Jürgen Rehm Robin Room
Why do we need international regulations for alcohol control?
I
n the main report of the World Health Organization’s (WHO) Commission on Social Determinants of Health
(2008) an ambitious program of actions to tackle health inequity is laid out. The Commission notes the substantial contribution of alcohol to injury, disease and death worldwide (Rehm et al. 2004), and proposes that the WHO and member nations should be “learning from the FCTC”—the 2005 Framework Convention on Tobacco Control— as a model for “regulatory action for alcohol control” (142). What are the main arguments for such an internationally binding set of regulations presumable initiated and implemented by the WHO? First, as already mentioned, alcohol is a contributory cause to many disease and injury categories (Rehm et al. 2009), acute and chronic diseases, non-communicable disease as well as communicable diseases (for the latter see Parry et al. 2009). A quick look into the International Classification of Diseases reveals that there are more than 30 diseases which have alcohol, alcoholic or alcohol-induced in their name, meaning that these diseases do not exist in countries or population groups, where no alcohol is consumed. Not only is alcohol a major contributor to burden of disease but this burden also seems to have increased lately, mainly driven by increases in consumption in the world’s most populous countries, China and India (Rehm et al. 2004). Second, the burden of death and disability is very heavy. Globally, the net burden of disease and injury linked to alcohol is about the same size as for tobacco (Ezzati et al. 2004). This is a net burden because the beneficial effects of alcohol on ischemic diseases categories and diabetes have been subtracted out (Rehm et al. 2004). It is five times larger than the burden of illicit drugs. Yet, alcohol is the only widely-used psychoactive substance which is NORDIC STUDIES ON ALCOHOL AND DRUGS
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not subject to international control. For
or alcohol policies. There is debate on the
tobacco there is the 2003 Framework
rights of society to prevent drinkers’ self-
Convention;
drugs
destruction. But even those who think
there is the 1961 Single Convention;
for
plant-based
drinkers should be left to their fate agree
for psychopharmaceuticals there is the
that society should protect its members
1971 convention on Psychotropic Drugs.
from harm caused by others, and should
In addition, there are sports doping
establish policies to minimize such harm.
conventions for psychoactive substance
This logic is a solid foundation for estab-
used as performance enhancers. (Room et
lishing the rationale for alcohol policy
al. 2008)
right across the political spectrum.
Third, even though alcohol is mainly
We have presented the arguments for es-
discussed in terms of health, there is
tablishing alcohol policy, but why is there
tremendous
associated
a need for an international dimension –
with alcohol. In the social cost studies
social
burden
why could it not be done just on a national
which have been conducted, costs related
or regional level? The answer is, national
to social harm often outweigh the costs
and local policies are indeed needed, but
associated with alcohol in the health
they are not enough. We are living in a glo-
care system (Rehm et al. 2009). The
balized world, and the ability of national
social harm includes but is not limited to
or regional governments to implement
effects on the work place, on the family,
alcohol policy has been weakened by in-
on
criminality
ternational treaties, not the least treaties
(Klingemann & Gmel 2001). An elderly
neighbourhoods,
on
which consider alcohol as an “ordinary
couple walking home at night may be
commodity” (Grieshaber-Otto et al. 2000;
threatened by carousing teenagers. A child
Holder et al. 1998; Room et al. 2006). Even
may be left stranded when an adult sup-
though a country may want to impose high
posed to pick the child up from preschool
taxation as a means to reduce alcohol-re-
overstays an after-work drinking session.
lated problems, it may fail when alcohol is
A sober bystander attempting to separate
much cheaper in a neighbouring country,
two men who are drunk and fighting may
and trade agreements forbid limitations
himself be injured when they turn on him,
to border trade. An international agree-
and have to miss work. An adult daughter
ment on alcohol can empower individual
may find herself at her wit’s end over the
countries to establish the control neces-
drinking of her live-in father. A small firm
sary without the control measures being
may be driven into bankruptcy by mis-
eroded from the outside. As the FCTC
takes or misdeeds of its employees who
shows for tobacco, such international trea-
have been drinking on the job (Babor et al.
ties also serve as good practice guides to
2003).
individual countries on potential policies
The last point underlines that alco-
to adopt. And finally, international regu-
hol has effects not only on the drinkers
latory systems can establish a watchdog,
themselves but also on those around the
a body which looks over the operation of
drinker and on society as a whole. This
and compliance with the treaty.
may be the strongest argument for social 448
NORDIC STUDIES ON ALCOHOL AND DRUGS
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In addition to implementing interna-
Commentaries on WHO:s alcohol strategy
tional regulations, monitoring and surveil-
and surveillance we will be able to meas-
lance of trends in alcohol consumption,
ure the effects of alcohol policies – or of
alcohol-related harm and alcohol policies
the lack of such policies. Decision makers
is important. Again, while tobacco and il-
will be sensitized to real size of the prob-
legal drugs are closely monitored, such a
lem, and will be able to identify priority
system, called for by recent World Health
areas for action.
Assembly Resolutions, is only now under
Most alcohol problems are local, and
development for alcohol (Rehm & Room,
policy responses will continue to be
in press). As observers of and contribu-
needed at the local and national level. But
tors to the WHO effort to collect consump-
these efforts need to be backed up inter-
tion data from all countries in the world,
nationally. A regime of alcohol control at
we can already see the impact of moni-
the international level is needed, as well
toring. More and more countries develop
as monitoring and surveillance as one of
and implement their own monitoring and
the necessary components of the control
surveillance systems, and multinational
policy.
organizations such as the European Commission are moving to develop standardized monitoring systems in the European Union countries. The policy effects of such efforts can be identified even now, at the beginning of the process. Just to give one example: the German Health Ministry was quite shocked at seeing the recent large rise in emergency room visits related to alcohol poisoning by underage adolescents, in particular females. Facts and real data destroy myths, such as the myth of a traditional German style of moderate drinking, with intoxication as a rare exception, which will prevent the disgusting excesses of drinking by “Anglo-Saxon” teenagers. The challenging of such myths is just an example of important revela-
Jürgen Rehm Public Health and Regulatory Policy, Centre for Addiction and Mental Health, Toronto, Ontario, Canada Dalla Lana School of Public Health, University of Toronto, Canada Department of Psychiatry, University of Toronto, Canada Epidemiological Research Unit, Klinische Psychologie & Psychotherapie, Technische Universität, Dresden, Germany E-mail:
[email protected] Robin Room School of Population Health, University of Melbourne, Australia AER Centre for Alcohol Policy Research, Turning Point Alcohol & Drug Centre, Fitzroy, Victoria, Australia Centre for Social Research on Alcohol and Drugs, Stockholm University, Sweden E-mail:
[email protected]
tions. Clearly with systematic monitoring
References Babor, T. & Caetano, R. & Casswell, S. & Edwards, G. & Giesbrecht, N. & Graham, K. & Grube, J. & Gruenewald, P. & Hill, L. & Holder, H. & Homel, R. & Österberg, E. & Rehm, J. & Room, R. & Rossow, I. (2003): Alcohol: No ordinary commodity. Research and public policy. Oxford and London:
Oxford University Press Ezzati, M. & Lopez, A. & Rodgers, A. & Murray, C. (2004): Comparative quantification of health risks. Global and regional burden of disease attributable to selected major risk factors. Geneva, Switzerland: WHO Grieshaber-Otto, J. & Sinclair, S. & Schacter, NORDIC STUDIES ON ALCOHOL AND DRUGS
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N. (2000): Impacts of international trade, services and investment treaties on alcohol regulation. Addiction 95: 491–504 Holder, H. & Kühlhorn, E. & Nordlund, S. & Österberg, E. & Romelsjö, A. & Ugland, T. (1998): European integration and Nordic alcohol policies: changes in alcohol controls and consequences in Finland, Norway and Sweden, 1980–1997. Aldershot, UK: Ashgate Klingemann, H. & Gmel, G. (2001): Mapping social consequences of alcohol consumption. Dordrecht, Netherlands: Kluwer Academic Publishers Parry, CDH. & Rehm, J.R. & Poznyak, V. & Room, R. (2009): Alcohol and infectious diseases: are there causal linkages? Addiction 104: 331–332 Rehm, J. & Mathers, C. & Popova, S. & Thavorncharoensap, M. & Teerawattananon, Y. & Patra, J. (2009): Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 373: 2223–2233 Rehm, J. & Room, R. (Accepted): Monitoring of alcohol use and attributable harm from an international perspective. Contemporary
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Drug Problems Rehm, J. & Room, R. & Monteiro, M. & Gmel, G. & Graham, K. & Rehn, N. & Sempos, C.T. & Frick, U. & Jernigan, D. (2004): Alcohol Use. In: Ezzati, M. & Lopez, A. & Rodgers, A. & Murray, C. (eds): Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Volume 1. Geneva: WHO Room, R. & Giesbrecht, N. & Stoduto, G. (2006): Trade agreements and disputes. In: Giesbrecht, N. & Andree Demers & Evert A. Lindquist (eds.): Sober reflections: commerce, public health, and the evolution of alcohol policy in Canada, 1980–2000. Montreal & Kingston: McGill-Queen’s University Press Room, R. & Schmidt, L. & Rehm, J. & Mäkelä, P. (2008): International regulation of alcohol. A framework convention is needed, as for tobacco control. British Medical Journal 337: a2364 WHO Commission on Social Determinants of Health (2008): Closing the gap in a generation: health equity through action on the social determinants of health. Geneva, Switzerland: WHO.
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