Health Systems and Policy Research

Keywords

Government, Alcohol industry, Civil society organizations

Introduction

The emergence of neoliberal policies in 1980s have changed government regulations and policies related to various issues, including health, education, social exclusion as well as human rights for the sake of promoting good governance agenda. Neoliberal policies enforced market interventions and proposed minimal state interventions assuming that people are rational actors who measure and maximize their benefits; while markets are solutions to many of their problems. However, while neoliberal approaches seem to have undermined state’s role, much of the interventions related to health requires government cooperation with various actors -industries and public health agencies- to come up with cost effective and efficient measures of tackling certain public health issues. This article focuses on alcohol consumption and alcohol related harm in the United Kingdom (UK) and suggests possible ways to tackling them.

Nature of the threat to public health

The UK is marked by vast disparities in health due to various risk factors among which alcohol is the third most significant risk factor for poor health and premature death, following tobacco and hypertension [1]. In the UK, there have been longstanding concerns about health and societal harms related to the consumption of alcohol and harmful drinking patterns [2]. According to Bellis [3], recent data shows that average adult in the UK drinks approximately 26 units of alcohol per week, equal to around three bottles of wine. While there is an increase in number of hospital admissions and deaths due to higher level of alcohol consumption, each year in the UK, almost 50% of the two million violent acts are committed due to high level of alcohol consumption [4]. According to the WHO [5], annually in the UK, alcohol related deaths are around 5792 for men and 2956 for women. Alcohol consumption is linked to greater number of social and health harms [6]. The WHO [5] reports that alcohol consumption can impact human health and capital across the life span. Therefore, effective and efficient policies are needed to tackle alcohol related harm.

Government intervention

Government plays fundamental role in policy and decision making process. Legislation and enforcement interventions appear at the top of the ladder of interventions and often involve restricting or eliminating choice to individuals. In the UK, for example, there is minimum (18+) age restriction on alcohol consumption, yet, there is pressure to increase the age limit for alcohol consumption which might not necessarily be effective. According to Room [7], the task of the state to develop and implement alcohol policy is divided between various levels and departments of the government. These departments comprise all those areas concerned with trade and industry, employment, agriculture, health and finance. Each of them contributes to policy process and implementation related to various issues, including alcohol, yet so often, unequal power or zero-sum game may arise due to conflict of interests and priorities. This is often noted in price and tax intervention policies related to alcohol.

Price interventions

According to Babor [8], interventions to influence the price of alcohol have been widely used internationally. Several systematic reviews have now demonstrated a consistent negative relationship between affordability and consumption, so that as alcohol becomes more affordable, its consumption increases and vice versa [9]. Increasing the rate of alcohol by means of tax has been recognized as the most effective intervention to decrease alcohol misuse. One of the benefits of taxation is that profit generated will come back to government and could compensate some of the expenses linked with misuse of alcohol. Traditionally, governments have used alcohol taxation as a policy both, to increase revenue and to raise prices [10]. Research evidence on the basis of economic theories reveals that rising price is a successful method of decreasing harms at the population level due to alcohol consumption [11]. Elder [12] states that in the US, increase tax on alcohol lead to higher alcohol price; yet same is not true for the UK market where due to high taxes, very low prices in discount rate is seen in the off-trade sector, even to the point that few items are sold in supermarkets below the level of cost as loss leader products. It is; however, important to understand that tax policies that are efficient and effective in one country context may result in different outcomes in other countries context.

Minimum Unit Price (MUP) intervention: Another important and complementary approach to reducing the affordability of alcohol has been to introduce a price floor below which alcohol should not be sold.-known as Minimum Unit Price (MUP) intervention. Ludbrook [13] argue that the policy of MUP might be a more effective means of decreasing alcohol related harms than taxation, because targets of minimum pricing are low-cost products, and it cannot be avoided by retails, and producers cannot absorb it as they absorb tax increase. However, Gruenewald [14] argue that price change related to expensive alcohols may lead to an increase in the consumption of alcohol, because consumers shift to cheaper products. Hence, intervention focused on the cheapest alcohol, as envisaged by minimum pricing, were predicted to be the most effective approach in reducing alcohol consumption and harm. For example, in the UK, minimum price policy would decrease consumption among heavy drinker by 10.3% as well as decline in the sale of alcohol [15]. Although there is a potential efficiency of this intervention for heavy drinkers, but objections have been raised that minimum price per unit may unjustly penalize moderate drinkers. Booth [9] states that certainly the heaviest drinkers are more likely to buy alcohol per se; the top 30% of drinkers drink almost 80% of alcohol in the UK. Minimum pricing has been implemented in areas where tax increase cannot convert into increase in prices. While the problems with minimum price intervention disproportionately affect poor people, the policy might be unfair since low income people may get affected unreasonably by such intervention [13]. According to Scottish Health Action on Alcohol Problems (SHAAP) [16] organisation, minimum unit price has been largely advocated by public health practitioners including medical officers, UK health associations, including the Royal College of Psychiatrist. A major study conducted by the UK DOH used data of sales to approximate the influence of various price approaches such as a ban on discount for bulk purchases, price increase through excise duty and implementation of minimum price ranges from 20 pence to 70 pence per unit. This experiment revealed that minimum unit price as one of the best targeted method to impact the consumption of drinkers who consume alcohol heavily [17]. Rice and Drummond [18] argue that minimum unit pricing will produce revenue for retailers and it is not for the public purpose. Therefore, both of these policies, taxation and minimum price interventions are an effective way of tackling alcohol related harm, yet, uncertainty has been seen for the implementation of both [19]. But does it have to do with neoliberal policies? According to Butler [20], UK government fails to take action on national alcohol policies in Ireland based on principles of public health and its neo liberal policy which is specifically antagonistic to the fact that the government should interfere directly in the alcohol market with a view to preventing related problems; and this creates barrier for public health practitioners to push policies on alcohol [21]. It raises a question about who should decide the alcohol price. During the Gorbochev’s regime in the Soviet Union, when alcohol policy was implemented, both, the price and distribution of alcohol was under the government control. As a result, satisfactory outcomes in the field of public health, in terms of decline in mortality rate, alcohol related harms; including progress in economic developments were noted [22]. Hawkins [23] claims that alcohol related harm policies have failed implementations in the UK. Government seem to have concluded that people in the UK are aware of the side effects of drinking by emphasizing that in the sovereign nation citizens choose what is better for their own health and wellbeing [20]. It is obvious that policy advocates of public health practitioners differ from those of industry actors [24]. Given that there are many actors in play determining alcohol policies, it raises a question about who holds authority and power in building alcohol policies in the UK. Whether it is true that at the cost of public health, there is a big economic benefit attached to alcohol consumption in the UK?

Alcohol Industries’ alcohol policy

The emergence of trade agreements and common markets along with neoliberal processes has substantially weakened government abilities to intervene into the markets for alcohol. Alcohol industries are among the drivers of these markets and they play fundamental role in alcohol policy process and implementation [25]. It is widely acknowledged that the alcohol industry has a crucial role to play in reducing alcohol related harm; however, its level of influence in the development of alcohol policy is often criticized due to a clear conflict of interest. Alcohol marketing is prominent in many countries across the world and is associated with increased rates of consumption [26]. The alcohol industry has often been successful in ensuring that marketing remains subject to relatively little independent regulation, and with the UK market being self-regulated by an industry body [27]. Industries actors have strongly opposed the regulatory approaches on price and they have always shown favour for the unsustainable interventions such as school based education programs on alcohol related harm and mass media campaign [28]. Industry actors stress on partnership with state in preference to legislation and self-regulation [6]. This, according to Holden and Lee [29], includes emphasis on alcohol industry standard of practice, alliances with various interest groups, and the usage of front group creating corporate social responsibility (CSR).

Corporate Social Responsibility (CSR)

CSR is defined as a “moral obligation of stakeholders which states the notion that business is responsible to society in general and thus corporations should be answerable to those who directly or indirectly affect or are affected by a firm’s activity” [30]. According to Yoon and Lam [31], CSR is a significant component of the alcohol industry representation and image. These include community awareness dialogue, some sort of sponsorships, education programmes and partnership with state as well as voluntary code of practice for advertising and marketing. They claim that they are the socially responsible actors in the society who are eager to hold society concerns on alcohol related harms. But the overall significance of the alcohol industry’s CSR still remains questionable; public health practitioners underline that there is considerable contradiction between their promotion of alcoholic products and alcohol industry’s claim of responsibility [31]. For example, Hill views alcohol industry’s CSR as a strategy for public relations who ultimately promote marketing of alcohol globally, instead of addressing the risk inherent in alcohol and impact on health due to its consumption [32]. Similarly, Casswell [33] shows concerns over the nature of CSR practices, stating that it is misleading, because primary role of an industry is to serve alcohol business interest rather than enhance public health related harm. In the past, those who sold alcohol needed to get license from the state and follow certain rules and laws. For example, in 1604 licensees were prevented from serving alcohol to the point of drunkenness. Authors further state that in last 50 years, consumption of alcohol has been doubled in the bars and pubs, especially during the nightlife in the UK. For example, Bellis and Hughes [34] point that while nightlife is a great venue for gathering in the context of the UK, it has led to the increase in alcohol related harms. Various interventions have been taken forward at the local level to minimize the risk of experiencing harm (while not seeking to necessarily reduce consumption) have had successes. These include lighting of street, mid night transport security, laws of licensing, enhance policing and CCTV camera network have been put forward, but at the local level. Perhaps, implementing such intervention is cost significant. Nevertheless, national level needs tighter control over marketing of alcoholic beverages. It should be noted that there is also a need for policies related to tackling drunkenness [8]. One of the WHO [35] policies points at “reducing the negative consequences of drinking and alcohol intoxication” which could be well controlled by relevant authorities through monitoring and involving health lobbies, public health organizations-which I call together - civil society.

Civil Society Intervention

A strong reply to the dominant power of the alcohol industry actors comes from opposite pressure groups, which can be called as health lobbies. Any institution can provide support for health promotion such as nongovernmental institutions, professional associations, insurance industry programmes, and publically funded institutions [36]. In many countries, due to the lack of financial power, political support and access to resources, health lobbies and public voice have been found to be as one of the obstacles to the reform of alcohol policy [37]. However, WHO [38] states that these organizations are important actors in policy process and implementation. In addition, they are essential component of a modernized civil society in providing awareness to the people and raising their concerns, advocating change, creating a discussion on policy and exposing industry actors [38]. They empower community through various means and encourage community participation as well as develop sense of ownership over decision making [25]. They increase people power through building broad-based coalitions which is- one of the recommended ways to act against the dominant power roles of the industry actors. Public health evidence regarding alcohol-related harms and the efficacy of proposed policies has an important role in managing the influence of industry. Public health evidence counteracts industry’s lack of understanding of alcohol-related problems (which some see as deliberate ignorance) [39]. According to Baggott [39], “the body of public health evidence was seen as a particular threat to the industry because it provided strong arguments for control policies” [39]. The government cannot be seen to simply ignore strong evidence for policy change; therefore, lessening the political influence of industry. It is hoped the analysis contained. In this document will help steer local policy and strategy by providing local intelligence.

Conclusion

The UK alcohol policies show a complex power dynamics between government, industries and civil society organisations in terms of who holds decision making power and who to hold accountable. Government plays fundamental role in shaping policies and implementations. Encouraging minimum price interventions on alcohol in the UK is fair- as it is shown to be the most effective way of reducing alcohol consumption and related harm. However, much of the government responsibilities have been transferred or shaped by neoliberal policies that encourage markets to play dominant role in finding solutions to people’s problems. Alcohol industries are among those who try to invest in their CSR, yet focus on their own interests in the market. CSR of alcohol industries in the UK needs to be revised in close coordination with government and civil society to assure no harm to public health and to strengthen public health and health promotion in the UK. Health lobbies are among the groups that try to come up with various activities to tackle alcohol related harm. They use people’s participation in their approach to come up with solutions, evidence based policies and interventions. This is an effective approach to encourage community participation in finding solution to alcohol related harm that impacts their health. From the perspective of public health, there should be regular means of cooperation and partnership in order to ensure that alcohol consumption and related harm have not been undermined by various government sectors in national, regional and local levels, but have been prioritized and mandated.

Recommendation

While each of these actors- government, alcohol industries and civil society offer various interventions and policies to tackle alcohol related harms, none of them seem to have gone further about tackling the reasons of alcohol consumptions and related harms. Perhaps, policies trying to enforce decrease in alcohol consumption or related harm through various interventions might not be effective if different actors, including those mentioned above, try to change people’s behaviour by changing their context or way of life. This requires understanding of reasons why people consume alcohol-family issues, stress, social economic status, peer pressure, social norms etc., and tacking them through policies. However, this is another research that I might bring some time later.

Funding

No funding sources.

Competing Interests

None declared, Ethical approval not required.

Highlights

• Alcohol and related harm cause fundamental public health challenges

• However, so often, interventions of different actors cause conflict of interest.

• Actors include government, alcohol industry and other civil society organizations

• The aim is to highlight the need for cooperation between these actors

• This will promote a healthier society in the long run.

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