Background

There are only two major statements which define alcohol policy development at the global level. There has not been any comparative analysis of the details of these key texts, published in 2010 and 2022 respectively, including how far they constitute similar or evolving approaches to alcohol harm.

Methods

Preparatory data collection involved examination of documents associated with the final policy statements. A thematic analysis across the two policy documents was performed to generate understanding of continuity and change based on comparative study. Study findings are interpreted in the contexts of the evolving conceptual and empirical literatures.

Results

Both documents exhibit shared guiding principles and identify similar governance challenges, albeit with varying priority levels. There is more emphasis on the high-impact interventions on price, availability and marketing in 2022, and more stringent targets have been set for 2030 in declaring alcohol as a public health priority therein, reflecting the action-oriented nature of the Plan. The identified roles of policy actors have largely remained unchanged, albeit with greater specificity in the more recent statement, appropriately so because it is concerned with implementation. The major exception, and the key difference in the documents, regards the alcohol industry, which is perceived primarily as a threat to public health in 2022 due to commercial activities harmful to health and because policy interference has slowed progress.

Conclusions

The adoption of the Global Alcohol Action Plan 2022-30 potentially marks a pivotal moment in global alcohol policy development, though it is unclear how fully it may be implemented. Perhaps, the key advances lie in advancing the ambitions of alcohol policy and clearly identifying that the alcohol industry should not be seen as any kind of partner in public health policymaking, which will permit progress to the extent that this influences what actually happens in alcohol policy at the national level.

Alcohol has garnered increased attention at the global health level in recent decades [1, 2]. There is a growing consensus in public health that global cooperation led by the World Health Organization (WHO) is needed to support the national policy changes that are required to address alcohol effectively as a public health issue [3,4,5]. The WHO has had a long-standing interest in reducing alcohol harms, playing key roles in developing scientific principles and evidence since the 1950s [3]. More recently, however, it has actively sought to establish a more explicit policy role, drawing the global community’s attention to the health, social, and economic burden of alcohol and how it can be reduced. These efforts have been vital in securing the inclusion of alcohol on the agendas of the World Health Assembly (WHA), the WHO’s key decision-making body.

Internationally, individual states and groups of Member States have proven to be influential players in advancing these global efforts [6]. Recent studies have shown that global institutions, particularly the WHO, are key sites of political contestation between the industry and public health actors over alcohol policy [7,8,9,10,11,12,13]. There is, however, a paucity of studies of how approaches to global alcohol policy development have actually shifted in substance in recent years [14].

Alcohol was first discussed during the fifty-eighth WHA in 2005. The Director-General was requested to report to the sixtieth WHA on “evidence-based strategies and interventions to reduce alcohol-related harm, including a comprehensive assessment of public health problems caused by harmful use of alcohol” [15]. This led to the convening of the WHO Expert Committee on Problems Related to Alcohol Consumption to review the evidence on alcohol-related harms and potential policy responses [16]. The WHA did not reach a consensus on a strategy in 2007 and instead recommended consultation to facilitate the development of a strategy by 2010 [17]. Following several rounds of consultation, the WHO Executive Board (EB) finalised the global strategy in January 2010. The Global Strategy for Reducing the Harmful Use of Alcohol (hereafter Global Global Strategy (GS)) was adopted at the WHA?s sixty-third session in May 2010 [2]. The GS provided guidance to Member States on ways to reduce the harmful use of alcohol [18]. Several WHO regional offices have since developed or revised regional strategies to align with the GS [for example: 19, 20].

Policy development by Member States has been decidedly slow and uneven. According to the WHO assessment in 2018, limited progress had been made in tackling alcohol-related harm, including on the key indicator of reduced per capita consumption [21]. Some attribute the strategy’s limited progress to its recommendations lacking “clear targets and specific goals” [22]. Moreover, implementation has been slowest for the most effective measures which reduce availability, affordability and marketing, and in low- and middle-income countries where it may be particularly needed.

Several efforts have been underway to overcome governance obstacles to implementation. First, the SAFER initiative was launched in 2019, aimed at promoting the adoption of the most cost-effective and under-used interventions. SAFER was designed to promote the implementation of high-impact policies – most importantly, pricing, retail and marketing interventions [23]. Second, as SAFER was not regarded as sufficient by itself to achieve the 2010 target of a 10% reduction by 2025, further actions were deemed to be needed, and key developments subsequently unfolded at the political level.

In February 2020, in its resolution, EB146 [18], the EB advocated for accelerated action to reduce the harmful use of alcohol. It called on the WHO Director-General “to develop an action plan (2022–2030) to effectively implement the Global strategy to reduce the harmful use of alcohol as a public health priority, in consultation with Member States and relevant stakeholders” [24]. The decision to develop an action plan also stemmed from an unsuccessful proposal to the EB by some low- and middle-income countries seeking to establish a working group tasked with reviewing the feasibility of an international treaty on alcohol control, akin to the Framework Convention on Tobacco Control (FCTC) [25]. The draft action plan was approved by the EB and adopted by the seventy-fifth WHA in 2022. The Global Alcohol Action Plan (GAAP) includes more ambitious targets for reducing alcohol consumption and specifies action areas in which to concentrate implementation efforts. The revised targets include a 20% reduction from a 2010 baseline in per capita consumption by 2030, in alignment with the Sustainable Development Goals architecture.

These policy developments have occurred alongside key advances in the evidence base on alcohol policy. First, there is broad scientific consensus that population-level approaches, including controls on alcohol pricing [26, 27], advertising [28,29,30], and availability [31] are needed to reduce alcohol-related harm. Recent analyses of policy developments in Scotland [32], Ireland [33], Lithuania [34] and Estonia [35] demonstrate the importance of this evidence base in facilitating policy change. Second, researchers have identified the alcohol industry as a key barrier to the enactment and implementation of evidence-informed policies at the national level [36, 37,38,39,40]. The evidence-base has expanded rapidly in recent years, with studies adding greater depth to our understanding of how industry actors have effectively mobilised to oppose alcohol policy development and implementation across the world [7, 9, 10, 41, 42]. There have also been significant advances in some countries, providing important lessons on how industry opposition may be overcome [32, 33, 42, 43,44,45,46,47,48,49,50,51].

Several conceptual frameworks have been developed to better understand the nature, scope, and complexity of industry power in policymaking [52,53,54]. Another emerging framework, the commercial determinants of health (CDoH), specifies the system-level factors, underlying ideas, and commercial practices that perpetuate commercial influence [55]. The latter encompasses several different political (e.g., lobbying), scientific (e.g., funding research), and reputational practices (e.g., corporate social responsibility) that promote commercial interests [55]. The nature of these practices is variable between commercial sectors and companies within sectors, with all such practices having capacity to steer policy decisions at global, regional and national levels, particularly for the largest companies and sectors [56,57,58,59,60,61]. This literature is particularly relevant for well consolidated health-harming commercial sectors such as alcohol [55].

This study explores the development of global alcohol policy against the backdrop of recent developments permitting more nuanced understanding of the alcohol industry and its political activities. This study provides the first systematic comparison of the GS and GAAP from a public health perspective. These two policy documents serve as the fundamental framework for alcohol policy globally. Therefore, our analysis aims to identify whether and how global approaches to alcohol policy have evolved, while also highlighting significant consistencies, over time. This investigation thus examines comparatively the substantive content of the two texts, with interpretation informed by the evolving conceptual and empirical literatures.

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