to be learnt from other ethnic minority groups: low rates of consumption
(and, hence, alcohol-related mortality) are found in men and women born in
most of the rest of the world and now resident in the UK.3 We endorse Ian
Gilmore’s suggestion that a bigger more public conversation is needed
about our attitudes to alcohol as a society, but this conversation needs
to include everyone in our multi-ethnic society.
1. Gilmore I. Alcohol and social marketing. BMJ 2009;339:b3646
2. Haworth EA, Soni Raleigh V, Balarajan R. Cirrhosis and primary liver
cancer amongst first generation migrants in England and Wales. Ethn
Health. 1999 Feb-May;4(1-2):93-9.
3. Bhala N, Bhopal R, Brock A, Griffiths C, Wild S. Alcohol-related and
hepatocellular cancer deaths by country of birth in England and Wales:
analysis of mortality and census data. J Public Health (Oxf). 2009
Jun;31(2):250-7. Epub 2009 Mar 18.
4. Fisher NC, Hanson J, Phillips A, Rao JN, Swarbrick ET. Mortality from
liver disease in the West Midlands, 1993-2000: observational study. BMJ.
2002 Aug 10;325(7359):312-3.
Competing interests:
NB and RB are a Trustee and a Patron respectively of the not-for-profit medical research charity South Asian Health Foundation (www.sahf.org.uk).
Competing interests: No competing interests
To think that banning advertising of alcohol will have a profound
impact on the levels of underage drinking is a rather optimistic view of
deep seated societal problem which I believe will require a revolutionary
approach to make any headway. The exalted place that alcohol occupies in
the minds of large section of the population with the held view that
consumption, in moderation, is an entirely acceptable activity makes any
form of open marketing censorship almost pointless.
The evidence of the impact of advertising is compelling, but will
banning advertising just make the demand for particular brands to suffer,
while the overall drink culture remains largely affected?
Alcohol advertising is an integral part of funding of sport which we
all enjoy with motorsport, football, cricket, rugby and golf being major
beneficiaries. These activities will certainly suffer in the face of cuts
in sponsorship.
The availability of alcohol and the effect of peer influence are
factors that are simply not going to go away. If older family members,
friends and other people in their circles drink it is virtually impossible
to expect young people not to want to take part at some point.
The societal acceptance of alcohol consumption will make any
additional regulation unpopular. The UK Chief Medical Officers call for
stricter controls and higher pricing has been met with strong opposition
from across the political spectrum.
A courageous stance needs to be taken which will have impact on
formative minds starting from homes, primary schools and secondary schools
in which the benefits of refraining completely from alcohol need to be
extolled. I was less than impressed with the half hearted message my son
received in primary school pertaining to alcohol and smoking.
It is difficult to gauge whether ‘responsible drinking’ campaigns
such as ‘DRINKAWARE’ actually have the overall effect of reducing the
number of problem drinkers, while possibly encouraging more people, young
people included, to drink regularly some of whom will undoubtedly drink to
excess.(1)
I favour the approach adopted by the Surgeon General of the US which
encourages a greater degree of individual responsibility across the
board.(2) This is one of presenting simple factual information with
practical steps that can be taken by individuals at any level. Greater
personal family and a family based approach have been shown to have a
positive effect even in situations where alcohol related problems already
exist.(3)
References:
(1)http://www.Drinkaware.co.uk
(2)http://www.surgeongeneral.gov/topics/underagedrinking/familyguide.pdf
(3) http://alcalc.oxfordjournals.org/cgi/reprint/39/2/86.pdf
Competing interests:
None declared
Competing interests: No competing interests
It is hard to argue with the proposition that the UK has a
problem with alcohol, but it is is distressingly easy to
argue that the BMA's proposed solutions are both highly
illiberal and unlikely to work.
The BMA hates government interference with the rights and
freedoms of its members but there appear to be no
constraints on its advocacy of nanny-state solutions for
everyone else. There appears to be no recognition that, in a
free society, people have to be allowed to make bad choices
and that limits governments' ability to coerce people into
good choices.
In the case of the proposed prohibitionist measures around
booze (increased price, reduced availability, no
advertising...) they are also wrong because they are
unlikely to work.
The prohibitionists assert that their stance is "evidence
based" but this requires some misdirection around what the
evidence says. The main drivers of consumption, according
the Ian Gilmore and the BMA, are availability and price. But
this interpretation of the evidence requires a subtle piece
of misdirection. There is good evidence that sudden changes
in price and availability have immediate affects on
consumption. That pretty well applies to every consumer
good. But the actual levels of price and availability don't
explain much of the difference in long term levels of
consumption across countries (otherwise the UK would be
already be a low-consumption country). And surely it is the
long term we should care about if we are trying to improve
this country's health?
The BMA's proposed actions sound logical and are tabloid and
Daily Mail friendly, but the best we can hope for is a short
term gain at the price of punishing the two-thirds of the
population who don't abuse alcohol. There is plenty of good
evidence that the whole prohibitionist approach is a long
term failure. The problem is that prohibitionism assumes
that people can't be trusted (or educated) to make good
choices about how much they drink leaving only government
imposed constraints to hold them back. But we have the
results from a major experiment on giving people more
freedom--the recent relaxation of licensing laws--and the
result of that increased access has been lower levels of
drinking!
There is a reasonable explanation of the lowering of
consumption after increased freedom. It is that, when we
think the government is doing the job of constraining their
consumption, people don't bother and adopt unhealthy binge-
drinking habits. Some evidence that this might be true is
that the countries with the worst binge problems tend to be
prohibitionist but those with relaxed attitudes tend to
consume alcohol more sensibly. In other words, more
prohibition might make our attitudes worse. That this might
be true is reinforced by recent european experiments with
the medicalization and decriminalization of illegal drugs
which seem to lead to lower consumption and less crime.
Incidentally, total prohibition of illegal drugs doesn't
seem to have done too much too curb consumption yet has led
to a great deal of collateral damage.
We do need to change the culture of alcohol consumption in
the UK. Some people drink too much (though it is not clear
that the government's guidelines are either right or
helpful); others become highly antisocial when drunk (note
that these are often unrelated problems). We should target
interventions that will change these deep seated social
attitudes as they are the drivers of long-term behavior.
There is no excuse for illiberal, knee-jerk measures the
benefits of which are, at best, short terms and which will
probably make things worse in the long term.
Competing interests:
Consumer of alcohol (unlike
some advocates for
prohibition)
Competing interests: No competing interests
The vexing subject and twiddling of policy around Alcohol will remain
problematic as long as the research is exclusive of all drug policy; licit
and illicit.
This has become evident in New Zealand post its early 1990's National
Drug Policy formulation processes where best practice almost got there by
avoiding both the legal status and 'drug by drug' approaches to
intoxicating and psychoactive substance (mis)use.
Subsequent lobbying by the alcohol industry politicised the process
and led to a split policy based entirely on legal status as the guiding
health promotion context.
The recent USA publication "Marijuana, Are we driving people to
drink?" [Amazon top20] provides an insight by both its title and its
popularity.
Until this titanic historical grievance is addressed and the public
fully informed surrounding the concept of less harm, Alcohol's
aspirational goal of 'best practice' good health promotion remains 'moving
deck chairs'.
That such a task presents formidable difficulties should not and must
not stand in the way of Ottawa Charter principled policy development.
Competing interests:
None declared
Competing interests: No competing interests
I agree with several points raised by both the BMA and Professor
Gilmore. Yes - advertising is now more subtle and influences the younger
generations more than the more mature generations. Alcopops that taste
like the fizzy drinks they drank only a few months before makes alcohol
appealing and "easy to drink" for many youngsters. The alcohol content of
many alcopops are also higher than the average pint of brains SA - and to
young taste buds far more appetising than your traditional ale!
However, to call for a blanket ban on all alcohol related
advertising, as well as sponsorship sets a dangerous precedent. Where will
it end? Should we then call for a ban on all chocolate advertising which
undoubtedly helps the obesity epidemic? If that is the case then there is
no chance of the Cadbury's premier league! Gambling which can lead to an
addiction means that Betfair and 777.com can't sponsor darts and snooker
events anymore. Coca Cola and the football league - sugar is bad for the
teeth, for diabetes and the waist line. Again having these names
associated with sports and starts leads to changes in behaviours.
Maybe the pharmaceutical companies may like to step up to sponsor
teams - the Pfizer league or the GSK cup? But then - don't they influence
the prescribing habits of juniors more than textbooks and genuine facts?
If we call for a ban on alcohol sponsorship not only will it
jeopardise sports teams and competitions, some of which promote local and
community projects but it will also increase the perception of medical
professions' "big brother image". Before we call for a ban maybe we should
look closer to home and our own habits - I'm sure that most medical
societies drink at their functions and I know several have wine clubs!
However, I await the day when I can go to watch teams competing for
the Costa coffee championship!
Competing interests:
None declared
Competing interests: No competing interests
It is a legal requirement that beer and cider are sold by the pint.
Were we to proceed further down the road of metrication and insist that
these beverages were sold in 500ml glasses, we would immediately reduce
the alcohol consumption of many regular pub drinkers by 13%.
Competing interests:
None declared
Competing interests: No competing interests
Research that can be badged as public health and which leads to the
politically correct conclusion seems to have special status in medicine.
The rules of EBM appear not to be applied, and even simple errors of fact
are permitted. The Hastings report is no exception. For example
- Alcohol consumption in the UK has increased rapidly in recent years
No, it hasn't. As the report later admits
- the figures peaked in 2003-04
- the UK is among the heaviest alcohol consuming countries in Europe
No, it isn't.
-The difference between the retail price index and the alcohol price
index has also fallen, meaning that the rate of increase of the price of
alcoholic drinks, relative to all retail items, has decreased.
Goodness knows what this means - but the real price of alcohol has
not decreased(see Office of National Statistics data). Further, alcohol
excise taxes rise at a higher rate than inflation.
And there is absolutely no evidence that licensing law reform has led
to increased consumption, even on the 'post hoc ergo propter hoc' argument
which would not be accepted in any other branch of medical research.
Competing interests:
None declared
Competing interests: No competing interests
Cigarette packaging now comes with full technicolour images of the
damage and pain tobacco inflicts upon its victims. This alongside a
multifaceted and long standing campaign to decrease tobacco usage
including prohibitive pricing, negative media messages and the outlawing
of tobacco consumption in public places is decreasing the numbers of
British youngsters who become addicted to tobacco. Although sadly new
demographics of consumer are now being inticed into tobacco consumption.
The only way Britain can defuse the ticking time bomb of alcohol
abuse is to start treating alcohol in the same manner. This however will
be extremely difficult considering the differing cultural, social and
historical attitudes we as a country have in relation to these two
substances.
What we need to avert a massive number of future cirrhotic patients
is to change public attitudes and relations with a substance, alcohol,
which has been used by human society for millennia. This can only be
achieved through leadership from the government and in partnership with
the medical profession.
Competing interests:
None declared
Competing interests: No competing interests
Alcohol is global; As is the alcohol industry
The UK Department of Health recognised in its 2008 report that
"Health is global", and UK health policy can not be addressed in isolation
from the rest of the world.
The effect of alcohol on ethnic minorities has been highlighted, but
should we also be aware of the potential effects of an alcohol ban on
people living in other countries? Whilst the UK and much of Europe has
some success in reducing tobacco consumption, we see tobacco consumption
increasing at a fast rate in developing countries such as China.
Authors recognise the need for a global strategy on alcohol as
advertisements can reach UK from abroad, but a global strategy is also
needed to avoid simply deflecting corporate advertising and sales from the
UK to countries that have even fewer resources to tackle the social,
environmental and health problems that alcohol can cause.
Corporations have creative strategies, and profit is their
prerogative. The response to protect health will need to be equally
creative, looking to neutralise threats to health and society. Individuals
make decisions about alcohol use due to cultural, social and environmental
pressures and preferences, all of which are vastly swayed by powerful
profit-driven advertising.
Addressing the problems of alcohol use and misuse requires strategies
to protect individuals and societies across globe from the alcohol
industry's unhealthy messages.
Competing interests:
None declared
Competing interests: No competing interests