Description of the condition
Alcohol is estimated to be the third leading risk factor for global disability-adjusted life years (DALYs) for all ages and sexes (Lim 2012). This estimate has increased by 28% from 1990 to 2010. For people aged 15 to 49 years, alcohol is the leading risk factor for DALYs worldwide. Over 2.3 million deaths (95% uncertainty index 2,153,733 to 2,512,207) are attributed to alcohol use linked to injury (intentional, unintentional and transport), cardiovascular disease, cirrhosis, cancer, mental and behavioural disorders, HIV/AIDS and tuberculosis, and neurological disorders (Lim 2012). Alcohol affects not only the health of the drinking individual, but in pregnant women the neurotoxic effects of alcohol may cause a range of congenital defects including foetal alcohol spectrum disorders and foetal death, stillbirth, and infant and child mortality (Burd 2012).
In addition to its effects on mortality and morbidity, alcohol has significant adverse social and economic effects. A 2006 review of studies estimating the global economic burden of alcohol found that alcohol accounts for 1.3% to 3.3% of total health costs, 6.4% to 14.4% of total public order and safety costs, 0.3 to 1.4 per thousand USD of gross domestic product (GDP) for criminal damage costs, 1.0 to 1.7 per thousand USD of GDP for drink-driving costs, and 2.7 to 10.9 per thousand USD of GDP for workplace costs (absenteeism, unemployment and premature mortality) (Baumberg 2006). The authors caution readers to consider the methodological differences between studies and inherent design limitations, but their findings are supported by a 2009 analysis conducted in partnership with the World Health Organization. The aggregate analysis of reviews of published work found that costs associated with alcohol amounted to 1% of GDP in high-income and middle-income countries, with social harm the greater proportion of these costs, in addition to health costs (Rehm 2009). In a 2010 United Kingdom multi-criteria decision analysis to assess the relative harms of 20 drugs, harms both to the user and others were greatest for alcohol compared with all other drugs, including heroin and cocaine. Harms assessed included crime, family adversity and decline in social cohesion within communities (Nutt 2010).
In an overview of systematic reviews and quantitative meta-analysis, Rehm and colleagues evaluated the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injury and quantified those relationships identified as causal (Rehm 2010). Their findings indicate that alcohol is causally related to many chronic and acute disease outcomes as well as to injury. They report that there is evidence that both the average volume and the specific drinking pattern are causally related to ischaemic heart disease, foetal alcohol syndrome and both intentional and unintentional injury. They postulate that episodes of heavy drinking are likely to influence additional disease outcomes but that epidemiological research to date has had a limited focus on drinking patterns. Due to an absence of research, they were unable to conclude whether the quality of alcohol is a significant factor in disease outcomes.
Description of the intervention
One of the main aims of commercial advertising is to encourage the consumer to use and purchase promoted products. In their extensive 2009 review of the effectiveness and cost-effectiveness of alcohol policies and programmes, Anderson, Chisholm and Fuhr report that alcohol is increasingly marketed using sophisticated advertising in mainstream media, through linking alcohol brands to sports and cultural activities, through sponsorships and product placements, and through direct marketing such as the Internet, podcasting and mobile telephones (Anderson 2009). Alcohol marketing campaigns have recently targeted social networking sites such as Facebook and Twitter, which are disproportionately used by young people (Hastings 2013). In a systematic review of 13 longitudinal studies of 38,000 young people, Anderson et al found that longitudinal studies consistently suggest that there is an association between exposure to media and commercial communications and alcohol and adolescents starting to drink alcohol, and with increased drinking amongst baseline drinkers (Anderson 2009a). In another systematic review of seven cohort studies of young people, Smith and Foxcroft suggest that while there is an association between exposure to alcohol advertising or promotional activity and subsequent alcohol consumption in young people, the modest effect sizes may be limited by the potential influence of residual or unmeasured confounding in the included studies (Smith 2009). Snyder et al in their longitudinal investigation found empirical evidence suggesting direct measurable effects on both drink initiation and consumption levels due to exposure to advertising (Snyder 2006).
In their 2008 independent review of the effects of alcohol pricing and promotion for the United Kingdom Department of Health, Booth and colleagues identify the methodological complexity of linking advertising to consumption (Booth 2008). Cross-sectional studies will fail to meet the causality criteria of temporality (the intervention predates the effect), and cohort studies and time series analyses may be prone to confounding unless adequately controlled. In addition, they point out that sub-populations such as problem drinkers are likely to be under-represented in general population aggregated data which are primarily used in national or state-level studies. Despite these methodological limitations, they conclude that there is evidence for an effect of alcohol advertising on underage drinkers and that exposure to television, music videos and billboards which contain alcohol advertising predict onset of youth drinking and increased drinking (Booth 2008).
How the intervention might work
Prevention strategies to reduce the quantity of alcohol consumed and the age of initiation of alcohol use include several public health interventions targeted at the general population. One such strategy is the reduction and banning of all forms of advertising of alcohol. The reduction in marketing may be voluntary and implemented by the alcohol, media or advertising industries, or mandatory and implemented by government decree.
Theoretically, a reduction or a ban of alcohol advertising may reduce consumption of alcohol across the general population and may raise the age of initiation of drinking in young people. In their 2001 international comparison of bans on broadcast advertising of alcohol in 17 Organization for Economic and Cooperation Development (OECD) countries between 1977 and 1995, Nelson and Young report that there are several theoretical models of advertising, including social learning theory which argues that advertising contributes to normalising perceptions of drinking in society (Nelson 2001). They also describe conflicting economic theories with advertising either increasing or decreasing consumption because it affects both demand and the levels of prices that sellers find optimal. They warn that partial bans of advertising using specific forms of media may drive substitution towards other advertising media (Nelson 2001).
In their review of policies and programmes, Anderson et al indicate that making alcohol less available and more expensive and placing a ban on alcohol advertising are the most cost-effective ways to reduce the harm caused by alcohol (Anderson 2009a). However, little evidence is provided to support the statement on banning alcohol advertising. The authors acknowledge that in regions where alcohol marketing relies on self regulation (rather than regulatory banning or restrictions), several studies show that these voluntary systems do not prevent marketing content directed at young people. In another study of pooled time series data from 20 countries over a 26-year period, the authors' primary conclusion is that alcohol advertising bans do decrease consumption by 5% to 8% (Saffer 2002). Similarly, a cross-sectional study in the emerging market context of Brazil found evidence of association, but not causation, between alcohol consumption and alcohol promotion (Pinsky 2010).
Why it is important to do this review
In the 2012 Global Burden of Disease report, the authors state that public policy to improve the health of populations will be more effective if policies address the major causes of disease burden. They argue that small reductions of population exposure to large risks will yield substantial health gains (Lim 2012). Reducing or banning alcohol advertising may reduce exposure to the very large risk posed by alcohol both to the individual and to the general population. To date, no systematic review has evaluated the effectiveness, possible harms and cost-effectiveness of this intervention. This Cochrane review aims to evaluate, in a systematic manner, the benefits and harms of reducing or banning alcohol advertising and the cost-effectiveness of such an intervention.