International regulation of alcohol

The World Health Organization’s Commission on Social Determinants of Health has just issued its main report, which lays out an ambitious programme of actions to tackle health inequity. The commission notes the substantial contribution of alcohol to injury, disease, and death worldwide,2 and it proposes that WHO and member nations should use the 2005 framework convention on tobacco control as a model for alcohol control. We agree that it is time to adopt such a framework.

The commission’s work underscores the urgent need for international agreements that promote alcohol controls throughout the developing and developed world. Increasing affluence in the fastest developing regions of the world—East Asia, the Pacific region, and South Asia—has led to increased alcohol consumption, along with a higher burden of harm caused by alcohol. These increases foreshadow future trends in consumption and harm for other developing countries—such as those in Africa, Central America, and South America—if and when increased affluence makes them attractive untapped markets for global alcohol producers and distributors.

In developed countries, alcohol is widely and readily available, and the real prices (minutes of work needed to buy one drink of alcohol) have decreased. Greater availability causes more health and social harm,5 and the increase in availability seems to be associated with greater health inequity. At the same time, the spread of free market ideology and intergovernmental trade agreements has undercut the ability of nation states to control alcohol related harms through controls on marketing, monopolies, and tax policies. To counterbalance the globalisation of alcohol trade, we need international agreements that protect public health.

The irony is that we know more today than ever about which strategies can effectively control alcohol related harms. But policymakers have been slow to put this knowledge into practice. Policies that tax alcohol and restrict its availability, marketing, and distribution—thereby reducing alcohol related harm—are strongly supported by evidence. Evidence that such policies can also reduce related health inequities is limited but growing. Despite this knowledge, policymakers still rely mainly on public information campaigns and education programmes, most of which have been shown to be marginally effective.

A framework convention for alcohol control would protect public health in three ways. Firstly, such a convention could place restraints on international trade in alcohol. Although most alcohol is consumed in its country of origin,3alcoholic drinks are still an important trade item. Current international trade agreements and dispute adjudications tend to treat alcohol like any other commodity. This ultimately breaks down national and local controls on the alcohol market—the very policies that can effectively promote public health. In a globalising world, one of the strongest arguments for international agreements is the need to control cross border trafficking of alcohol. A framework convention for alcohol “would provide an international community of support” for effective policies and could “add weight to the defence of such policies under trade disputes.”

Secondly, the adoption of a framework convention for alcohol control is likely to have persuasive effects across all levels of government and society. Most provisions in the current framework for tobacco are voluntary—countries signing up are urged to consider the measures but do not have to implement them. Nevertheless, such international treaties become calls to action and road maps to help legislators and governments to learn about and implement effective evidence based policies.

Finally, framework conventions commonly become a base of operation for a secretariat and oversight committees charged with making the mechanisms and provisions of the convention more effective. A secretariat for the convention could, for example, establish an international clearing house of information on evidence based approaches to alcohol control, thus providing an infrastructure for knowledge sharing between countries and regions.

Alcohol is the only strong psychoactive substance in common use that is not controlled internationally. Tobacco has the 2005 framework convention, plant based drugs have the 1961 single convention, and psychopharmaceuticals have the 1971 convention on psychotropic drugs. We now have sports doping conventions for psychoactive substances used as performance enhancers. Yet the global health and social burdens attributable to alcohol are greater and affect the poorest populations and nations of the world disproportionately. The WHO commission’s call to apply the model of the framework convention on tobacco control to control of alcohol is well founded and timely.