How dependent is the alcohol industry on heavy drinking in England?

Alcohol purchases through online stores and mobile applications in the late phase of the COVID-19 pandemic in Poland

Aim: Online alcohol sales have grown rapidly, but their impact on alcohol consumption and harms is not well understood. This study explores the association between online alcohol purchasing and drinking behaviours during the late phase of COVID-19 pandemic in Poland. Design: A nationally representative survey was conducted in May 2022 of 2000 Polish residents aged 18-50 years selected from a probability-based web panel. Measures included past-year alcohol purchasing through e-stores, food/delivery apps and retail apps. Alcohol consumption was quantified using the Beverage-Specific Quantity-Frequency method. Logistic regression was used to identify sociodemographic and behavioural correlates of online alcohol purchasing. Results: Of the study respondents, 19% purchased alcohol through e-stores, 17% via delivery apps and 15% with retail apps. Spirits were commonly purchased in e-stores (57%), while beer was purchased via apps (58%-60%). Most online buyers took advantage of price promotions (69%-75%) and reported some kind of age verification (67%-68%). Higher odds of online purchasing were found among men (adjusted odds ratio [aOR] 1.38-1.54), younger drinkers (aOR 1.65-2.04) and to some extent university graduates (aOR 1.75 for e-stores purchases). Compared to moderate drinkers, risky (aOR 2.32-3.02) and harmful drinkers (aOR 5.06-6.61) showed substantially increased odds of buying alcohol online. Conclusion: Results suggest online alcohol purchasing, especially through mobile apps, is linked to more excessive drinking. Apps enable easy access to alcohol anytime anywhere, circumventing policies restricting sales to minors and intoxicated persons. With youth drinking declining globally, online sales are an emerging issue for public health. Restricting mobile app-based alcohol delivery could be an important policy measure to curb excessive drinking enabled by digital sales.

Dark patterns, dark nudges, sludge and misinformation: alcohol industry apps and digital tools

Many alcohol-industry-funded (AIF) organizations disseminate eHealth/mHealth tools that claim to assist users in making health decisions by monitoring alcohol consumption, e.g. blood alcohol calculators, AUDIT scores, consumption trackers. Previously, AIF materials were found to contain health misinformation that could increase consumption (dark nudges) or make healthy behaviour change more difficult (sludge). The accuracy and functionality of AIF tools have never been analysed, and given the history of AIF materials it is possible they contain misinformation and function as covert marketing channels to promote alcohol-industry-friendly narratives on the causes and possible solutions of alcohol-related harms. We evaluated the information accuracy and framing, behaviour change techniques (BCTs), and functions of AIF digital tools (n = 15, from the UK, Ireland, the USA, Canada, New Zealand, Australia; including Drinkaware, Drinkwise, Educ'alcool and others), compared to a non-industry-funded independent sample (n = 10). We identified misinformation and 'dark patterns' (interface design strategies for influencing users against their interest) throughout AIF tools; significantly fewer provided accurate feedback (33% vs 100%), and significantly more omitted information on cancer (67% vs 10%) and cardiovascular disease (80% vs 30%) and promoted industry-friendly narratives (47% vs 0%). AIF tools encouraged consumption through priming nudges (53%) and social norming (40%). AIF tools utilized fewer BCTs, provided users with more limited pre-set options (54%), and fewer drink choices (mean 24 vs 275). Their input structure often impeded their ability to provide guideline advice. We conclude that AIF tools contain pro-industry misinformation strategies and dark patterns that misinform users about their consumption and could 'nudge' them towards continuing to drink alcohol-characteristics of 'Dark Apps' designs.

Digital alcohol marketing and gender: A narrative synthesis

ISSUES

Alcohol marketing on social media platforms is pervasive and effective, reaching wide audiences and allowing interaction with users. We know little about the gendered nature of digital alcohol marketing, including how women and men are portrayed, how different genders respond and implications for gender relations. This review aimed to identify how males, females and other genders are targeted and represented in digital alcohol marketing, and how they are encouraged to engage with digital alcohol marketing content.

APPROACH

A narrative synthesis approach was employed. Academic literature and research reports were searched for studies on digital alcohol marketing published within the previous 10 years with a range of methods and designs. We reviewed the studies, extracted data relevant to gender and synthesised findings thematically.

KEY FINDINGS

The review included 17 articles and 7 reports with a range of designs and methods, including content analyses of digital material, interviews, focus groups and surveys. Our analysis identified three conceptual themes that captured many of the gendered results, namely: (i) leveraging a diversity of idealised femininities; (ii) amplifying hegemonic masculinity; and (iii) infiltrating everyday gendered life.

IMPLICATIONS AND CONCLUSION

Alcohol marketing on social media is highly gendered and is designed to embed itself into everyday life in agile ways that reinforce traditional and evolving gendered stereotypes, activities, lifestyles and roles. Gendered engagement strategies are widely used to link alcohol to everyday gendered activities and identities to encourage alcohol purchase and consumption. This marketing normalises alcohol consumption and reproduces harmful gender norms and stereotypes.

Two online randomised controlled trials examining effects of alcohol calorie labelling on hypothetical ordering of calories from alcohol and food

BACKGROUND

Providing calorie information for alcoholic beverages is a potential public-health intervention which may serve to reduce alcohol use but also prevalence of overweight/obesity. Equivocal evidence has been found for the effectiveness of alcohol calorie information at reducing drinking intentions as well as purchasing and consumption. However, the extent at which calorie information 'on-trade' will impact consumer behaviour for both alcohol and food consumption has not been investigated.

AIMS

(1) To examine the presence of alcohol calorie labelling for hypothetical purchasing of alcohol and food in typical UK restaurant scenarios. (2) To determine the characteristics of individuals who will be likely to choose to view alcohol calorie labels.

METHODS

Two online randomised control trials using a hypothetical menu selection. In experiment one (N = 325) participants were randomised to the presence or absence of alcohol calorie labels. In experiment two (N = 1081) individuals were randomised to alcohol calorie labels absent or the choice to view alcohol calorie labels. The primary outcome for each study was calories ordered from alcoholic beverages.

RESULTS

There was no evidence that the presence of alcohol calorie information on restaurant menus impacted the number of calories ordered from alcoholic beverages or from food and soft drinks. Younger individuals and individuals who exhibit greater motives for good health were more likely to choose to view alcohol calorie labels.

CONCLUSIONS

In two online, hypothetical experiments there is no evidence for alcohol calorie labelling impacting consumer decisions to order alcohol or food. Given the choice, a self-selecting group of individuals who are more motivated by health concerns will view alcohol calorie labels, and in turn may be less likely to order alcohol.

The Dependence of Online Gambling Businesses on High-Spending Customers: Quantification and Implications

Online gambling has grown to be a significant industry but it faces regulatory threats because of perception that it is heavily dependent on a small segment of its customers who gamble heavily and at a level carrying elevated risk of harm. Employing a large multi-operator data set from Britain, which records individual transactions by some 140,000 individuals observed over one year, we are enabled to provide more precise estimates of the degree of concentration of revenue, compared with previous studies. High dependence on a relatively small number of customers is shown though there is variation from product to product in how small the group of account-holders of potential concern is. We conclude with a discussion of prospects for the industry in light of heightened awareness of gambling harm and resulting restrictions on online gambling spending introduced or proposed by governments or regulators in several jurisdictions.

The Pitfalls of Ascribing Moral Agency to Corporations: Public Obligation and Political and Social Contexts in the Commercial Determinants of Health

Policy Points Government and civil society should be held more accountable for creating food and beverage regulatory policies rather than assigning moral agency to the food and beverage industry. Nutrition policymaking institutions should ensure civil society's ability to design regulatory policy. Government policymaking institutions should be isolated from industry interference.

(Mis)understanding alcohol use disorder: Making the case for a public health first approach

'Alcohol use disorder' (AUD) is used by several contemporary conceptualizations to identify, treat and prevent problems associated with alcohol use. Such conceptualizations encompass diagnostic classifications and broader frameworks for policy and practice. However, current AUD concepts are subject to multiple tensions and limitations in capturing and responding to the complex and heterogeneous nature of alcohol problems. Further, public understandings of alcohol problems are heavily divergent from professional AUD concepts and remain embedded within an 'alcoholism' master narrative in which disease model stereotypes come with multiple costs for prevention and 'recovery'. The persistence of a problematic 'alcoholism' paradigm reflects the coalescing of multiple forces including the cognitive appeal of reductionism, motives to stigmatize and 'other', and an over-emphasis on AUD as an individually located biomedical problem. Public misperceptions of AUD as a matter of the individual, the individual's essence, and misconceived notions of responsibility and control have been bolstered by industry interests and the ascension of neuroscience and genetics, in turn diverting attention from the importance of the environmental and commercial determinants of health and the effectiveness of under-utilized public health policies. We call for multiple stakeholders to support efforts to prioritize a public health first approach to advancing AUD research, policy and treatment in order to make significant advances in AUD prevention and treatment. We offer several recommendations to assist in shifting public understanding and scientific limitations in AUD concepts and responses.

Should we promote alcohol problems as a continuum? Implications for policy and practice

The highly heterogeneous nature of alcohol use and problems has presented significant challenges to those attempting to understand, treat or prevent what is commonly termed alcohol use disorder (AUD). However, any attempts to capture this complex phenomenon, including the various current criterion of AUD, come with a number of limitations. One particular limitation has been how alcohol problems are represented or understood in ways which do not capture the broad spectrum of alcohol use and harms and the many potential routes to prevention, treatment, and recovery. One possible response to this has been proposed as more explicitly framing or conceptualizing a continuum model of alcohol use and harms. In this commentary, we attempt to identify the key implications of a continuum model for policy and practice, examining the historical and current context of alcohol problem classifications and models. We argue a continuum model of alcohol use and problems holds a number of advantages for advancing public health goals, but also some potential limitations, both of which require further examination.

The emperor has no clothes: a synthesis of findings from the Transformative Research on the Alcohol industry, Policy and Science research programme

BACKGROUND AND AIMS

The Transformative Research on the Alcohol industry, Policy and Science (TRAPS) programme investigates the alcohol industry, with an innovative focus on public health sciences. TRAPS adds to an under-developed literature on the study of alcohol industry influence on alcohol science and policymaking. This paper provides a synthesis of TRAPS findings to inform future research.

METHODS

We conducted an interpretive review of TRAPS research findings across its component studies, identifying and integrating the key contributions made by individual studies to the literature on alcohol policymaking and science, and identifying areas where TRAPS progress was limited. This produced themes for consideration in future research agenda setting.

RESULTS

TRAPS explored the interventions of the alcohol industry in science and policymaking using various methods, including systematic reviews and qualitative interviews. These studies identified the industry's activities in several key areas, such as the debate over minimum unit pricing (MUP), cardiovascular health and alcohol research and a long-running public relations programme developed in close connection with the tobacco industry. Collectively, the research shows that alcohol policymaking has involved a contest between the research community and alcohol industry actors about whether and how science should be used to inform policy.

CONCLUSIONS

The TRAPS programme demonstrates the need for a transdisciplinary approach to understand the nature of corporate political activity; the crucial role industry involvement in science plays in the development of corporate political power; and how public health actors have successfully overcome industry opposition to evidence-based policies. Advances in alcohol policy should be underpinned by strong, reflexive public health sciences, alert to the role of industry in the alcohol harms under study and thorough in their investigation of the alcohol industry as an object of study in itself.

Alcohol: No Ordinary Commodity-a summary of the third edition

BACKGROUND AND AIMS

This article summarizes the findings and conclusions of the third edition of Alcohol: No Ordinary Commodity. The latest revision of this book is part of a series of monographs designed to provide a critical review of the scientific evidence related to alcohol control policy from a public health perspective.

DESIGN

A narrative summary of the contents of the book according to five major issues.

FINDINGS

An extensive amount of epidemiological evidence shows that alcohol is a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. Trends in alcohol products and marketing are described, indicating that a large part of the global industry has been consolidated into a small number of transnational corporations that are expanding their operations in Asia, Africa and Latin America. The main part of the book is devoted to a review of strategies and interventions designed to prevent or minimize alcohol-related harm. Overall, the most effective strategies to protect public health are taxation that decreases affordability and restrictions on the physical availability of alcohol. A total ban on alcohol marketing is also an effective strategy to reduce consumption. In addition, drink-driving counter-measures, brief interventions with at-risk drinkers and treatment of drinkers with alcohol dependence are effective in preventing harm in high-risk contexts and groups of hazardous drinkers.

CONCLUSION

Alcohol policy is often the product of competing interests, values and ideologies, with the evidence suggesting that the conflicting interests between profit and health mean that working in partnership with the alcohol industry is likely to lead to ineffective policy. Opportunities for implementation of evidence-based alcohol policies that better serve the public good are clearer than ever before as a result of accumulating knowledge on which strategies work best.

Food as harm reduction during a drinking session: reducing the harm or normalising harmful use of alcohol? A qualitative comparative analysis of alcohol industry and non-alcohol industry-funded guidance

BACKGROUND

The aim of this study was to critically analyse information concerning the relationship between alcohol and food consumption provided via alcohol industry (AI) funded and non-AI-funded health-oriented websites, to determine the role it plays within the alcohol information space, and how this serves the interests of the disseminating organisations.

METHODS

Information on food as a harm reduction measure while drinking alcohol was extracted from 15 AI websites and websites of AI-funded corporate social responsibility (CSR) organisations. As a comparison group, non-AI-funded health websites were also searched (n = 16 websites with food and alcohol-related content). Information was included from webpage content and associated downloadable documents. Critical discourse analysis (CDA) was adopted to allow the texts analysed to be situated within the broader political and social context. Analysis was carried out iteratively, involving continuous comparison within and between websites. Discursive themes were identified by three researchers. Identified discursive elements were discussed to reach a consensus, and a final coding framework was then developed. "Tone" analysis was used to assess whether the overall tone within individual websites was considered to be pro-alcohol consumption, neutral or discouraging of alcohol consumption.

RESULTS

There were some commonalities across AI and non-AI-funded websites, whereby both appeared to normalise alcohol consumption and to encourage use of food as a measure to enable sustained drinking, to avoid drinking in a way that results in short-term harms, and to prevent or "cure" a hangover. The fact that both AI-funded and non-AI-funded organisations shared many of these narratives is particularly concerning. However, a discourse of food and alcohol that served to promote "moderate" drinking as beneficial to health was used exclusively by AI-funded organisations, focusing on special occasions and individual-blaming.

CONCLUSIONS

Alcohol consumption, including heavy and harmful consumption, is frequently normalised within the online information space. Emphasising food consumption with alcohol may have the effect of supporting consumers to drink for longer periods of time. Health professionals and independent health organisations should review the information they provide in light of our findings and challenge why AI-funded organisations, with a major conflict of interest, and a history of health misinformation, are often given the responsibility for disseminating health information to the public.

The Alcohol Industry and Social Responsibility: Links to FASD

Fetal Alcohol Spectrum Disorder is directly linked to the consumption of alcohol during pregnancy. Prevention programs have been targeted at women of childbearing age and vulnerable populations. The beverage alcohol industry (manufacture, marketing, distribution, and retail) is often seen as playing a role in prevention strategies such as health warning labels. In this paper we explore the nature of the relationship between the industry and prevention programming. We consider the place of alcohol in society; the prevalence, social and economic costs of FASD; the ethical notion of alcohol-related harm and then move onto the question of public health partnerships with the industry including the potential conflicts of interests and ethical challenges in such partnerships.

Intended and unintended consequences of the implementation of minimum unit pricing of alcohol in Scotland: a natural experiment

Background

Scotland was the first country to implement minimum unit pricing for alcohol nationally. Minimum unit pricing aims to reduce alcohol-related harms and to narrow health inequalities. Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. This study comprised three components.

Objectives

This study comprised three components assessing alcohol consumption and alcohol-related attendances in emergency departments, investigating potential unintended effects of minimum unit pricing on alcohol source and drug use, and exploring changes in public attitudes, experiences and norms towards minimum unit pricing and alcohol use.

Design

We conducted a natural experiment study using repeated cross-sectional surveys comparing Scotland (intervention) and North England (control) areas. This involved comparing changes in Scotland following the introduction of minimum unit pricing with changes seen in the north of England over the same period. Difference-in-difference analyses compared intervention and control areas. Focus groups with young people and heavy drinkers, and interviews with professional stakeholders before and after minimum unit pricing implementation in Scotland allowed exploration of attitudes, experiences and behaviours, stakeholder perceptions and potential mechanisms of effect.

Setting

Four emergency departments in Scotland and North England (component 1), six sexual health clinics in Scotland and North England (component 2), and focus groups and interviews in Scotland (component 3).

Participants

Research nurses interviewed 23,455 adults in emergency departments, and 15,218 participants self-completed questionnaires in sexual health clinics. We interviewed 30 stakeholders and 105 individuals participated in focus groups.

Intervention

Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers.

Results

The odds ratio for an alcohol-related emergency department attendance following minimum unit pricing was 1.14 (95% confidence interval 0.90 to 1.44; p = 0.272). In absolute terms, we estimated that minimum unit pricing was associated with 258 more alcohol-related emergency department visits (95% confidence interval –191 to 707) across Scotland than would have been the case had minimum unit pricing not been implemented. The odds ratio for illicit drug consumption following minimum unit pricing was 1.04 (95% confidence interval 0.88 to 1.24; p = 0.612). Concerns about harms, including crime and the use of other sources of alcohol, were generally not realised. Stakeholders and the public generally did not perceive price increases or changed consumption. A lack of understanding of the policy may have caused concerns about harms to dependent drinkers among participants from more deprived areas.

Limitations

The short interval between policy announcement and implementation left limited time for pre-intervention data collection.

Conclusions

Within the emergency departments, there was no evidence of a beneficial impact of minimum unit pricing. Implementation appeared to have been successful and there was no evidence of substitution from alcohol consumption to other drugs. Drinkers and stakeholders largely reported not noticing any change in price or consumption. The lack of effect observed in these settings in the short term, and the problem-free implementation, suggests that the price per unit set (£0.50) was acceptable, but may be too low. Our evaluation, which itself contains multiple components, is part of a wider programme co-ordinated by Public Health Scotland and the results should be understood in this wider context.

Future work

Repeated evaluation of similar policies in different contexts with varying prices would enable a fuller picture of the relationship between price and impacts.

Trial registration

Current Controlled Trials ISRCTN16039407.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

A public health approach to gambling regulation: countering powerful influences

Often portrayed as a harmless leisure activity in the UK, gambling is being increasingly recognised as a public health concern. However, a gambling policy system that explicitly tackles public health concerns and confronts the dependencies and conflicts of interest that undermine the public good is absent in the UK. Although there is a window of opportunity to change the gambling policy system, with the UK Government's launch of a review of the Gambling Act 2005, the adoption of a comprehensive and meaningful public health approach is not guaranteed. Too often, government policy has employed discourses that align more closely with those of the gambling industry than with those of the individuals, families, and communities affected by the harms of gambling. In view of the well described commercial determinants of health and corporate behaviour, an immense effort will be needed to shift the gambling discourse to protect public health. In this Viewpoint, we seek to advance this agenda by identifying elements that need challenging and stimulating debate.

Strategies for engaging policy stakeholders to translate research knowledge into practice more effectively: Lessons learned from the Canadian Alcohol Policy Evaluation project

INTRODUCTION

Evidence-based alcohol policies have the potential to reduce a wide range of related harms. Yet, barriers to adoption and implementation within governments often exist. Engaging relevant stakeholders may be an effective way to identify and address potential challenges thereby increasing reach and uptake of policy evaluation research and strengthening jurisdictional responses to alcohol harms.

METHODS

As part of the 2019 Canadian Alcohol Policy Evaluation project, we conducted interviews with government stakeholders across alcohol-related sectors prior to a second round of researcher-led policy assessments in Canada's 13 provinces and territories. Stakeholders were asked for feedback on the design and impact of an earlier policy assessment in 2013 and for recommendations to improve the design and dissemination strategy for the next iteration. Content analysis was used to identify ways of improving stakeholder engagement.

RESULTS

We interviewed 25 stakeholders across 12 of Canada's 13 jurisdictions, including representatives from government health ministries and from alcohol regulation, distribution and finance departments. In providing feedback on our stakeholder engagement strategy, participants highlighted the importance of maintaining ongoing contact; presenting results in accessible online formats; providing advance notice of results; and offering jurisdiction-specific webinars.

DISCUSSION AND CONCLUSIONS

This study offers important insight into the engagement preferences of government stakeholders involved in the health, regulation, distribution and financial aspects of alcohol control policy. Findings suggest that seeking input from stakeholders as part of conducting evaluation research is warranted; increasing the relevance, reach and uptake of results. Specific stakeholder engagement strategies are outlined.

Changing Alcohol Cravings Using Social Media Comments

Background: Alcohol marketing has proliferated on social media. When exposed to social media advertisements, users view comments written in response to the ad and user engagement metrics, in addition to the ad itself. Here, the independent effect of different types of comments on alcohol craving was assessed. Methods: In all, n = 722 participants were randomized to view either no comments, pro-drinking comments, anti-drinking comments, warning labels, or industry responsibility messages associated with six alcohol ads. Alcohol cravings, measured using the Desires for Alcohol Questionnaire (DAQ), were assessed before and after ad exposure. Smoking urges were also assessed. The significance of main effects was determined using repeated-measures ANCOVA. Results: Warning labels significantly decreased scores on the desires and intentions to drink DAQ sub-scale (p = .025) and decreased smoking urges (p = .024). Pro-drinking comments significantly increased scores on the control of drinking sub-scale (p = .006). Conclusions: The findings suggest that user-generated comments can influence the desire to drink and smoking urges, beyond the effects of ads themselves. If so, alcohol warning labels may decrease alcohol cravings when used in this way. Additionally, to limit the loss of control over drinking, the ability of social media users to post pro-drinking comments may need to be curtailed.

News Media and the Influence of the Alcohol Industry: An Analysis of Media Coverage of Alcohol Warning Labels With a Cancer Message in Canada and Ireland

OBJECTIVE

Media coverage of alcohol-related policy measures can influence public debate and is often more aligned with interests of the alcohol industry than public health. The purpose of this study was to examine the framing of news coverage of alcohol warning label (AWL) initiatives that included a cancer message on alcohol containers in two different countries. Policy contexts and industry perspectives were also evaluated.

METHOD

We identified and systematically reviewed news articles published between 2017-2019 covering an AWL academic study in Yukon, Canada, and labeling provisions in a Public Health (Alcohol) Bill in Ireland. Both included a cancer message. News stories were coded for media type and topic slant; inclusion of alcohol industry perspectives was examined using content analysis.

RESULTS

Overall, 68.4% of media articles covering the Yukon Study (n = 38) and 18.9% covering the Ireland Bill (n = 37) were supportive of AWLs with a cancer message. The majority of articles in both sites presented alcohol industry perspectives (Yukon, 65.8%; Ireland, 86.5%), and industry arguments opposing AWLs were similar across both contexts. In articles with statements from industry representatives, the label message was frequently disputed by distorting or denying the evidence that alcohol causes cancer (n = 33/43).

CONCLUSIONS

News coverage of AWLs with a cancer message was more supportive in Canada than Ireland, where alcohol industry perspectives were consistently foregrounded. Industry arguments opposing the cancer label bore similarities across contexts, often distorting or denying the evidence. Increasing awareness of industry messaging strategies may generate more critical coverage of industry lobbying activities and increase public support for alcohol policies.

Baseline Assessment of Alcohol-Related Knowledge of and Support for Alcohol Warning Labels Among Alcohol Consumers in Northern Canada and Associations With Key Sociodemographic Characteristics

OBJECTIVE

Evidence-informed alcohol warning labels (AWLs) are a promising, well-targeted strategy to increase consumer awareness of health risks. We assessed consumers' baseline knowledge of alcohol-related cancer risk, standard drinks, and low-risk drinking guidelines as well as levels of support for AWLs. We further assessed associations with sociodemographic factors.

METHOD

Forming part of a larger study testing new evidence-informed AWLs in a northern Canadian territory compared with a neighboring territory, baseline surveys were completed among liquor store patrons systematically selected in both sites. Chi-square and multivariable logistic regression analyses were performed to assess outcomes.

RESULTS

In total, 836 liquor store patrons (47.8% female) completed baseline surveys across both sites. Overall, there was low knowledge of alcohol-related cancer risk (24.5%), limited ability to calculate a standard drink (29.5%), and low knowledge of daily (49.5%) and weekly (48.2%) low-risk drinking guideline limits. There was moderate support for AWLs with a health warning (55.9%) and standard drink information (51.4%), and lower support for low-risk drinking guideline labels (38.7%). No sociodemographic characteristics were associated with cancer knowledge. Identifying as female and having adequate health literacy were associated with support for all three AWLs; high alcohol use was associated with not supporting standard drink (adjusted odds ratio = 0.60, 95% CI [0.40, 0.88]) and low-risk drinking guideline (adjusted odds ratio = 0.57, 95% CI [0.38, 0.87]) labels.

CONCLUSIONS

Few consumers in this study had key alcohol-related health knowledge; however, there was moderate support for AWLs as a tool to raise awareness. Implementation of information-based interventions such as evidence-informed AWLs with health messages including alcohol-related cancer risk, standard drink information, and national drinking guidelines is warranted.

Recruiting the "Heavy-Using Loyalists of Tomorrow": An Analysis of the Aims, Effects and Mechanisms of Alcohol Advertising, Based on Advertising Industry Evaluations

Restricting alcohol advertising and marketing is a cost-effective intervention for reducing alcohol harms. However, the alcohol industry maintains that advertising does not affect consumption, claiming that its purpose is to help consumers choose brands, it is not aimed at young people, it only promotes "responsible consumption", and any relationships with consumption are not causal. We reviewed 39 case studies (1981-2016) published by the advertising industry, which evaluate the effects of alcohol advertising campaigns. We used these to examine these industry claims. 30/39 (77%) of the case studies mentioned increasing/maintaining market share as an objective, or used this to assess the effectiveness of advertising campaigns. Most (25/39, 64%) found that campaigns increased consumption-related outcomes. Some campaigns targeted women, and heavy drinkers (e.g., Stella Artois lager, Famous Grouse whisky). Campaigns often (13/39, 33%) targeted younger drinkers. These data show that advertising does influence market share. Other effects reported in the case studies include changing the consumer profile towards: younger drinkers, women, new/lapsed drinkers, and heavy drinkers. They also present evidence of a causal relationship between advertising and consumption. In conclusion, this analysis, based on industry data, presents significant new evidence on (i) the effects of alcohol advertising on consumption-related outcomes, and (ii) the mechanisms by which it achieves those effects.

Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK

This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities. We continue to press for reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place, and the introduction of minimum unit pricing in England, targeted at the heaviest drinkers. Results from the introduction of minimum unit pricing in Scotland, with results from Wales to follow, are likely to seriously expose the weakness of England's position. The increasing prevalence of obesity-related liver disease, the rising number of people diagnosed with type 2 diabetes and its complications, and increasing number of cases of end-stage liver disease and primary liver cancers from non-alcoholic fatty liver disease make apparent the need for an obesity strategy for adults. We also discuss the important effects of obesity and alcohol on disease progression, and the increased risk of the ten most common cancers (including breast and colon cancers). A new in-depth analysis of the UK National Health Service (NHS) and total societal costs shows the extraordinarily large expenditures that could be saved or redeployed elsewhere in the NHS. Excellent results have been reported for new antiviral drugs for hepatitis C virus infection, making elimination of chronic infection a real possibility ahead of the WHO 2030 target. However, the extent of unidentified cases remains a problem, and will also apply when new curative drugs for hepatitis B virus become available. We also describe efforts to improve standards of hospital care for liver disease with better understanding of current service deficiencies and a new accreditation process for hospitals providing liver services. New commissioning arrangements for primary and community care represent progress, in terms of effective screening of high-risk subjects and the early detection of liver disease.