杏吧原创

IMAGINE, if you can, drinking 33 litres of vodka. Not easy 鈥� but if you鈥檙e an average British adult that鈥檚 roughly the amount of booze you put away in a year, enough to exceed the government鈥檚 week in, week out.

The Brits deserve their reputation for booziness, but most other western countries are worse or not far behind. Even supposedly abstemious Americans each knock back the equivalent of 24 litres of vodka per year (see diagram).

With so many people drinking at unsafe levels, it鈥檚 no surprise that alcohol is rising up the public health agenda. In May 2010, the World Health Organization published its first on reducing the harm caused by alcohol, seen as the launch of a worldwide war on booze.

The WHO was stung into action by a grim toll of disease and death. According to its own figures, harmful drinking kills 2.5 million people annually 鈥� around . Excessive drinking accounts for an estimated . Overall, it is the third most important contributor to ill health, behind only high blood pressure and tobacco (see diagram).

Even the alcohol industry, with global sales of some $1 trillion a year, accepts that excessive drinking is a problem, and that it has a responsibility to do something about it. Indeed, the WHO鈥檚 strategy acknowledges that industry has a role to play. But behind the scenes, the two are locked in a struggle for control of the health agenda.

The mantra of the alcohol industry is 鈥渄rink responsibly鈥�. Its prescription is a mixture of personal restraint and industry self-regulation: targeting problem drinkers, promoting the use of designated drivers and adopting voluntary codes to prevent advertising from targeting children. Who could argue with that?

But here鈥檚 the rub: the industry鈥檚 preferred policies are not the most effective. An extensive makes it clear that the best policies are those imposed by governments 鈥� increasing price, restricting availability and banning advertising.

The clash between these two perspectives is now playing out on a global scale. The WHO is encouraging governments to use the levers of price, availability and curbs on advertising to treat humanity鈥檚 collective drink problem. But it must compete with the multinational companies鈥� own, rather different, approach.

To the casual observer, this struggle can seem like a phoney war. Rather than directly challenging the WHO, the industry talks in terms of 鈥渃orporate social responsibility鈥�. It also speaks the language of science, drawing especially on the output of a think tank in Washington DC called the . ICAP is .

Critics complain that ICAP鈥檚 publications either downplay the evidence on price and availability, or claim there is debate among researchers on these issues where there is not. 鈥淭hey are experts at muddying the scientific waters,鈥� claims in Baltimore, Maryland, who recently published a critical review of ICAP鈥檚 science and its strategies for influencing policy ().

At the same time, alcohol producers are investing heavily in marketing, including campaigns that critics claim are calculated to reach underage drinkers 鈥� a charge that the companies involved vigorously deny (see 鈥�Joe Camel in a bottle?鈥�).

Sound familiar? These tactics more or less follow the playbook written by the tobacco industry as it fought measures to restrict sales and advertising of its products 鈥� though with one significant difference.

鈥淭obacco companies made a huge tactical error in taking the stance that their products don鈥檛 cause harm,鈥� says , an alcohol-policy consultant based in Felton, California. That approach exploded in the industry鈥檚 face in the 1990s after US states . The action laid bare internal company documents showing that executives understood the science very well, yet pursued an aggressive strategy of denial.

Those documents also revealed covert attempts to manipulate science, including paying consultants to place industry-friendly papers in journals and even the creation of a scientific society to question the evidence on passive smoking.

In contrast to big tobacco鈥檚 secrecy, the alcohol industry has long acknowledged that excessive drinking is harmful and is transparent in its support for ICAP. These tactics seem to work. While tobacco companies today have pariah status, the alcohol industry has retained a generally positive public image, and has the ear of many powerful politicians.

There are still reasons for concern, however. ICAP鈥檚 stance is notably industry-friendly. Its key publication is the , a guide to policy that focuses on targeting heavy drinkers. This may help, but conspicuously absent, note critics, are statements on the effectiveness of raising the price, restricting availability and banning adverts.

Jernigan concedes that ICAP鈥檚 publications contain some useful contributions, but he complains that proven policies are either neglected or covered in a way that stresses uncertainty. For instance, ICAP鈥檚 states: 鈥淭he impact and effectiveness of taxation as a health policy tool remain the source of much debate.鈥�

Pressed on this point, ICAP does not dispute that increasing taxes can reduce overall harm. But its deputy president, Marjana Martinic, questions whether it is effective for the heaviest drinkers, who may 鈥渢rade down鈥� to cheaper forms of alcohol.

Priced out

It鈥檚 true that the effects of higher taxes are weaker for the heaviest drinkers. Still, when results from many studies are considered together, it is clear that increasing the price significantly reduces consumption 鈥� including for heavy boozers ().

Despite this evidence, industry executives are bullish in rejecting policies based on price, availability and curbs on advertising. 鈥淲hile these measures may reduce overall consumption, they would have precious little impact on hazardous and underage drinking,鈥� argues Guy Smith, executive vice-president for corporate relations with Diageo, the world鈥檚 largest producer of distilled spirits.

Diageo instead backs approaches including , which aims to identify people with a drink problem or a risk of developing one and get them into treatment.

There is good evidence that this is a necessary component of a comprehensive strategy. But in terms of bangs for buck it falls short of what can be done by increasing price and restricting sales.

If you look at who drinks and how much, it鈥檚 hardly surprising that manufacturers should be wary of measures that could strongly curtail excessive drinking. 鈥淭hey basically live off harmful consumption,鈥� claims of the Centre for Addiction and Mental Health in Toronto, Canada, who studies the global health burden caused by drinking.

鈥淚f you look at who drinks and how much, it鈥檚 hardly surprising that manufacturers should be wary of these policies鈥�

In the UK, for instance, the heaviest-drinking 10 per cent consumes about ; in the US that figure is . What鈥檚 more, total consumption in nations such as the UK is at such high levels that even relatively moderate drinkers are still endangering their health.

The reason that controls on price and availability work so well is that they seem to cut drinking across the board, delaying the onset of diseases like liver cirrhosis in the heaviest drinkers, while preventing others from reaching harmful levels of consumption.

So if that鈥檚 the message from science, should we worry that the industry takes a different view? Yes, say advocates for public health, who are especially worried about the industry鈥檚 influence in developing countries.

鈥淭he elephant in the room is that you鈥檝e got huge markets 鈥� in South Asia, the Pacific Rim, Africa and Latin America 鈥� where young people are coming to prime drinking age,鈥� says , a specialist in alcohol and public health at the University of Connecticut in Farmington.

These territories represent the alcohol companies鈥� main opportunity for growth and are where their marketing and lobbying are increasingly being brought to bear.

Making a connection between alcohol companies and the promotion of policies that favour their interests is hard, but one case has been documented. In 2008 脴ystein Bakke and Dag Endal of , a Norwegian NGO, analysed draft alcohol policies being developed by Botswana, Lesotho, Uganda and Malawi. The documents were broadly in line with ICAP鈥檚 recommendations and the texts were remarkably similar to one another. In two cases, the Microsoft Word files indicated that the 鈥渁uthor鈥� was Mitch Ramsey, policy and issues manager with the African arm of brewer SABMiller, one of ICAP鈥檚 sponsors and the facilitator of workshops from which the drafts emerged (). The documents largely ignored .

Global action

That affair may have caused some embarrassment, but it has not stopped the industry pursuing its preferred policies. Through an initiative called , many of the biggest companies are led by ICAP to promote self-regulation across the world 鈥� including key emerging markets such as Brazil, Mexico, China and India.

These efforts are a complement to government regulation, not an alternative, says ICAP鈥檚 Martinic. But critics fear that in many of the countries, it will be the industry鈥檚 position that prevails. 鈥淭hey are investing tremendous resources in the promotion of self-regulation,鈥� says Babor.

Is there any hope of reducing the harm caused by alcohol? Right now, the most encouraging signs come from countries that are reaping a devastating harvest from decades of industry-friendly policies.

Step forward Scotland, where consumption has doubled over the past five decades as the price of alcohol has fallen and controls on sales have been relaxed. Alcohol-related health problems now cost this nation of 5.25 million people . 鈥淚n 1960, Scotland had one of the lowest liver cirrhosis death rates in western Europe. Today we have one of the highest,鈥� says .

In a bold move, the Scottish government intends by April to impose a minimum price of 50 pence per unit (10 millilitres) of alcohol. According to run by a team at the University of Sheffield, UK, this would cut overall consumption by 5.7 per cent.

Minimum pricing has an important advantage over hiking taxes. Tax increases can be partly absorbed by producers and retailers, but a minimum unit price must be borne by consumers. That will eliminate the bargain-basement booze favoured by some of the heaviest drinkers 鈥� white cider, for example, which can be bought for less than 13 pence a unit. This would address concerns about trading down. The Sheffield team鈥檚 simulations suggest that consumption by the heaviest drinkers 鈥� men drinking more than 50 units a week and women 35 鈥� would fall by 10.7 per cent.

The move faces a from industry groups, due to be heard on 15 January in Scotland鈥檚 . As well as questioning the evidence that minimum prices cut consumption, the challenge argues that it breaches European competition law.

But the sobering idea is taking hold: the UK government is in the middle of a consultation period on a 45-pence minimum unit price for England and Wales, which the modelling suggests should cut overall consumption by 4.3 per cent and reduce the annual number of alcohol-related deaths in England by more than 2000 a year. Ireland also says it intends to follow Scotland鈥檚 lead.

As the boozy British Isles rethinks the merits of decades of industry-friendly policies, the rest of the world will be watching with interest. The health of millions of people could hinge on the outcome.