Policy Approaches for Regulating Alcohol Marketing in a Global Context: A Public Health Perspective
Annual Review
Abstract
Alcohol consumption is responsible for 3.3 million deaths globally or nearly 6% of all deaths. Alcohol use contributes to both communicable and noncommunicable diseases, as well as violence and injuries.
The purpose of this review is to discuss, in the context of the expansion of transnational alcohol corporations and harms associated with alcohol use, policy options for regulating exposure to alcohol marketing.
The researchers first provide an overview of the public health problem of alcohol consumption and describe the association between exposure to alcohol marketing and alcohol consumption.
The researchers then discuss the growth and concentration of global alcohol corporations and their marketing practices in low- and middle-income countries, as well as in higher-income societies. They review the use and effectiveness of various approaches for regulating alcohol marketing in various countries before discussing challenges and opportunities to protect public health.
EXPOSURE TO ALCOHOL MARKETING AND ALCOHOL USE
Longitudinal studies on youth exposure to alcohol marketing and alcohol consumption have reached consistent conclusions. Two systematic reviews, including a combined total of 25 studies, found that young people exposed to alcohol marketing were more likely to initiate alcohol use or, if already consuming alcohol, to consume more. Youth exposure to alcohol marketing seems to have a cumulative impact such that young people with greater exposure are likely to increase their alcohol use as they age into their mid-twenties, whereas young people with less exposure are likely to reduce their alcohol use sooner. Furthermore, a study of persons aged 15–26 years in the United States found that young people consumed 1% more alcohol for each additional ad seen per month and 3% more alcohol with each additional dollar spent per capita on alcohol advertising in their media market.
Studies have also documented associations between exposure to brand-specific alcohol advertising and consumption patterns of underage alcohol users.
In a study of young adults aged 13–20 years in the United States, the amount of the exposure to alcohol advertising, on a brand-specific basis, was associated with the quantity of alcohol consumed of those brands. The same survey showed that among underage alcohol users who reported binge alcohol intake, the top 25 alcohol brands out of 898 brands included in the survey accounted for more than 46% of the brands consumed while binge consuming.
Most evidence on the association between exposure to alcohol marketing and drinking comes from high-income countries; however, an emerging body of research documents the effects of alcohol marketing on alcohol use in emerging markets as well. A study of students aged 11–16 years in Zambia found that students who reported ever receiving a free alcoholic drink from a company representative had more than 40% greater odds of reporting drinking to intoxication and experiencing alcohol-related problems (e.g., missing school or fighting) relative to students who had not received one or more free drinks.
In the Philippines, students who reported ever receiving a free alcoholic drink from a company representative had 84% greater odds of reporting alcohol use to intoxication compared with students who had not received one or more free alcoholic drinks. Filipino students’ exposure to alcohol advertisements in newspapers or magazines and at public events (e.g., sporting events or concerts) was also associated with 65% and 50% greater odds of alcohol use to intoxication, respectively, relative to students without such exposure.
Longitudinal research in Taiwan that followed 2,315 young people found that exposure to alcohol promotion in tenth grade across four forms of media was associated with initiation and persistence of alcohol use a year later.
EXPANSION OF GLOBAL ALCOHOL CORPORATIONS
Figure 1 Conceptual framework on the growth of alcohol corporations, exposure to alcohol marketing, and alcohol-related public health problems.
The growth of global alcohol corporations and concentration of the global alcohol market in the hands of a small number of companies is a public health concern because it may be associated with increased population-level exposure to alcohol marketing. Alcohol oligopolies in many countries permit oligopoly profit taking, which in turn facilitates higher marketing spending and acts as a barrier to entry, thereby preserving the oligopolies.
Increased marketing activity, in the form of both product development and promotion, can be used to segment and target groups that have historically not consumed much alcohol. In many LMICs, this includes women.
- A case study of alcohol marketing in Estonia found intentional industry efforts to increase alcohol use among women.
- Increased marketing of alcopops, flavored vodkas, and other products thought to be attractive to women has coincided in the United States with the narrowing of the gap between men’s and women’s alcohol use.
- In India, Diageo, a London-based global alcohol corporation, has explicitly targeted marketing toward women.
These examples point to the possible impact of increased resources for marketing on alcohol use in populations other than youth.
Because oligopoly organization plays such a key role in the global shape of alcohol marketing, it is necessary to understand the degree to which that organizational form dominates global alcohol. Two multinational alcohol corporations were among the world’s 500 largest companies based on revenue in 2016, according to Fortune’s Global 500 list:
- Belgium-based Anheuser-Busch InBev (AB InBev) had revenue of $43,604 million for a rank of 211, and
- Netherlands-based Heineken had revenue of $23,208 million for a rank of 459.
For comparison, the Philip Morris International tobacco corporation had revenue of $26,794 million for a rank of 398.
As of 2016, AB InBev sold more than 100 varieties of beer and other alcoholic beverages in more than 100 markets on 6 continents. It is the world’s largest brewer, accounting for 25% of the global market, and its market is soon to be even larger. In late 2016, AB InBev acquired SABMiller (based in the United Kingdom); the completed merger will lead to control of 30% of beer sales worldwide.
With pervasive alcohol marketing and sponsorship associated with the expansion of global alcohol corporations in LMICs, many societies have experienced social and cultural shifts, marked by an increase in the proportion of the population consuming alcohol, increased consumption among alcohol users, or both. The alcohol industry is attracted to the economic development in emerging markets, as well as to groups that typically have high rates of alcohol abstention, including women and young people.
Africa
The merger between AB InBev and SABMiller will facilitate AB InBev’s growth globally and particularly in Africa, where SABMiller makes almost one-third of its profits. AB InBev predicts a 16% global volume growth in the beer market by 2025, with a growth rate of 44% in the African region, leveraging SABMiller’s aspirations to dominate beer sales in Africa.
Given that the average African has to work between two and six hours to pay for a half-liter of beer, SABMiller is keeping the cost of beer low as a long-term strategy for growth. The company has also invested more than $100 million to strengthen brewing capacity in countries such as Ghana, Nigeria, and Zambia, facilitating the production of local brews that can be marketed with nation-specific symbolism. Global alcohol corporations, such as SABMiller (one of the top ten marketers in African countries), also spend millions on alcohol advertising; in 2010, SABMiller spent US$74.5 million on advertising in South Africa alone.
With societal shifts occurring in alcohol environments in Africa and the development of innovative alcoholic products that draw from African culture, the proportion of the African population abstaining from alcohol is shrinking.
Diageo has launched innovative products in the African region, including beverages appealing to women. One such beverage is Snapp, which Diageo described as its “first brand in Africa to be developed and marketed exclusively for women, providing a more stylish and sophisticated alternative to beer” and as the “most successful launch of a new brand, ever”. The industry has also designed sachets and mini liquor bottles to package alcohol that can reach remote rural areas and are also attractive to young people because of their low price and small sizes.
The alcohol industry has also been involved in the development of alcohol policies in African countries. A case study of draft national alcohol policies in four sub-Saharan African countries (Lesotho, Malawi, Uganda, and Botswana) suggested that the alcohol industry had a lead role in their development, resulting in proposed policies that served the industry’s interests, with a disproportionate focus on economic benefits and a lack of evidence-based population-level interventions for effectively reducing the harmful use of alcohol. Alcohol marketing policies in Africa are often not well enforced, and even in countries where alcohol marketing restrictions exist, alcohol ads appear on the radio, billboards, posters, and product displays, in paintings on walls or fences, and with promotional items.
Asia
Similar to the African region, several LMICs in Asia, such as India and China, have been affected by globalization, and global alcohol companies are increasingly present in these societies. A growing middle class with increasing levels of disposable income to spend on alcohol has been associated with a cultural shift toward greater acceptance of alcohol consumption. Diageo’s 2016 annual report describes the establishment of “footholds in key emerging markets,” including a local whisky in India and baijiu (a clear distilled spirit) in China. The company expects that alcohol sales in India and Africa will account for nearly half of its global growth.
Latin America
For the reasons mentioned above, the global alcohol industry finds Latin America to be an attractive market, in particular its youth and women, who have a high rate of alcohol abstention, compared with these segments in mature markets such as the United States and Western Europe.
Although the economies in many Latin American countries are developing, public health systems to regulate and enforce policies for effectively reducing harmful alcohol use remain weak, in the face of more pressing needs to address other imminent health crises (e.g., malnutrition, sanitation, and infectious diseases).
These weak alcohol regulatory systems provide economic opportunities for the alcohol industry.
Alcohol companies fund corporate social responsibility programs all over the world, including in Latin America and the Caribbean, with stated public health and philanthropic objectives. However, a content analysis of these corporate social responsibility programs showed that 55% of the 215 activities analyzed had a marketing potential, whereas only 3% were based on scientific evidence of effectively reducing alcohol harm.
High-Income Countries
Similar to the strategies used in emerging markets, global alcohol corporations also use sophisticated marketing techniques and create innovative alcohol products that appeal to youth and women in high-income countries. With marketing that is attractive to youth, ready-to-drink alcoholic beverages, such as Smirnoff malt beverages, Mike’s Hard Lemonade, and Bacardi malt beverages, are popular among youth in countries such as the United States and New Zealand. Since the late 1990s, the gap between men’s and women’s alcohol use in some high-income countries, such as the United States and the United Kingdom, has narrowed; some researchers have attributed the normalization of a culture of heavier alcohol use among women to alcohol marketing that shows women using alcohol to cope with daily stress.
Multinational alcohol corporations have also begun to produce and market “healthier” alcoholic beverages, including gluten-free, vegan, and flavored vodka with real fruit juice instead of high-fructose corn syrup, as an appeal to the growing population of health-conscious alcohol consumers. Furthermore, as craft beers have become increasingly popular in many societies, the global alcohol corporations have begun acquiring brewers selling craft beers and creating quasi-craft brands. In December 2015, AB InBev acquired three separate craft brewers.
Global alcohol corporations continue to grow, and few countries, including both LMICs and developed countries, have effective alcohol marketing regulations in place.
The alcohol industry’s own voluntary marketing codes are routinely violated.
USE AND EFFECTIVENESS OF APPROACHES FOR REGULATING ALCOHOL MARKETING
Few coordinated global initiatives to prevent alcohol harm existed before 2005.
In 2005, the 58th World Health Assembly endorsed its Resolution on Public Health Problems Caused by Harmful Alcohol Use. In 2010, the 63rd World Health Assembly endorsed the Global Strategy to Reduce the Harmful Use of Alcohol, referred to as the WHO Global Alcohol Strategy, which aims to increase awareness about alcohol-related harms to alcohol users and to others, as well as awareness about the economic burden on societies. In addition, the WHO Global Alcohol Strategy provides information on effective alcohol policies and interventions across 10 priority areas, including alcohol marketing, pricing strategies (e.g., increasing alcohol taxes), and interventions to regulate the availability of alcohol (e.g., reducing the geographic density of places selling alcohol).
Multifaceted approaches, including various evidence-based population-level alcohol policy interventions, will likely yield the greatest public health improvements, but the researchers focus on approaches for regulating alcohol marketing.
The WHO Global Alcohol Strategy recommends the use of regulatory or coregulatory frameworks, ideally with a statutory basis, for regulating the content and volume of marketing, direct or indirect marketing in certain or all media, and sponsorship activities that promote alcoholic beverages. Evidence suggests that comprehensive alcohol marketing restrictions are a cost-effective strategy for preventing and reducing alcohol harm if they are well enforced. A Danish study found that switching from a ban that restricts alcohol marketing that targets children to a comprehensive ban on multiple media types had a 100% probability of cost savings.
The strength of alcohol marketing policies varies widely across regions and countries. The range of policy options for alcohol marketing restrictions includes four main categories:
- no restrictions,
- voluntary regulation or self-regulation,
- partial restrictions (e.g., on content, time and place, or particular audiences), and
- complete bans.
No Restrictions or Self-Regulation
In 2012, nearly 40% of the 159 countries that provided information to the WHO on the status of their alcohol marketing policies reported having no restrictions in place. Having no restrictions or use of the industry’s voluntary, self-regulated alcohol marketing approach is common worldwide, with little change from 2002 to 2012. Data on the use of these approaches globally beyond 2012 were not available at the time of this study.
The self-regulated alcohol marketing codes allow alcohol corporations to voluntarily develop guidelines for their marketing practices. However, recent reviews of more than 100 studies of alcohol industry self-regulation suggest that gaps in this self-regulatory approach greatly limit its effectiveness, including in the protection of vulnerable populations such as youth. Voluntary, self-regulated alcohol marketing codes often do not cover all types of media (e.g., the Internet or social media), or the codes may exclude sponsorship (e.g., at sporting events). The ineffectiveness of voluntary, self-regulated alcohol marketing is parallel to evidence of the ineffectiveness of self-regulated tobacco marketing prior to the adoption of the Framework Convention on Tobacco Control.
Self-regulatory approaches often focus on the content of alcohol advertisements rather than on the placement of or exposure to advertising; multiple studies have documented the ineffectiveness of the content provisions for protecting vulnerable populations. In addition, evidence has shown that voluntary restrictions on ad placements are ineffective in preventing the targeting of underage youth. Voluntary, self-regulated guidelines may leave open the possibility for varying interpretations of which advertisements constitute code violations; studies have found that alcohol companies interpret the marketing codes differently than public health professionals do. Moreover, the industry may also modify the voluntary guidelines, making acceptable the advertisements that did not previously meet the voluntary standards.
In many African countries, alcohol marketing is not restricted or the codes are voluntary and self-regulated by the alcohol industry, meaning there are no legally binding restrictions on alcohol advertising, product placement, sponsorship, or sales promotion. The voluntary, self-regulated codes in Ghana and Uganda do not limit the volume of outdoor advertising nor do they include stipulations about the content of alcohol ads. In a study of outdoor alcohol advertising in five African countries, countries with self-regulated alcohol marketing generally had larger outdoor alcohol advertisements (e.g., billboards and posters) compared with countries that had more alcohol marketing restrictions. In addition to using outdoor advertising, alcohol companies also distribute free alcoholic drinks as a strategy to market their products; studies have found that this strategy increases the risks of youth alcohol inebriation and heavy alcohol use.
Alcohol marketing in the United States is also primarily self-regulated; however, US youth are exposed to a substantial amount of advertising. From 2005 to 2012, young people below the legal age for alcohol consumption were exposed to more than 15 billion advertising impressions that were not in compliance with the industry’s own code, occurring mostly on cable television. Evidence suggests that youth are also exposed to alcohol advertising in digital formats (e.g., on the Internet and social media), with self-reported levels of exposure higher than those of adults. Hollingworth et al. modeled the potential impact of a complete ban on alcohol marketing in the United States and concluded that it would be associated with a 16% reduction in alcohol-related years of life lost among young adults who were 20 years old in the year 2000, whereas a partial ban would be associated with a 4% reduction in alcohol-related years of life lost in the same population.
Partial Restrictions
Some countries have partial restrictions on alcohol marketing, such as restrictions on content, time and place, or time and content, although this approach is less prevalent than having no restrictions or voluntary, self-regulatory alcohol marketing codes. The strength of these restrictions of alcohol marketing can vary widely by country.
A few countries have restrictions against alcohol marketing on broadcast media, such as television and radio. For example, in India, the Press Council of India and the Cable Television Network Act of 1995 ban broadcast alcohol advertising at the national level. However, Indians are increasingly exposed to alcohol marketing, as the alcohol industry commonly uses surrogate advertising, which is a practice of placing the name of alcohol brands on nonalcoholic beverages or placing advertising for the company on nonalcoholic products, such as water or music. Alcohol corporations also sponsor events, sports teams, and airlines using the same name as alcoholic beverages.
Gambia also bans alcohol advertising on national television and radio; however, outdoor alcohol ads and print marketing are permitted. On television channels in Gambia where alcohol ads are permitted, a health warning message is displayed as well. Despite such restrictions on alcohol advertising in broadcast media, populations are still exposed to alcohol marketing as global alcohol corporations fund and implement branded social responsibility programs, which are seldom evidence based and can serve as a marketing strategy.
The French Loi Évin provides a model partial ban. It prohibits alcohol advertising on television, in cinemas, at festivals, and as sponsorship. Alcohol advertising of drinks with more than 1.2% alcohol by volume is banned on media targeting young people. Some types of alcohol advertising are permitted, such as on the radio at selected hours overnight, on billboards, online, and at points of sale. Alcohol advertising content is restricted to factual product information, and other marketing techniques (e.g., association between alcohol consumption and pleasure or success) are prohibited. Alcohol advertisements must also include a health warning disclaimer. Under pressure from the alcohol industry, the French have reduced the comprehensiveness of this law since its implementation in 1991. Today, alcohol advertising in France is generally permitted online, and the advertising of regional or cultural alcoholic drinks is allowed on media where it was previously prohibited, including television and cinemas.
In Finland, a more restrictive alcohol marketing policy went into effect in 2015. The policy extends the hours when alcohol advertising is banned on television and increases alcohol marketing placement restrictions, including a ban on outdoor advertising, except at public events. Including alcohol ads in digital games and promoting user interaction, such as liking or sharing, online are also banned.
An assessment of alcohol advertising that aired during the televised broadcast of the 2014 Fédération Internationale de Football Association (FIFA) World Cup Tournament in eight countries (including Argentina, Brazil, Canada, Finland, France, Mexico, Spain, and the United States) found that only the countries with stronger alcohol marketing policies (France and Finland) effectively protected young people and vulnerable populations from exposure to alcohol marketing.
Complete Bans
Despite the effectiveness of complete bans in reducing exposure to alcohol marketing, such bans are rare, occurring in 10% of the 159 countries that provided information to the WHO about the status of their alcohol marketing policies in 2012. Owing to the influence of Islam, countries with complete alcohol advertising prohibitions cluster in the predominantly Islamic regions of northern Africa and the Middle East.
Public health researchers have recently called for global action to prevent the exposure of vulnerable populations to alcohol marketing. They indicated that “the most effective response to alcohol marketing is likely to be a comprehensive ban on alcohol advertising, promotion and sponsorship, in accordance with each country’s constitution or constitutional principles”. Although several countries have increased the magnitude of the partial restrictions on alcohol marketing, as described in the previous section, few countries have implemented complete bans. South Africa has made an effort to do so. In September 2013, the South African Cabinet moved forward a bill to ban alcohol marketing in the country; however, it has faced delays with strong opposition from the alcohol industry.
CHALLENGES AND OPPORTUNITIES FOR REDUCING EXPOSURE TO ALCOHOL MARKETING AND ALCOHOL-RELATED HARM
Several barriers exist in addressing alcohol harm, which have complicated the implementation of statutory regulation to completely prohibit alcohol marketing.
- Global public health funding has been increasingly dominated by philanthropy, and no major philanthropic organization has prioritized alcohol.
- Leaders and countries may lack the political will or public health infrastructure to implement policies found effective in reducing alcohol-related harms, including comprehensive alcohol marketing restrictions.
- There are notable contradictions between alcohol industry efforts and evidence-based strategies to prevent and reduce alcohol harm. For example, a review of 17 studies identified strategies that the alcohol industry uses to influence marketing regulations, including the promotion of self-regulation and the dissemination of information disputing the evidence on the effectiveness of statutory regulations. Case studies in Brazil and four African countries also demonstrate the alcohol industry’s influence in legislative initiatives.
- In light of rapidly developing marketing innovations, all-encompassing alcohol marketing bans are challenging to establish and maintain. As youth are increasingly exposed to alcohol marketing on digital media, approaches for regulating alcohol marketing would ideally include all forms of media (e.g., radio, cable television, Internet, and social media).
- With a public health goal of preventing and reducing alcohol harm among adults rather than promoting total abstinence, justification of public health–oriented alcohol policies is more complex than it has been with tobacco, for instance, for which there is no safe level of consumption.
Despite these challenges, opportunities exist for the implementation of comprehensive, statutory regulations restricting alcohol marketing to protect youth and other vulnerable populations. At the country level, a recent technical note from the Pan American Health Organization recommends that nations, to the extent constitutionally feasible, adopt total and comprehensive bans on alcohol marketing, including advertising, promotion, and sponsorship, and designate an independent body to implement, monitor, and enforce such a ban. If a total ban is constitutionally infeasible, countries are encouraged to begin with a comprehensive ban and then write into statute minimal exceptions to that ban, an approach similar to that of the French Loi Évin.
At the global level, some researchers and professional organizations have called for a binding international treaty to reduce alcohol use and related problems, similar to the WHO Framework Convention on Tobacco Control. Like its tobacco counterpart, a global Framework Convention on Alcohol Control could be a platform for governments to commit to a minimum set of actions to address issues such as price, taxation, physical availability, and illicit trade as well as the advertising, marketing, and sponsorship of alcohol products.
Public health researchers and legal experts posit that an international alcohol marketing code could be developed in a nonbinding form with recommended action for WHO Member States. On the basis of existing WHO codes of select consumer products, they propose that an international alcohol marketing code could address the promotion of alcoholic products to the public, advertising at the point of sale, and product labels. The code could be designed to recommend limiting the promotion of alcohol to certain media (e.g., traditional print media but not on the Internet), restrictions on alcohol sponsorship (e.g., at public events such as festivals), and restrictions on the placement of alcohol products in films and television programs. There is no consensus in the public health community about whether an international treaty on alcohol marketing or a nonbinding code would be most effective, as both come with advantages and disadvantages. However, either form would assist governments in strengthening their country’s alcohol marketing policies to protect vulnerable populations from the adverse impact of alcohol marketing exposure.
The WHO Global Alcohol Strategy serves as a platform for the provision of technical support to countries seeking to reduce alcohol consumption and harm; however, it does not function as an international alcohol marketing code or international treaty. For the greatest potential impact on reducing alcohol use and harm, countries and jurisdictions may consider more widespread use of comprehensive, evidence-based approaches, including the development and adoption of statutory alcohol marketing regulation that incorporates principles disseminated by the Pan American Health Organization as well as other population-level strategies recommended by the WHO (e.g., increasing alcohol taxes and regulating the density of alcohol outlets).
Alcohol harm is not typically perceived as a health crisis, but it is a leading preventable cause of death and disability. A multifaceted approach for reducing alcohol-related harm—including widespread use of policies that effectively reduce exposure to alcohol marketing by vulnerable populations, increase alcohol taxes, and reduce the physical availability of alcohol—could prevent the deaths of millions of young people and adults each year.