Intended for healthcare professionals

Editorials

Alcohol must be recognised as a drug

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3944 (Published 20 September 2018) Cite this as: BMJ 2018;362:k3944
  1. Kypros Kypri, professor1,
  2. Jim McCambridge, professor2
  1. 1School of Medicine and Public Health, University of Newcastle, Australia
  2. 2Department of Health Sciences, University of York, UK
  1. Correspondence to: K Kypri kypros.kypri{at}newcastle.edu.au

To strengthen policy responses to harms caused by addiction industries

Alcohol, actually ethanol (C2H5OH), is a psychoactive molecule ingested by 2.4 billion people globally.1 A central nervous system depressant, it exists naturally and can be produced in people’s homes. Any alcohol consumption confers health risks, including for a range of cancers,2 and any possible cardiovascular benefits are smaller than was previously understood.3 Alcohol harms users through intoxication, organ toxicity, and addiction, which cause an estimated 2.8 million deaths every year.1 In a recent systematic review and meta-analysis the Global Burden of Disease Alcohol Collaborators concluded that the “the level of alcohol consumption that minimised harm across health outcomes was zero.”1

Greater access to alcohol increases consumption and a wide range of health and social problems in a dose-response manner, and the most effective policies are those that increase the price and reduce the availability of alcohol.4 Because such measures threaten commercial interests they are challenging to adopt, and ineffectual policy responses often prevail.5 Broadening how we think about alcohol policies based on clear recognition that alcohol is a drug could have important benefits for public health.

Treating alcohol as a drug

Tobacco companies for decades deflected attention from the fact that their products were addictive drugs. When forced to recognise that alcohol is a drug, industry actors ask, “Why does it matter?”6 Words do matter in the shaping of public policy,7 and the clear identification of alcohol as a drug matters a great deal to the alcohol industry, and to society, because the policy implications are so important.

According to expert opinion, alcohol is the drug that causes most harm in the UK—more than heroin, crack, or tobacco.8 Like tobacco, alcohol kills some users slowly through the diseases it causes. Unlike tobacco, alcohol also kills quickly, through injury and poisoning. Consequently, deaths occur at younger ages on average than those caused by tobacco. As is the case for many illegal drugs, alcohol intoxication also causes harm to others, including injury and sexually transmitted infection.

Accordingly, although there is a large difference in the overall number of deaths from alcohol and tobacco, the difference in overall years of life lost is much smaller. In England these were estimated to be 301 000 years for alcohol compared with 360 000 for tobacco in 2015. That year, alcohol alone accounted for 16% of all working years lost in England.9

Drug production and distribution industries that are legal and those that are illegal are clearly different. But there are commonalities among what have been described as addiction industries—those involved in promoting products and activities known to cause addiction and associated problems10 such as tobacco, alcohol, and gambling. Profiting from addiction is a defining feature of these industries, along with obstructing the implementation of effective countermeasures.10

The merger of the world’s two biggest brewers, the third largest merger in any industrial sector, means a single company now produces one third of all beer sold globally.11 Its second largest shareholder, Altria, owns Philip Morris, a tobacco company.12 The rationale for this merger was to develop alcohol markets in Africathe smaller of the two companies has helped to draft the alcohol policies of four sub-Saharan countries.13

The consequences of the planned expansion of the alcohol industry in low and middle income countries are predictable; weakly regulated developing markets will generate epidemics of injury and disease caused by rising alcohol consumption.

Coordinated approach

Contemporary addiction policy science finds that dichotomies based on the legal status of drugs obstruct learning about management of drug use in populations.14 Bringing alcohol, tobacco, and other drugs together in unified policies may support policy coherence, stimulate creative thinking about new countermeasures, and improve societal outcomes. Box 1 details the policy implications that stem from more clearly identifying alcohol as a drug.

Box 1

Possible effects of recognising alcohol as a drug

  • Confirmation that the regulation of production, supply, and promotion is necessary because alcohol is dangerous

  • Requirement that all research and development data, including product design and marketing, are made available to regulators

  • New provisions in company law for alcohol and other addiction industries to make them accountable for the societal costs, reducing the burden borne by the public for the externalities of industry activities

  • New windfall taxes on excess profits resulting from addiction to pay for the health and social harms of alcohol

  • Better protection of public health policies from interference by alcohol industry interests (in the same way as international law does for tobacco)

  • Possibility of combining attention to alcohol and tobacco under a “harmful drugs” rubric in national and international policies

  • Alcohol and drug policies that are fully integrated with health, economic, and social policies

RETURN TO TEXT

Sweden offers perhaps the most integrated example so far, having established a “cohesive strategy for alcohol, narcotic drugs, doping, and tobacco (ANDT) policy.”15 Framed in terms of public health, the Swedish strategy recognises the need for a long term coordinated effort across many government agencies, specifies each party’s responsibilities, and makes provision for external evaluation.15 The Swedish example shows that alcohol policies can be framed within wider public policies to reach important long term objectives such as reducing the exposure of children to all psychoactive substances.

Another feature of the addiction industries is that they provide psychosocial benefits to their users. A more holistic approach must take this into account and could be helped by new forms of public involvement in policy development.16 Clearer recognition of alcohol as a drug will help inform global public health and wider society’s management of this costly and growing problem.

The current narrow framing of alcohol policy debates serves the interests of the alcohol industry. The relative weakness of forces representing the health and social interests of wider society, including people whose lives are damaged by alcohol, prevents the implementation of effective countermeasures. Dealing with this drug more assertively should be a priority for all governments.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References