South Africa faces a formidable threat to public health attributable to alcohol use and misuse. Current epidemiological evidence from burden of disease studies indicate that the use of alcohol is associated with a range of adverse chronic health and economic consequences (1,2). Heavy and episodic alcohol use result in acute negative physical and social outcomes including: accidents, unintentional injuries and deaths, interpersonal violence and sexual risk (3,4). The economic costs associated with harmful alcohol use in South Africa have been estimated at between R245 933 – 280 687 billion. This is approximately 12% of the country’s gross domestic product (5). This estimation takes into account both tangible (treatment and rehabilitation, crime prevention, road accidents) and intangible (premature morbidity and mortality resulting in loss of productivity and income) costs. What it is unable to calculate are the social and emotional costs to those around the drinker (children, spouses, co-workers), which no doubt are significant in itself.
Given its substantial burden on public health, international and local actors have articulated evidence-informed recommendations to adopt preventive programmes and policies to reduce harmful drinking and its associated risks (6). Evidence-based strategies to reduce alcohol use and misuse include; drink-driving prevention and counter measures, pricing and taxation regulations, regulating availability of alcohol, modifying the drinking contexts, as well as education and awareness programmes (7). The mainstay of the public health argument has been that all preventive efforts must be seen as complementary approaches to addressing alcohol use and misuse.
Progress in establishing a ban on alcohol advertising
Although the ban on alcohol advertising has been on the government’s agenda for more than five years, the past two years has seen increased public dialogue between the South African government, academic, civil society organisations and the alcohol and advertising industries on a proposed ban on alcohol advertising in South Africa.
Arguments in support of the ban have been voiced by public health researchers and practitioners in response to the substantial evidence for alcohol related harms. The rationale behind a ban on alcohol advertising is substantiated by credible and consistent evidence in international literature showing that; exposure to alcohol (particularly to adolescents) through media and other communication channels is associated with increased probability that adolescents will initiate alcohol use and continue to drink more after initiation (8). Other research has shown that exposure to alcohol through advertising promotes underage drinking (9,10). This is particularly concerning given that early initiation of alcohol use has been associated with increased likelihood of developing alcohol dependence and substance use problems later in life (11). Furthermore, previous research refutes the alcohol and advertising industry arguments that advertising of alcohol only impacts the choice of brand (8,12).
In a recent South African Medical Journal (SAMJ) issue Parry, and colleagues (2012) (13) amply capture the public health case for a ban on alcohol advertising. They argue that previous experience with Tobacco control legislation and the strong evidence base indicates that advertising affects not just brand choice, but also increased likelihood of engaging in alcohol behaviours. This make a ban on alcohol advertising – preferably supplemented by other policy efforts – an effective strategy in reducing alcohol related harms. The evidence base in support of the ban on alcohol advertising as an effective public health approach is based on credible research findings. Studies show that banning advertising of alcohol goods, banning all sport and arts sponsorships, and the prohibition of alcoholic beverage promotion will reduce exposure to alcohol, thereby reducing the likelihood of early alcohol use and its related harms (14). Therefore researchers and other public health advocates are candid in their views that rapid and decisive action must be taken to adopt a total ban on alcohol advertising.
The public health argument has been met with vociferous opposition from the alcohol industry (including the Industry at the helm of the Association for Responsible Alcohol Use- ARA) and other detractors, who cite that a ban on alcohol advertising would have “a devastating effect on the economy” (15). These effects they say, would be manifested through the loss of almost 12 000 jobs, mainly in the advertising industry. In addition, the alcohol industry claim that a ban would result in increased illicit trade of alcohol, which could also negatively impact the economy. What can only been seen as a weak justification by the alcohol industry (which is self-regulated) are arguments that, given the high proportion of alcohol abstainers in South Africa, the onus to drink in a safe and responsible manner rests with the individual drinker. They go on to assert that education and awareness can help to mitigate the risks of harmful alcohol use.
Taking a wide lens approach to the issue, public health has (and should) be concerned with understanding how multiple factors interact to produce an adverse effect on health. Alcohol use and misuse are associated with a range of determinants and consequences operating within multiple domains in which the drinker exists. Consequently exposure to alcohol advertising is viewed as an important contributory factor accounting for alcohol use and misuse. Given the evidence that exposure through advertising has consistently been shown to increase the likelihood to drink and continue drinking, it follows that decisive action must to be taken to bring advertising under control through public health policies and regulations.
The somewhat short-sighted and individually focused approach, proposed by the industry, fails to recognise that a ban on alcohol advertising is one (albeit an important) component of a more comprehensive and multi-faceted suite of policies and health promotion interventions to mitigate the adverse effects of alcohol use on public health. South Africa currently ranks among the highest alcohol per capita consumers in the world, is the lead drinking country in Sub-Saharan Africa, and rates as one of the riskiest drinking nations globally, in terms of patterns of drinking (mainly heavy episodic drinking) (16). This evidence combined with alcohol attributable harms, refutes the industry’s defence that personal responsibility (supported by education and awareness) will singularly result in a reduction in alcohol related harms.
Appointment of an Interministerial Committee
The South African government signalled their political will and commitment to a reduction in alcohol related harms by appointing an Interministerial Committee (IMC) in 2010, under the direction of the Minister of Social Development. This committee was tasked to develop and implement strategies and interventions to reduce the harm associated with alcohol use. The most recent global status report on alcohol use cites the establishment of the IMC as a significant country level effort and show of political leadership to reduce alcohol related harms (16). In 2013 cabinet approved the “The Control of Marketing of Alcoholic Beverages Bill”, another signal of the IMC’s commitment to seeing a ban on alcohol advertising brought to fruition.
Given the vested interests of the government (which profits significantly from the alcohol industry’s contribution to South Africa’s GDP) and the alcohol industry, it is unsurprising that not all government ministries share the public health argument for a ban on alcohol advertising. Ongoing dialogue on this issue has seen a fair amount of opposition from ministries, such as the Department of Trade and Industry and National Treasury, as well as the South African Chamber of Commerce and Industry. These stakeholders understandably stand to lose and/or have to confront the consequences of, the loss of fiscal power in the event of a ban. Nonetheless, the IMC projects a unified front in their support of the public health approach to the ban. When the Department of Social Development Minister, Mnr Bathabile Dlamini announced cabinet’s approval of the draft Bill banning alcohol advertising, she affirmed that the approval was couched within a strong scientific evidence-base. In addition she cited that the tangible cost of alcohol use doubled that of which is brought in by excise tax and valued added tax combined (17). This clearly showed government’s sway in favour of the public health approach. Furthermore, the fact that relevant ministries (including those that are potentially opposed to the ban) have been appointed to jointly address a reduction in alcohol related harms is encouraging. It reflects a commitment to consultation, inclusivity and collaboration on alcohol laws and public health policy development in South Africa.
Notwithstanding the intrinsic worth of inter-ministerial collaboration, policy development is by its very nature, a messy and fraught process. This was clearly demonstrated over two decades ago when the ban on tobacco advertising was called for. Industry opposition, delays in parliamentary debates, deferments in political decision making, claims of job losses, and claims of attacks on personal freedom characterised that advertising ban (18). In spite of this fractious policy development process, a strong evidence base, political will and leadership and advocacy efforts, saw the Tobacco Products Control Act being adopted in 1993, implemented in 1995 and amended in 2007. The latter amendments indicate that despite a long delay in initial adoption of the tobacco control policy, tobacco control has remained at the forefront of public health discussions.
The draft bill on a ban on alcohol advertising is subject to mandatory public comment, and regulatory impact assessments (RIA). The Department of Health completed an RIA previously. However, a request for an independent RIA quietly slipped through in November 2013, resulting in a further delay to proposals to ban alcohol advertising. Questions remain as to whether these delays are simply the result of a natural process of public health policy development or if government is buckling under the weight of industry and opposing ministries to the ban. As we proceed slowly, but steadily toward the adoption of an advertising ban on alcohol products we can only hope that commercial interests do not dwarf the interests of public health.