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Abstract
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A recent peer-reviewed publication, 'Restricting alcohol marketing to reduce alcohol consumption: A systematic review of the empirical evidence for one of the "best buys"',1 reached the conclusion that evidence does not justify a ban on alcohol marketing as a 'best buy'.
The 'best buys' are a concept first developed as part of the global response to non-communicable diseases, and they have been widely cited in global documents since then. According to the WHO,2 the 'best buys' reflect evidence of cost-effectiveness and relative ease of implementation. They provide a strong normative statement supporting the incorporation of the 'best buy' of comprehensive bans on alcohol marketing in statements such as the 2022 Global Alcohol Action Plan3 and SAFER,4 a WHO-led initiative supporting the implementation of alcohol policy in low- and middle-income countries (LMICs).
The conclusions recently published questioning the validity of bans on alcohol marketing as a 'best buy' therefore deserve close examination and may have implications for the approach to evaluating other policies in global health discourse.
Methodological challenges to evaluating alcohol marketing bans
The methodological approach of Manthey et al1 has been proven useful in the evaluation of alcohol and other CODH policies and informed the establishment of 'best buys'. But its application to the alcohol marketing domain is counter-indicated by several characteristics of marketing.5-7
These characteristics suggest that the impacts of alcohol marketing bans may be additional to or different from short-term changes in general population alcohol consumption, the outcome measure used in many evaluations of marketing restrictions. Assessing these impacts requires a broader system-level evaluation approach.8 Alcohol advertising is a complex system and, by extension, a system perspective is needed in any review seeking to understand the effects of alcohol advertising restrictions. Systemic effects occur at the individual, societal and commercial levels. At the commercial level, for example, marketing serves as a barrier to entry by new actors and generates oligopoly profits, which can then be used for further marketing.9 A further counter indication is the cumulative and lagged effects of advertising, sometimes referred to as accumulated advertising goodwill.10 These are considerable and mean that effect sizes in short-term outcome evaluations will be diluted.
Varied functions and effects of alcohol marketing
Marketing performs important roles for commercial interests, and these vary across different contexts, including the stages of market development. Thus, a range of factors can inform the evaluation of the value of a policy intervention.
Within expanding markets, such as in middle-income countries with growing economies and young populations, advertising theory predicts an increase in consumption as a result of marketing.11 Marketing in this context works to recruit new consumers in sectors where the prevalence is low, such as younger people and women. It also encourages the purchase of commercial products, replacing and/or adding to traditional beverages, and promotes the use of alcohol products in settings in which alcohol would not previously have been used.
It is highly likely, however, that marketing will not increase the prevalence of drinking beyond its already high level in the saturated markets found in some high-income countries; nevertheless, it performs important functions. Population replacement requires that cohorts of new potential drinkers have to be supported in valuing alcohol products, as did their elders. Of particular significance are the future heavy drinkers, a very important sector for the profits of the industry.12 Marketing also supports norms around alcohol products as ordinary commodities with the implication, therefore, of not requiring stringent controls on supply, affordability and marketing.
Marketing as normalisation
Marketing is directed towards stakeholders as well as consumers. This function of marketing serves to contribute to the normalisation of alcohol products as part of everyday life and creates powerful positive associations with alcohol brands and products. These norms and attitudes provide a hostile environment for health promotion13 and policy development. The implication of the messaging is that restrictions on the sale and marketing of products are not needed. If a ban on alcohol marketing affects ideas about what policies are seen as appropriate, leading to policy change, this will have potential longer-term effects on consumption.
Lack of case studies of total bans
Evaluation requires good examples. The WHO14 policy recommendation to ban alcohol marketing has been identified as the least well-implemented NCD policies globally and implementation fell between 2015 and 2017.
Language: en |