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.

The identification of artefacts in reporting of drug-induced deaths using structural breaks analysis of time series statistics

INTRODUCTION

Drug-related mortality is a key epidemiological indicator that is collected nationally and internationally. Significant efforts were made in 2006-2007 to improve the quality of data concerning drug-related mortality in the Czech Republic. The aim of this article is to identify the effect of a quality improvement project on the drug-induced mortality data reported in the General Mortality Registry (GMR), and to demonstrate how to identify, quantify and interpret changes in drug-induced mortality based on the example of the Czech Republic.

METHODS

We extracted data on illicit drug-induced deaths from the Czech Republic GMR and Special Mortality registry (SMR) for the years between 2004 and 2012, and aggregated monthly and quarterly time series. We applied a new procedure to identify structural breakpoints in time series based on dating structural changes in standard linear regression models.

RESULTS

In the GMR, breakpoints were identified in three time series: (i) opioid-related deaths; (ii) other stimulant-related deaths; and (iii) total drug-induced deaths. In the SMR, the structural breaks were identified for opioids, volatile substances and selection D time series. In each of these time series, the analysis identified a decrease in the intercepts in the different segments.

DISCUSSION AND CONCLUSIONS

The structural breaks identified and quantified in the GMR time series were plausibly caused by the quality improvement efforts that started in 2006. These results demonstrate that it is critical for the analysis and use of drug mortality data collected in the registries to identify practice changes in the relevant registries, to quantify their influence and to adjust mortality estimates accordingly.

The Relationship Between Exposure to Alcohol Marketing and Underage Drinking Is Causal

Objective:

This article summarizes the findings of narrative and systematic literature reviews focused on the relationship between exposure to alcohol marketing and youth drinking, viewed in context of criteria for causality. We also consider the implications of this proposition for alcohol policy and public health.

Method:

Our descriptive synthesis of findings is from 11 narrative and systematic reviews using the nine Bradford Hill causality criteria: (a) strength of association, (b) consistency, (c) specificity of association, (d) temporality, (e) biological gradient, (f) biological plausibility, (g) coherence, (h) experimental evidence, and (i) analogy.

Results:

Evidence of causality for all nine of the Bradford Hill criteria was found across the review articles commissioned for this supplement and in other previously published reviews. In some reviews, multiple Bradford Hill criteria were met. The reviews document that a substantial amount of empirical research has been conducted in a variety of countries using different but complementary research designs.

Conclusions:

The research literature available today is consistent with the judgment that the association between alcohol marketing and drinking among young persons is causal.

Setting Limits: Gambling, Science and Public Policy-summary of results

The gambling industry has grown into a global business in the 21st century. This has created the need for a new emphasis on problem prevention. This article highlights the core themes of the book Setting Limits: Gambling, Science and Public Policy, taking a broad view of the consequences of gambling for society as a burden on health, well-being and equality. The book covers the extent of gambling and gambling-related problems in different societies and presents a critical review of research on industry practices, policy objectives and preventive approaches, including services to people suffering from gambling and its consequences. It discusses the developments in game characteristics and gambling environments and provides evidence on how regulation can affect those. Effective measures to minimize gambling harm exist and many are well supported by scientific evidence. They include restrictions on general availability as well as selective measures to prevent gamblers from overspending. The revenue generated from gambling for the industry, governments, and providers of public services funded from gambling returns presents an obstacle to developing policies to implement harm-reduction measures. A public interest approach must weigh these interests against the suffering and losses of the victims of gambling.

Needs-Based Planning for Substance Use Treatment Systems: Progress, Prospects, and the Search for a New Perspective

The articles presented in this issue of the Journal of Studies on Alcohol and Drugs (Supplement No. 18) describe the rapid improvements over the past decade in methods, theories, and data systems used for needs-based planning of addiction treatment services. In this concluding essay, the editors describe the progress, prospects, and implications of this new wave of research. It is concluded that these developments can be used to maximize the impact of treatment services at the population level.

Les articles dans ce Supplément, décrivent les améliorations rapides ayant eu lieu au cours de la dernière décennie quant aux méthodes, théories et systèmes de données qui sont utilisés pour la planification des services de traitement de la dépendance en s’appuyant sur les besoins populationnels. Dans cet essai de conclusion, les éditeurs décrivent les progrès, les perspectives et les implications de cette nouvelle vague de travaux de recherche. Il est conclu que ces développements peuvent être utilisés afin de maximiser l’impact des services au plan populationnel.

Los documentos presentados en este Suplemento describen las rápidas mejoras en la última década en métodos, teorías y sistemas de datos utilizados para la planificación basada en las necesidades de servicios de tratamiento de adicciones. En este ensayo final, los editores describen los avances, perspectivas e implicaciones de esta nueva ola de investigación. Se concluye que estos desarrollos se pueden utilizar para maximizar el impacto de los servicios de tratamiento a nivel de la población.

Advancing public health policy making through research on the political strategies of alcohol industry actors

Development and implementation of evidence-based policies is needed in order to ameliorate the rising toll of non-communicable diseases (NCDs). Alcohol is a key cause of the mortality burden and alcohol policies are under-developed. This is due in part to the global influence of the alcohol industry. We propose that a better understanding of the methods and the effectiveness of alcohol industry influence on public health policies will support efforts to combat such influence, and advance global health. Many of the issues on the research agenda we propose will inform, and be informed by, research into the political influence of other commercial actors.

The Relationship Between Exposure to Alcohol Marketing and Underage Drinking Is Causal

OBJECTIVE

This article summarizes the findings of narrative and systematic literature reviews focused on the relationship between exposure to alcohol marketing and youth drinking, viewed in context of criteria for causality. We also consider the implications of this proposition for alcohol policy and public health.

METHOD

Our descriptive synthesis of findings is from 11 narrative and systematic reviews using the nine Bradford Hill causality criteria: (a) strength of association, (b) consistency, (c) specificity of association, (d) temporality, (e) biological gradient, (f) biological plausibility, (g) coherence, (h) experimental evidence, and (i) analogy.

RESULTS

Evidence of causality for all nine of the Bradford Hill criteria was found across the review articles commissioned for this supplement and in other previously published reviews. In some reviews, multiple Bradford Hill criteria were met. The reviews document that a substantial amount of empirical research has been conducted in a variety of countries using different but complementary research designs.

CONCLUSIONS

The research literature available today is consistent with the judgment that the association between alcohol marketing and drinking among young persons is causal.

Perceptions of Alcohol Advertising Vary Based on Psychological Characteristics

BACKGROUND

The alcohol industry recognizes children and pregnant women as population sub-groups vulnerable to the effects of alcohol marketing. Research indicates that heavy alcohol users are also potentially vulnerable to alcohol marketing. The purpose of the current study is to determine if sub-groups defined by psychological characteristics should be classified as potentially vulnerable as well.

METHODS

College students (n = 326) from two northeast schools were recruited to complete a survey containing questions on demographics, alcohol use, and psychological characteristics (alcohol expectancies, alcohol dependence, sensation seeking traits, and past delinquent behaviors). Additionally, after viewing each of five alcohol ads (4 television and 1 magazine), participants answered questions about their perceptions of alcohol consumption, responsible drinking, excessive drinking, and appeal of the ads. Main effects were assessed using hierarchical linear modeling, with adjustment for age, sex, race, ethnicity, and AUDIT score.

RESULTS

Alcohol expectancies (p < .001), particularly the social and physical pleasure and social expressiveness sub-scales, and sensation seeking traits (p = .002) were positively associated with alcohol ad appeal. Alcohol dependence symptoms, specifically impaired control and tolerance, were positively associated with perceptions of responsible drinking (p = .035), even though mean perceived number of drinks consumed met the definition of binge drinking.

CONCLUSIONS

Individuals with positive alcohol expectancies, sensation seeking traits, and alcohol dependence may be vulnerable to alcohol advertising and marketing. Because alcohol advertising often contains content that can serve as a cue or reinforce to drink, specific regulations may be needed to prevent alcohol-related harm from occurring in these sub-populations.

Is the alcohol industry doing well by 'doing good'? Findings from a content analysis of the alcohol industry's actions to reduce harmful drinking

OBJECTIVES

The aims of this study were to: (1) describe alcohol industry corporate social responsibility (CSR) actions conducted across six global geographic regions; (2) identify the benefits accruing to the industry ('doing well'); and (3) estimate the public health impact of the actions ('doing good').

SETTING

Actions from six global geographic regions.

PARTICIPANTS

A web-based compendium of 3551 industry actions, representing the efforts of the alcohol industry to reduce harmful alcohol use, was issued in 2012. The compendium consisted of short descriptions of each action, plus other information about the sponsorship, content and evaluation of the activities. Public health professionals (n=19) rated a sample (n=1046) of the actions using a reliable content rating procedure.

OUTCOME MEASURES

WHO Global strategy target area, estimated population reach, risk of harm, advertising potential, policy impact potential and other aspects of the activity.

RESULTS

The industry actions were conducted disproportionately in regions with high-income countries (Europe and North America), with lower proportions in Latin America, Africa and Asia. Only 27% conformed to recommended WHO target areas for global action to reduce the harmful use of alcohol. The overwhelming majority (96.8%) of industry actions lacked scientific support (p<0.01) and 11.0% had the potential for doing harm. The benefits accruing to the industry ('doing well') included brand marketing and the use of CSR to manage risk and achieve strategic goals.

CONCLUSION

Alcohol industry CSR activities are unlikely to reduce harmful alcohol use but they do provide commercial strategic advantage while at the same time appearing to have a public health purpose.

Advertising Content, Platform Characteristics and the Appeal of Beer Advertising on a Social Networking Site

Aims

The current study was conducted to investigate how changes in the content of a social media ad, user engagement values associated with the ad and user-generated comments (UGCs) associated with the ad can influence the appeal (i.e. source appeal, informational appeal and emotional appeal) of a social media ad.

Short summary

Facebook beer ads that violated the guidelines of a relevant marketing code were rated as more emotionally appealing compared to Facebook beer ads that did not violated the guidelines. Increased emotional appeal in beer advertising increases the probability that the ad will be remembered and influence future drinking occasions.

Methods

A 2 (ad regulatory compliance: compliant vs. non-compliant) × 2 (user engagement: low vs. high) × 2 (UGC congruence: pro- vs anti-alcohol) mixed factorial experiment was conducted with 120 young adults, 21-24 years old. Each participant viewed four Facebook beer ads that were previously evaluated for thematic content and regulatory compliance. Participants were randomized to view either high or low user engagement values and either pro- or anti-drinking user-generated comments. After each ad exposure, ad appeal was assessed. Statistical analysis was conducted using hierarchical linear modeling. Models were adjusted for demographics, Alcohol Use Disorders Identification Test (AUDIT) scores and Facebook involvement.

Results

Source appeal (P = 0.034) and informational appeal (P < 0.001) were significantly higher among ads that were compliant with existing advertising regulations. Emotional appeal was significantly higher among ads that were non-compliant (P = 0.004). The effect of user engagement and UGCs were non-significant (p's > 0.05). Additionally, AUDIT scores (p's < 0.01) and Facebook involvement scores (p's < 0.01) were positively associated with all forms of ad appeal.

Conclusion

The appeal of Facebook beer ads may be primarily determined by ad content. Increased emotional appeal in advertising caused by non-compliant advertising may increase the probability that the ad will be remembered and influence future drinking occasions.

Alcohol Advertising on Facebook and the Desire to Drink Among Young Adults

OBJECTIVE

Social networking sites (SNSs) may influence the behavior of SNS users by exposing them to information about the number of other users who engaged with a SNS post (i.e., user engagement) and any comments left in response to a post (i.e., user-generated comments [UGCs]). The current study hypothesized that beer advertisements with higher user engagement levels and pro-drinking UGCs would be positively associated with the desire to drink and ad engagement. The effect of ad content in relation to regulatory compliance was also investigated.

METHOD

A 2 (regulatory compliant vs. noncompliant) × 2 (low vs. high user engagement) × 2 (pro- vs. anti-alcohol UGC) mixed factorial experiment was used. A total of 120 young adults viewed two compliant and two noncompliant ads. Participants were randomized into four groups: ads with high or low user engagement values, which were paired with either pro- or anti-drinking UGCs. Dependent variables included desire to drink and engaging (i.e., Liking or Sharing) with the ad.

RESULTS

When associated with high user engagement values, the desire to drink was 3.5 times greater in the pro-drinking UGC group compared with the anti-drinking UGC group (odds ratio = 3.48, 95% CI [1.60, 7.55]). Ad engagement was 2.3 times greater among those exposed to pro-drinking UGCs (odds ratio = 2.30, 95% CI [1.09, 4.85]).

CONCLUSIONS

Pro-drinking comments may increase the desire to drink and ad engagement, both of which may be predictive of future drinking behavior. Regulations are needed to limit the ability of SNS users to engage with alcohol ads.

Perceptions of Alcohol Advertising among High Risk Drinkers

BACKGROUND

Individuals who are particularly vulnerable to the influence of alcohol advertising, such as youth, need special protections, yet little research has been done to determine if other vulnerable groups exist. Secondary data analysis was conducted to determine if perceptions of alcohol advertising differ between groups based on their alcohol use and whether the definition of "vulnerable" should be expanded beyond demographic categories.

METHODS

Students (n = 326) from 2 U.S. colleges viewed 5 alcohol ads and rated them using a scale designed to detect violations of the alcohol industry's self-regulated marketing codes. Individuals with a history of excessive alcohol use, as measured by the Alcohol Use Disorders Identification Test (AUDIT), were considered potentially vulnerable to alcohol advertising and were compared against individuals without a history of excessive alcohol use. Hierarchical linear modeling was used to determine between-group differences in 4 dependent variables (ad appeal, perceived alcohol consumption, perceived excessive drinking, and perceived responsible drinking). All models were adjusted for age, race, ethnicity, sex, and parental alcohol use.

RESULTS

AUDIT risk categories were positively associated with ad appeal (p < 0.001), the amount of alcohol perceived to be consumed (p < 0.01), and perceptions of responsible drinking (p < 0.05). There was no significant associated with perceptions of excessive drinking.

CONCLUSIONS

Individuals with a history of heavy alcohol use perceived greater alcohol consumption in alcohol ads but perceived this consumption, which often met the definition for binge drinking, to be responsible. Stricter regulations may be needed to protect heavy alcohol users from the effects of alcohol advertising.

Reliability and Validity of a Two-Question Version of the World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test: The ASSIST-FC

OBJECTIVE

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), developed for the World Health Organization (WHO), screens for risks associated with the use of tobacco, alcohol, and seven categories of drugs. Although the ASSIST has acceptable psychometric properties, it is relatively long for a screening test. This study was designed to identify a subset of questions from the full ASSIST instrument having comparable psychometric properties for the classification of low-, moderate-, and high-risk substance use.

METHOD

The study used three data sets from prior studies using the WHO ASSIST. Samples 1 and 3 were obtained from WHO multisite studies conducted in seven countries. Sample 2 included patient data from a U.S.-based screening and brief intervention program that incorporated the ASSIST into its clinical protocol. Samples 1 and 2 were used to conduct psychometric analyses for combinations of ASSIST items. Sample 3 was used to estimate sensitivity, specificity, and positive and negative predictive value for a two-item ASSIST.

RESULTS

Based on correlation statistics, reliability metrics, and validation analyses, a new, two-item version is proposed. The ASSIST-FC contains one question about the frequency (F) of current use and a second question about current or past concern (C) expressed by others. The ASSIST-FC demonstrates no substantial loss in reliability, validity, and predictive ability when statistically compared with the full-length ASSIST.

CONCLUSIONS

The ASSIST-FC has advantages for clinical applications in settings where a brief, efficient, reliable screening test is needed to identify patients with hazardous and harmful substance use who would benefit from a brief intervention. It can also be used to identify patients who are manifesting symptoms of substance dependence that would require further diagnostic evaluation.

Caveat Emptor: Predatory Publishers, Rogue Journals, and the Potential Corruption of Addiction Science

The name predatory publisher has been applied by academic librarian Jeffrey Beall to describe an open-access, scholarly publishing business model in which publication fees are charged to authors without providing the editorial judgment, peer-review process, and publishing services associated with more established journals. In the addiction field, as many as 20 journal titles now operate according to this model, and most of their editors are either nonexistent or impossible to contact. Although predatory publishing should not be equated with open access, this article argues that predatory publishers are diluting scientific quality in the addiction field by taking advantage of the open-access movement. Beyond the damage done to the reputations of naive authors and figurehead editorial board members, there is a cascade of effects resulting from the shabby publication process itself. If the addiction field is to be protected from predatory publishers, all sectors need to be involved. Declarations of "buyer beware" and "the emperor has no clothes" are just the first steps in a process of preventing further damage to the integrity of addiction science. As described in this article, concerted action will be required by authors, editors, and professional societies.

Predicting Regulatory Compliance in Beer Advertising on Facebook

Aims

The prevalence of alcohol advertising has been growing on social media platforms. The purpose of this study was to evaluate alcohol advertising on Facebook for regulatory compliance and thematic content.

Methods

A total of 50 Budweiser and Bud Light ads posted on Facebook within 1 month of the 2015 NFL Super Bowl were evaluated for compliance with a self-regulated alcohol advertising code and for thematic content. An exploratory sensitivity/specificity analysis was conducted to determine if thematic content could predict code violations.

Results

The code violation rate was 82%, with violations prevalent in guidelines prohibiting the association of alcohol with success (Guideline 5) and health benefits (Guideline 3). Overall, 21 thematic content areas were identified. Displaying the product (62%) and adventure/sensation seeking (52%) were the most prevalent. There was perfect specificity (100%) for 10 content areas for detecting any code violation (animals, negative emotions, positive emotions, games/contests/promotions, female characters, minorities, party, sexuality, night-time, sunrise) and high specificity (>80%) for 10 content areas for detecting violations of guidelines intended to protect minors (animals, negative emotions, famous people, friendship, games/contests/promotions, minorities, responsibility messages, sexuality, sunrise, video games).

Conclusions

The high prevalence of code violations indicates a failure of self-regulation to prevent potentially harmful content from appearing in alcohol advertising, including explicit code violations (e.g. sexuality). Routine violations indicate an unwillingness to restrict advertising content for public health purposes, and statutory restrictions may be necessary to sufficiently deter alcohol producers from repeatedly violating marketing codes.

Short summary

Violations of a self-regulated alcohol advertising code are prevalent in a sample of beer ads published on Facebook near the US National Football League's Super Bowl. Overall, 16 thematic content areas demonstrated high specificity for code violations. Alcohol advertising codes should be updated to expressly prohibit the use of such content.

A review of the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and USAUDIT for screening in the United States: Past issues and future directions

BACKGROUND

The US Preventive Services Task Force recommends that clinicians screen all adults for alcohol misuse and provide brief counseling to those engaged in risky or hazardous drinking. The World Health Organization's (WHO's) Alcohol Use Disorders Identification Test (AUDIT) is the most widely tested instrument for screening in primary health care.

OBJECTIVES

This paper describes the structural and functional features of the AUDIT and methodological problems with the validation of the alcohol consumption questions (AUDIT-C). The content, scoring, and rationale for a new version of the AUDIT (called the USAUDIT), adapted to US standard drink size and hazardous drinking guidelines, is presented.

METHOD

Narrative review focusing on the consumption elements of the AUDIT. Four studies of the AUDIT-C are reviewed and evaluated.

RESULTS

The AUDIT has been used extensively in many countries without making the changes in the first three consumption questions recommended in the AUDIT User's Manual. As a consequence, the original WHO version is not compatible with US guidelines and AUDIT scores are not comparable with those obtained in countries that have different drink sizes, consumption units, and safe drinking limits. Clinical and Scientific Significance. The USAUDIT has adapted the WHO AUDIT to a 14 g standard drink, and US low-risk drinking guidelines. These changes provide greater accuracy in measuring alcohol consumption than the AUDIT-C.

Reliability and validity of the Alcohol Marketing Assessment Rating Tool (AMART)

Objective

Current national responses to the monitoring and prevention of alcohol marketing to vulnerable populations, such as youth, typically rely on partial bans, co-regulation and industry self-regulation. Efforts to evaluate compliance with existing regulations are often cumbersome and resource intensive. We sought to develop a short questionnaire to assess compliance of alcohol advertising to existing alcohol industry self-regulated marketing codes.

Methods

Questions for the Alcohol Marketing Assessment Rating Tool (AMART) were taken from a longer rating instrument that was originally developed to detect violations of a self-regulated alcohol marketing code. Secondary analysis of data from three studies of alcohol advertisements was performed to determine the reliability and validity of AMART at detecting code violations, using the longer form as the criterion. One sample was used as an exploratory set. Two samples were used to validate the questionnaire.

Results

In the exploratory set, the reliability of AMART was considered near perfect (kappa = 0.92). Sensitivity was 97%, and specificity was 100%. Positive predictive value (PPV) was perfect and negative predictive value (NPV) was approximately 90%. In the validation sets, reliability was considered substantial to near perfect (kappa = 0.71-0.94). Specificity and PPV remained perfect, and NPV was 86%-90%.

Conclusion

The AMART is a reliable tool to detect violations of a self-regulated marketing code in alcohol advertising. It significantly decreases the amount of resources needed to evaluate a finite number of advertisements.