As the Director of the Division of Non-communicable Diseases and Promoting Health through the Life-course, Bente Mikkelsen focuses her work on achieving the SDGs through the reduction of premature deaths from NCDs by one third before 2030, promoting health, and through impacting at country level in the context of the WHO General Programme of Work. WHO co-hosted the session “European alcohol policies – rethinking and strengthening implementation” at the European Health Forum Gastein 2019, which was organised together with EHFG, EU-HEM, MCI Management Center Innsbruck, IOGT-NTO and International Youth Health Organization, and supported by the Republic of Slovenia.
JK: WHO co-hosted the session “European alcohol policies – rethinking and strengthening implementation” at the European Health Forum Gastein 2019. Why does WHO prioritise this particular topic?
BM: Worldwide 3 million people die from alcohol consumption every year, in Europe, it is 1 million people. It is one of the biggest causes of premature death, especially among men and the youth. Alcohol is a risk factor for cardiovascular diseases and cancer and causes a lot of ill-health. Reducing the harmful use of alcohol as a risk factor for NCDs (non-communicable diseases) is a very important priority in the WHO European region of 53 countries.
JK: In how far is there a need to “rethink” the implementation of policies?
BM: First of all, I think that the policies we have in the region, under the WHO European Action Plan for reducing harmful use of alcohol, are already fairly good. We have had three consultations this year – one with the Member States, one with multi-stakeholder organisations like NGOs, and just this week (1st week of October 2019) we had a consultation with 35 Member States in Prague. It was confirmed that what we call the WHO “best buys” are still the “best buys”. This is confirmed scientifically; the measures are proven to be affordable and really effective.
JK: What are the WHO “best buys”?
BM: The “best buys” is sort of a buzzword for cost-effective policy interventions. In the whole area of NCDs, we have 88 defined interventions and 16 of them are labelled as “best buys”. It is about banning or restricting marketing, pricing and taxation, and reducing access to alcohol, and it is about. This is the winning strategy if you want to protect the population against harmful use of alcohol.
But we can see that industries and retailers react to these strategies. For example, they can adjust to tax increases by reducing their price and consequently the price for the consumer is still the same regardless of the tax. Therefore, we need to refine the policies and interventions in place. Even if we have the right tools, we are not able to scale up the implementation in all countries in Europe in order to improve the health of the population.
JK: You mentioned that the ones who suffer the most are men and the youth. Do you think there is a gendered dimension to harmful use of alcohol?
BM: 1.5 years ago, the WHO European region put forward a “men’s health strategy”. This was done because we could see that we are generally doing well when it comes to the reduction of premature deaths – except for men. We see that so-called masculine lifestyles are unhealthy, as men take a lot more risks, they drink more, they smoke more, they do not go to the doctor, they are not health literate, and they underuse the health system. So, there is certainly a gender difference on the use of alcohol. And if you add drink-driving you have yet another component. We know that in the WHO European region, one in every 5th death in young people is attributable to alcohol consumption, namely due to injuries; the most important category is road traffic accidents due to drink-driving.
JK: What needs to be done?
BM: I think we need to scale up the implementation of the tools which we then call the “best buys” the “good buys” and also the “buys”. And we have figures on how impactful they are on mortality and on DALYs (Disability Adjusted Life Years). We are looking more and more into the lifestyles, and we start with health literacy at an early age. We see that we have to regulate social media and advertisements much more, because the youth is being bombarded by unhealthy choices via these channels. And through the life course, we have many different options; we can work with kindergartens, schools, workplaces, and also cities quite easily. At the national level it always takes very long to pass legislations etc. while on city level you can implement measures much more quickly. And also, we have to follow very closely how the commercial sector is acting. Unfortunately, the alcohol sector is also learning from the tobacco sector and many of the already identified tactics used by the tobacco industry are now also being used by the alcohol industry, as already documented in several scientific publications.
JK: In how far does WHO collaborate with the industry to work on these issues?
BM: In the context of alcohol it is not really a partnership. We organise ourselves at WHO under what we call the “framework for non-state actors”, used to assess conflicts of interest or perceived conflicts of interest. For example, accepting funds from an alcohol producer, even if it is a very small amount of money, can be perceived as a conflict of interest. It is very important to note that our interaction with the alcohol industry should never lead to or imply “partnership”, “collaboration” or any other similar type of engagement that could give the impression of a formal joint relationship, the reason being that such engagements would put at risk the integrity, credibility and independence of WHO’s work.
JK: How is the “framework for non-state actors” organised?
BM: WHO holds dialogue meetings with the umbrella organisations for alcohol producers. The nature of this interaction is limited to dialogue and exchange of information for achieving positive outcomes for public health.
JK: This year’s theme of the EHFG was about disruption. Can you think of a disruptive way forward regarding harmful use of alcohol?
BM: I think the disruption lies in the way of implementation rather than in the actual tools we are using. Just now we published a case study from Russia. What we can do is use more nuanced instruments, as for example models for differentiated prices according to the drinking patterns. But I would call that refinement. I think the disruption is more about how to mobilise the population so they actively request from their governments to be protected from alcohol.
JK: Alcohol consumption is also very much of a cultural practice. How can social norms be changed? Does it need disruption or will change occur over a longer period of time?
BM: It is said that drinking alcohol is part of a larger European culture, and this is also why we (Europeans) are the biggest consumers of alcohol in the world. Nowhere else is alcohol used to that extent. And of course, alcohol marketing is aimed at reinforcing these so-called “cultural practices” that sustain high levels of alcohol consumption. Unfortunately, I do not think it will be possible to change this immediately but we know that social norms can be changed. I think there are countries that want to protect their youth by waiting longer until alcohol is accessible to them, like in the Scandinavian countries, where you have alcohol monopolies, for example. I think it is probably a bit of both (disruption and change over time), because we know what works but we just have to do it.
That said, one of the big misconceptions is that one glass of red wine protects your heart. But we have proof that this is not true at all. So, there is absolutely no health in any one unit of alcohol. If we are at least able to present science in a good way so that people can take healthy choices, then this is the way forward. And maybe this is a slow way, but it is still the way we need to go.
You know when we went to this consultation in Prague, we only had non-alcoholic drinks. For the first time, there was non-alcoholic champagne, wine and beer. We can see that producers are also refining the taste. You would not have guessed that there was no alcohol in it. So maybe that’s some disruption?
JK: Imagine the EHFG in 10 years from now with yet another session on alcohol policies. What would you like to see there?
BM: I think we need a Greta! (referring to environmental activist Greta Thunberg). We need somebody who really understands the harm of alcohol. And maybe then we will also see a lot of youth mobilising for healthier lives, where alcohol is not included. We already see a steady decrease in consumption. But in the end, we are not talking about a full ban on alcohol, but we clearly say that “less is better”.
|The WHO “best buys” to reduce the harmful use of alcohol |
|Increase excise taxes on alcoholic beverages|
|Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media)|
|Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale)|
 World Health Organization (2017), Tackling NCDs – “best buys” and other recommended interventions for the prevention and control of non-communicable diseases, www.who.int/ncds/management/best-buys/en/
The interview was conducted by Young Gasteiner Johanna Kostenzer, Marie Sklodowska-Curie Postdoc Researcher at Erasmus University Rotterdam.