Medical morals

Call time on soft approach to Big Alcohol

Gauging the pressure to make changes to the law. Elliott Brown, CC BY

Ten years ago the World Health Organisation’s Framework Convention on Tobacco Control (FCTC) came into force. It was not the first international health treaty negotiated by the WHO, but in many ways it was the most remarkable. Achieving global consensus around any kind of public health treaty is quite a feat. So achieving a consensus when the main target of the treaty was, in effect, that most slippery and dangerous of customers – Big Tobacco – was close to miraculous.

Within a year, 168 states had signed the treaty and many more are now parties to the convention. As the WHO loudly (and rightly) trumpets, this makes it “one of the most rapidly and widely embraced treaties in the history of the United Nations”.

In the decade that has passed since the FCTC earthquake shook the international health law landscape, the global public health community has increasingly turned its attention to another industry: Big Alcohol. So far the WHO has stopped short of using its authority to create a Framework Convention on Alcohol Control (FCAC).

Instead it has opted for a more softly-softly approach. This has primarily taken the form of a global strategy to reduce the harmful use of alcohol which was endorsed by the 63rd World Health Assembly in 2010. This strategy is designed to tackle the growing impact of alcohol on individuals and society. However, as a “portfolio of policy options and measures that could be considered for implementation and adjusted as appropriate at the national level” it growls more than it bites.

The calls for FCAC

The unwillingness of the WHO to grasp the framework nettle has annoyed many a medical expert. The World Medical Association, the American Public Health Association and the American Society of Addiction Medicine have issued policy statements calling for an international convention to control alcohol and many leading medical journals such as The Lancet have published supportive editorials.

Smoking and drinking both cost. Drinking by Shutterstock

The underlying reason for these calls relates to the fact alcohol is beginning to rival tobacco in the deadly harvest that it reaps. Tobacco still rules the roost in terms of the global impact on health; around half of the billion-strong smokers living today will probably die of tobacco-related diseases. However, the global burden of disease attributable to alcohol is very similar to the burden attributable to tobacco and in certain groups, especially the young, alcohol may already cause more havoc.

Harm caused by alcohol

In 2012, 5.9% of all global deaths and 5.1% of the global burden of disease and injury were attributable to drinking alcohol. This translates into 3.3m souls succumbing to the allure of beer, wine and spirits. The problem is especially acute in countries like Russia. But the UK is badly affected too.

Alcohol, like tobacco, can also affect third parties. Adults and children who cultivate tobacco are exposed to a number of hazards and may develop conditions like acute nicotine sickness. Passive smokers are also at risk. However, alcohol has much more wide-ranging impacts on third parties. Road traffic incidents and domestic violence are prime examples.

Alcohol also downs a lot of resources. The NHS forks out £3.5 billion annually to treat the consequences of alcohol misuse. This is a bit more than the cost to the NHS of treating diseases caused by smoking. When other costs, such as policing and lost productivity are added, the total bill for England alone is about £21 billion per annum. This dwarfs the UK-wide tax receipts generated from alcohol duties which amounted to £10 billion in 2013-2014.

Tobacco but not alcohol?

Given the similarities between alcohol and tobacco it may seem odd that there is a legal framework for tobacco but not for alcohol.

Two simple explanations for the difference in approach can be dismissed quite quickly. The first is that tobacco, unlike alcohol, is always dangerous. The second is that alcohol, unlike tobacco, has health benefits. The first claim is strained. If your total tobacco consumption amounts to smoking one – and only one – cigar on your birthday the extra risk to your health is either non-existent or infinitesimally small.

Red wine debate still bubbling away. Derek Gavey, CC BY

The second claim has more force, especially (perhaps) when the alcohol consumed takes the form of red wine. However, the health benefits of alcohol are increasingly contested and according to some experts may evaporate entirely when the evidence is properly scrutinised.

What other reason could there be for the different approach to alcohol? One procedural explanation is that international legal treaties take a lot of time and effort to negotiate – the FCTC took ten years and cost in excess of US$34m. Having expended so much effort on the FCTC is it possible that framework-fatigue has already kicked in?

A more cynical explanation is that Big Alcohol has lobbied the WHO more effectively than Big Tobacco ever managed to do. The recent debacle in England regarding a minimum price for a unit of alcohol certainly suggests that policymakers can be under the influence.

Calling time

Even the most ardent supporter of tobacco and alcohol – and I speak as a never smoker but a regular drinker – must admit that these products are causing an immense amount of ill-health to users around the world, and significant harm to children and third-parties. As such, a firm legislative and global response is needed.

This is not some kind of paean to prohibition. Aside from the fact that criminalising consumption or sale of alcohol or tobacco does not work, competent adults have the right to take risks with their own health.

Instead, this is a call for legally binding international conventions to help defend tobacco and alcohol control policies in trade courts and help countries deal with issues, such as web advertising, that can leak across national borders. It is also a call for global conventions that would enable ministries of health to implement strong domestic regulation and would empower non-governmental organisations to bring legal and social pressure to bear on corporations and corrupt legislators.

Thanks to the WHO we already live in a world governed by such a convention relating to tobacco. We should now call time on the soft approach to Big Alcohol by implementing some hard law.