The Role of Society in Promoting or Deterring Alcohol Use and Addiction

of disclosing conflicts of interest. J Legal Stud. 2005;34(1):1---25.

68. Hrynaszkiewicz I, Norton ML, Vickers AJ, Altman DG. Preparing raw clinical data for publication: guidance for journal edi- tors, authors, and peer reviewers. BMJ. 2010;340:C181.

69. Hrynaszkiewicz I, Altman DG. To- wards agreement on best practice for publishing raw clinical trial data. Trials. 2009;10:17.

70. Vickers AJ. Whose data set is it anyway? Sharing raw data from random- ized trials. Trials. 2006;7:15.

71. Riley RD, Lambert PC, Abo-Zaid G.

Meta-analysis of individual participant

data: rationale, conduct, and reporting.

BMJ. 2010;340:c221.

72. National Institutes of Health. NIH

Grants Policy Statement, Part II: Terms and

Conditions of NIH Grant Awards, Subpart

A: General, Section 8: Administrative Re-

quirements, 8.2.3.1 Data Sharing Policy;

October 15, 2010. Available at: http://

grants.nih.gov/grants/policy/nihgps_

2010/nihgps_ch8.htm#_Toc271264950.

Accessed January 17, 2011.

73. Ross JS, Madigan D, Hill KP, Egilman DS, Wang Y, Krumholz HM. Pooled analysis of rofecoxib placebo-controlled clinical trial data: lessons for postmarket pharmaceutical safety surveillance. Arch Intern Med. 2009;169(21):1976---1985.

74. Konstam MA, Weir MR, Reicin A, et al. Cardiovascular thrombotic events in controlled, clinical trials of rofecoxib. Circulation. 2001;104(19):2280---2288.

75. Reicin AS, Shapiro D, Sperling RS, Barr E, Yu Q. Comparison of cardiovas- cular thrombotic events in patients with osteoarthritis treated with rofecoxib ver-

sus nonselective nonsteroidal anti-inflam- matory drugs (ibuprofen, diclofenac, and nabumetone). Am J Cardiol. 2002;89(2): 204---209.

76. Weir MR, Sperling RS, Reicin A, Gertz BJ. Selective COX-2 inhibition and cardiovascular effects: a review of the rofecoxib development program. Am Heart J. 2003;146(4):591---604.

77. Godlee F, Clarke M. Why don’t we have all the evidence on oseltamivir? BMJ. 2009;339:b5351.

Global Alcohol Producers, Science, and Policy: The Case of the International Center for Alcohol Policies

In this article, I document

strategies used by alcohol

producers to influence na-

tional and global science

and policy.

Their strategies include

producing scholarly publica-

tions with incomplete, dis-

torted views of the science

underlying alcohol policies;

pressuring national and in-

ternational governmental in-

stitutions; and encouraging

collaboration of public health

researchers with alcohol in-

dustry–funded organizations

and researchers.

I conclude with a call for an

enhanced research agenda

drawing on sources seldom

used by public health re-

search,morefocusedresourc-

ing of global public health

bodies such as the World

Health Organization to coun-

terbalance industry initiatives,

development of technical as-

sistance and other materials to

assist countries with effective

alcohol-control strategies,

and further development of

an ethical stance regarding

collaboration with industries

that profit from unhealthy

consumption of their prod-

ucts. (Am J Public Health.

2012:80–89. doi:10.2105/

AJPH.2011.300269)

David H. Jernigan, PhD

THERE IS GROWING RECOGNI-

tion among public health au- thorities in the United States and

globally that the harmful use of

alcohol is a global public health

issue of serious proportion. At

the global level, the most recent

estimates attribute to alcohol

4.6% of the global burden of

disease and disability, roughly

the same level as tobacco. Alco-

hol use is also responsible for

3.8% of global deaths.1 In the

United States, excessive alcohol

use causes 79 000 deaths per

year, according to the Centers for

Disease Control and Prevention

(CDC).2 In the United Kingdom,

the House of Commons Health

Committee reported early in

2010 that alcohol consumption

has nearly tripled since 1947,

and deaths from liver cirrhosis

had quintupled between 1970

and 2006.3 In Russia, more than

half of male deaths between the

ages of 15 and 54 in the 1990s

were caused by alcohol use.4 In

Brazil, nearly 18% of male dis-

ability-adjusted life years are at-

tributable to alcohol use; the

analogous statistic in Thailand

matches that of the United States

at 12%.1 Although female mortality

rates attributable to alcohol are

lower, a review of the evidence from developing country settings

concluded that, throughout the

world, although men do more

of the drinking, women dispro-

portionately suffer the conse-

quences, through impact on fam-

ily budgets, domestic violence,

and so on.5

There is also a growing con-

sensus about how to prevent and

reduce alcohol problems. The

World Health Organization

(WHO) has sponsored periodic

research reviews assessing the

global research evidence regard-

ing effective approaches. The

most recent review, published in

2010, recommends the following

interventions: minimum legal

purchase age laws, government

monopolies of retail sales, re-

strictions on hours or days of sale, outlet density restrictions,

alcohol taxes, random breath

testing and lower blood alcohol

concentration limits for drivers,

administrative suspension of

driving licenses for exceeding

those limits, graduated licensing

for novice drivers, and brief

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interventions (preferably in pri- mary care settings) for hazardous drinkers.6 The CDC does sys- tematic reviews for its Guide to Community Preventive Ser- vices. Its alcohol reviews have found restricting outlet density, maintaining limits on hours and days of sale, increasing alcohol taxes, and enhanced enforce- ment of laws banning sales to minors to be effective.7 The Lancet in 2009 published a re- view of the most effective and cost-effective strategies. Raising the price of alcohol and banning advertising led the list in the latter category.8

The WHO both at its head- quarters and in its regional offices has begun to develop compre- hensive strategies to address harmful use of alcohol. In Ge- neva, 2009 and 2010 witnessed an intensive period of research and consultation that resulted in the passage by the World Health Assembly of the first-ever Global Strategy to Reduce the Harmful Use of Alcohol. The strategy marks a commitment by the health ministers of 193 Member States to take action in 10 areas, including alcohol pricing, mar- keting, and physical availability.9

The regional strategies in some cases endorse these even more strongly. For example, the West- ern Pacific Regional Strategy, recognizing that alcohol con- sumption in the region is increas- ing, calls for the establishment of alcohol taxation systems, the reg- ulation or as appropriate banning of alcohol marketing, and regula- tion of times and places for sale of alcohol.10 The African regional strategy observed that ‘‘adequate polices were few,’’ called for reg- ulation of ‘‘the content and scale of alcohol marketing,’’ stated that ‘‘taxation should be increased,’’ and encouraged Member States

to ‘‘restrict the times and places of sale.’’11(p2---6)

Leading global alcohol pro- ducers welcomed WHO’s strategy, calling it ‘‘an important and con- structive step forward in helping address alcohol issues around the world’’ and pledging to

work constructively with WHO and Member States to help pro- mote implementation of the strat- egy by supporting and contribut- ing to feasible and effective policies that help reduce harmful drinking.12

In contrast to leading tobacco companies, whose 1994 denial that nicotine was addictive ‘‘pene- trated the smoke screen’’ of their relationship with public health and made clear that collaboration was not an option,13 alcohol com- panies are on record as seeking a different route.

I explored how industry- funded organizations have acted in the context of efforts to reduce alcohol-related harms. What strategies has industry employed in response to the public health initiatives? What has been the relationship of industry to public health evidence? I also examined the relationship of leading alco- hol producers with public health science as exemplified in partic- ular by the activities of their ‘‘alcohol policy think tank’’ (as the Global Alcohol Producers Group Web site refers to it), the International Center for Alcohol Policies (ICAP). Sources exam- ined included the publications of the ICAP itself, tax filings in the United States by the ICAP, and comments of industry leaders about the ICAP and about alco- hol policy found in searches for any of the words ‘‘alcohol,’’ ‘‘al- cohol policy,’’ or ‘‘International Center’’ in the internal tobacco in- dustry documents available from legal settlements at the University

of California at San Francisco. Comparison of ICAP research and policy statements with findings from the WHO and other public health bodies and researchers showed how the industry has si- multaneously cast itself as repre- senting public health and ignored key findings of public health re- search regarding effective ap- proaches to the prevention and reduction of alcohol-related prob- lems.

THE GLOBAL ALCOHOL INDUSTRY

According to market research estimates, the total alcoholic drinks market was worth $979 billion in 2007, with the global beer trade worth an estimated $498 billion and the spirits trade worth $216 billion.14-16 In gen- eral, the high-income country markets for alcohol are ‘‘mature,’’ and consumption in those coun- tries is for the most part de- creasing. By contrast, in the low- and middle-income countries, al- cohol consumption is increasing, and these are the places the in- dustry views as its best chance for growth.5 This was exempli- fied in the industry by statements such as Seagram’s in its annual report in 1996: ‘‘Our single big- gest opportunity is global expan- sion.’’17

Pursuing this opportunity has led to unprecedented globaliza- tion of the industry, to the point where a relatively small number of beer and distilled spirits com- panies dominate global trade in alcohol.18 Particularly in the case of beer, the 1990s and early 2000s witnessed successive waves of mergers and acquisi- tions, resulting in the dominance of the global beer trade by a small number of companies, as mea- sured by the concentration of

ownership in the trade, which nearly tripled as the share of the market held by the 10 largest companies grew from 28% in 1979---1980 to 72% in 2008.

The global spirits industry has also experienced rapid concentra- tion. As shown in Table 2, in recent years the 10 leading pro- ducers have consistently con- trolled more than 40% of sales (by volume).

This growing concentration of the beer and distilled spirits in- dustries has created an unprece- dented concentration of re- sources at global and national levels for participating in and influencing policy debates re- garding alcohol.

THE INTERNATIONAL CENTER FOR ALCOHOL POLICIES

To this end, in 1995, 10 of the world’s largest distilled spirits and beer marketers at that time (Allied Domecq Spirits and Wine [as of 2006 split up between Pernod Ricard, Diageo, and Beam Global Spirits and Wine], Bacardi-Martini, Brown-Forman, Coors Brewing Company, Guin- ness PLC [now part of Diageo], Heineken NV, International Dis- tillers and Vintners [now part of Diageo], Miller Brewing Com- pany [now controlled by SAB- Miller, a conglomerate formed by joining Miller with South African Breweries, with the Philip Morris successor company Altria retain- ing a 20% interest], Joseph E. Seagram & Sons [whose spirits brands were acquired primarily by Pernod Ricard and Diageo in 2000], and South African Brew- eries [now SABMiller]) banded together to found the ICAP. One of these companies, Miller Brew- ing, was then controlled by to- bacco giant Philip Morris. In the

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1996 Philip Morris CEO briefing book that came to light as one of many internal tobacco industry documents released after the Master Settlement Agreement between US state attorneys gen- eral and tobacco companies, there is a section explaining Miller’s involvement in the ICAP as follows:

As Miller continues to expand in- ternationally, we will need a better grasp on how different governments may regulate our products . . . [this is] the latest initiative in managing worldwide issues, and assisting our sales and marketing group in an increasingly competitive market- place.22(p6)

To lead the ICAP, the alcohol industry turned to Marcus Grant, a former member of the staff of the WHO. As has been described in greater detail elsewhere,23

Grant had come to the WHO in 1983 as the organization was experiencing pressure from con- servative, pro-business govern- ments in the United States and the United Kingdom, in part be- cause of the WHO’s stance in support of protests against the marketing of infant formula in developing countries. The US government made it clear to WHO leadership that it opposed programs that were not in line with the principles of private enterprise. In the face of this pressure, the WHO in 1983 can- celled a major project investigat- ing the marketing strategies of alcohol transnational corpora- tions, focusing particularly on their plans to globalize the alco- hol market. Grant began his work for the WHO as a consultant, de- veloping a report that would downplay this project’s findings regarding the impact of the transfer of aggressive marketing techniques perfected in devel- oped countries to less-resourced countries. He joined the WHO

staff and stayed until 1994, when he resigned to become a consul- tant to Seagram, Guinness, In- ternational Distillers and Vint- ners, and Hiram Walker (all of which are now part of either Diageo or Pernod Ricard).

This consultation led to the in- ception of the ICAP. In a letter announcing the formation of the ICAP in 1995, Grant outlined 4 goals for the new organization: (1) elaborating a more integrated approach to alcohol policy, in- volving all interested sectors; (2) developing a common language for promoting more effective di- alogue; (3) encouraging initiatives designed to meet the needs of developing countries; and (4) pro- moting responsible lifestyles (letter from M. Grant to D. H. Jernigan, April 7, 1995).

As ICAP activities would dem- onstrate, these goals require some translation. A subsequent ICAP brochure described the first goal as an effort to reassess ‘‘current theories with a primary focus on the differences between posi- tive and negative patterns of drinking.’’24 This emphasis on the patterns of drinking (as opposed to population levels of consumption) and positive effects of alcohol use would be a major ICAP focus in its first decade, developed in a 1998 conference titled ‘‘Permis- sion for Pleasure,’’ and a subse- quent edited collection of essays titled, Alcohol and Pleasure: A Health Perspective.25 ‘‘Involving all interested sectors’’ would in practice mean pushing for and engaging in active alcohol industry involvement in public health poli- cymaking regarding alcohol, directing debate over alcohol pol- icy into areas where the alcohol industry could agree, and thus focusing on education and identi- fication and treatment of the heaviest drinkers (among the least

effective and least cost-effective approaches to alcohol problems8) and staying away from population- level strategies such as increased taxes or restrictions on marketing or physical availability. The sec- ond goal would seek to remove phrases troubling to the industry such as ‘‘alcohol and other drugs’’ from the official lexicon (see sec- tion, ‘‘Influencing Public Health Decision-Makers at the Global and National Levels’’). The third would aim to protect the industry’s ability to expand in areas where its potential for growth was greatest, by influencing and encouraging weak alcohol policies in this re- gion.26 The fourth goal would in practice mean promoting drinking and the drinker’s right to obtain alcohol.

The actual work of the ICAP is described through examination of its voluminous output of sci- entific conferences, book-length collections of articles, issue re- ports and briefing papers, and other written products from 1998 to 2010. Additional infor- mation about ICAP activities has been gleaned from its reports to the US Internal Revenue Service on the annual forms that body requires that every not-for-profit organization submit to it on an annual basis. Insights also come from analyses others have done of specific aspects of the ICAP’s work.26---28

Becoming the Industry’s

Voice in Public Health

I believe that I have contributed more to public health in my 5 years at ICAP than in double that time in WHO.29(p2) (ICAP found- ing director Marcus Grant, 2000)

Much of the ICAP’s activities have focused on countering the influence of the WHO and lead- ing alcohol researchers by es- sentially functioning like a WHO

unit on alcohol, with certain key omissions. Building on Grant’s decade of experience at the WHO in creating and distribut- ing edited collections of contri- butions by scholars from around the world, the ICAP would com- mission and produce 10 such book-length collections between 1998 and 2010, as well as 2 other monographs, 6 briefing papers for consultation with the WHO, 20 brief issue reports, 4 in-depth ICAP reviews of issues in alcohol policy, 5 periodic re- views of drinking and culture, 8 peer-reviewed journal articles written by ICAP staff and paid consultants, 1 special issue of a journal devoted to alcohol and harm reduction, and 22 charters, working papers, progress reports, and other brief policy statements or guides to policy implementa- tion. It also produced 4 policy guides, 9 health briefing papers, 8 issue briefing papers, and 4 policy tool kits, ‘‘guides for implementation of interventions to reduce harmful drinking.’’ During the same period WHO headquarters in Geneva put out 17 publications about alcohol. Whereas the ICAP publications all focused on some aspect of drinking patterns and alcohol policy, 4 WHO publications looked at aspects of identification and treatment of alcohol use disorders, a topic to which the ICAP has devoted little attention.

To produce its monographs, the ICAP initially tried to recruit current WHO staffers as writers, reviewers, and advisors. Its pub- lications mirrored some of the publications being put out in the same period by the WHO. However, the WHO publica- tions avoided inclusion of works by industry representa- tives, and ICAP publications were often collaborations between

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academics and industry repre- sentatives that would conclude the opposite of what WHO pub- lications were concluding. It per- formed ‘‘literature reviews’’ that were incomplete, not subject to traditional peer review, and ei- ther supportive of industry posi- tions or emphasizing high levels of disagreement among scientists. Finally, it provided model na- tional and global alcohol policies based on the least effective strat- egies, and offered technical assis- tance in how to adopt and imple- ment these policies.

These publications were distin- guished not by what was in them, which often included useful con- tributions to various aspects of alcohol studies, but by what was not: they excluded or attempted to refute evidence regarding the most effective strategies to reduce and prevent alcohol-related harm. In replicating the work of the WHO, the ICAP’s efforts to recruit current WHO staffers working on alcohol issues were unsuccessful, so it relied on employees in other sectors (such as the Department of

Mental Health, which at the time was separate from the Program on Substance Abuse), employees in WHO regional offices, and retired WHO officials. As Table 3 illus- trates, 7 of the ICAP’s 10 book- length collections included con- tributors with ties to the WHO. The ICAP also drew contributors from well-respected institutions such as Brown University, the Canadian Centre on Substance Abuse, the University of Sydney, the University of the South Pa- cific (Fiji), the National Council Against Addiction (Mexico), the Addiction Research Foundation (Toronto, Canada), the University of Zimbabwe, Johns Hopkins Uni- versity, University College (Dub- lin, Ireland), and the University of Chile. Nine of the 10 edited col- lections also included at least 1 chapter written by someone who had previously been or was cur- rently employed in strategic af- fairs, corporate social responsibil- ity, or a similar capacity for an alcohol company.

Although the WHO was pro- ducing fewer publications during

this period, several ICAP publi- cations seemed to attempt to counter or pre-empt similar WHO publications. For instance, in 1994 the European office of the WHO had sponsored a group of 17 scientists from 9 countries to produce a comprehensive review of the global research literature on alcohol and public health.30

The book made a strong, evi- dence-based argument for popu- lation-level strategies such as ex- cise tax increases and controls over physical availability. The ICAP’s first policy manifesto appeared in 1998, and was titled Drinking Patterns and Their Con- sequences.31 It sought to reframe the debate from societal mea- sures to individual patterns of drinking, which could be harmful or beneficial. This reframing also shifted the focus from the product and the practices of the industry to the behavior of individual drinkers. The WHO also spon- sored a group of 12 researchers–– 6 from well-resourced and 6 from less-resourced countries––to pro- duce a book on alcohol and pub- lic health in developing societies.5

The ICAP produced its own ed- ited collection titled Alcohol and Emerging Markets: Patterns, Problems and Responses.32 The WHO has devoted significant resources in the past decade to better measurement of alcohol’s role in the global burden of disease, and this has been reflected in WHO33,34 as well as in various other research publications.1 Whereas WHO estimates have placed alcohol’s role in the global burden of disease on a par with that of tobacco, the ICAP, in a publica- tion of its own titled Alcohol Consumption and the Burden of Disease,35 focused on the limita- tions of the study, including claiming (incorrectly) that the

estimates had failed to take into account different patterns of drinking. In fact, the WHO- sponsored study developed and tested a scale for classifying country-level patterns of drink- ing, and incorporated that mea- sure into its calculations in combination with measures of population-level consumption of alcohol.36---38

Two other ICAP publications directly addressed the well- documented public health strat- egies of increasing alcohol taxes and restricting physical avail- ability. There is broad consensus in the alcohol research field that increasing alcohol excise taxes is an effective tool for reducing alcohol problems.39 The Na- tional Research Council and In- stitute of Medicine included tax increases as part of its compre- hensive program for reducing underage drinking.40 A recent meta-analysis combined data from 112 studies of alcohol pri- ces to conclude that, like sales of other commodities, alcohol sales increase when prices fall, and decrease when prices (or taxes) increase, and that tax in- creases affect heavy as well as other drinkers.41 Systematic re- views of the literature by the CDC42 as well as the interna- tional group of researchers sponsored by the WHO43 have reached similar conclusions. Despite this high level of agree- ment among public health scholars and organizations, the ICAP report states that

[t]the effectiveness of taxation and pricing policies as public health and social tools for reducing consumption, abuse and problems has been much debated,44(p3)

and that ‘‘[t]here is evidence that taxation does not effectively target those who abuse alcohol or who have risky drinking

TABLE 1—Concentration of Ownership in the Global Beer

Industry, 1979–1980 Versus 2008

Global Market Share, % (Ranking)

Corporation (Headquarters) 1979–1980 2008

AB/Inbev (Belgium) 6.5 (1; AB) 24.2 (1)

SABMiller (United Kingdom) 4.8 (2; Miller) 12.3 (2)

Heineken NV (Netherlands) 2.8 (4) 9.4 (3)

Carlsberg Breweries A/S (Denmark) 3.1 (3) 7.4 (4)

China Resources Enterprise Ltd (China) a

4.2 (5)

Molson Coors Brewing Co (United States) a

3.2 (6)

Tsingtao Brewery Co Ltd (China) a

3.1 (7)

Grupo Modelo (Mexico) 1.3 (12) 3.1 (8)

Beijing Yanjing Beer Group (China) a 2.5 (9)

FEMSA (Mexico) 0.84 (20) 2.4 (10)

Total market share of top 10 companies 28.0 72.0

Source. 1979–1980 data from Cavanagh and Clairmonte 19

; 2008 data from Impact Databank.

20

a Did not exist or not in the top 30 in 1979–1980.

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problems.’’44(p6) It concludes by warning that ‘‘taxation is a blunt tool and does not differentiate between problematic and un- problematic drinking pat- terns.’’44(p11)

A CDC systematic review of the literature on the relationship be- tween physical availability of al- cohol and health outcomes found

sufficient evidence of a positive association between outlet density and excessive alcohol consump- tion and related harms to recom- mend limiting alcohol outlet density through the use of regula- tory authority (e.g., licensing and zoning) as a means of reducing or controlling excessive alcohol con- sumption and related harms.45(p570)

Again, other reviews of the global literature have corrobo- rated this finding.6,46 The ICAP review of the same literature states that ‘‘a debate has been developing around the effective- ness of availability control mea- sures,’’ claims that ‘‘[t]here is evidence that efforts by those desiring to circumvent existing controls has fueled organized crime’’ (with the cited source

being an article by a Diageo em- ployee published in another ICAP collection), and concludes that

As research has increasingly dem- onstrated, harmful outcomes of al- cohol consumption are more closely associated with particular drinking patterns among specific groups, not with overall consumption. As a re- sult, gross-level measures such as availability controls may not be sufficient . . . .47(p9)

In the past 15 years, the WHO has also embarked on a series of exercises in global epidemio- logic surveillance, which have produced several survey-based global status reports on alcohol, alcohol policy, and alcohol and youth.48---51 The ICAP in turn partnered with and later adop- ted as a subsidiary the London- based Center for Information on Beverage Alcohol, which has produced tables on alcohol pol- icies and related issues for vari- ous ICAP reports. A close anal- ysis of the methodology used to produce the WHO alcohol poli- cies report with that of the ICAP on the same topic concluded that

The ICAP report, in particular, seems to present conclusions that are inconsistent with its own data or unwarranted because of faulty survey methodology.28(p136)

The ICAP has also produced a series of briefing papers, re- views of alcohol policy issues that claim to be surveys of the research literature. Unlike sys- tematic reviews, such as those done by CDC’s Guide to Com- munity Preventive Services,42,52

or meta-analyses, such as the tax study described previously drawing on 112 studies of alcohol prices,41 the ICAP reviews pro- vide no detail on the methods used in identifying studies or assessing their findings. The ICAP papers focus on the dis- agreements and inconclusiveness of alcohol policy research. For instance, the ICAP briefing paper on health warning labels on alcohol reflects ‘‘the equivocal nature of the contemporary HWL [health warning label] debate.’’53(p6) The ICAP’s report on alcohol and pregnancy con- cludes that

many feel there is insufficient evidence regarding moderate consumption of alcohol during pregnancy and the effect it may have on a developing fetus . . . .54(p1)

An ICAP report on estimating costs associated with alcohol consumption remarks that ‘‘some economists argue that taxes are not the most effective way to discourage problem drin- king.’’55(p5) Other reports reflect the alcohol industry’s interest in promoting alcohol consumption. For instance, the ICAP report on safe drinking levels concludes by noting that ‘‘both the UK and the US guidelines draw attention to the health benefits of moderate alcohol consumption.’’56(p4) The ICAP report on drinking age

limits states that some ‘‘argue that a minimum drinking age of 21 is impractical’’ and that ‘‘the em- phasis should be less on stigmatizing alcohol and more on promoting re- sponsible consumption of alco- hol.’’57(p9)

The ICAP has also created and disseminated model alcohol poli- cies for less-resourced countries and has offered expert technical assistance in implementing those policies.26 The seminal work on alcohol policies, Alcohol Control Policies in Public Health Perspec- tive,58 is known within the field as the ‘‘purple book.’’ The ICAP de- veloped its own ‘‘blue book,’’ an Internet-based set of ‘‘practical guides for alcohol policy and tar- geted interventions.’’59 In keeping with the ICAP’s overall goals, de- scribed previously, the ICAP blue book is based on 3 central ele- ments:

drinking patterns and their out- comes as a sound scientific basis for policy development; targeted inter- ventions that address specific ‘at- risk’ populations, potentially harm- ful contexts and drinking patterns; and partnerships that allow the in- clusion of the public and private sectors, the community, and civil society all working toward a com- mon goal.60(p1)

Described as ‘‘a new way to address the role of alcohol in society,’’ the blue book offers 23 ‘‘modules’’ for policy develop- ment. Conspicuously missing from these modules is any men- tion of 3 of the most effective policy approaches to alcohol problems: taxation, restrictions on advertising and marketing, and limits on physical availabil- ity.6

Influencing Public Health

Decision-Makers

Publications are perhaps the most public activity engaged in by the ICAP. At least as important

TABLE 2—Concentration of Ownership in the Distilled Spirits

Industry, 2006 Versus 2008

Global Market Share, % (Ranking)

Corporation (Headquarters) 2006 2008

Diageo plc (United Kingdom) 10.8 (1) 10.2 (1)

Pernod Ricard (France) 8.3 (2) 8.9 (2)

United Spirits Ltd (India) 6.7 (3) 7.9 (3)

Bacardi (Bermuda) 3.7 (4) 3.4 (4)

Beam Global Spirits & Wine (United States) 3.7 (5) 3.3 (5)

Central European Distribution Corp (Poland) 1.8 (7) 2.1 (6)

Brown-Forman (United States) 1.9 (6) 1.9 (7)

Gruppo Campari (Italy) 1.7 (9) 1.7 (8)

Sazerac Co Inc (United States) 1.7 (10) 1.5 (9)

Suntory (Japan) 1.8 (8) 1.5 (10)

Total share of top 10 41.8 42.5

Source. Data from Impact Databank. 21

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have been its efforts to influence public health officials. ICAP staff are frequent visitors to the WHO in Geneva and a reliable presence during WHO Executive Board and World Health Assembly meetings. During debates over the recently adopted WHO Global Strategy to Reduce the Harmful Use of Alcohol, the ICAP was a leading voice advocating a greater role for ‘‘economic oper- ators’’ in designing alcohol poli- cies and programs. This advocacy led to the delay and near-failure in 2007 and 2008 of efforts to create the Global Strategy.61 The ICAP has also sent representa- tives to numerous less-resourced countries to provide ‘‘technical assistance’’ regarding alcohol policy.26

In the United States, during the Clinton administration, the ICAP convened with the federal Center for Substance Abuse Prevention (CSAP) a ‘‘Joint Working Group on Terminology.’’ The purpose of the group was to

review current terminology used by public health advocates and others in relation to alcohol abuse; to identify key concepts so as to achieve a better understanding of

different definitions; and to explore opportunities for promoting greater consensus on terminology, taking into account international and cross-cultural definitions.62(p7)

The Working Group produced a report, with a forward by Karol Kumpfer, PhD, the CSAP director, and Adrian Botha, chair- man of the ICAP Board of Direc- tors and an official of South Afri- can Breweries. Regarding whether to use the term ‘‘alcohol and other drugs,’’ which was standard CSAP usage at that time, the report stated:

Perhaps the only simple answer to the question whether alcohol is a drug, is an incomplete one: ‘‘Yes, but . . . .’’ Much more to the point is the sub- sidiary ‘‘Why does it matter?’’62(p29)

Beyond this, however, the report describes no commitments being made on either side of the debate, concluding by saying only that

If semantics are driving and keeping us apart, let us think through new phrases that will help frame new ways of doing ‘win---win’ business together.62(p31)

A speech by a leading industry official to the World Association of Alcohol Beverage Industries in 1996 revealed what actually

happened in those meetings. In a transcript of her speech available in the internal documents re- leased as part of the tobacco Master Settlement Agreement, Patti McKeithan, the vice presi- dent of corporate relations for Miller Brewing, stated:

As you will recall, CSAP is the orga- nization that popularized the term ‘‘alcohol and other drugs.’’ We have long fought against the use of this term, which incorrectly and unjustly equates our products with illegal drugs. I am pleased to be able to tell you that . . . working through ICAP . . . we have been able to reach an agreement with CSAP . . . by which they have changed their editorial guidelines . . . to discontinue use of this expression . . . using instead the term ‘‘substance abuse.’’ This is a ma- jor victory, and was achieved through patient negotiation . . . and the force of logic. It is truly a triumph of alcohol education . . . and should help us dial down the rhetoric of the anti-alcohol lobby.63(p12)

Encouraging Public Health

Collaboration

A guest editorial in the journal Addiction in 2000 began by warning,

Alcohol producers are engaged in a campaign to capture the hearts and minds of alcohol researchers and public health people, as part of a

major effort to win the war of ideas that shapes alcohol policy at national and international level.27(p179)

Some of the ICAP’s efforts to promote and implement collabo- ration between industry and public health have already been described in this article. In a field where such collaboration is cus- tomarily provided gratis or for modest sums, the ICAP in the late 1990s was paying more than $13 000 for a chapter-sized con- tribution (letter from M. Grant and ICAP social policy specialist E. Houghton to D. Everett, exec- utive director, Community Agency for Social Enquiry, Johannesburg, South Africa, Au- gust 7, 1997).

Two other substantial efforts deserve scrutiny. The first was the creation in 1997 of The Dublin Principles of Cooperation Among the Beverage Alcohol Industry, Governments, Scientific Re- searchers, and the Public Health Community. Not surprisingly, these principles argued ‘‘that aca- demic and scientific communities should be free to work together with the beverage alcohol indus- try, governments and non-gov- ernmental organizations’’ to con- tribute to a better understanding of ‘‘the relationships among alco- hol, health and society.’’64(p640)

The principles were published in the journal Alcohol & Alcoholism, accompanied by an editorial that predicted that time would tell whether the industry’s ‘‘involve- ment in the Dublin Conference was a genuine attempt at meeting their social responsibilities, or merely a publicity exercise.’’65(p637)

Internal tobacco documents show that executives in that industry also found the princi- ples of interest: David O’Reilly, now head of public health and scientific affairs at British Amer- ican Tobacco, discovered the

TABLE 3—ICAP Monographs and Industry and WHO-Linked Contributors, 1998–2010

Contributors

Year ICAP Publications Total Alcohol Industry WHO-Affiliated

1998 Drinking Patterns and Their Consequences 28 4 1

1998 Alcohol and Emerging Markets: Patterns, Problems and Responses 19 1 1

1999 Alcohol and Pleasure: A Health Perspective 38 2 2

2001 Learning About Drinking 18 1 0

2004 Moonshine Markets: Issues in Unrecorded Alcohol Beverage Production 25 0 0

2005 Corporate Social Responsibility: The Need and Potential for Partnership 20 6 2

2006 Drinking in Context 13 1 1

2008 Swimming With Crocodiles: The Culture of Extreme Drinking 19 3 0

2009 Working Together to Reduce Harmful Drinking 8 4 1

2010 Expressions of Drunkenness (Four Hundred Rabbits) 11 3 1

Note. ICAP = International Center for Alcohol Policies; WHO = World Health Organization.

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principles in 2000 and wrote to colleagues at British American Tobacco, ‘‘They make interest- ing reading. Something to aspire to?’’66(p1)

In 1999, as the WHO was initiating negotiations on the Framework Convention on To- bacco Control, the ICAP began a series of regional and global consultations of its own that would culminate in a document titled, The Geneva Partnership on Alcohol: Toward a Global Alcohol Charter.67 Despite the inclusion of ‘‘Geneva’’ in the document’s title (based on a meeting held in Ge- neva to review its contents), there was no involvement in this ‘‘global charter’’ from staff at the WHO in Geneva, the most obvi- ous ‘‘Geneva partner.’’ Although it was subsequently struck from the final document, early drafts of the charter stated that, ‘‘Public poli- cies should not treat alcohol dif- ferently from similar products, except where a compelling reason to do so exists’’; ‘‘Consumers have a right to reasonable access to beverage alcohol’’; and ‘‘those who make a well-informed choice to drink responsibly should not be subjected to pressures to re- frain’’ (D. H. J., personal collection, undated).

Costs

As a not-for-profit organiza- tion, the ICAP is required to file with the US Internal Revenue Service annual Form 990s detailing its income and expenses. At the time of the study, these forms were available online for 2004, 2006, 2007, and 2008. They show an annual organiza- tional budget of $1.9 million in 2004, and close to $2.7 million in 2006, 2007, and 2008.68---71

ICAP President Marcus Grant received $444 855 in com- pensation for his services in

2008. In that year, the organiza- tion also reported spending $571 945 to ‘‘allow the Center to work more closely with other similar Asian organizations by complementing and supporting their ongoing work,’’ $341 860 to ‘‘intensify a dialogue with the World Health Organization, in order to encourage a more bal- anced approach to alcohol pol- icy,’’ and $317 058 on scientific reviews to

undertake a critical examination of existing evidence on the contribu- tion of drinking to the global dis- ease burden and set a novel agenda for future research; to assess the viability of current policy ap- proaches and to offer pragmatic alternatives; to help position drinking patterns within a broader social, economic, and political con- text.71(p2)

THE TOBACCO CONNECTION

The ICAP experience reflects both direct connections to and lessons learned from the tobacco industry. Philip Morris was among the founding companies of the ICAP. Guy Smith, the current ex- ecutive vice president responsible for corporate relations and mar- keting public relations for Diageo, the world’s largest spirits pro- ducer, was previously the vice president---corporate affairs and senior public affairs and public relations officer for the Philip Morris Companies from 1975 to 1992. Between his service at Phi- lip Morris and joining Diageo, he ran a consulting business in Washington, DC, ‘‘focused on reputation and crisis manage- ment.’’72

The ICAP and its alcohol in- dustry sponsors apparently learned from tobacco that indus- try must be out front in terms of social responsibility, able to fore- shadow and pre-empt public

health initiatives, as the ICAP has consistently done with its publi- cations and other activities mir- roring the work of the WHO. Industry arguments must be ‘‘science-based’’ and clothed in research credentials, as the ICAP has done with its many briefing papers and policy reviews. Rather than direct confrontation with public health, which the ICAP has studiously avoided, partnership is critical. Finally, the industry must consistently em- phasize alcohol education. As Miller’s vice president of corpo- rate relations told a meeting of alcohol industry executives in 1996, when the beer company was still under the control of Philip Morris,

First, we must continue to edu- cate consumers to drink our products responsibly . . . . Second, we must continue to educate the public . . . that there is a vast difference . . . between consump- tion . . . and abuse . . . of our products . . . and between alcohol . . . and illegal drugs . . . . And third, we must continue to edu- cate policy makers . . . that we . . . and the 100 million Americans who drink alcohol beverages . . . don’t need higher taxes . . . and more restrictive regulations . . . . For our industry, a positive image . . . based on accurate informa- tion about our products . . . is not a luxury . . . but a necessity . . . a necessity for survival . . . . This is hardball . . . and we’ve got to play to win.’’63(pp3---18)

THE PUBLIC HEALTH RESPONSE

What should the public health response be to the efforts to influence science and policy made by the alcohol industry through organizations like the ICAP? First, we need to use and expand on public health re- search tools to build greater awareness of and sophistication about such organizations. As

Jahiel has pointed out, this work requires use of sources not usu- ally examined by epidemiolo- gists, such as trade journals, re- ports to stockholders and the Securities and Exchange Com- mission, and newsletters advis- ing investors on stocks, and careful analysis of scientific re- ports and other publications re- leased by corporations and their allies.73 Given the ICAP’s pro- digious written output, applica- tion of tools such as ethno- graphic content analysis74 and discourse analysis,75 which have been useful in studying tobacco industry---funded products,76

may also be useful in analyzing how research findings may be distorted on behalf of corporate interests.27

Second, it is critical that public health organizations such as the WHO and its regional offices re- ceive sufficient resources to pro- vide a substantial and substantive public health voice, particularly in less-resourced countries, and that scarce resources be used to best effect. Others have docu- mented the work of the ICAP in sub-Saharan Africa to promote weak national alcohol policies26; these efforts too often fill a vac- uum created by underresourced public health sectors in these countries and regions. In light of the findings in this article, there is particular need for aggressive public communications to put forward the public health view of the problem and the most effec- tive approaches to it. Technical assistance and mini-grants to in- dependent organizations in re- source-poor countries are needed so that industry-funded organiza- tions like the ICAP cannot take advantage of an underresourced public health sector to put for- ward industry constructions of the problem.77

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As countries seek to implement the WHO’s Global Strategy to Re- duce Alcohol-Related Harm, it is also critical that they not avoid some of the more controversial but also more effective public health strategies such as taxation and regulation of physical avail- ability and marketing, despite the industry’s efforts to direct atten- tion away from these approaches. The Lancet78 and the American Public Health Association79 have called for the development of a Framework Convention on Alco- hol Control. Such a convention may be one avenue toward this, but a complementary path lies in the development of case studies, practical guides, and other forms of off-the-shelf technical assistance materials to assist countries to move in these regulatory direc- tions.

Finally, the public health re- sponse requires clear recognition of the ethical issues and practical limitations of collaboration with entities such as the alcohol bever- age industry. In the United States, underage and excessive drinkers account for half of the alcohol consumption.80 This context cre- ates a clear conflict of interest between public health and alcohol companies. In 2001, the health ministers of the European Union adopted a declaration on alcohol and young people, the preamble to which stated that ‘‘[p]ublic health policies concerning alcohol need to be formulated by public health interests, without interference from commercial interests.’’81 This was reiterated in the European Alcohol Action Plan, endorsed in September 2011 by the 53 Mem- ber States of the WHO’s European Region:

[T]he Regional Office will strengthen its processes of consul- tation and collaboration with NGOs and relevant professional bodies

that are free of conflict of interest with the public health interest . . . guided by the principle that public policies and interventions to pre- vent and reduce alcohol-related harm should be guided and for- mulated by public health interests and based on clear public health goals and the best available evi- dence.82(p25)

The ICAP and other alcohol industry organizations continue to argue, advocate, and promote the alcohol industry’s involve- ment in medicine and public health. However, at least 1 prominent public health re- searcher and editor has argued that the industry’s tactics may bring it even closer to the to- bacco industry in reputation. As Griffith Edwards, then-editor of the journal Addiction, wrote in the British Medical Journal in 1998:

So, should researchers take re- search money from a tainted in- dustry which exploits vulnerable populations, mounts attacks on valid research and independent researchers, and which, through its front organisations, tries to distort the truth? . . . If the drinks industry goes on behaving in Britain and in other countries in its present unethical manner, it will inevitably and deservedly, join the tobacco industry in a pariah status.83(p336) j

About the Author David H. Jernigan is with the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Correspondence should be send to David H. Jernigan, PhD, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 292, Baltimore, MD 21218 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the ‘‘Reprints/Eprints’’ link.

This article was accepted May 1, 2011.

Acknowledgments This work was supported in part by the Institute on Medicine as a Profession and the American Legacy Foundation.

The author is grateful to participants in the November 2009 Drug, Alcohol, Food and Tobacco Symposium for their

insightful comments on an earlier draft of this article.

Human Participant Protection No protocol approval was required be- cause no human participants were in- volved.

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