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Keywords:

  • Context;
  • drinking;
  • industry;
  • policies;
  • science promotion

WHY THIS EDITORIAL?

  1. Top of page
  2. WHY THIS EDITORIAL?
  3. THE SUBTEXT
  4. THE BOOK'S POTENTIAL FOR REAL HARM
  5. SCIENTISTS' ROLE
  6. THE BOTTOM LINE
  7. Acknowledgements
  8. References

This editorial was prompted by the publication of Drinking in Context: Patterns, Interventions, and Partnerships[1], a book emerging from a collaboration between four organizations: the International Harm Reduction Association, the World Federation for Mental Health, the International Center for Alcohol Policies (ICAP) and the Institut de Recherches Scientifiques sur les Boissons. This is not the first time that some of these organizations have come together. The International Harm Reduction Association supports the ‘Dublin Principles’, which proposes working cooperation between the alcohol industry and ‘governments, and the scientific and academic community’ (http://www.icap.org/BuildingPartnerships/DublinPrinciples/tabid/249/Default.aspx). The ‘Principles’ result from a collaboration between the National College of Ireland, ICAP and the Institut de Recherches, which is also a participant in the creation of the ‘Principles’. These two latter organizations acknowledge their sponsorship by the alcohol industry.

The book is organized into 10 chapters, addressing drinking patterns, assessment of drinking, targeted and tailored interventions, alcohol-impaired driving, public disorder related to drinking, drinking by young people, interventions minimizing harm, key players and partnerships and ‘finding common ground’. Although four ‘authors’ are listed on the front cover of the book (G. Stimson, M. Grant, M. Choquet & P. Garrison), each from one of the partnering organizations, 22 other individuals are identified as ‘contributing authors’. These come from a variety of organizations, including those already mentioned above, plus universities and the alcohol industry.

The authorship arrangement deserves some attention because it is rather unusual. Further information in the book's ‘Foreword’ indicates that there was also an ‘Editorial Advisory Group’ with 15 of the 26 authors, which met twice ‘under the chairmanship of Professor Norman Sartorius’ (who is not listed as an author). This group produced the overall plan for the book and reviewed a draft manuscript. This draft was produced under the ‘guidance’ of the main editor, Professor Stimson, who wove together the ‘many contributions, some greater, some smaller’ from the other authors. According to the Foreword, this process created a ‘sense of collective responsibility’, which ‘led to the decision not to attribute authorship of particular chapters to particular individuals’. This may have been the case, but as can be inferred from the description herein it has also resulted in a rather obfuscating process that does not seem to reflect accepted authorship attributions, which implies creative input, individual ownership and public responsibility for the contents of the chapters.

Concerns about previous attempts such as this one to promote scientific research in the alcohol field by the alcohol industry have already been identified [2]. While attempting to produce this type of ‘scientific work’, the alcohol industry continues to behave unethically [3]. Industry practices in marketing and advertising (e.g. flavored malt beverages) have been identified as a potential factor triggering an ‘industrial epidemic’ of alcohol problems [4]. Unethical behavior is also present in developing countries where profit maximization is the industry's main goal [5–7]. In the paragraphs below I try to look beyond the smoke and mirrors, to describe the apparent underlying intentions behind the book, the harms this specific effort can trigger and puzzlement at why some alcohol scientists continue to participate in these efforts.

THE SUBTEXT

  1. Top of page
  2. WHY THIS EDITORIAL?
  3. THE SUBTEXT
  4. THE BOOK'S POTENTIAL FOR REAL HARM
  5. SCIENTISTS' ROLE
  6. THE BOTTOM LINE
  7. Acknowledgements
  8. References

The book is presented as arising from the ‘conviction that the time had come to air some fresh approaches to alcohol policy’ ([1], p. XI). Key words such as ‘culture’, ‘context’, ‘patterns’ and ‘partnerships’ are then presented to explain why ‘targeted interventions’ are preferred over ‘population-wide measures’. Explicitly, once the smoke dissipates, this is really an attempt to use the link between culture and drinking patterns to draw attention away from two of the most effective alcohol problem prevention measures [8]—control of availability and taxation—and focus attention on measures that do not have the potential of triggering reductions in per capita alcohol consumption.

Here is a good example of the smoke and mirrors: chapter 2 begins with a discussion of patterns of drinking and their outcomes. This chapter develops in detail the idea that in order to understand fully the link between alcohol consumption and outcomes it is necessary to understand factors such as: (i) the characteristics of the drinkers (age, gender, socio-economic factors); (ii) the context where drinking occurs (culture, settings and venues); and (iii) behavior. Positive and negative outcomes of drinking are also discussed. Secondly, there is a detailed discussion of the need to assess drinking patterns before implementing policies. The authors never absolutely discard the use of taxation and reductions in alcohol availability as policies. However, using the now common liquor-speak created by the industry [2,9], such policies are referred to as inadequate because they are ‘off the shelf’ or ‘one size fits all’, due to their lack of attention to the culture that influences local drinking practices. This series of statements about the characteristics of the drinker, the inclusion of drinking in the culture of a country and the lack of appreciation for these important cultural aspects of alcohol use by public health professionals is carried throughout the book in one form or another.

However, concern for who is the drinker, the type of beverage consumed, the pattern of alcohol consumption (e.g. binge versus no binge) and the context of drinking have been present in the most visible publications by those of us who propose population level alcohol control measures as the most effective way to minimize alcohol-related problems. For instance, recently the 14 authors of the book Alcohol: No Ordinary Commodity[8] dedicated a full chapter (chapter 3) of their book to discussing alcohol consumption trends and patterns of drinking. Indeed, the treatment of the topic in that chapter covers much of the same territory covered by Stimson et al. [1], paying attention to type of beverage, the drinking context, frequency and quantity of drinking per occasion, the role of intoxication, gender, age and indigenous groups. This focus is present in Babor et al. [8] precisely because no one has proposed that taxation and control of availability should be used in isolation from other policies developed nationally or at the local level. In fact, the potential limitations of alcohol control policies identified by Stimson et al. in chapter 4 of their book are well known in the alcohol field.

To summarize, the book appears to be an attempt to take focus away from effective alcohol control population-level policies by supporting policies that are focused in special subpopulation groups (e.g. hard core drinkers) or that are directed to the larger population but are ineffective. The establishment of an international collaboration between industry, non-governmental organizations, policy makers and scientists appears to be a ruse to achieve this aim. The dichotomy between alcohol control policies aimed at reducing alcohol consumption and other types of interventions focused upon selected population subgroups does not exist, and is not advocated by public health professionals. These policies are complementary. The real dichotomy is between effective and ineffective policies.

THE BOOK'S POTENTIAL FOR REAL HARM

  1. Top of page
  2. WHY THIS EDITORIAL?
  3. THE SUBTEXT
  4. THE BOOK'S POTENTIAL FOR REAL HARM
  5. SCIENTISTS' ROLE
  6. THE BOTTOM LINE
  7. Acknowledgements
  8. References

If all that this book triggered was a discussion about the relative importance of population level alcohol control policies vis-à-vis measures directed at high-risk groups, my concerns would be minimal. Unfortunately, however, some of the suggestions put forward by the authors have the potential to cause real harm. Some examples follow.

Minimizing the importance of effectiveness data in guiding choices about prevention interventions

To defend the fact that many of the targeted approaches advocated in the book lack data on effectiveness, the authors state that: ‘It is important to remember that lack of evaluation is by no means proof that certain approaches do not work’ ([1], chapter 8, p. 176). True, but if there are proven approaches, why would one select unproven ones? Minimizing the importance of effectiveness data is seriously misleading advice. It may lead local governments and communities to waste scarce resources implementing ineffective interventions while alcohol problems remain unabated.

Restricting prevention of fetal alcohol spectrum disorders (FASD) to pregnant women

Here the authors advocate a focus on targeted interventions in health settings (assessment, screening, support, treatment). These interventions are all directed at women who are already pregnant, missing a major opportunity for FASD prevention, associated with a focus on the larger group of women of child-bearing age. This group of women (15–44 years of age) is not small, constituting 41% of the women in the US population (about 60 million women) [10]. Most of these women are sexually active but do not plan to become pregnant. In the United States about 50% of the pregnancies each year are unintended [11]; this means that many women who become pregnant continue to drink at the time of conception and for a period thereafter until they become aware of their status. Policies targeting women who already know they are pregnant miss the boat, because at the moment of conception most of these women did not know they were pregnant, and many of them were drinking then. Also, much of the industry's marketing activity is directed at young men and women, who are being encouraged to take up recreational drinking at a time in their lives when they are most sexually active.

However, as recommended by the US Preventive Services Task Force [12] and the US Institute of Medicine [13], FASD prevention should include universal approaches advocated above but also selective (e.g. screening, brief interventions) and targeted prevention efforts (e.g. treatment for alcohol-dependent women). Thus, the book errs in restricting its recommendation in the FASD area to the two latter approaches without including universal interventions.

Undue focus on ‘hardcore drunk drivers’

Driving under the influence of alcohol is one of the three areas of problematic behaviors discussed in the book. The authors recognize the importance of law enforcement and of effective measures such as roadside checkpoints. Unfortunately, most of the other interventions advocated in the book have little or no effectiveness [8]. Examples of these are designated drivers programs, alternative transportation services, on-site education campaigns, server training programs, education programs and holiday and ‘fiesta’ campaigns. There also is an undue focus on frequent heavy drinkers and ‘hard core drunk drivers’ throughout. From a US perspective, this chapter fails to recognize that most of those reporting driving under the influence of alcohol are not alcohol-dependent or ‘hard core drunk drivers’. For example, analysis of data on self-reported driving under the influence (DUI) (not necessarily leading to an arrest) from the US National Household Survey on Drug Abuse (now the National Survey on Drug Use and Health) showed that only 11% of those reporting DUI in the 12 months prior to the interview were alcohol-dependent [14]. Adding those who meet criteria for ‘alcohol abuse’ makes the proportion 30%, still a minority of those reporting DUI. A more recent analysis focusing on US Hispanics, which considers the frequency with which respondents engaged in DUI in the 12 months prior to the survey interview, showed that alcohol-dependent drivers are responsible for 34–51% of the DUI events reported, depending on Hispanic country of origin [15]. Regardless of the result being considered, these data suggest that strategies with a focus on alcoholics or ‘hard core drunk drivers’ fail to target the majority of the individuals driving under the influence in the United States. These are the moderate drinkers who will be affected by interventions that reduce per capita consumption, lower blood alcohol concentration (BAC) standards and promote law enforcement, but not by ‘targeted’ interventions unless they are arrested.

Proposing that using legal age limits for drinking may not be realistic

The book's discussion of drinking by ‘young people’ (chapter 7) appears to include adolescents and young adults. This is important because the first group is not permitted to drink in most countries of the world. The second group can drink, whether the legal threshold is 18, as it is the case in most countries, or 21, as in the United States. However, the authors' advice on preventing youth or underage drinking ignores this distinction. Based on the fact that underage drinking does occur, they state: ‘In many countries, many young people drink before the legal age. One might conclude that abstinence-based approaches are unrealistic and that a more sensible approach is to ensure that drinking, if it does occur, causes the least possible harm’ ([1], p. 161). There is an assumption here that in allowing underage drinking to take place, it would also be possible to keep it at a harmless level in volume and pattern. This is naive, at best. In putting forward such a suggestion, the authors ignore the considerable scientific evidence in support of the benefits of legal drinking limits [16]. This advice is also in direct contradiction with the recommendations in the recent report on reducing underage drinking by the Institute of Medicine of the US National Academy of Sciences [17]. This report dedicates a chapter to discuss and propose a role for the industry in preventing underage drinking. Given that underage drinking accounts for 10–20% of the alcohol consumed in the United States, representing a considerable share of the overall consumption, any advice by industry sponsored organizations to forget ‘abstinence-based approaches’ has to be taken critically.

SCIENTISTS' ROLE

  1. Top of page
  2. WHY THIS EDITORIAL?
  3. THE SUBTEXT
  4. THE BOOK'S POTENTIAL FOR REAL HARM
  5. SCIENTISTS' ROLE
  6. THE BOTTOM LINE
  7. Acknowledgements
  8. References

If the book is really flawed as it seems to be, why did 26 individuals agree to this collaboration? Obviously, the answer is not easy. Eight of them are not independent scientists, but either work for the industry or for organizations funded by the industry. It is not surprising, therefore, that they joined this effort; but what about the other 18, who are affiliated with universities or who have a previous history of working with international health organizations or for governments? These may include some who must have genuine disagreements with the public health approach and the use of alcohol control policies to reduce per capita consumption. They may also feel that collaboration with the industry offers a platform to promote what they believe to be more effective policies. However, are there some who are simply ignorant of the relationship between organizations such as ICAP and the industry, and who joined this specific effort thinking that this was just another opportunity to share their research with colleagues? It may be difficult to accept that there are individuals in the broader field who may not be aware of those connections and their implications. Nevertheless, this is possible, especially if such individuals are working in developing countries, and they should be given the benefit of the doubt.

It is important for scientists who believe they are joining a legitimate enterprise to realize that the alcohol industry is international and that it has long arms. Because it does not appear to be motivated to undertake effective self-regulation, its unethical marketing methods and exploitation of vulnerable populations are more visible in unregulated environments, i.e. developing countries [5,6]. Consequently, the apparent absence of unscrupulous actions by the industry close to home, especially if home is a highly regulated environment in a First World country, does not mean that such behavior is not present in other parts of the world. Further, Babor [3] suggests, and I agree, that because of the small amount of funds distributed, active collaboration with the alcoholic beverage industry contributes little to the advancement of science or public health. The industry rarely funds large and original research projects, and there is no evidence that partnerships between scientists and the industry have served any legitimate scientific purpose of advancing knowledge in the alcohol field. Yet, however small, these efforts are self-serving. They help the industry promote itself as concerned with the use of its products and its effects on the health of the population. The book in question is a good example of such promotion. It was launched in London at the Houses of Parliament, and it also had other launches in Nairobi, Kenya and Tokyo, Japan. This is a clear attempt by the industry to reach an international audience in both developed and developing nations. On the other hand, scientists who collaborate with these efforts enter a situation described recently as ‘moral jeopardy’[18] in which they may be at risk of doing harm to public health. This could be damaging to any scientist, but it may be particularly so to those at the beginning of their careers.

THE BOTTOM LINE

  1. Top of page
  2. WHY THIS EDITORIAL?
  3. THE SUBTEXT
  4. THE BOOK'S POTENTIAL FOR REAL HARM
  5. SCIENTISTS' ROLE
  6. THE BOTTOM LINE
  7. Acknowledgements
  8. References

Is this association with the industry defensible? I would argue that genuine disagreements can be discussed in more impartial environments and that the time for ignorance of the industry's actions both at home or abroad has passed. This is not the first, nor will it be the last instance of cooperation between scientists and the organizations funded by the alcohol industry [2]. Questions about such collaboration must continue to be raised. A few years ago Edwards [3] asked: ‘why should researchers associate themselves with a tainted industry which exploits vulnerable populations, mounts attacks on valid research and independent researchers, and which, through its front organizations tries to distort the truth?’. Unfortunately, the question is still valid today.

Acknowledgements

  1. Top of page
  2. WHY THIS EDITORIAL?
  3. THE SUBTEXT
  4. THE BOOK'S POTENTIAL FOR REAL HARM
  5. SCIENTISTS' ROLE
  6. THE BOTTOM LINE
  7. Acknowledgements
  8. References

Work on this paper was supported by a grant (R37-AA10908) from the National Institute on Alcohol Abuse and Alcoholism to the University of Texas School of Public Health.

References

  1. Top of page
  2. WHY THIS EDITORIAL?
  3. THE SUBTEXT
  4. THE BOOK'S POTENTIAL FOR REAL HARM
  5. SCIENTISTS' ROLE
  6. THE BOTTOM LINE
  7. Acknowledgements
  8. References
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