Alcohol marketing versus public health: David and Goliath?

Brief interventions 2.0: a new agenda for alcohol policy, practice and research

BACKGROUND

Alcohol problems are increasing across the world and becoming more complex. Limitations to international evidence and practice mean that the screening and brief intervention paradigm forged in the 1980s is no longer fit for the purpose of informing how conversations about alcohol should take place in healthcare and other services. A new paradigm for brief interventions has been called for. BRIEF INTERVENTIONS 2.0: We must start with a re-appraisal of the roles of alcohol in society now and the damage it does to individual and population health. Industry marketing and older unresolved ideas about alcohol continue to impede honest and thoughtful conversations and perpetuate stigma, stereotypes, and outright fictions. This makes it harder to think about and talk about how alcohol affects health, well-being, and other aspects of life, and how we as a society should respond. To progress, brief interventions should not be restricted only to the self-regulation of one's own drinking. Content can be orientated to the properties of the drug itself and the overlooked problems it causes, the policy issues and the politics of a powerful globalised industry. This entails challenging and reframing stigmatising notions of alcohol problems, and incorporating wider alcohol policy measures and issues that are relevant to how people think about their own and others' drinking. We draw on recent empirical work to examine the implications of this agenda for practitioners and for changing the public conversation on alcohol.

CONCLUSION

Against a backdrop of continued financial pressures on health service delivery, this analysis provokes debate and invites new thinking on alcohol. We suggest that the case for advancing brief interventions version 2.0 is both compelling and urgent.

Constructing public-private partnerships to undermine the public interest: critical discourse analysis of Working Together published by the International Alliance for Responsible Drinking

BACKGROUND

The global burden of alcohol harm has increased and is forecast to grow further without effective policy implementation. Public-private partnerships aiming to address global health, and other societal challenges, are a burgeoning feature of neoliberal governance. Rhetorically distancing themselves from tobacco, the major alcohol companies are committed to tackling 'harmful drinking' and have created a distinct type of public relations organization for this purpose. The activities of such organizations are increasingly recognized as an impediment to the implementation of policies to reduce alcohol harm, including in low- and middle-income countries where markets are expanding.

METHODS

The approach of critical discourse analysis is used to examine the discursive tactics and strategies used in Working Together; a 'toolkit' published by the key global level alcohol industry public relations organization, the International Alliance for Responsible Drinking (IARD). This study considers how it works discursively to set the terms of, and overcome skepticism about partnerships, to define aims and position various actors by constructing their roles. The construction of prospective partners provides insights into the alcohol industry itself.

RESULTS

The toolkit operates as an ideological resource for forming public-private partnerships across the world based on the accumulated know-how of the major companies through IARD. This allows the largest alcohol companies to exercise leadership of the industry, while remaining off-stage. The toolkit relies on a form of rhetorical work which creates distance from obvious corporate interests and the harms caused to population health and society. This is accomplished by working against evidence-informed population level approaches, and thus avoiding policies that will make any significant difference to overall alcohol harm. Unspecific "complexity" affords opportunity for preferred types of "actions", and "partnership" provides opportunity to gain credibility by association, further minimizing the likelihood of any material harm being reduced.

CONCLUSIONS

The toolkit is designed to not only legitimate the inclusion of alcohol industry actors as initiating 'partners', but also assigns them roles as managers of a set of carefully constructed relationships. This vision of public-private partnership reproduces the hegemonic narrative that has successfully blocked policy advances for decades and led to growing alcohol harm globally.

'Odds Are: They Win': a disruptive messaging innovation for challenging harmful products and practices of the gambling industry

OBJECTIVE

This paper presents an evidence informed rationale for focussing on harmful gambling products and industry practices in public health messaging through the example of a recent innovation called 'Odds Are: They Win'.

METHODS

'Odds Are: They Win' was initially developed through coproduction involving public health professionals and people with lived experience of gambling harms and implemented across a city-region area. A review of relevant evidence was undertaken, upon which the research team reflected to draw out the implications of 'Odds Are: They Win' for gambling harms messaging.

RESULTS

Evidence is mounting that safer gambling campaigns framed in terms of individual responsibility are ineffective and can generate stigma. 'Odds Are: They Win' presents an alternative focus that is not anti-gambling but raises awareness of industry manipulation of the situational and structural context of gambling. This is in-keeping with historical lessons from the stop smoking field and emerging research in critical health literacy. The latter highlights the potential of education on the social and commercial determinants of health to stimulate behaviour change and collective action.

CONCLUSION

'Odds Are: They Win' is a potentially disruptive innovation for the gambling harms field. Research is required to robustly evaluate this intervention across diverse criteria, target audiences, and delivery settings.

The public health implications of the cost-of-living crisis: outlining mechanisms and modelling consequences

The UK, and other high-income countries, are experiencing substantial increases in living costs. Several overlapping and intersecting economic crises threaten physical and mental health in the immediate and longer term. Policy responses may buffer against the worst effects (e.g. welfare support) or further undermine health (e.g. austerity). We explore fundamental causes underpinning the cost-of-living crisis, examine potential pathways by which the crisis could impact population health and use a case study to model potential impacts of one aspect of the crisis on a specific health outcome. Our modelling illustrates how policy approaches can substantially protect health and avoid exacerbating health inequalities. Targeting support at vulnerable households is likely to protect health most effectively. The current crisis is likely to be the first of many in era of political and climate uncertainty. More refined integrated economic and health modelling has the potential to inform policy integration, or 'health in all policies'.

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.

Reactions to being allocated to a waiting list control group in a digital alcohol intervention trial

OBJECTIVE

To study reactions of control group participants allocated to two different presentations of basic health information in a digital alcohol intervention trial.

METHOD

Control participants were randomised to wait with one of two different presentations of basic health information. Multiple choice questions and free-text comments assessed reactions, four months post randomisation. Effects of differential health information on responses were estimated, as were associations between responses, baseline characteristics and change in alcohol consumption.

RESULT

Of 1066 control group participants, 572 (54%) responded to the questionnaire. Contrasting two different presentations of basic health information revealed no statistically significant differences. Responses revealed that 38% were interested sufficiently to look at the information while 42% felt frustration, irritation, or disappointment about having to wait. Approximately 55% responded that they decided to reduce their drinking whilst 17% stated that they continued to drink as usual, and 11% gave up on the idea of reducing their drinking. The two latter groups reported markedly higher alcohol consumption at follow-up in comparison to the former (probability of association >99.9%).

CONCLUSION

Being made to wait may invite negative research participation effects.

PRACTICE IMPLICATION

Comparator guidance should be updated to reflect the potentially negative consequences which are under researched.

Would the Brazilian population support the alcohol policies recommended by the World Health Organization?

OBJECTIVE

To evaluate the support of the Brazilian population to the alcohol-policies proposed by the World Health Organization to decrease alcohol harm (specifically: to decrease alcohol availability and advertising, and to increase pricing). In addition, we evaluated the factors associated with being against those policies.

METHODS

Data from 16,273 Brazilians, aged 12-65 years, interviewed in the 3rd Brazilian Household Survey on Substance Use (BHSU-3) were analyzed. The BHSU-3 is a nationwide, probability survey conducted in 2015. Individuals were asked if they would be against, neutral, or in favor of seven alcohol policies grouped as: 1) Strengthen restrictions on alcohol availability; 2) Enforce bans or restrictions on alcohol advertising, sponsorship, and promotion; and 3) Raise prices on alcohol through excise taxes and pricing. Generalized linear models were fitted to evaluate factors associated with being against each one of those policies and against all of policies.

RESULTS

Overall, 28% of the Brazilians supported all the above mentioned policies, whereas 16% were against them. The highest rate of approval refers to restricting advertising (53%), the lowest refers to increasing prices (40%). Factors associated with being against all policies were: being male (AOR = 1.1; 95%CI: 1.0-1.3), not having a religion (AOR = 1.4; 95%CI: 1.1-1.8), being catholic (AOR = 1.3; 95%CI: 1.1-1.5), and alcohol dependence (AOR = 1.6; 95%CI: 1.1-2.4).

CONCLUSIONS

The Brazilian government could count on the support of most of the population to restrict alcohol advertising. This information is essential to tackle the lobby of the alcohol industry and its clever marketing strategy.

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.

"Using information to shape perception": tobacco industry documents study of the evolution of Corporate Affairs in the Miller Brewing Company

BACKGROUND

The Miller Brewing Company (MBC) was wholly owned by Phillip Morris (PM), between 1970 and 2002. Tobacco industry document studies identify alliances between the alcohol and tobacco industries to counter U.S. policies in the 1980s and 1990s. This investigation sought to study in-depth inter-relationships between MBC and PM, with a particular focus on alcohol policy issues. We used the Truth Tobacco Industry Documents library to trace the evolution of corporate affairs and related alcohol policy orientated functions within and between MBC and PM.

RESULTS

MBC was structured and led by PM senior executives from soon after takeover in 1970. Corporate Affairs sought to influence public perceptions of alcohol to align them with business interests. Alcohol education was specifically designed to prevent the adoption of policies inimical to those interests (e.g., raising excise taxes). Strategic consideration of alcohol policy issues was integrated within company-wide thinking, which sought to apply lessons from tobacco to alcohol and vice versa. PM directly led key alcohol industry organisations nationally and globally, which have successfully delayed the adoption and implementation of known effective policy measures in the U.S. and worldwide.

CONCLUSIONS

PM has been a key architect of alcohol industry political strategies. This study builds on earlier work on alcohol companies in the tobacco documents, and offers historical data on how tobacco companies have used commercial involvements in other sectors to influence wider public health policy. We are only beginning to appreciate how multi-sectoral companies internally develop political strategies across product categories. Global health and national governmental policy-making needs to be better protected from business interests that fundamentally conflict with public health goals.

The alcohol industry, the tobacco industry, and excise taxes in the US 1986-89: new insights from the tobacco documents

BACKGROUND

The UCSF Industry Documents Library has provided public health researchers with key insights into the organization of political activities in the tobacco industry. Much less is known about the alcohol industry. In the US, there is some existing evidence of cooperation between the two industries, particularly in areas where there are mutual interests and/or policy goals at stake. Efforts to raise excise taxes on tobacco and alcohol products are one such example.

METHODS

We systematically searched the UCSF Industry Documents Library for data on alcohol industry actors and their political activities. Using content generated by alcohol and tobacco actors, we sought to identify new evidence of collaborations to shape excise tax policy debates in the US in the 1980s and 1990s.

RESULTS

We uncover evidence of the alcohol industry's efforts to shape excise tax policy debates, both at the national and state level. Excise taxes were defined by both alcohol and tobacco companies and related organisations as a key threat to profits. We show how the alcohol industry confronted this challenge in the late 1980s in the US, uncovering the range of monitoring, coordinating, and public-facing activities used to defeat proposed tax increases at both state and federal levels. The former draws particular attention to Oregon, where alcohol industry actors were not simply operating at the behest of the tobacco industry, but actively led a campaign to advance both brewing and tobacco interests.

CONCLUSIONS

The tobacco documents offer a key resource for studying economic interests beyond that of the tobacco industry, operating in collaboration with tobacco companies. Here, brewers advanced shared interests with tobacco, and these findings have implications for advancing understanding of alcohol and tobacco industry political strategies. The findings also suggest that financial documents from other public repositories could be used to generate new inferences about corporate political activities.

Factors Associated with Adolescents' Support for Product Information and Health Messaging on Alcohol Packaging: A Cross-Sectional Study in the United Kingdom

AIMS

Adolescents in the UK are among the heaviest drinkers in Europe. The World Health Organization recommends alcohol product labelling to inform consumers about product information and health risks associated with alcohol use. This study investigates support for product information and health messaging on alcohol packaging among UK adolescents.

METHODS

The 2019 UK Youth Alcohol Policy Survey was an online cross-sectional survey among 3388 adolescents aged 11-19. Participants indicated their support for seven forms of messaging on packaging (e.g. number of alcohol units, links to health conditions). Logistic regression models investigated associations between support for each of the seven forms and alcohol use, perceived risks of alcohol use, and previous exposure to messaging.

RESULTS

Between 60 and 79% of adolescents were supportive of different aspects of product labelling. Compared to lower-risk drinkers, higher-risk drinkers (AUDIT-C 5+) had higher odds of supporting including the number of alcohol units (OR: 1.82, 95% CI: 1.31-2.54), calories (OR: 1.52, 95% CI: 1.04-1.68), and strength of the product (OR: 1.73, 95% CI: 1.19-2.52) but lower odds of supporting including information on alcohol-related health conditions (OR: 0.68, 95% CI: 0.53-0.87). Adolescents who perceived risks of alcohol use more strongly were more likely to support all forms of product information and messaging.

CONCLUSIONS

The majority of adolescents supported improved alcohol labelling. Higher-risk drinkers were supportive of improved product information but less supportive of health-related messaging. Adolescents who believe alcohol carries health risks were more likely to support messaging.

Addressing complex pharmacy consultations: methods used to develop a person-centred intervention to highlight alcohol within pharmacist reviews of medications

Background

Alcohol is challenging to discuss, and patients may be reluctant to disclose drinking partly because of concern about being judged. This report presents an overview of the development of a medications review intervention co-produced with the pharmacy profession and with patients, which breaks new ground by seeking to give appropriate attention to alcohol within these consultations.

Methods

This intervention was developed in a series of stages and refined through conceptual discussion, literature review, observational and interview studies, and consultations with advisory groups. In this study we reflect on this process, paying particular attention to the methods used, where lessons may inform innovations in other complex clinical consultations.

Results

Early work with patients and pharmacists infused the entire process with a heightened sense of the complexity of consultations in everyday practice, prompting careful deliberation on the implications for intervention development. This required the research team to be highly responsive to both co-production inputs and data gathered in formally conducted studies, and to be committed to working through the implications for intervention design. The intervention thus evolved significantly over time, with the greatest transformations resulting from patient and pharmacist co-design workshops in the second stage of the process, where pharmacists elaborated on the nature of the need for training in particular. The original research plans provided a helpful structure, and unanticipated issues for investigation emerged throughout the process. This underscored the need to engage dynamically with changing contexts and contents and to avoid rigid adherence to any early prescribed plan.

Conclusions

Alcohol interventions are complex and require careful developmental research. This can be a messy enterprise, which can nonetheless shed new insights into the challenges involved in optimising interventions, and how to meet them, if embraced with an attitude of openness to learning. We found that exposing our own research plans to scrutiny resulted in changes to the intervention design that gained the confidence of different stakeholders. Our understanding of the methods used, and their consequences, may be bounded by the person-centred nature of this particular intervention.

Reactions on Twitter towards Australia's proposed import restriction on nicotine vaping products: a thematic analysis

OBJECTIVE

In June 2020, the Australian Government announced that personal importation of nicotine vaping products (NVP) would be prohibited, pending a 12-month classification and regulation review by the Therapeutic Goods Administration. This brief report examines the themes of responses on Twitter to this announcement.

METHODS

Simple random sampling was used to retrieve tweets containing keywords from 19 to 26 June 2020. Tweets were manually coded and descriptive statistics calculated for themes and policy position.

RESULTS

The vast majority of the 1,168 tweets were anti-policy. Themes included: criticism towards government (59.8%), activism against NVP restriction (38%), potential adverse consequences (30.8%) and support for NVP restriction (1.4%). Tweets that identified potential adverse consequences of NVP restriction cited: smoking relapse for individuals currently using NVPs (75.6%); the impact of policy enforcement (8.6%); illicit market (8.3%); panic buying (3.6%); difficulty obtaining prescriptions (2.8%); and impacts on NVP businesses (2.8%).

CONCLUSION

Tweets predominately objected to the policy announcement. Approximately three-quarters of tweets that cited potential adverse consequences of the policy mentioned smoking relapse as their primary concern. Implications for public health: User-generated content on Twitter was primarily used to lobby against the proposed policy, which was subsequently amended.