Alcohol use is responsible for more than 1 in 20 deaths globally and in the WHO Making South-East Asia safer South-east Asia Region. It causes more deaths than those caused by tuberculosis, HIV/AIDS, and diabetes, each. Notably, more than one in every ve deaths from from alcohol related harm: tuberculosis is attributed to alcohol use. The societal costs of alcohol a ecting the partners, children, families and communities of drinkers are estimated to be twice those Current status and way forward incurred by drinkers themselves. The per capita alcohol consumption has been increasing substantially in the South-East Asia Region since 2000. Bold policy actions and their e ective implementation are required to reverse the trends in increasing per capita consumption. WHO launched “SAFER” – an action package prioritizing ve high-impact policy action domains. The paper provides the current status of implementation of SAFER policy action package in WHO South-East Asia Region.
9 789290 227274
Making South-East Asia SAFER from alcohol-related harm: current status and way forward Making South-East Asia SAFER from alcohol-related harm: Current status and way forward
ISBN: 978 92 9022 727 4
© World Health Organization 2019
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.. Suggested citation. Making South-East Asia SAFER from alcohol-related harm: Current status and way forward. New Delhi: World Health Organization, Regional Office for South-East Asia; 2019. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in India Cover Painting: Miss Wikawee Rattanamanee, Bangkok, Thailand Contents
List of figures, tables and boxes iv
Abbreviations and acronyms vi
Foreword by Regional Director vii
Acknowledgments ix
Executive summary x
Harmful use of alcohol: A public health and developmental urgency 1
SAFER: alcohol control initiative 4
Implementation of SAFER in WHO SEA Region: a baseline assessment 5
S: Strengthen restrictions on alcohol availability 5
A: Advance and enforce drink-driving countermeasures 14
F: Facilitate access to screening, brief intervention and treatment 18
E: Enforce bans or comprehensive restrictions on advertising, sponsorship and promotions 21
R: Raise prices on alcohol through excise taxes and pricing policies 27
Monitoring and evaluation 36
The call for action 37
References 39 List of figures, tables and boxes
Figures Fig. 1: Percentage of all deaths and DALYs in WHO South-East Asia Region attributed to alcohol among all ages, and among 15–49-years-old by sex, 2017 Fig. 2: Current and projected trends in total alcohol per capita consumption (APC) (15+ years) in Litters of pure alcohol in WHO South-East Asia Region Fig. 3: WHO SAFER action package Fig. 4: The overall physical availability restrictiveness score for alcoholic beverages in WHO SEA Region, 2016 Fig. 5: The overall score for stringency of drink-driving countermeasures on a scale of 1–5 in WHO South-East Asia Region, 2016 Fig. 6: Marketing restrictiveness index (scale of 1 to 5) for alcohol in WHO South-East Asia Region, 2016 Fig. 7: Overall pricing stringency score for policies enacted to raise the price of alcoholic beverages in WHO south-East Asia Region (2017) Fig. 8: SAFER policy content score on a scale of 1–100 for selected Member States of SEA Region iv Tables Table 1: Licensing requirements and government monopolies to regulate production, export– import, retail sales in WHO South-East Asia Region, 2016 Table 2: Off- and on-premise sale restrictions on sale of alcohol Table 3: Restrictions on alcohol use in public places in WHO South-East Asia Region, 2016 Table 4: Legal blood alcohol concentration limits and driver screening methods Table 5: Penalties for drink driving for first/repeated offence in WHO South-East Asia Region, 2016 Table 6: Coverage of health services response for detection and treatment of harmful and hazardous alcohol use in WHO SEA Region, 2014–2016 Table 7: Policy situation on alcohol marketing, advertising and sponsorship in WHO South-East Asia Region Table 8:Status of taxation on alcoholic beverages and other pricing policies in WHO South- East Asia Region, 2016
Boxes Box 1: Public health burden related to Alcohol in SEA Region Box 2: Alcohol consumption levels and pattern in SEA Region Box 3: Policy options and interventions for regulating availability of alcohol
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Box 4: Government monopoly on both wholesale and retail distribution Box 5: Days of restricted/no alcohol sale in SEA Region Box 6: Restriction on h of sale Box 7: Physical availability restrictiveness score Box 8: Drink driving countermeasures score Box 9: Health services score Box 10: Policy options and interventions for marketing restrictions Box 11: Marketing restrictiveness score Box 12: Pricing stringency score to curb alcohol consumption Box 13: Policy response to reduce harmful use of alcohol in SEA Region: key points
v
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Abbreviations and acronyms
AAF alcohol-attributable fraction AIDS acquired immune deficiency syndrome APC alcohol per capita consumption BAC blood alcohol concentration DALYs disability-adjusted life year GSHS global school-based student health survey HED heavy episodic drinking HIV human immunodeficiency virus I$ International dollar MDA minimum drinking age MPA minimum purchasing age NCD noncommunicable disease RBT random breath testing SDG Sustainable Development Goal SEA South-East Asia vi STEPS STEPwise approach to surveillance TB tuberculosis UT union territory WHO World Health Organization
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Foreword by Regional Director
The harmful use of alcohol has a direct – and very negative – impact on public health and development across the world. Every year it is estimated to cause 3.3 million deaths, equating to one in every 20, and accounts for more than 5% of the global disease burden.
To counter the problem, in 2018 WHO, in collaboration with a range of development partners, launched the SAFER Initiative – an action-oriented technical package and roadmap that prioritizes five high-impact and cost-effective strategies including three ‘best buys’ to help Member States reduce alcohol’s damaging effect on health, the social fabric and economy. As the following report details, the WHO South-East Asia Region is harnessing the Initiative’s momentum, including by documenting the status of alcohol use in the Region and charting the way forward. In doing so, the report provides Region-specific policy insights pertaining to each of the Initiative’s five key strategies. There is a clear need for action. Across the Region, the harmful use of alcohol causes more than 650 000 deaths each year – more than those caused by each of tuberculosis, HIV/AIDS or diabetes. Notably, more than one in every five deaths from tuberculosis—the battle against which is one of the Region’s Flagship Priorities – are attributed to alcohol use. Increased consumption is of concern. Alcohol is a psychoactive substance with addictive vii potential. Alcoholic products are not groceries. World-wide, the WHO South-East Asia Region is one of two regions where per capita alcohol consumption has increased since 2010. It is projected to continue to rise in coming years, with young people becoming increasingly exposed to it. Should this happen, the Region’s drive to reach several key targets will be impeded. Among others, this includes the alcohol-specific 25x25 goal of a 10% relative reduction in alcohol use by 2025, the drive to End TB by 2030, Sustainable Development Goal target 3.5, which demands a 25% reduction in premature mortality from noncommunicable diseases (NCDs), and the Region’s Flagship Priority of preventing NCDs. Notably, any economic benefits connected to the production, sale and use of alcohol are dwarfed by its costs. It must be carefully regulated. WHO is committed to strengthening Region-wide efforts to prevent and reduce alcohol- related harm at all levels. We have a strong history to draw on. A resolution on the South-East Asia Regional Action Plan to implement the Global Strategy to Reduce the Harmful Use of Alcohol (2014–2025), for example, was adopted at the Sixty-seventh Session of the Regional Committee Meeting. At the same meeting, Member States adopted a Regional Action Plan to address the problem. Though the task ahead is indeed immense, by providing quality information and strong policy guidance, the following document represents a critical step forward. Together we must take many more.
Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Acknowledgments
This report was prepared by Dr Manju Rani, Regional Adviser for NCD Governance, Policy and Surveillance from the Department of Noncommunicable Diseases and Environmental Health at the World Health Organization (WHO) Regional Office for South-East Asia. Substantive contributions to the report were made by the following colleagues from the Department of Noncommunicable Diseases in the Regional Office: Dr Thaksaphon Thamarangsi, Dr Thushara Eraj Indranath Fernando, Dr Gampo Dorji and Dr Nazneen Anwar. Feedback and suggestions received from colleagues from WHO country offices – Dr Kedar Marahatta, Dr Pradeep Joshi, Dr Kencho Wangdi, Mr Suveendran Thirupathy, Dr Tara Kessaram – also contributed substantially to the development of the report. In addition, contributions are acknowledged from colleagues at WHO headquarters, in particular Ms Alexandara Flesichmann, Dr Dag Rekve and Dr Vladimir Poznyak, who coordinated the overall administration and compilation of data of the 2016 Global Alcohol and Health Survey, which has been used in this report for the policy content analysis.
Mr Naveen Agarwal and Ms Rajisha Sharma (intern) from the NCD and Tobacco Surveillance Team assisted in the compilation of the report by facilitating literature review, data extraction process, preparation of specific graphs and in formatting the report. Editorial, layout, and cover design support was provided by Document and Reports Designing team in the Regional Office.
Sincere thanks are conveyed to all WHO Member States for their assistance in reporting viii data to WHO in the Global alcohol and health survey, 2016, which made the compilation of these data and indicators possible.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Executive summary
Alcohol use is responsible for more than 1 in 20 deaths across the world and in the South-East Asia Region. It causes more deaths than those caused by each of tuberculosis (TB), human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) or diabetes. Notably, more than one in every five deaths from TB – the battle against which is one of the Region’s flagship priorities – are attributed to alcohol use. Excessive alcohol use adversely affects not just drinkers themselves, but also their partners, children, families and communities.
While all Member States in World Health Organization (WHO) South-East Asia Region have set a goal of 10% reduction in harmful use of alcohol by 2025 relative to 2010 levels in their national multisectoral plans for action, per capita alcohol consumption has increased substantially in the Region since 2010, and is projected to increase further in coming years, if it remains business as usual.
SAFER initiative In 2018, acknowledging the urgency to control and prevent the alcohol-related public health and development burden, WHO launched “SAFER” – an action package prioritizing five high- impact WHO “best buys” and “good buys”1 out of the 10 policy areas outlined in the Global Strategy to Reduce Harmful Use of Alcohol.
ix The SAFER action package S Strengthen restrictions on alcohol availability A Advance and enforce drink driving counter measures F Facilitate access to screening, brief interventions and treatment E Enforce bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion R Raise prices on alcohol through exercise taxes and pricing policies
Using data from the latest round (2016) of biennial global surveys on alcohol and health conducted by WHO, this report presents a baseline assessment of policy content across the five policy interventions prioritized under SAFER. Data are supplemented by systematic literature review as well as data from WHO ATLAS-SU Questionnaire Survey (2014) for access to screening and brief intervention.
A score was developed on a scale of 1 to 5 based on the strength of policy content for each of the five prioritized SAFER interventions. Further, a composite SAFER scorecard was developed for all the five domains on a scale of 1 to 100. In the composite score, policies that were “best buys” were given a weightage of 25% each and “good buys”,’ 12.5%. Score cards were presented for all the countries except India (where alcohol policy is a subnational subject), Democratic People’s Republic of Korea (no data available) and Maldives (which has a complete ban on alcohol).
1 The “best buys” and “good buys” categorization was published in The Updated Appendix 3 of the Global Action Plan for the Prevention and Control of NCDs 2013–2020. “Best buy” policies had an average cost–effectiveness ratio of
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Strengthen restriction on alcohol availability (best buy) Licensing systems are quite widespread in WHO South-East Asia (SEA) Region Member States. Most countries have increased the number of licenses since 2010 for any of production, retail, wholesale or all, effectively increasing the availability of alcohol. Almost all Member states have placed some restrictions for on- and off-premise sales either by hours, days, or places, though the coverage and extent of restrictions vary. Except for Timor-Leste, which has no legal minimum alcohol purchasing age, all other Member States have set a minimum legal age varying from 18 years (Bhutan, Myanmar and Nepal), to 20 years (Thailand), 21 years (Indonesia and Sri Lanka) and 18–25 years (India). The extent of restrictions on drinking in public places in different settings varies among the Member States. The overall physical availability restrictiveness score on a scale of 1-5 varies from 1.8 in Timor-Leste to 5 in Maldives with a complete ban.
Advance and enforce drink driving countermeasures (good buy) Though most countries in the Region have set blood alcohol concentration levels at 0.05% or less as per global recommendations, Sri Lanka and Myanmar have less strict limits at 0.08%. Though eight and four of the total of 10 countries reported random breath testing and sobriety check points to deter and detect drink-driving, respectively, enforcement was perceived to be rather weak. The overall score for stringency of drink-driving countermeasures varied among Member States from 2.5 to 4.6 on a scale of 1 to 5. x Facilitate access to screening, brief intervention and treatment (good buy) Several individual level interventions, such as screening for alcohol use disorders, brief intervention for harmful drinking and treatment of alcohol dependence delivered in health-care settings may reduce harmful use of alcohol and improve health outcomes. Only half of the Member States have recommendations for screening and brief intervention for alcohol use in primary health-care settings. Data on percentage of health facilities that provide screening and brief intervention or treatment are lacking in many Member States. Bhutan stands out as an exception in reporting that most of health facilities provide screening, and treatment coverage is high (more than 40%). The overall score varied from 0 to 1.9 across Member States on a scale of 1 to 5.
Enforce bans or comprehensive restrictions on advertising, sponsorship and promotions (best buy) The overall marketing restrictiveness score on a scale of 1 to 5 varied from 0.4 in Timor-Leste to 5 in Bangladesh, Bhutan and Sri Lanka, all of which have put in comprehensive bans on direct or indirect marketing of alcoholic beverages in all media including on internet/social media and at point of sale, and put in place systems to deter and detect the infringements. Many Member States have only put in either partial bans or self/voluntary restrictions for some of the media. Even though internet and social media are taking an increasing share of marketing, only a few countries have placed restrictions on alcohol advertising in these
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward media. Similarly, many Member States may strengthen the policy by strengthening restrictions on product placement, sponsorships in sports and youth events and on sale promotions by producers, retailers or owners of pubs/restaurants.
Raise prices on alcohol through excise taxes and pricing policies (best buy) While all the Member States levied excise taxes on alcohol, none implemented taxation with a key mandate of limiting the consumption of alcohol to reduce alcohol-related morbidity and mortality, and none adjusted the levels of taxes for changing inflation and income levels. The tax incidence was not assessed in 2016, but was assessed to be rather low by the five Member States that reported in 2012. Few Member States taxed traditional/indigenous alcohol, which accounts for nearly half of all consumed alcohol in the Region. With few exceptions, none of the Member States in the Region combines taxation with other supplemental pricing policies. Hence, there is a risk that the alcohol industry can compensate for the tax burden by offering promotion of alcohol. Overall, the price stringency score on a scale of 1 to 5 varied from 0.75 to 1.75. It may be useful to set an aspirational goal at regional or global level for the level of taxes (e.g. 70% or 75%) as a percentage of the final price, as has been done for tobacco.
Overall SAFER score On a scale of 1 to 100, the overall SAFER composite score varied from 31.3 to 68.3. This shows substantial policy space to further strengthen the policies to prevent alcohol-related morbidity and mortality in the Region. xi
The analysis presented in the paper should be interpreted keeping in mind the limitations of the data and the scoring system. The scoring for each prioritized intervention gave equal weightage to different components, though they may have different impacts on alcohol consumption. The data mainly pertain to policy content and not the implementation. Literature and common perceptions point to weak implementation of the policies, which may reduce the impact of these policies even if well framed. Achievement of the Sustainable Development Goal (SGD) goal 3.4 and national goal of 10% relative reduction in alcohol consumption by 2025 will require mobilization of sufficient resources (financial and human) and establishment and strengthening of sound organizational structures to fully implement policies. In addition, the monitoring systems need to be strengthened to regularly monitor policy implementation at the population level as well as alcohol consumption patterns.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward xii
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Harmful use of alcohol: A public health and developmental urgency
In the World Health Organization (WHO) South-East Asia Region,2 home to 1.9 billion persons or almost 29% of world’s population, 1 in 20 deaths is attributed to alcohol consumption (1–3). This amounts to more than 650 000 deaths each year, which is more than the deaths caused in the Region by each of diseases such as tuberculosis (TB), human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), diabetes and cervical cancer.3 Alcohol use is a threat to socioeconomic development of the Region as it is a top risk factor for disease and disability among the Region’s economically productive population in the 15–49 years’ age group (Box 1 and Fig. 1).
Box 1: Public health burden related to alcohol in SEA Region – key points 1
¤¤ Causes more deaths and disability than caused by each of diseases such as TB, HIV/AIDS or diabetes mellitus in the Region.
¤¤ It is responsible for 8.3% of all deaths among males and almost in 1 in 20 deaths, overall.
¤¤ Directly affects men of younger ages (15–49 years) disproportionately compared to women and older persons.
¤¤ The leading causes of alcohol-attributable deaths in the Region include cardiovascular diseases (22%), TB (21%), neoplasms (17%) and cirrhosis and other chronic liver diseases (15%).
¤¤ TB, road accidents and self-harm are the leading causes for alcohol-related deaths among the 15–49-years age group; cancer is the leading cause for alcohol-related deaths among those 50 years of age and older.
¤¤ Tuberculosis (20%), cardiovascular diseases (16%), digestive diseases (13%), alcohol use disorders (13%) and self-harm and interpersonal violence (9%) are the leading contributors to burden of disease and injury caused by alcohol as measured in disability-adjusted life years (DALYs).
2 WHO South-East Asia Region comprises of 11 Member States located in South Asia and East Asia, namely, Bhutan, Bangladesh, Democratic Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. 3 In SEA Region, while alcohol is estimated to have caused 684 781 deaths in 2017, TB caused 573 518 deaths, HIV/AIDS caused 881 001 deaths and DM and cervical cancer were estimated to have caused 448 529 and 95712 deaths, respectively (3).
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Furthermore, second-hand effects of alcohol are substantial and extend much beyond drinkers themselves, affecting their partners, children, families and communities. For example, the 2015–16 National Family Survey in India noted that 73.4% women whose husbands got drunk ‘often’ reported experiencing emotional, physical or sexual violence compared to 51% women whose husbands got drunk ‘sometimes’ and only 25% of women who husbands did not drink (5). The societal costs of alcohol affecting the partners, children, families and communities of drinkers are estimated to be twice those incurred by drinkers themselves (6).
Notwithstanding the unacceptably high alcohol-related public health, social and economic burden, alcohol control policies have not been very visible in the public health decision-making in most of the countries in WHO South-East Asia Region.
Fig. 1: Percentage of all deaths and DALYs in WHO South-East Asia Region attributed to alcohol among all ages, and among 15–49-years-old by sex, 2017
16.0% 14.8% 14.0% 12.0% 10.2% 10.0% 8.3% 8.0% 6.7% 6.0% 4.0% 1.6% 2.0% 1.0% 0.8% 1.1% 0.0% 2 Male Female Male Female Male Female Male Female All ages 15-49 years All ages 15-49 years Deaths DALYs
DALY – disability-adjusted life year Source: Institute for Health Metrics and Evaluation (2017) (http://ghdx.healthdata.org/gbd-results-tool, accessed 1 July 2019).
South-East Asia is one of the two WHO regions4 that has witnessed an increase in per capita alcohol consumption since 2000 (a relative increase of 28.6% from 2010 to 2016) (Fig. 2, Box 2) (1, 6). The age-standardized prevalence of heavy episodic drinking also stagnated with almost no sign of decline between 2010 and 2016 (1). With business as usual, the total alcohol per capita consumption and its associated public health burden is projected to increase further in most of the countries in the Region (Fig. 2) (1).
The Sustainable Development Agenda has recognized the importance of controlling harmful use of alcohol. Sustainable Development Goal (SDG) target 3.5 calls for strengthening the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol. Alcohol per capita consumption is one of two indicators to monitor SDG target 3.5. Furthermore, harmful use of alcohol also has a direct impact on many health-related targets of SDGs, such as maternal and child health, infectious diseases (HIV, hepatitis and TB), noncommunicable diseases (NCDs), mental health, injuries and poisoning. Hence, controlling the harmful use of alcohol and reversing the current trends of alcohol use is a public health and development imperative in WHO South-East Region.
4 Another WHO region witnessing increase is WHO Regional Office for Western Pacific.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Fig. 2: Current and projected trends in total alcohol per capita consumption (APC) (15+ years) in Liters of pure alcohol in WHO South-East Asia Region
10.0 Thailand 9.0
8.0 India
7.0 Myanmar 6.0 Timor-Leste 5.0 Sri Lanka 4.0
In litres of pure alcohol 3.0 Nepal 2.0
1.0
– 2010 2016 2020 2025
Source: WHO Global Survey on Alcohol and Health, 2016.
Box 2: Alcohol consumption levels and pattern in SEA Region
¤¤ Rapidly increasing adult consumption levels: The average adult alcohol per capita consumption (APC) increased from 2.9 Litters in 2005 to 3.4 Litters in 2010 and 3 4.5 Litters in 2016 – an increase of almost 104% between 1990 and 2016 (1).
¤¤ Increase is much more rapid in some Member States: Between 2010 and 2017, the following increases in APC were recorded: India (4.3 to 5.7 Litters), Myanmar (2.9 to 4.8 Litters), Thailand (7.6 to 8.3 Litters) and Timor-Leste (0.7 to 2.1 Litters);
¤¤ The APC is projected to increase further to 2030 in seven of the Member States accounting for a majority of the Region’s population (1);
¤¤ Decrease in lifetime abstinence rates in many Member States;
¤¤ Large share of unrecorded alcohol: Unrecorded alcohol makes up nearly half (45.4%) of total alcohol consumption in the Region, especially in Bhutan, India, Maldives, Myanmar, Nepal and Timor-Leste (1).
¤¤ Adolescents: Alcohol use is starting early in many Member States with increasing use among adolescents, with almost, one fourth of schoolgoing adolescents (15-17 years) reporting drinking alcohol in some Member States.
A global target of 10% relative reduction in harmful use of alcohol by 2025 compared to 2010 was adopted as part of the global voluntary target on NCD prevention and control in Global Action Plan for Prevention and Control of NCDs (2013–2020) (7) and has been incorporated in the national multisectoral plans for action for NCDs by almost all the Member States in the Region (8). Fully implementing WHO “best buys” for alcohol (9) can help to achieve these targets.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward SAFER: alcohol control initiative
In September 2018, WHO launched SAFER – an action package and roadmap – outlining five high impact and cost-effective strategies that are prioritized for implementation to reduce alcohol-related health, social and economic consequences (Fig. 3). These include three WHO “best buys” for overall control and prevention of NCDs (restricting availability of alcohol, comprehensive marketing restrictions, and raising prices of alcohol through taxes and other pricing policies) and two “good buys” related to drink-driving countermeasures and health services response (9).
Three key principles underpin SAFER: implement, monitor, protect. The key components for the implementation of SAFER include: advocacy, resource mobilization, technical capacity building and programmatic action at country level. 4
Fig. 3: WHO SAFER action package The SAFER action package S Strengthen restrictions on alcohol availability A Advance and enforce drink driving counter measures F Facilitate access to screening, brief interventions and treatment E Enforce bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion R Raise prices on alcohol through exercise taxes and pricing policies Source: WHO’s SAFER alcohol control initiative to prevent and reduce alcohol-related death and disability (https://www.who.int/substance_abuse/safer/launch/en/, accessed 13 July 2019).
Using data from WHO Global Survey on Alcohol and Health, 2016 and other surveys (Annex 3), this publication examines in detail the current status of enactment of policies and legislations related to the five key strategies prioritized under SAFER in WHO South-East Region. The paper reflects on the gaps in the current policies and way forward to implementation and monitoring of the SAFER initiative in the Region to achieve the targeted relative reduction of 10% in harmful use of alcohol by 2025.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Implementation of SAFER in WHO SEA Region: a baseline assessment
All the assessment findings reported below are based on WHO Global Survey on Alcohol and Health, 2016 unless a specific source is noted otherwise. An effort was made to validate the data submitted in the 2016 survey by communicating with national counterparts via WHO country offices. The data were updated where a discrepancy was noted and a reasonable documentary proof provided to support the update. An overall composite index has been created for each of the five specified interventions, which were then combined to develop an overall SAFER score for selected Member States to help compare over time and across Member States.
The interventions have been discussed individually in succeeding sections.
S: Strengthen restrictions on alcohol availability 5
Rationale Limiting commercial availability of alcohol may prevent easy access to alcohol, especially by vulnerable and high-risk groups, and may influence social availability, contributing to changing social and cultural norms.
Policy options Physical availability of alcoholic beverages could be controlled by many means, including control on supply chain (importers, producers, distributors, sellers, product) through licensing/monopolies; on condition of sales (time and place); and on purchasers (minimum legal age) (Box 3).
Policy situation in SEA Region for regulating physical availability of alcohol Most Member States have enacted at least some legislation to restrict physical availability of alcohol as below.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Box 3: Policy options and interventions for regulating availability of alcohol (10)
¤¤ Operational licensing systems or government monopolies to regulate production, wholesaling, retail sales and serving of alcoholic beverages
¤¤ Regulating the on-premise (e.g. bars and restaurants) and off-premise (e.g. liquor stores, corner groceries, etc.) sales of alcoholic beverages by regulating the hours and days of retails sales; numbers, density and location of outlets; and regulating sales in certain places or during special events
¤¤ Establishing a minimum age for purchase or consumption of alcoholic beverages
¤¤ Preventing sales to intoxicated persons and those below the legal age
¤¤ Restricting drinking in specified public places or at official activities and functions
¤¤ Reducing or eliminating availability of illicit production, sale and distribution of alcoholic beverages
¤¤ Regulating or controlling informal (untaxed/illicit, indigenous) alcohol.
a. National control of production and sale through licensing, monopoly or ban
6 Data were elicited in the Global Survey for all the five levels of the alcohol market – import, export, production, wholesale distribution and retail sales – for both licensing and monopolies for three types of alcoholic beverages – beer, wines and spirits.
Total ban Maldives have a total ban on alcohol.5 In India, where alcohol policy is enacted at subnational level by different states, some states (Bihar, Gujarat, Manipur, Mizoram and Nagaland) and one union territory (UT) have totally prohibited sale, production and consumption of alcohol (11). Bangladesh has near total ban on alcohol, and muslims need a medical prescription to obtain an alcohol permit to consume alcohol.
Licensing and monopolies The two key models to regulate the production and sale of alcoholic beverages are monopolies and licensing systems (Box 4) (12) . Monopolies can decrease alcohol consumption by limiting the number of outlets, the outlets’ operating hours and eliminating the incentive to maximize sales (12). Having a licensing system for sale of alcohol allows opportunities for control, since infringement of laws can be met by revocation of the license (10). Furthermore, licensing can be used to limit the availability by controlling the number of licenses issued.
5 Except to be sold at tourist resorts
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Box 4: Government monopoly on both wholesale and retail distribution
Tamil Nadu State Marketing Corporation and Kerala State Beverages Corporations are unique in India, as they have state-sanctioned monopoly on both the wholesale and retail trade of commercial alcoholic beverages. Government monopolies on all or part of the retail or wholesale market is considered an effective mechanism for implementing alcohol control measures, provided monopolies operate from a public health perspective.
Monopolies Alcohol monopolies exist when governments exercise exclusive control over the alcohol market or some aspects of it. Few SEA Region Member States have enacted government monopoly on sales of alcohol and most countries use licensing systems (Table 1). Some countries use a combination of licensing and monopoly systems. For example, Bangladesh has a licensing system at all levels of the alcohol market as well as government monopoly for import, production and retail sales of all three types of beverages. In India, each state and UT has full control of its alcohol legislation and hence the licensing and monopoly systems vary across states. Some states have government monopolies for wholesale and/or retail sales, while others use different forms of licensing systems. For example, four states (Andhra Pradesh, Chhattisgarh, Delhi, Orissa) have monopolies of wholesale distribution, while others have only retail sales monopolies (Bihar, Jharkhand, Karnataka) and some have monopolies for both wholesale and retail sales (Kerala, Rajasthan, Tamil Nadu) (11). 7 Seven of the nine responding Member States reported monopolies as well as licensing only for import of alcohol.
For all other levels of the alcohol market, Member States reported having licensing systems (Table 1).
While the widespread presence of licensing systems regulating alcohol shows potential for effective regulation, in practice countries may increase the availability of alcohol by increasing the number of licenses. Most of the countries in the Region have indeed increased the number of licenses for either production, retail sales and/or wholesale (Table 1). b. Off- or on-premise sale restrictions Regulating the hours and days of sale and the density of alcohol outlets, i.e. the concentration of alcohol outlets in a geographical location is another effective method of restricting physical availability of alcohol at the population level. The Global Survey on Alcohol and Health 2016 elicited information on restrictions of h, days, places, outlet density and on specific events for off-premise sales as well as for on-premise sales, separately for all three categories of alcoholic beverages. In general, the restrictions did not vary by the category of alcoholic beverages. All countries in the Region with the exception of Timor-Leste are using this policy tool to regulate the availability of alcohol (Table 2).
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward No No No No No 4.2 Yes Yes Yes Yes beer No data Increased Increased Yes, only for Timor-Leste 5 No No No No Yes Yes Yes Yes Yes Yes No data No data Thailand Increased 5 No No No No Yes Yes Yes Yes Yes Yes Increased Increased Increased Sri Lanka 1 1 1
** ** ** ** ** ** ** ** 2.5 Yes Yes No No No No Yes Yes Yes Yes Nepal* increased increased increased 5 No No No No Yes Yes Yes Yes Yes Yes for bear Increased Increased Myanmar Increased only 8 *** *** *** *** No No No No Yes Yes Yes Yes Yes 3.75 Yes Indonesia Increased Increased Increased 5 No No No No Yes Yes Yes Yes Yes Yes Bhutan Increased Unchanged Unchanged 5 No No Yes Yes Yes Yes Yes Yes Yes Yes Increased Unchanged Unchanged Bangladesh License required for Export
Wholesale/distribution Retail sales Monopolies Export Import Licensing/monopoly score Wholesale/distribution Retail sales Import Production Changes in licenses issued for (change since 2010) Production Production Retail sales Wholesale/distribution Table 1: Licensing requirements and government monopolies to regulate production, export–import, retail sales in WHO South-East Asia Reg ion, 2016 Notes: Maldives is not shown in the table as it has a total ban on alcohol. India also included each state differ ent licensing and monopoly systems. Source: WHO Global Survey on Alcohol and Health, 2016. *Nepal data refers to the year 2012. ** The are updated based co mmunication from MoHP focal point Nepal. *** data for Indonesia updated based on communication from WHO Country office.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Restricting days of alcohol sale This tool to reduce the overall alcohol consumption is rather under-used. Even among the Member States that have used the tool, most are motivated by religious or other extraneous considerations (e.g. law and order), with few exceptions. The number and types of these days also vary across Member States, ranging from once a week to only few days in a year (Box 5).
Box 5: Days of restricted/no alcohol sale in SEA Region countries
Bangladesh: Fridays, a day of religious importance for Muslims.
Bhutan: Tuesday as “dry day”.
India: All states/UTs have provisions for closure of liquor shops generally on national holidays, election days and particular day(s) in a week/month. National holidays and election days are “dry days” at national level. States in India can assign any other day as “dry day”. For example, Andaman and Nicobar has assigned pay day as “dry day”; Delhi keeps sale closed on all the major religious and national holidays.
Sri Lanka: No sale on full moon poya day, and all major Buddhist religious festivals.
Thailand: No sale on key religious days such as Buddhist holidays.
9 Restricting hours of alcohol sale Except Timor-Leste, all Member States have restricted the number of hours of on-premise alcohol sale. Thailand has the most restricted hours of off-premise sale, allowing off-premise sale only for 8 hours a day from 11:00 to 14:00 and then from 17:00 to 22:00 (Box 6).
Box 6: Restrictions on hours of sale
Bhutan: 13:00 to 22:00
Nepal: 10:00 to 22:00 (new National Alcohol Regulatory and Control Act proposes timings from 17:00 to 00:00)
Sri Lanka: 11:00 to 22:00 (on-premise); 08:00 to 22:00 (off-premise)
Thailand: 11:00 to 14:00, and 17:00 to 22:00 (off-premise)
Alcohol outlet location Legal restrictions for controlling locations of alcohol outlets in some Member States are closely related to restricting alcohol use in public settings. Nepal, India and Thailand have set
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward regulations to disallow issue of license if a premise is located close to educational institutions or places of worship. In Nepal, alcohol outlets are restricted within 200 m of school/colleges, temples or any major historical venues, though gaps in implementation remain.
In India, the Supreme Court has banned sale and advertising of alcohol on national and state highways. Liquor shops cannot be situated within a distance of 500 m from the outer edge of the highways or service lanes and cannot be directly accessible from the highways.
Alcohol outlet density Control of alcohol outlet density is an effective means of addressing alcohol availability at the macroeconomic level; however, it is not much used in WHO SEA Region. Only two countries in the Region reported regulating the density of alcohol outlets – Sri Lanka for both on- and off-premise outlets; and Myanmar only for on-premise outlets. In India, subnationally, many states such as Haryana, Himachal Pradesh, Jammu and Kashmir, Kerala, Maharashtra and Orissa regulate the density of outlets (11). 10
Control on specific events Sale to intoxicated persons: Most Member States reported having restrictions of on-premise sale of all types of alcoholic beverages to intoxicated persons, except Indonesia and Timor-Leste. India did not report such restrictions at national level but may have subnational regulations.
Off-premise sale restrictions at petrol stations: Limiting availability of alcohol to drinkers in transportation settings will help prevent negative consequences to drivers, passengers and pedestrians, reducing overall road traffic injuries. However, less than half of the Member States (Bhutan, Nepal, Sri Lanka and Thailand) reported enacting this policy (Table 2).
The overall on-premise sale restrictiveness score ranged from 1.1 in Timor-Leste to 5.0 in Sri Lanka. The score for off-premise sale restrictiveness ranged from 0 in Timor-Leste to 3.3 in Thailand to 5.0 in Sri Lanka.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Table 2: Off- and on-premise sale restrictions on sale of alcohol
Intox- Outlet Specific Petrol Overall Days hours Place icated Member density events stations score States persons Off On Off On Off On Off On Off On Off On Off On Bangladesh Yes Yes Yes Yes No No Yes Yes Yes Yes No Data Yes 2.5 4.2 Bhutan Yes Yes No Yes No No Yes Yes Yes Yes Yes Yes 2.5 4.2 Indonesia No No Yes Yes NR ND Yes Yes Yes2 Yes2 No No 1.7 1.7 Myanmar No No Yes Yes No Yes Yes Yes Yes Yes No Yes 2.5 4.2 Nepal* No1 No1 Yes Yes No No Yes Yes NR Yes Yes No 0 0.8 Sri Lanka Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 5.0 5.0 Thailand Yes Yes Yes Yes No No Yes Yes No No Yes Yes 3.3 3.3 Timor-Leste No No No No No Yes No No No No No No 0 1.1 Source: WHO Global Survey on Alcohol and Health, 2016. *For Nepal, the data refers to 2012 round 1 The data are updated based on communication from MoHP focal point Nepal 2 Data for Indonesia updated based on communication from WHO Indonesia Country office. c. National minimum purchasing age
Increasing the national legal minimum age for purchase of alcohol can reduce alcohol 11 consumption and related harms among young people and particularly drink-driving accidents (13). National legal age limits for purchasing alcohol for both on- and off-premise sales, taken from the Global Information System on Alcohol and Health, are summarized below.
Maldives and Bangladesh have total prohibition- of alcohol sales and consumption and hence may not need any age limit regulation. The remaining eight countries in the Region except Timor-Leste have enacted national or subnational laws specifying the minimum legal age for alcohol purchase, which is the same for both off-premise sales and on-premise service and does not vary by type of alcoholic beverage. The minimal legal age varies across the Region, being 18 years in Bhutan, Myanmar, and Nepal, 20 years in Thailand and 21 years in Indonesia and Sri Lanka. India does not have a national minimum legal age, but many states (at subnational level) have specified the minimum legal age varying from 18 years (Rajasthan) to 25 years (Haryana, Maharashtra, Punjab, Chandigarh and Delhi) (11).
Furthermore, most Member States have set the same legal age limit for minimum purchasing age (MPA) and minimum drinking age (MDA), except Thailand, where the MPA is 20 years, implemented under the 2008 Alcohol Beverage Control Act, and MDA is 18 years, enacted under the Child Protection Act, 2003 (14).
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward The status of enforcement of the national legal minimum age needs to be further assessed in the Region, as almost one fourth of schoolgoing adolescents 13–17 years of age in Bhutan and Thailand are reported to be current drinkers, as reported in the most recent round of Global school-based student health surveys (GSHSs) in these countries (15, 16).
d. Restrictions on drinking in public Restrictions on alcohol use in public places is seen as an approach to promoting public order and safety. Alcohol-free settings can be broadly categorized into three groups: workplace setting, public facility areas, and areas for social, cultural and leisure events (14).
All the countries in WHO South-East Asia Region, with few exceptions, have either banned alcohol use in work settings (government offices and workplaces) or put in partial restrictions (Myanmar, Sri Lanka and Thailand). Only Indonesia reported either no restrictions or voluntary or self-regulation (Table 3). All the Indian states and UTs have implemented this ban across all settings except at leisure events (where the restrictions vary sub-nationally by state), with penalties for violation varying from INR 200 to INR 50 000.
Table 3: Restrictions on alcohol use in public places in WHO South-East Asia Region, 2016
Country Govern- Work- Educa- Health- Public Parks Plac- Leisure Sport- ment places tional care estab- trans- and es of events ing offices build- lishments port streets wor- events ings ship 12 Bangladesh Ban Ban Ban Ban Ban Ban Ban Ban Ban Bhutan Ban Ban Ban VR/SR Ban NR Ban NR VR/SR India Ban Ban Ban Ban Ban Ban Ban VR/SR Ban Indonesia Bana Bana Bana Bana Bana Bana Bana Bana Bana Maldives Ban Ban Ban Ban Ban Ban Ban Ban Ban Myanmar Ban PR Ban Ban PR PR Ban PR PR Nepal* Ban Ban Ban Ban PR VR/SR Ban PR Ban Sri Lanka Bana Ban Bana Bana Bana PR VR/SR NR PR Thailand PR PR PR Ban PR PR NR NR Timor-Leste Ban PR Ban Ban Ban PR PR PR PR
PR – partial restriction; VR – voluntary; SR – self-restricted; NR – no restrictions Source: Global Survey on Alcohol and Health (2016) *Nepal data is from 2012 survey a The data are updated based on communication from country and different from those reported in Global Survey (2016)
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Overall score of restrictiveness of physical availability of alcohol in SEA Region The overall composite score of restrictiveness of physical availability (Box 7) on a scale of 1 to 5 varied from 1.8 in Timor-Leste to 5.0 in Maldives with complete ban, showing that Timor-Leste overall has the least restrictive policy environment, while Maldives, Bangladesh and Sri Lanka have a more restrictive policy environment (Fig. 4).
Box 7: Physical availability restrictiveness score
An overall physical availability restrictiveness score (1–5) was developed to assess the stringency of policies that restrict physical or commercial availability of alcohol. An equal score is assigned for each of the five policies included in the score and the final score is the average of all policies. The scoring for each of policy was done as below.
Licensing/monopoly: A score of 1 is assigned for each beverage type (beer, wine and spirit), for each of the four levels of alcohol market (import, production, wholesale distribution, retail sales) if there is a licensing/monopoly, otherwise a score of 0 is given, giving a total score of 12 across all levels of market standardized to a scale of 5.
On-premise sales: A score of 1 is given if there are any restrictions by each of six criteria (days, hours, place, specific events, outlet density, to intoxicated persons), and 0 for no restrictions, giving a total score of 18 standardized to a scale of 5.
Off-premise sales: Similar to on-premise sales, except that the criteria for sale to 13 intoxicated persons is replaced by sale at petrol stations.
Legal age restrictions: If there is no minimal legal purchase age, the score is 0; 1 if 18 years or less; 2 if 19 years and above. The score is then standardized to a scale of 5.
Restrictions on drinking in public: Data on restrictions on public drinking was assessed for 9 places – work places (government building, workplaces), public facilities (educational building, establishments, public transport), areas of social, cultural and leisure events (parks and streets, places of worship, leisure events, sporting events). A score of 2 was given for complete ban, 1 for partial restrictions, and 0 for no or self- regulation, giving a maximum score of 18, standardized to a scale of 5.
A country with complete ban on alcohol such as Maldives will receive a score of 5, while a country with no licensing and no off- or on-premise sale restrictions, no minimum legal age and no restrictions on public drinking will receive a score of 0. The physical availability restrictiveness score varies from 1.6 in Timor-Leste to 5 in Maldives, which has a total ban on alcohol.
Limitation: The score does not take into account varying degrees of restriction (for example hours of on- or off-premise restrictions, and assigns the same score irrespective of whether it is a 1 hour or 4 hours restriction). Furthermore, different policy components may have different impact on population-level alcohol consumption; for example, off- premise sales may be more important than on-premise sales in many settings, but these are treated equally in the score. In addition, it does not take into account
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Fig. 4: The overall physical availability restrictiveness score for alcoholic beverages in WHO SEA Region, 2016
5.0 5.0 4.7 4.5 4.3 4.0 4.0 3.8 3.6 3.4 3.5 3.1 3.0 2.5 2.0 1.8 1.5 1.0
Physical availability restricveness score 0.5 0.0 Bangladesh Bhutan Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste
Note: India is not included as they have subnational regulations that vary by state. Source: WHO Global Survey on Alcohol and Health, 2016. Data for Nepal refers to 2012 survey round as well as updated based on communication from MoHP focal point Nepal.
14 A: Advance and enforce drink-driving countermeasures
Rationale In 2017, almost 8% of all deaths from injuries including road traffic injuries in the SEA Region were attributed to alcohol, varying from 10% in India to 13% in Thailand (3). Drink-driving countermeasures is a key policy tool to reduce both the alcohol-related problems and road traffic injuries, as driving under influence is one of the major risk factors for road traffic injuries not only among drivers, but also among passengers, other drivers and pedestrians.
Policy options Drink-driving countermeasures consist of both legislative and non-legislative measures (e.g. public awareness raising), both of which complement each other (14).
The legislative component is based on three key legal frameworks:
¤¤ Defining behaviour of driving under the influence of alcohol: Blood alcohol concentration is the gold standard. WHO recommends establishing blood alcohol concentration (BAC) limits of less than 0.05% with a lower limit of 0.02% for novices and professional drivers (operators of commercial vehicles) (10).
¤¤ Systems to screen any drink-driver on the road: Random breath testing (RBT) is the best practice and establishing sobriety checkpoints at certain fixed geographical points is the less effective alternative.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward ¤¤ Legal framework for penalty and further obligations for drink-driving offenders: Other policy options include graduated driving licenses for novice drivers, mandatory driver education, counselling/treatment programmes, provision of alternative transportation until after the closing time of drinking places and ignition interlocks where affordable, to reduce alcohol-impaired/influenced driving (10).
Policy situation in SEA Region All the SEA Region Member States have some type of drink-driving countermeasure legislation. Drink-driving countermeasures score is discussed in Box 8.
Box 8: Drink-driving countermeasures score
An overall drink-driving countermeasure score (1–5) was developed to assess the stringency of policies that detect and deter drink-driving. An equal score is assigned for each of the four policy components included in the score. The scoring for each policy component was done as follows:
Stringency of BAC levels: A score of 2 is assigned for BAC levels less than or equal to 0.05%, score of 1 if more than or equal to 0.08%, and a score of 0 if no legal blood alcohol concentration limits have been defined. The scoring is done separately for the general population, young/novice drivers and for professional/commercial drivers, giving a total maximum score of 6, standardized to a scale of 5.
Drink-driving deterrent measures: A score of 2 is given if the country has put in 15 place random breath testing, a score of 1 if it has sobriety checkpoints and additional score of 1 if it has graduated licensing, giving a total score of 4, which is standardized to a scale of 5.
Severity of penalties for drink-driving for first offence: For every type of penalty, 1 point is given, giving a total score of 7 across 7 possible types of penalties (community service, detention short- and long-term, fines, license suspended/revoked, mandatory treatment, penalty points, vehicle impounded). The score is standardized to a scale of 5.
Penalties for drink-driving for repeated offence: Same for penalties for first offence.
A country with a BAC level of less than or equal to 0.05% and with both random breath tests and sobriety check points as well as graduated licensing and severe penalties will have a score of 5.
The drink-driving countermeasure score varies from 2.5 in Myanmar, Sri Lanka to 4.6 in Timor-Leste.
Limitation: The score does not take into account varying degrees of penalties for each type (for examples of a country with a fine of $10 has been given the same score as another country with a fine of $1000). In addition, it does not take into account the level of implementation of the policies.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward a. Blood alcohol concentration limit Maldives have a total ban on alcohol. Bangladesh, Nepal and Indonesia have zero tolerance. India, Thailand and Timor-Leste have set the BAC level at 0.05% or lower as per the global recommendations. However, Bhutan (only for general population), Sri Lanka and Myanmar have set less strict BAC limits at 0.08% (Table 4). Research has estimated that countries experience a decrease in fatalities and injury crashes of between 5% and 18% after reducing their BAC limits from 0.08% to 0.05% (1).
Table 4: Legal blood alcohol concentration limits and driver screening methods
Country General Young/ Profes- Perceived Random Sobriety Graduated popula- novice sional/ level of breath check- licensing tion drivers commer- BAC en- testing points cial driv- forcement (RBT) use ers on a scale of 0–10 Zero Zero Zero Bangladesh 5 Yes Yes Yes tolerance tolerance tolerance Zero Zero Bhutan 0.08% 10 Yes No Yes tolerance tolerance India 0.03% 0.03% 0.03% 4 Yes Yes No data Zero Zero Zero Indonesia* No data Yes No No tolerance tolerance tolerance 16 Maldives Total ban Total ban Total ban No data No data No No data Myanmar 0.08% 0.08% 0.08% 2 Yes No No Zero Zero Zero Nepal** No data Yes No No tolerance tolerance tolerance Sri Lanka 0.08% 0.08% 0.08% 7 Yes No No Thailand 0.05% 0.05% 0.05% 4 No Yes Yes Timor-Leste 0.05% 0.05% 0.05% 3 Yes Yes Yes Source: WHO Global status report on alcohol and health, 2016. *Indonesia reported zero tolerance in 2012 and none in 2016 survey. We have used the 2012 response here . **Based on the policy interventions submitted to Regional Office
b. Establishment of systems to deter and detect drivers under the influence While three Member States (Bangladesh, India and Timor-Leste) reported having both random breath testing and sobriety checkpoints, four countries (Bhutan, Indonesia, Myanmar and Sri Lanka) reported only random breath testing. Thailand is the only country that reported only establishing sobriety checkpoints and no random breath testing. No response was received from Maldives, which however reported zero tolerance and total ban.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Bangladesh, Bhutan, Thailand and Timor-Leste also reported graduated licensing where new drivers receive restricted license with zero tolerance for alcohol use. This in essence has an effect of reducing the BAC limits for novice drivers. c. Drink-driving penalties Flat fines were the most common drink-driving penalty reported by Member States followed by short- or long-term detention. Some Member States also use driving license suspension (Bangladesh, Bhutan, India, Myanmar and Nepal), vehicle impoundment (Timor-Leste), penalty points (Bangladesh, Nepal and Timor-Leste), and mandatory treatment (Bhutan and Nepal) (Table 5). d. Perceived level enforcement of BAC In 2016, the average perceived level of enforcement of BAC policies among all reporting countries was only 5 (9) on a scale of 0 to 10, with 0 indicating “not enforced” and 10 indicating “fully enforced”. The perceived level of enforcement ranged from 2 and 3 in Myanmar and Timor-Leste, respectively (based on both expert and empirical basis) to 10 in Bhutan (Table 5).
Table 5: Penalties for drink driving for first/repeated offence in WHO South-East Asia Region, 2016
Country Commu- Detention Fines License Man- Penalty Vehicle im- nity (short- suspend- datory points pounded 17 service or long- ed/ re- treat- term) voked ment Bangladesh No Yes Yes Yes No Yes Yes Yes, for Yes, for first Bhutan No No Yes repeated No No offence only offences India No data No Yes No No No No Indonesia Yes Yes Yes Yes Yes Yes Yes Maldives No data No data No data No data No data No data No data Myanmar No Yes Yes Yes No No No Nepal* No1 Yes Yes Yes No1 Yes No Sri Lanka No Yes Yes Yes No No No Thailand Yes Yes Yes Yes No No No Timor-Leste No Yes Yes Yes Yes Yes Yes
Source: WHO Global Survey on Alcohol and Health, 2016; * for Nepal data from 2012 survey was used; 1 The data are updated based on communication from MoHP focal point Nepal.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Overall score for stringency of drink-driving countermeasures Most of the Member States in WHO South-East Asia Region have put in place some drink- driving policy countermeasures, with the overall score ranging from 1.3 to 4.6 (Fig. 5). While some Member States have not utilized all the policy tools available, in others the enforcement needs to be strengthened to have an impact on alcohol consumption levels and its associated health and social consequences.
Fig. 5: The overall score for stringency of drink-driving countermeasures on a scale of 1–5 in WHO South-East Asia Region, 2016
5.0 4.6 4.5 4.3 4.0 3.5 3.3 3.3 3.3
3.0 2.7 2.5 2.5 2.5 2.0 1.5
Stringency of drink-driving 1.0 0.5 0.0 Bangladesh Bhutan Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste 18
Source: WHO Global Survey on Alcohol and Health, 2016; Data for Nepal refers to 2012 survey round as well as updated based on communication from MoHP focal point Nepal.
F: Facilitate access to screening, brief intervention and treatment
Rationale Several individual-level interventions delivered in health-care settings are effective in reducing harmful use of alcohol and improving health outcomes for individuals, with a potential significant impact at population level. Health services may also help to raise awareness about alcohol-related harms, support alcohol interventions and advocate for community support.
Policy options The most effective interventions include: screening and assessment of alcohol use disorders; brief interventions for hazardous and harmful drinking; and treatment of alcohol dependence in varying severity. Screening and brief intervention for early identification of problem drinkers as the most effective intervention needs to be introduced through integration with health prevention and promotion programmes at the community level.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Situation of health services response in SEA Region Data from both Global Alcohol and Heath survey 2016 and WHO ATLAS-SU questionnaire survey (2014) of 162 countries, territories and areas have been used to assess coverage of health services response (17). The later survey gathers information on a wide range of available resources (administrative, financial and human, pharmacological treatment, regulations, resources for prevention, etc.) that contribute to the prevention and treatment of substance- use disorders (17) (see also Annex 1). a. Screening and brief intervention Health-care professionals need to be able to recognize harmful and hazardous alcohol use among patients presenting to a wide range of health services within a routine primary care setting or high-risk settings (e.g. trauma care, liver disease clinics) through opportunistic alcohol screening. Well-tested alcohol screening tools (e.g. AUDIT, AUDIT-C, FAST) are available, which are as valid as more complex clinical interviews. The screening should be followed by brief intervention or treatment for alcohol dependence, depending on the outcome of the screening.
Screening and brief intervention have not yet been initiated in most of the countries in WHO South-East Asia Region. Only Bhutan, India, Myanmar, Sri Lanka and Thailand reported having recommendations for screening and brief intervention for alcohol use in primary health care. Nepal is providing screening and brief intervention as part of NCD PEN protocol and mental health-care package (email communication). Except for Bhutan and Sri Lanka, which reported most of the health services in primary health care providing screening and brief intervention for alcohol use, others either reported none of the health facilities providing brief 19 intervention or have no data on it. In Thailand, there is an effort to set up routine screening in health services, especially for patients at risk and with alcohol problems such as pregnant women and chronic disease patients; however, it is not yet fully implemented in all health- care settings (14). b. Treatment for alcohol dependence Treatment of alcohol dependence consists of a series of interventions that can be provided simultaneously or sequentially. The starting point is a comprehensive assessment to identify the severity of alcohol dependence and to determine the level of risk (harmful alcohol use, moderate dependence, severe dependence) and urgency of care.
Availability of treatment services for alcohol dependence seems to be limited in SEA Region Member States, and is mostly concentrated in the large cities, if available at all. Except for Bhutan (in the capital city) and Sri Lanka and Nepal (in the major cities), no other country reported specialized treatment facilities for alcohol use disorders either in the capital cities or major cities.
Regarding specifying the main provider of the treatment and rehabilitation services, most of the countries (India, Indonesia, Maldives, Myanmar and Timor-Leste) either did not provide any data or reported “public health sector” (Bangladesh, Bhutan, Indonesia, Sri Lanka and Thailand) as the main sector for treatment of alcohol use disorders for outpatient and
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward inpatient treatment, detoxification as well as rehabilitation. Only Bhutan mentioned names of nongovernmental organizations (NGOs) for rehabilitation. In Nepal, psychiatric units of teaching hospitals/government hospitals are the major providers of detoxification services, whereas NGOs run by ex-users and private sector provide rehabilitation services In line with the limited availability of treatment services. Most of the Member States reported limited or very limited coverage of these services. In the Global Alcohol and Health Survey 2016, only Bhutan reported a high treatment coverage for alcohol dependence (more than 40%). The remaining responding countries either reported limited coverage (11–20%) (Bangladesh and India), very limited (1–10%) (Nepal, Myanmar), or close to none (<1%) (Indonesia) or did not know the levels of treatment coverage (Thailand and Timor-Leste) (Table 6).
Table 6: Coverage of health services response for detection and treatment of harmful and hazardous alcohol use in WHO SEA Region, 2014–2016
Country Recommendations Percentage of services Estimated treatment for screening and that provide screening coverage for brief interventions and brief intervention people with alcohol for substance use in in primary health care1 dependence2 primary health care1 Bangladesh No None Limited (11–20%) Bhutan Yes Most (61–100%) High (more than 40%) India Yes No data Limited (11–20%) Close to none (around Indonesia Yes** No data 20 0%) Maldives No data No data No data Very limited (about Myanmar Yes No data 1–10%) Very limited (about Nepal* Yes 20–25% 1–10%) Sri Lanka Yes Most (61–100%) No data Thailand Yes No data Unknown Timor-Leste No data No data Unknown Sources: 1 WHO Atlas-SU Questionnaire Survey 2104; 2 WHO Global Survey on Alcohol and Health, 2016; *Data for Nepal refers to 2012 survey round as well as updated based on communication from MoHP focal point Nepal, not independently validated. ** data for Indonesia updated based on communication from WHO Indonesia Country office.
The overall health services score is given in Box 9.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Box 9: Health services score
An overall health services score (1–5) was developed to assess the overall access to screening, brief intervention and treatment services. An equal score was assigned to availability of screening, brief intervention and treatment coverage. The scoring for each component was done as below.
Screening and brief intervention: A score ranging from 0 to 4 was assigned as follows depending upon the percentage of health facilities/services that provide screening and brief intervention in primary health care: none, no data or unknown = 0; few (<10%) = 1 ; very limited (1–10%)=2; some (11–30%) = 3; many (31–60%) = 4; most (61–100%) = 5.
Estimated treatment coverage for people with alcohol dependence: A score ranging from 0 to 4 was assigned as follows depending upon the percentage of health facilities/services that provided treatment for alcohol dependence: none/no data/ unknown = 0; close to none = 1; very limited (1–10%) = 2; limited (1–20%) = 3; high (>40%) = 4.
Both the scores were added and standardized to a scale of 1–5, which ranged from 0 in Thailand and Timor-Leste to 5 in Bhutan.
Limitations: The score assigns equal weightage to screening/brief intervention and treatment coverage and does not take into account their potential differential impact on population-level outcomes. The coverage data reported by countries was not independently validated. 21
E: Enforce bans or comprehensive restrictions on advertising, sponsorship and promotions
Rationale Alcohol marketing promotes a collective alcohol normalization attitude, seeing alcohol consumption as an ordinary part of everyday life. It has a direct effect on those with intention to drink and those with intention to purchase, as well on initiation of drinking among youth (1).
Policy options Marketing restrictions is one of the 16 WHO best buys for overall NCD prevention and control, and is considered as one of affordable, feasible and highly cost-effective interventions (Box 10).
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Box 10: Policy options and interventions for marketing restrictions
¤¤ Setting up regulatory frameworks with a legislative basis, to regulate:
♦♦ content and volume of direct and indirect marketing in all media
♦♦ sponsorship activities (youth and sports events, etc.) that promote alcoholic beverages
¤¤ Restricting or banning sale promotions, especially in connection with activities targeting young people
¤¤ Regulating new forms of alcohol marketing techniques such as through internet and social media
¤¤ Developing effective systems to monitor marketing of alcohol products and detect any infringements and change in practices
¤¤ Setting up effective administrative and deterrence systems for infringements on marketing restrictions.
Policy situation in SEA Region for marketing, promotion and sponsorship of alcohol 22
a Advertising restrictions in traditional electronic and print media Data was elicited on advertising restrictions in key traditional media: TV (national, cable), radio (national, local), print media, cinema and billboards.
Advertising restrictions in traditional media in WHO SEA Region range from no restrictions (in Timor-Leste) to partial ban (India, Nepal, Thailand) and total ban (Bhutan, Bangladesh, Indonesia, Maldives and Myanmar).
Nepal issued a decree in 1999 to ban alcohol advertising in electronic media (TV and radio) but has not imposed a ban on print media and cinema.
In India, Programme Advertising Code under Cable Television Network Rules, 1994 and Norms of Journalist Conduct, 2010 (formed under Press Council Act, 1978) prohibit advertisement of tobacco and alcohol in print and electronic media. However, the status of advertising restrictions varies from one state to another, with no restrictions in some states (Andhra Pradesh, Arunachal Pradesh, Assam, Jharkhand, Tamil Nadu and Uttar Pradesh) to partial and complete ban in other states. Himachal Pradesh, a northern state, has complete ban on direct and surrogate ads (11).
The advertisement restrictiveness score for traditional media on a scale of 1–5 ranges from zero in Timor-Leste to 2.9 in Nepal and 5 in Bangladesh and Bhutan (Box 11).
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Box 11: Marketing restrictiveness score
An overall marketing restrictiveness score (1–5) was developed to assess the stringency of policies that restrict marketing, promotion and sponsorship of alcohol. An equal score is assigned for each of the 6 policy components included in the score and the final score is the average of all policy components. The scoring for each of policy component was done as below. Advertising restrictiveness in traditional media: For each beverage type (beer, wine and spirits) and for each of the 7 media types, a score of 0 is assigned if there are no restrictions, 1 for partial restrictions and 2 for complete ban, giving a total score of 42 across all 7 traditional media, which is standardized to a scale of 5. Advertising restrictiveness in new emerging media (internet and social media) and at point of sale: For each beverage type (beer, wine and spirits) a score of 0 is assigned if there are no restrictions, 1 for partial restrictions and 2 for a complete ban for each of the 3 platforms – internet, social media and point of sale, giving a maximum score of 18. This is standardized to a scale of 5. Product placement restrictiveness: For each beverage type (beer, wine and spirits) a score of 0 is assigned if there are no restrictions, 1 for partial restrictions and 2 for a complete ban for product placement at each of the 3 platforms – national TV, cable television and in films/movies, giving a maximum score of 18, which is then standardized to a scale of 5. 23 Sponsorship restrictiveness: For each beverage type (beer, wine and spirits) a score of 0 is assigned if there are no restrictions, 1 for partial restrictions and 2 for a complete ban for sponsorships at youth and sports events, giving a maximum score of 12, which is then standardized to a scale of 5. Restrictions on sale promotions: For each beverage type (beer, wine and spirits) a score of 0 is assigned if there are no restrictions, 1 for partial restrictions and 2 for a complete ban on sale promotions by owners of pubs and bars, producers and retailers, giving a maximum score of 17, which is then standardized to a scale of 5.
Detection and penalties for infringement of marketing restrictions: A score of 1 is given if a country has any system of detecting infringements and 1 if it has at least one type of penalty system, giving a maximum score of 2, standardized to a scale of 5. The total score from all the six components was added (maximum score 30) and then again standardized on a scale of 5 to give overall marketing restrictiveness score. A country with a complete ban on any direct or indirect marketing of alcohol such as Maldives and Bangladesh will receive a score of 5, while a country with no restrictions on advertising, sale promotion, product placement or sponsorship will receive a score of 0. The marketing restrictiveness score varies from 0.41 in Timor-Leste to 5 in Maldives, Bangladesh and Bhutan. Limitation: The score does not take into account the implementation of the policies.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward b Advertising on internet and social media at point of sale New forms of media have emerged, such as internet and social media. With the exponential increase in people with internet access and on social media platforms such as Facebook and YouTube in almost all the countries of SEA Region, more and more of the population may be exposed to advertising and marketing of alcohol on these platforms. Hence, restricting advertising on these platforms will become increasingly important over time.
However, only Bangladesh, Bhutan, and Sri Lanka have a complete ban on advertising on these media. Thailand has only a partial ban. India and Nepal place no ban on alcohol advertising on internet/social media (Table 7).
Regarding advertising restrictions at the point of sale, Bangladesh, Bhutan, Nepal and Sri Lanka have placed a complete ban for all categories of beverages, while Myanmar and Thailand have only partial restrictions (Table 7). Only four states in India prohibit advertising of alcohol brands at point of sale (11).
The composite advertisement restrictiveness score on internet/social media/point of sale on – scale of 1-5 ranges from zero in Timor-Leste to 1.66 in Nepal to 5 in Bangladesh, Indonesia, Bhutan, and Sri Lanka.
c Restrictions on product placement Product placement refers to the sponsorship of, for example, a TV production by an economic entity, if their alcoholic beverages are shown in such production. Most of the countries in the 24 Region have put in legally binding restrictions to ban product placements on national television, cable television and in films and movies (Table 7). Only Thailand has partial restrictions and Timor-Leste has no restrictions. The product placement restrictiveness score varies from 0 in Timor-Leste to 2.5 for Thailand and 5 for Bangladesh, Bhutan, and Sri Lanka.
d Restrictions on sponsorships in sports and youth events Sponsorship refers to supporting an event financially or through the provision of products or services as part of brand identification and marketing. This is an important form of marketing, targeted at key population groups. While many countries in the Region have legally binding restrictions to ban alcohol industry sponsorship of sporting events or youth events such as concerts, etc., Nepal and Timor-Leste have no such restrictions and Thailand has only partial restrictions (Table 7).
e Restrictions on sale promotions Sales promotion refers to marketing practices designed to facilitate the purchase of a product. Such promotions may be offered by producers (e.g. at a parties and events), or from retailers including supermarkets in the form of sales below cost (e.g. two for one, buy one get one free) or from owners of pubs and bars in the form of serving alcohol free.
Most of the countries in the Region ban sale promotions of alcohol from all entities (producers, retailers and owners) except for Nepal and Timor-Leste (Table 7). The status of restrictions in India varies by state.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward NR No NR NR NR NR NR NR Yes V/SV V/SV V/SV V/SV V/SV V/SV Leste Timor- The data differs a PR PR PR PR PR PR PR PR PR PR Yes Yes Ban Ban Ban Thailand a a Yes Yes Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Sri Lanka a NR No No NR NR NR NR NR NR Ban Ban Ban Ban Ban Nepal cable TV); NR (movies/cinema) Ban (national TV, updated based on communication with WHO country office. b PR PR PR Yes Yes Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Myanmar Yes Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban
No data 25 Maldives b No Yes Ban Ban Ban Ban Ban Ban Ban Ban Ban (beer) (beer) (beer) (beer) Ban, PR Ban, PR Ban, PR Ban, PR Indonesia b b PR NR Yes Yes Ban Ban Ban Ban Ban V/SR V/SR V/SR V/SR V/SR India No data Yes Yes Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Bhutan Yes Yes Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Ban Table 7: Policy situation on alcohol marketing, advertising and sponsorship in WHO South-East Asia Region Bangladesh Marketing infringements Detection Penalties Alcohol sponsorship Sale promotion*** Internet Private TV National radio Alcohol* advertising restrictions National TV Policy Social media Point of sale Restrictions on Product placement** Cinema Local radio Billboards Print media PR – partial restrictions; V/SR voluntary/self-restricted; NR no restrictions Source: WHO Global Survey on Alcohol and Health. where made is note A beverages. alcoholic different theses across vary not did generally responses the as together presented spirits, and wine beer, includes Alcohol * there were different restrictions across beverages. ** On national/cable TV and films/movies for beers, wines spi rits. ***Restrictions on sales promotion from owners of pubs and bars (alcohol for free), producers (parties events), retailers (sales below cost) 3 t ypes alcoholic beverages. from that reported in Global survey and has been updated based on further evidence provided by Country.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward The score of sale restrictions varies from 0 in Timor-Leste to 5 in Bangladesh, Bhutan, and Sri Lanka.
f Method of detecting infringements of marketing restrictions For the marketing restrictions to be effective, Member States must have methods to detect and penalize any infringements of legal restrictions to ensure compliance. The systems to detect marketing restrictions may include active surveillance systems, complaint systems, case by case reports, police, self-regulation or enforcement by a liquor licensing authority. Most countries reported at least one system, except for Nepal. Only Thailand and Sri Lanka reported having an active surveillance system to detect any infringements. Police was the most common system, reported by seven of the nine reporting countries, followed by four countries each reporting complaint systems, case-by-case reports and by the liquor licensing authority.
Three of the member states (Indonesia, Nepal and Timor-Leste) reported no penalties. Others reported fines (Bangladesh, Bhutan, India, Myanmar, Sri Lanka and Thailand). Sri- Lanka, Thailand and India (with state-specific laws) also reported imprisonment as a penalty for marketing infringements. Only Sri Lanka reported withdrawal of licensure.
Overall marketing restrictiveness score in WHO SEA Region Restricting only one aspect of the marketing mix often results in an expansion of activity in the other part of mix. Hence, the overall marketing restrictiveness should be examined holistically – in general, the more complete the regulation on marketing activities, the easier the regulation 26 will be to implement and more effective it will be in reducing alcohol-related harm.
Marketing restrictiveness index for alcohol in WHO SEA Region for 2016 is given in Fig. 6.
Fig. 6: Marketing restrictiveness index (scale of 1 to 5) for alcohol in WHO South-East Asia Region, 2016
5.0 5.0 5.0 5.0 5.0 4.6 4.5 4.4 4.0 3.5 3.5 3.0 2.5 2.0
1.5 1.3 1.0 Marketing restrictiveness index 0.5 0.4 0.0 Bangladesh Bhutan Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste
Source: WHO Global Survey on Alcohol and Health, 2016 Notes: No data are available for DPRK, and the index not developed for India, as alcohol policy is a subnational subject and varies across different States in India.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward R: Raise prices on alcohol through excise taxes and pricing policies Price polices are the most cost-effective WHO best buy for reducing the burden of harmful alcohol use (9).
Rationale Even though evidence shows that an alcohol price increase of 10% generally results in about a 5% decrease in consumption (implying that alcohol is relatively an inelastic good in economic terms as reduction in demand is smaller than the increase in price), when multiplied across the population, this relatively small decline in consumption has substantial impact on alcohol- related harm (18–20).
Increase in the price of alcohol has the following effects:
¤¤ Reduces the general population’s alcohol consumption as well as frequency of heavy drinking episodes.
¤¤ Delays drinking initiation and slows young people’s progression towards drinking large amounts.
Policy options Higher alcohol prices are most commonly and effectively achieved through taxation, though in some settings minimum prices make an important contribution. Different pricing policies 27 recommended in WHO Global strategy 2010 (10) are:
¤¤ Taxation: Excise tax system with regular adjustments to account for changing inflation and income levels. This is the most significant mechanism to raise prices of alcoholic beverages.
¤¤ Minimum price per unit of alcohol: Reduces the availability of low- and cut-priced alcohol.
¤¤ Ban on below-cost selling
¤¤ Ban on volume discounts: Flat rates for unlimited drinking or other types of volume discount effectively reduces the price of alcohol to customers and should be banned.
¤¤ Incentives for producing low content or non-alcoholic beverages at lower price, as affordability of alcohol relative to other goods also has a key role in consumer choice.
Policy situation in SEA Region a Implementation of excise taxes on alcoholic beverages: All the 10 Member States levy excise taxes on all the three major categories of alcoholic beverages (beer, wine, and spirits). Excise tax rates may be set based on the volume of pure alcohol in the product (specific rate) (e.g. in Nepal and Indonesia); based on volume of beverage (unitary rate); based on price of alcohol (ad valorem) (e.g. in Myanmar); or using
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward some combination of the three (e.g. in Thailand which uses a specific or ad-valorem rate, whichever provides greater tax amount) (21).
Excise taxes in Nepal Excise taxes are levied on all the three main alcoholic beverage categories (beer, wine and spirits). The tax rates are applied by volume of alcoholic beverages: beer – NPR 115 per liter; wine – NPR 80 per liter (for <12% alcohol concentration), NPR 280 per liter (for 12–17% alcohol concentration) and NPR 325 per liter (for >17% alcohol concentration). For spirits also, the taxes progressively increase based on concentration.
In the Global Alcohol and Health Survey 2012,6 four Member States provided data on tax incidence as a percentage of excise tax relative to retail price. The tax burden on alcoholic beverage prices varied from 4% (Myanmar) to 50% (Thailand) for beer, from 4% (Myanmar) to 50% (Thailand) for wine and from 4% (Myanmar) to 72% (Nepal) for spirits. Myanmar had
28 the lowest tax burden, whereas Thailand had the highest, except for spirits in Nepal. When comparing the excise tax per price of 1 liter pure alcohol, the tax burden on alcohol price ranged from 3.3% in Nepal to 22.2% in Thailand.
In the Global Alcohol and Health Survey 2016, many countries reported levying value added tax (VAT) ranging from 2.5% in Timor-Leste to 7% in Thailand and 15% in Bangladesh and Sri Lanka, in addition to the specific tax rate
In India, where there is no national legislation or regulations for alcohol, the rates of tax and consequently the final retail price of alcoholic beverages for the consumer varies across states, even for the same brand of alcoholic beverage. The Goods and Services Tax (GST) introduced in 2017 to unify the indirect taxes being levied on many goods and services across the country was not applied to purchase of alcoholic beverages, giving the freedom to individual states to raise taxes. Many states such as West Bengal, Maharashtra, Kerala and Karnataka have increased excise taxes on alcohol products in 2018.
In addition to levying taxes on the final alcohol product, almost all the reporting countries (except Bhutan and Timor-Leste) in the Region levy taxes on production of ethanol. This is not deducted from excise taxes in India and Thailand, giving an overall higher tax burden in these two countries.
6 This information was not elicited in the 2016 Survey.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward The purpose of alcohol taxation and the methods of implementation can affect the impact it has on public health. Taxation on sales of alcohol is a major revenue earner for most of the countries in the Region. For example, many states in India receive almost one fifth of their revenues from alcohol taxation, and is the second largest source of income after sales tax (22). Hence, in most countries including India, in alcohol policies, alcohol is treated as a revenue generating commodity. None of the countries reported implementing taxation with a key mandate of limiting the availability and consumption of alcohol to reduce alcohol-related morbidity and mortality.
Adjustment of level of excise taxes for changing inflation and income levels None of the Member States reported regularly adjusting the level of excise taxes for inflation and income levels (Table 8), which may reduce the effectiveness of this policy tool as incomes rise in countries and the products become more affordable.
Taxation of traditional alcohol The SEA Region has one of the highest proportions of total alcohol (45.4%) consumed as unrecorded alcohol (1). A large proportion of this unrecorded alcohol includes indigenous or traditional alcohol, especially in some of the Member States such as Bhutan, Myanmar, India, Nepal and Timor-Leste. However, a few Member States tax indigenous alcohol. For example, Thailand taxes traditional beverages as wine, and Sri Lanka taxes toddy. India taxes country liquor that has alcohol content around 30% by volume. In Bhutan, the traditionally home produced ara is taxed if sold commercially, but is tax-exempt if sold from home. 29
Controlling the illicit trade in alcohol in India: In the excise policy of 2013–14, the state government of Karnataka decided to utilize 1% of the total revenue collected by the excise department to rehabilitate and provide alternative jobs to those engaged in the illicit alcohol industry. The estimated revenue target for the excise department for the year 2013–14 was INR 12 400 crores (124 000 million). In another effort to curb this illicit trade, the Government of Kerala planned to introduce hologram tax stamps for alcohol products in its excise policy for 2013–14. These stamps would have information like the date of manufacture, batch number and serial number so that the alcohol products could be traced. Some other states have also used tax stamps as a security measure for the same purpose.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Use of duty-paid, excise or tax stamps or labels on alcoholic beverages containers/bottles Eight responding countries reported using tax stamps or other labels, except Bhutan and Sri Lanka. Maldives have a complete ban. Use of tax stamps may help to reduce the illicit trade in alcohol, though it does not guarantee this as some smugglers manage to make duplicate stamps, or enforcement of having stamps on each container may be not strong enough. Some countries have used high-tech hologram stamps that have information like the date of manufacture, batch number and serial number to permit alcohol products to be traced. For example, Government of Kerala in India introduced hologram tax stamps for alcohol products in its excise policy for 2013–14.
Earmarking of taxes on alcoholic beverages for specific purposes Only Thailand provides 2% of alcohol and tobacco excise taxes to Thai Health Promotion Foundation (ThaiHealth) to fund health promotion activities, including alcohol and tobacco control. No other member State reported earmarking of taxes for any specific purpose.
None of the Member States in SEA Region combines taxation with other supplemental pricing policies. Hence, there is a risk that the alcohol industry can
30 compensate for the tax burden by offering promotion of alcohol (10).
b Setting minimum price per unit of alcohol Increased taxes may not necessarily lead to increased prices if alcohol producers and retailers offset tax increases by reducing prices. Establishing a legal minimum price per g of alcohol fixes a floor price of alcohol, which prevents the sale of very inexpensive products and may help to reduce alcohol consumption among heavy consumers of cheap alcohol. However, none of the Member States except Timor-Leste reported using this policy tool. Timor-Leste reported setting the minimum price per Litters of pure alcohol at US$1.90, 2.50 and 19.0 for beer, wine and spirits, respectively. 17 states and union territories in India have fixed the minimum sale price to ensure uniformity and quality, and to prevent illegal sale (11).
c Ban on below-cost selling None of the nine responding Member States have banned below-cost selling of alcoholic beverages.
d Ban on volume discounts None of the nine responding Member States reported any ban on volume discounts.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward e Incentives for producing non-alcoholic beverages at lower price None of the nine responding Member States reported providing any tax rebates or other incentives for producing non-alcoholic beverages at lower price.
f Pricing to discourage high volume/underage drinking: None of the nine responding member states reported any specific polices in effect to discourage high volume or underage drinking or for production of low or no alcohol content beer (Table 8, Box 12).
Table 8: Status of taxation on alcoholic beverages and other pricing policies in WHO South-East Asia Region, 2016
Sri Timor- Pricing policy Bangladesh Bhutan India Indonesia Maldives Myanmar Nepal Thailand Lanka Leste Taxation on alcohol beverages Levying of excise taxes on beers, wines and Yes Yes* Yes Yes Yes Yes Yes Yes Yes Yes spirits Tax stamps on beverage containers Yes No Yes Yes No Yes Yes No Yes Yes for beers, wines and spirits Taxes on traditional No No Yes No No No No Yes Yes No alcohol 31 Taxes adjusted for No No No No No No No No No No changing inflation Taxes earmarked for No No No No No No No No Yes No specific purposes Supplemental pricing policies Setting minimum price No No No# No No No No No No Yes per unit of alcohol Ban on below-cost No No No No No No No No No No selling Ban on volume No No No No No No No No No No discounts Incentives for producing non- No No No No No No No No No No alcoholic beverages at lower price Pricing to discourage high volume/underage No No No No No No No No No No drinking Tax incentives/rebates for production of low No No No No No No No No No No or no alcohol content beer Source: WHO Global Survey on Alcohol and Health Notes: * In Bhutan, excise taxes are levied only if the pure alcohol content is over 8%,are beer is subjected to 100% sales tax. # In India, no national policy on setting minimum price, though 17 states/union territories have set minimum price for alcohol
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Box 8: Pricing stringency score to curb alcohol consumption
An overall pricing stringency score (1–5) was developed to assess the stringency of policies that are put in place to increase the price of alcohol and reduce its affordability to the consumers. The scoring for each of policy component was done as given below.
Existence of excise taxes on alcohol products and public health mandate for taxation: A score of 3 is assigned if the country levies any excise taxes and a score of 3 is given if the taxation policy is motivated by public health concerns to reduce alcohol consumption.
Adjustment of taxes regularly for changing inflation and income levels: A score of 2 is given if a country has put in place a policy to regularly adjust the tax rates by changing inflation and income levels.
Use of duty paid/tax stamps on alcoholic beverages containers/bottles: Two points are given if the country requires duty paid/tax stamps on alcoholic beverages containers or bottles, which may help to curb illicit trade.
Earmarking of taxes for specific purpose: A score of 2 is given if a country earmarks the alcohol excise taxes for a particular purpose.
Other pricing policies: A score of 2 each is given for having a minimum price, ban on below-cost selling, volume discounts and incentives for producing cheaper non-alcoholic 32 or low-content alcoholic beverages, giving a total score of 8 for other pricing policies.
The score all the elements are added, giving a total score of 20, which is standardized to a scale of 5.
Limitations: The score does not take into account varying degrees of excise taxes (for example, a country with an excise incidence of 5% is given the same score as a country with an excise incidence of 50%. Further, the scoring given to a policy element may not be proportional to differential effectiveness of each in reducing alcohol consumption. In addition, it does not take into account the level of implementation of the policies.
The scoring system should be improved taking into account these issues.
Overall price stringency score in SEA Region The overall price stringency score for policies enacted to raise the price of alcoholic beverages for various Member States of the Region is given in Fig. 7.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Fig. 7: Overall pricing stringency score for policies enacted to raise the price of alcoholic beverages in WHO south-East Asia Region (2017)
5.0 4.5 4.0 3.5 3.0 2.5
2.0 1.75 1.75 1.5 1.25 1.25 1.25 1 1.0 Overall pricing stringency score 0.75 0.75 0.5 0.0 Bangladesh Bhutan Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste
Source: WHO Global Survey on Alcohol and Health.
33
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Overall SAFER policy content score in WHO South-East Asia Region
Box 13 shows the policy response of the five priority interventions identified in WHO SAFER initiative launched in 2018.
Box 13: Policy response to reduce harmful use of alcohol in SEA Region: key points
¤¤ Still in very early stages in most of the countries; none of the countries have fully implemented all the best buys.
¤¤ Drink-driving countermeasures: Advocacy with Sri Lanka and Myanmar to reduce the maximum permissible BAC to 0.05% or lower. Improve the 34 level of enforcement, as average perceived level of enforcement was only 5, much lower than the global average.
¤¤ Limited infrastructure to provide screening, brief intervention and treatment for alcohol dependence. Limited or very limited treatment coverage for alcohol dependence.
¤¤ Need for more comprehensive marketing restrictions across all media types including internet and social media.
¤¤ While most countries levy excise taxes, only a few countries raise them regularly to adjust for changing inflation and income levels. Use of other supplemental pricing measures is almost negligible.
An overall SAFER policy content score has been created on a scale of 1–100, where the three WHO best buys are given a weightage of 0.25 each, and two good buys (drink-driving countermeasures and health service response) a weight of 0.125 each.
Fig. 8 shows the overall SAFER score for selected countries. No score has been produced for India, which has no national alcohol policy and policies are developed and implemented at the subnational level (states). Similarly, no score is given for Maldives which has a total ban on production, sale and consumption of alcohol. Furthermore, in the absence of any data from Democratic People’s Republic of Korea, no scoring is done for it.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward The SAFER policy content score varies from 31.3% in Timor-Leste to 68.3% Bangladesh. This shows considerable policy content gaps in the Region. This can be improved by improving the policy framework and strengthening the policy content based on best available evidence and as per WHO recommendations (10).
Furthermore, the implementation of the policies which we did not assess in this paper, need to be strengthened greatly, involving multisectoral action.
Fig. 8: SAFER policy content score on a scale of 1–100 for selected Member States of WHO South-East Asia Region
100.0 90.0 80.0 68.3 70.0 64.5 61.9 60.0 56.3 53.2 50.7 50.0 40.4 40.0 31.3 30.0 20.0 Overall pricing stringency score 10.0 0.0 Bangladesh Bhutan Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste 35
Source: WHO Global Survey on Alcohol and Health.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Monitoring and evaluation
The SAFER initiative recognizes the necessity of a strong and sustainable monitoring system to ensure accountability and track progress in the implementation of the SAFER interventions. Low availability and validity of alcohol-related information could largely hamper the collective effort to address alcohol-related problems.
An alcohol module is included as one of the core modules in the population-based household WHO STEPwise approach to surveillance (STEPS) surveys done every 3–5 years in a majority of Member States in the Region as part of routine surveillance of key NCDs and their risk factors. These surveys target the 15–69-year-old age group and assess the self-reported consumption patterns (e.g. prevalence of life-time abstinence, former drinkers, current drinking, heavy episodic drinking, as well as consumption of 36 unrecorded and indigenous/traditional alcohol) (23).
Some countries in the Region have expanded the core module to include questions to assess alcohol dependence as well implementation level of different alcohol policies, e.g. percentage of respondent’s alcohol-related marketing or sale promotion, or percentage of people that could buy alcohol during restricted days/hours, etc. All the countries in the Region have done at least one round of STEPS survey and have some population-level survey data. Annex 1 gives the key indicators on patterns of alcohol consumption computed from these surveys.
In addition to population-level household surveys targeting adult populations, many countries in the Region have also been regularly doing school-based surveys of 13–17-year-old adolescents as part of the WHO Global school-based student health survey initiative (24). These surveys help to assess the current alcohol use and prevalence of problem-drinking among schoolgoing adolescents 13–17 years of age. Annex 2 gives the indicators of alcohol use computed among 13–17-year-old adolescents in WHO South-East Asia Region from these surveys. Estimating the current drinking prevalence in this age group helps to assess the implementation and impact of minimum legal age policies in the Region.
However, there are still major gaps in monitoring and evaluation, especially in terms of assessing the implementation level of different policies and interventions. The administrative data systems also need to be strengthened in addition to the population-based surveys.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward The call for action
The policy content analysis for the five priority interventions identified in the WHO SAFER initiative shows that all the countries in WHO South-East Asia Region have taken some policy and legislative initiatives in the recent years. However, the increasing per capita consumption of alcohol and the high-level of heavy episodic drinking in almost all the countries of the Region suggest that policy actions taken till now are not sufficient to reverse or stall the increasing alcohol consumption. The WHO voluntary global NCD target for 2025 of a 10% reduction in harmful alcohol use is unachievable with the current pace of policy development/approaches and implementation level.
Alcohol control for achieving the regional 37 TB elimination goal More than 1 in 5 tuberculosis deaths in the Region are attributed to alcohol use. Alcohol per capita consumption is increasing rapidly in the Region including in India, which accounts for more than three-fourth of total tuberculosis deaths in the Region. WHO South-East Asia Region has a goal of TB elimination by 2030 and India aims to achieve it by 2025. Control of harmful use of alcohol must be included as one of the key strategies leading to achievement of TB elimination, otherwise the increasing alcohol use may jeopardize achievement of this goal.
Alcohol control will be central to achieving the SDG goal of reducing premature mortality by one third, as alcohol use accounts for 1 in 10 premature deaths in WHO South-East Asia Region. In addition, it will be central to achieving some of the other major goals in the Region by 2030, especially the regional TB elimination goal. While reducing harmful use of alcohol is acknowledged as one of the key strategies in the
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward regional action plans for control and prevention of NCDs, it is not yet sufficiently recognized and addressed in the relevant regional/national strategies/action plans for some major public health problems such as TB, hepatitis, sexually transmitted infections and mental health issues. Explicitly acknowledging the role of alcohol control in achieving other important public health goals, e.g. TB elimination goal in the Region will help to increase awareness and visibility for alcohol control and boost multisectoral action. Some Member States have initiated action in this regard. For example, in India, every TB patient is screened for alcohol use, and modalities are being explored to link the TB patient with nearst counselling services or toll free helpline number.
Alcohol use is complex, and comprehensive policies are required. The analysis presented here reveals substantial gaps in using the recommended SAFER policy tools in the Region. Furthermore, there is a need for more effective implementation of the tool where countries have enacted the policies. Weakness in policy implementation, particularly law enforcement, could hamper the theoretical effectiveness of alcohol policy in Member States of the Region. For example, despite their illegal status, untaxed alcoholic beverages and sale of alcohol to underage minors are very common and go almost unnoticed. Almost one fourth of the schoolgoing adolescents aged 13–17 years in Bhutan and Thailand reported currently using alcohol despite the minimum age of legal purchase of alcohol being 18 and 20 years, respectively. The awareness and level of enforcement should be assessed through population- based surveys and other special studies.
38
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward References
1. Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018. 2. The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry. 2018;5(12):987–1012. 3. Global burden of disease study 2017. Seattle: Institute of Health Metrics and Evaluation (IHME); 2018. 4. National Family Health Survey (NFHS-4), 2015–16. Mumbai: Indian Institute for Population Sciences (IIPS); 2017. 5. Laslett AM, Catalano P, Chikritzhs T, Dale C, Doran C, Ferris J et al. The range and magnitude of alcohol’s harm to others. Fitzroy, Victoria: AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Eastern Health; 2010. 6. Manthey J, Shield K, Rylett M, Hasan OS, Probst C. Alcohol exposure between 1990 and 2017 and forecasts until 2030: a global modelling study. Lancet. 2019;393:2493–502. 7. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva: World Health Organization; 2013. 8. National Capacity for prevention and control of noncommunicable diseases in WHO South-East Asia Region. Results from NCD Country Capacity Survey 2017. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018. 9. Tackling NCDs: “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases 2017. Geneva: World Health Organization; 2017.
10. Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization; 2010. 39 11. Alcohol Marketing and Regulatory Policy Enviroment in India. New Delhi: Public Health Foundation of India; 2013. 12. Babor T. Alcohol: no ordinary commodity: research and public policy. New York: Oxford University Press; 2010. 13. Wagenaar AC, Toomey TL. Effects of minimum drinking age laws: review and analyses of the literature from 1960 to 2000. J Stud Alcohol Suppl. 2002;14:206–25.. 14. Alcohol policy in WHO South-east Asia Region. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017. 15. Report on Bhutan global school-based student health survey 2016. New Delhi: World Health Organization Regional Office for South-East Asia; 2018. 16. Thailand 2015 Global School-Based Student Health Survey. Bangkok: World Health Organization Thailand Country Office; 2017. 17. Atlas on Substance use 2017: resources for the prevention and treatment of substance use disorders. Geneva: World Health Organization; 2017. 18. Wagenaar AC, Tobler AL, Komro KA. Effects of alcohol tax and price policies on morbidity and mortality: a systematic review. Am J Public Health. 2010; 100(11):2270–8. 19. Xu X, Chaloupka FJ. The effects of prices on alcohol use and its consequences. Alcohol Res Health. 2011; 34(2):236–45. 20. Wagenaar AC, Salois MJ, Komro KA. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction. 2009; 104(2):179–90.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward 21. Preece R. The effective contribution of excise taxation on non-alcoholic beverages to government revenues and social objectives: a review of literature. World Customs Journal. 2015;7(1):21–38. 22. Gururaj G, Murthy P, Rao GN, Benegal V. Alcohol related harm: implications for public health and policy in India. Bangalore, India: National Institute of Mental Health and Neurosciences (NIMHANS); 2011. 23. The WHO STEPwise approach to noncommunicable diseases risk factor surveillance: WHO STEPS Surveillance Manual. Geneva: World Health Organization; 2017. 24. Global School-based Student Health Survey (GSHS): purpose and methodology. Geneva: World Health Organization; 2019 (https://www.who.int/ncds/surveillance/gshs/methodology/en/, accessed 17 July 2019).
40
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Annex 1: Key indicators related to alcohol consumption from the most recent WHO STEPS surveys and other related surveys in WHO South-East Asia Region 0.4 0.2 2.8 8.8 0.5 5.0 2.0 d 0.06 32.8 Women
2.9 6.1 1.6 50.0 40.6 34.4 34.7 36.8 42.8 Men (past 30 days) (%) Current drinkers All 1.5 3.3 0.9 42.4 21.9 20.8 18.1 20.3 28.6 c NA 0.2 0.3 5.6 1.8 5.1 41.0 10.8 10.6 Women NA 8.7 3.9 57.4 49.3 38.6 50.0 47.5 53.7 Men Current drinkers (past 12 month) (%) All NA 4.4 2.1 50.2 27.6 23.9 26.6 28.4 36.8
41 b NA 0.2 9.3 0.2 2.1 2.7 1.8 8.3 2.8 Women (%) NA 8.4 3.2 5.3 9.6 6.9 12.1 12.4 20.9 Men Former drinkers All NA 4.3 1.7 7.3 4.0 5.8 5.5 10.8 14.4 (%) a NA 99.6 49.8 99.5 92.3 86.5 96.4 81.1 92.1 Women NA 82.9 30.6 92.9 38.4 56.0 40.4 31.6 39.4 Men population-level surveys (WHO STEP and other related surveys). All NA 91.4 39.0 96.2 65.1 72.2 67.6 57.2 57.8 Life-time abstainers Table 1: Selected indicators of alcohol use among adults in WHO South East Asia Region from most recent Country (STEP Survey year) Bangladesh (2018) (18-69 years) Bhutan (2014) (18-69 years) Indonesia (2018) (10+ years) Maldives (2011) (15-64 years) Myanmar (2014) (25-64 years) Nepal (2019) (15-69 years) Sri Lanka (2014) (18-69 years) Thailand* (2017) (15+ years) Timor-Leste (2015) (18-69 years) proportion of adults (age group) in a given population who have previously consumed alcohol, but not done so the p revious 12-month period. proportion of adults (age group) in a given population who have never consumed alcohol during their lifetime. proportion of adults (age group) in a given population who have previously consumed alcohol the previous 12-month period. Notes: All indicators assessed based on self-reports at the time of household survey. a b c d proportion of adults (age group) in a given population who have previously consumed alcohol the previous 30-days period. * The estimates were analyzed from National Tobacco and Alcohol Surveys, administered by the Statistical Office (NOS) of Thailand. NA – Not available.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward NA 3.7 20.3 22.5 16.2 14.6 43.1 34.4 11.8 Female NA 40.5 46.5 33.4 32.2 46.2 95.9 50.5 17.5 Male NA 39.5 41.9 32.4 28.4 43.0 60.8 44.7 17.4 Total Among current drinkers (12 months) (%) 1.0 2.4 0.1 1.7 0.8 2.1 0.0 29.0 0.02 Female
42 2.1 1.7 1.5 21.8 22.1 16.7 12.4 22.8 14.1 Male In general population (%) 8.6 6.8 2.1 0.8 0.8 14.5 11.9 11.9 22.4 Total Table 2: Prevalence of heavy episodic drinking a as estimated from WHO STEP surveys and other related surveys. consumption of 60 or more grams pure alcohol (6+ standard drinks in most countries) on at least one single occasion the 30 days prior to survey. a Timor-Leste (2015) (18-69 years) Thailand (2017) * (15+ years) Sri Lanka (2014) (18-69 years) Nepal (2019) (15-69 years) Myanmar (2014) (25-64 years) Maldives (2011) (15-64 years) Indonesia (2018) (15+ years) Bhutan (2014) (18-69 years) Bangladesh (2018) (18-69 years) Country Notes: NA – Not available. * Heavy episodic drinking is defined as alcohol more than 5 standard drinks per occasion in the last 12 months. The es timates were analyzed from National Tobacco and Alcohol Surveys, administered by the National Statistical Office (NOS) of Thailand.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward NA NA NA NA NA 5.3 0.82 35.5 across border Brought NA NA NA NA NA 20.5 15.9 43.9 Home- brewed wine/bear alcohol (%) Composition of unrecorded NA NA NA NA NA 80.7 41.2 50.1 spirts Home- brewed NA NA NA 6.9 2.4 8.7 33.5 57.8 Women NA NA NA 8.0 61.5 20.3 12.1 58.9 Men
All 43 NA NA NA 7.9 last 30 days/12 months) (%) 60.8 12.6 12.0 58.5 drinking of unrecorded alcohol (among current drinkers) (out of NA NA NA 0.7 0.7 0.3 18.9 Women NA NA NA 6.5 3.0 5.5 (%) 26.4 29.4 Men All NA NA NA 3.5 1.5 2.9 17.4 24.8 drinking of unrecorded* alcohol Table 3: Prevalence and share of consumption unrecorded alcohol among adults (15+) WHO South East Asia Region. Country (STEP year) Timor-Leste (2015) (18-69 years) Thailand ** (2014) (15+ years) Sri Lanka (2014) (18-69 years) Nepal (2019) (15-69 years) Myanmar (2014) (25-64 years) Indonesia (2018) Maldives (2011) (15-64 years) Bhutan (2014) (18-69 years) (15+ years) * Unrecorded alcohol refers to alcohol that is not taxed in the country where it is consumed because it is usually produced, distributed and sold outside the formal channels formal the outside sold and distributed produced, usually is it because consumed is it where country the in taxed not is that alcohol to refers alcohol Unrecorded * under government control. ** The estimates were analyzed from National Tobacco and Alcohol Surveys, administered by the Statistical Office (NOS) of Thailand. Unrecorded alcohol consumption refers to drinking either homebrew and smuggling alcohol in the last 12 months. NA – Not available.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Annex 2: Selected indicators of alcohol use among 13–17-year- olds from global school-based student health surveys
Selected indicators of alcohol use among 13 to 17 years old students in WHO South East Asia Region.
Country Current alcohol Drunkennessb Problem from (GSHS year) usea drinkingc All Male/ All Male/ All Male/ % Female % Female % Female ratio** ratio** ratio**
Bangladesh (2014) 1.6 17.14 1.3 # 1.3 #
Bhutan (2016) 24.2 2.07 23.3 2.27 10.1 2.36 India (2007) 8.0d 1.32 NA NA NA NA 13-15 years
Indonesia (2015) 4.4 4.64 3.7 7.35 2.7 6.21
Maldives (2014) 7.1 d 2.58 NA NA NA NA
44 Myanmar (2016) 4.6 5.78 3.7 9.33 1.7 6.62
Nepal (2015) 5.1 1.87 4.9 2.53 2.7 1.89
Sri Lanka (2016) 3.2 5.24 NA NA NA NA
Thailand (2015) 23.0 1.41 24.9 1.14* 10.7 1.65
Timor-Leste (2015) 15.1 2.32 10.3 3.43 8.8 2.87
Notes: ** The male/female ratio is significantly different from one at 95% level, unless noted otherwise; * The male/female ratio is significantly different from one at 90% level; NS – the male/female ratio is not significantly different from one at either 90% or 95% level; NA - data are not available; # the male/female ratio is not computable due to 0% prevalence among females. a During the past 30 days, on how many days did you have at least one drink containing alcohol? The indicator current alcohol was defined as drinking alcohol on one or more days in the past 30 days. b During your life, how many times did you drink so much alcohol that you were really drunk? The indicator was defined as being drunk one or more times during their lifetime. c During your life, how many times have you got into trouble with your family or friends, missed school, or got into fights, as a result of drinking alcohol? The indicator was defined as having gotten into a problem as a result of drinking alcohol one or more times during their lifetime. d For India and Maldives, the data on ‘current’ alcohol use were not available. The data presented here refers to ‘ever’ alcohol use computed indirectly from other question (e.g. how old you were when you had your first drink of alcohol other than a few sips).
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Annex 3: WHO Global Survey on Alcohol and Health and other data sources
WHO Global Survey on Alcohol and Health is a qualitative survey conducted by WHO every two years. The third and latest round of the survey was conducted in 2016 (previous two rounds were conducted in 2012 and 2014). National counterparts or focal points in all the Member States who were officially nominated by their respective ministries of health were enabled to complete the survey data collection tool online. Where this was not feasible, a hard copy of the tool was forwarded directly to those who requested it. The questionnaire used in 2016 was a modified version of the one used in 2012. The 44 questions were divided into three sections. Section A addressed alcohol policy, Section B addressed alcohol consumption and Section C addressed surveillance system and health services responses on alcohol and drugs. In the 2016 survey, nine out of 11 countries responded. No response was submitted by Democratic People’s Republic Korea and Nepal. In the report, responses from 2012 survey are used where possible. No data are presented for Democratic People’s Republic Korea.
WHO ATLAS-SU Questionnaire Survey of 162 countries, territories and area gathers information on a wide range of available resources (administrative, financial and human, pharmacological treatment, regulations, resources for prevention, etc.) that contribute to the prevention and treatment of substance use disorders [7]
Data from the latest round of survey conducted in 2014 were used for assessing the health services response in terms of coverage for screening and brief intervention, and availability of 45 the policy and guidelines for the same.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Annex 4: Glossary
Alcohol marketing: Any form of commercial communication or message that is designed to increase, or has the effect of increasing the recognition, appeal and/or consumption of particular products and services, which is not limited to advertising using traditional media outlets such as television, radio and print, but also through new media opportunities, including internet and social media as well as exploiting promotional activities, such as product design, distribution and pricing promotion. It includes sports and music marketing and sponsorship. Alcohol per capita consumption (APC): APC is defined as the per capita amount of alcohol consumed in Litters of pure alcohol in a given population within a calendar year. Alcohol-attributable deaths are defined as the number of deaths attributable to alcohol consumption. They assume a counterfactual scenario of no alcohol consumption. Thus, alcohol-attributable deaths are those deaths that would not have happened without the presence of alcohol. Alcohol-attributable fraction (AAF) is the proportion of all diseases and deaths that are attributable to alcohol. AAFs are used to quantify the contribution of alcohol as a risk factor to disease or death. AAFs can be interpreted as the proportion of deaths or burden of disease which would disappear if there had not been any alcohol. Blood alcohol concentration (BAC): is defined as the amount of alcohol in blood measured as mass per volume percentage. A legal maximum blood alcohol concentration limit is allowed while driving a vehicle in a country. The BAC limits are set for the general population, young/ 46 novice drivers and professional/commercial drivers. Current drinkers: The percentage of people in a given population who have consumed alcoholic beverages in the previous 12 months. Former drinkers: People who have previously consumed alcohol but who have not done so in the previous 12-month period. Graduated licensing is given to new drivers who receive a restricted license with zero tolerance for drug and alcohol use and limits on the time of day when and classes of roads where, one can drive. Heavy episodic drinking (HED): In the context of population-level data presented in this report from STEPS or equivalent surveys, HED is defined as consumption of 60 or more g of pure alcohol (6+ standard drinks in most countries) on at least one single occasion in the 30 days prior to survey. The indicator is presented in the overall population as well as among drinkers only. An ignition interlock device or breath alcohol ignition interlock device is a breathalyzer for an individual’s vehicle. It requires the driver to blow into a mouthpiece on the device before starting or continuing to operate the vehicle. Lifetime abstainers: People who have never consumed alcohol. The data are presented as “rates of abstention”, which is the percentage of people in a given population that have never consumed alcohol. Off-premise sale of alcohol: Where alcohol is sold for consumption elsewhere, e.g. liquor shops, supermarkets, corner groceries.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward On-premise sale of alcohol: Where alcohol is sold and consumed where it is sold, e.g. bars, restaurants. Random breath testing (RBT) is defined as a test given by the police to drivers chosen at random to measure the amount of alcohol the drivers have consumed. It means that any driver can be stopped by the police at any time to test their breath for alcohol consumption. Restrictions for on-/off-premise sales of alcoholic beverages on locations are defined as regulated limitations on the location (places and density) of sales of alcoholic beverages, both on-and off-premises in a country. Restrictions for sales of alcoholic beverages at petrol stations are defined as regulated limitations on off-premise sales of alcoholic beverages at petrol stations in a country. Restrictions on alcohol advertising are defined as legally binding restrictions enforced by law on alcohol advertising in a country by alcohol producers through a variety of media: national television, cable television, national radio, local radio, print media, cinemas, billboards, points-of-sale, internet and social media. Restrictions on alcohol industry sponsorship are defined as legally binding restrictions enforced by law on alcohol industry sponsorship of sporting events or youth events, such as concerts, in a country. Sponsorship refers to supporting an event financially or through the provision of products or services as part of brand identification and marketing. Restrictions on alcohol product placement are defined as legally binding restrictions enforced by law on alcohol product placement in a country. Product placement refers to the sponsorship of activities such as TV productions by economic operators, if their alcoholic beverage is shown in these productions. 47 Restrictions on alcohol sales promotion are defined as legally binding restrictions enforced by law on alcohol sales promotion (such as from producers, e.g. parties and events; or from retailers, including supermarkets, in the form of sales below cost, e.g. two for one, happy hour; or from owners of pubs and bars in the form of serving alcohol for free), in a country. Sales promotion refers to marketing practices designed to facilitate the purchase of a product. Restrictions on alcohol use in public places pertain to education buildings, government offices, health-care establishments, leisure events, parks and streets, public transport, religious places, sporting events and the workplace. Sobriety checkpoints are checkpoints or roadblocks established by the police on public roadways to control drink-driving. Unrecorded alcohol: Unrecorded alcohol refers to alcohol that is not taxed in the country where it is consumed because it is usually produced, distributed and sold outside the formal channels under government control. Unrecorded alcohol consumption in a country includes consumption of home-made or informally produced alcohol (legal or illegal), smuggled alcohol, alcohol intended for industrial or medical uses and alcohol obtained through cross-border shopping (which is recorded under a different jurisdiction). Sometimes, these alcoholic beverages are traditional drinks that are produced and consumed in the community or in homes. Home-made or informally produced alcoholic beverages are mostly fermented products made from sorghum, millet, maize, rice, wheat or fruits.
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward Annex 5: A SAFER score card for policy components
¤¤ Bangladesh
¤¤ Bhutan
¤¤ Indonesia
¤¤ Myanmar
¤¤ Nepal
¤¤ Sri Lank
¤¤ Thailand
¤¤ Timor-Leste
48
Making South-East Asia SAFER from alcohol-related harm: Current status and way forward A policy card to reduce harmful use of alcohol BANGLADESH
91.4% 4.4% 17.4% 1.6% Lifetime abstainers # Adult current drinkers a, # Heavy episodic drinkers b, # Adolescent current drinkers † Total score 68% 68.4/100 Policy component % Score S trengthen restrictions on alcohol availability 87% 21.7/25 Licensing/monopolies at different levels of alcohol market 100% 5/5 (import, production, distribution, retail sales)-Y for all On-premise sale restrictions 83% 4.2/5 (days, hours, outlet density, places, events, intoxicated persons) (Y, Y, N, Y, Y, Y) Off-premise sale restrictions 50% 2.5/5 (days, hours, outlet density, place, events, petrol stations) (Y, Y, N, Y, Y, ND) Minimum purchasing age (national, total ban) 100% 5/5 Restrictions on alcohol consumptions in public places (ban at all places) 100% 5/5 A dvance and enforce drink-driving countermeasures 86% 10.7/12.5 Strictness of BAC% limit for general population (young/novice drivers, commercial professional drivers 100% 5/5 less than or equal to .05) [zero tolerance] Deterrent & detection measures for drink–driving 100% 5/5 (Random Breath Testing, Sobriety checkpoints, graduated licensing) (Y, Y, Y) Drink–driving penalties for fi rst offence (community service, detention, fi nes, license suspension, 71% 3.6/5 mandatory treatment, penalty points, vehicle impoundment) (N, Y, Y, Y, N, Y, Y) Drink–driving penalties for repeated offence (N, Y, Y, Y, N, Y, Y) 71% 3.6/5 F acilitate access to screening, brief interventions and treatment 38% 4.7/12.5 Access to screening and brief interventions (proportion of health services with screening and brief 0% 0/5 intervention)*(none) Treatment for alcohol dependence (limited 11-20% of health facilities) 76% 3.8/5 E nforce ban or comprehensive restriction on alcohol advertising, sponsorship and sales promotions 100% 25/25 Advertising restrictions Seven traditional media 100% 5/5 (TV/cable, national/local radio, print media, billboards, cinema, internet, point of sale)- ban for all In internet, social media, and point of sale (B, B, B) 100% 5/5 Restrictions on product placement 100% 5/5 on national TV/cable TV/fi lms and movies (B, B, B) Restriction on sale promotions 100% 5/5 from owners of pubs/bars, from producers, and from retailers (B, B, B) Restriction on alcohol sponsorship at sports and youth events (B, B) 100% 5/5 Arrangements for detection and penalties for marketing infringements (Y, Y) 100% 5/5 R aise prices on alcohol through excise taxes and pricing policies 25% 6.3/25 Excise taxes on alcohol with an objective to reduce alcohol-related harms (Y, N) 50% 3/6 Taxes on traditional/indigenous alcohol (Bangla Mad, cholai Tari) (N) 0% 0/2 Use of duty paid/tax stamps on alcoholic beverages containers/bottles (N) 100% 2/2 Taxes adjusted regularly for changing infl ation and income level (N) 0% 0/2 Minimum price per unit of alcohol (N) 0% 0/2 Ban on volume discounts and below cost selling (N) 0% 0/2 Incentives for producing low content or non-alcoholic beverages at lower price (N) 0% 0/2 Earmarking of some alcohol taxes for health promotion including alcohol control (N) 0% 0/2 Source of data: Global Alcohol and Health Survey 2016; *WHO Atlas Substance Abuse survey 2014 <50% 50%-75% >75% #National NCD STEPs survey, 2018 (15-69 years); †National Global School-based Health Survey, 2014 (13-17 years) Y-Yes; N-No; ND-No data; B-Ban a in the past 12 months; b among adult current drinkers in past 30 days A policy card to reduce harmful use of alcohol BHUTAN
39% 50.2% 44.7% 24.2% Lifetime abstainers # Adult current drinkers a, # Heavy episodic drinkers b, # Adolescent current drinkers † Total score 65% 64.9/100 Policy component % Score S trengthen restrictions on alcohol availability 68% 16.9/25 Licensing/monopolies at different levels of alcohol market 100% 5/5 (import, production, distribution, retail sales)-Y for all On-premise sale restrictions 83% 4.2/5 (days, hours, outlet density, places, events, intoxicated persons) (Y, Y, N, Y, Y, Y) Off-premise sale restrictions 50% 2.5/5 (days, hours, outlet density, place, events, petrol stations) (Y, N, N,Y, N, Y) Minimum purchasing age (national, 18 years) 50% 2.5/5 Restrictions on alcohol consumptions in public places (B-govt/workplace/educational building/public 56% 2.8/5 transport/places of worship; NR/V/SR at others) A dvance and enforce drink-driving countermeasures 54% 6.7/12.5 Strictness of BAC% limit for general population (young/novice drivers, commercial professional drivers 83% 4.2/5 less than or equal to .05) [0.08, zero tolerance] Deterrent & detection measures for drink–driving 75% 3.8/5 (Random Breath Testing, Sobriety checkpoints, graduated licensing) (Y, N, Y) Drink–driving penalties for fi rst offence (community service, detention, fi nes, license suspension, 28% 1.4/5 mandatory treatment, penalty points, vehicle impoundment) (N, N, Y, N , N, Y, N) Drink–driving penalties for repeated offence (N, N, Y, Y , N, N, N) 29% 1.4/5 F acilitate access to screening, brief interventions and treatment 100% 12.5/12.5 Access to screening and brief interventions (proportion of health services with screening and brief 100% 5/5 intervention)*(Most, 61-100%) Treatment for alcohol dependence (high, >40% of health facilities) 100% 5/5 E nforce ban or comprehensive restriction on alcohol advertising, sponsorship and sales promotions 100% 25/25 Advertising restrictions Seven traditional media 100% 5/5 (TV/cable, national/local radio, print media, billboards, cinema, internet, point of sale)- ban for all In internet, social media, and point of sale (B, B, B) 100% 5/5 Restrictions on product placement 100% 5/5 on national TV/cable TV/fi lms and movies (B, B, B) Restriction on sale promotions 100% 5/5 from owners of pubs/bars, from producers, and from retailers (B, B, B) Restriction on alcohol sponsorship at sports and youth events (B, B) 100% 5/5 Arrangements for detection and penalties for marketing infringements (Y, Y) 100% 5/5 R aise prices on alcohol through excise taxes and pricing policies 15% 3.8/25 Excise taxes on alcohol with an objective to reduce alcohol-related harms [Y (only on alcoholic 50% 3/6 beverages with a pure alcohol content of over 8%@), N] Taxes on traditional/indigenous alcohol (Ara) (N) 0% 0/2 Use of duty paid/tax stamps on alcoholic beverages containers/bottles (N) 100% 2/2 Taxes adjusted regularly for changing infl ation and income level (N) 0% 0/2 Minimum price per unit of alcohol (N) 0% 0/2 Ban on volume discounts and below cost selling (N) 0% 0/2 Incentives for producing low content or non-alcoholic beverages at lower price (N) 0% 0/2 Earmarking of some alcohol taxes for health promotion including alcohol control (N) 0% 0/2 Source of data: Global Alcohol and Health Survey 2016; *WHO Atlas Substance Abuse survey 2014 <50% 50%-75% >75% #National NCD STEPs survey, (18-69 years); †National Global School-based Health Survey, 2014 (13-17 years) Y-Yes; N-No; ND-No data; B-Ban a in the past 12 months; b among adult current drinkers in past 30 days A policy card to reduce harmful use of alcohol INDONESIA
NA NA NA 4.4% Lifetime abstainers # Adult current drinkers a, # Heavy episodic drinkers b, # Adolescent current drinkers † Total score 58% 58.1/100 Policy component % Score S trengthen restrictions on alcohol availability 80% 20/25 Licensing/monopolies at different levels of alcohol market 100% 5/5 (import, production, distribution, retail sales)-(Y, Y, Y, Y) On-premise sale restrictions 44% 2.2/5 (days, hours, outlet density, places, events, intoxicated persons) (N, Y, ND, Y, Y, N) Off-premise sale restrictions 44% 2.2/5 (days, hours, outlet density, place, events, petrol stations) (N, Y, NR, Y, Y, N) Minimum purchasing age (national, 21 years) 100% 5/5 Restrictions on alcohol consumptions in public places (Ban at all places) 100% 5/5 A dvance and enforce drink-driving countermeasures 87% 10.9/12.5 Strictness of BAC% limit for general population (young/novice drivers, commercial professional drivers 100% 5/5 less than or equal to .05) [zero tolerance] Deterrent & detection measures for drink–driving 50% 2.5/5 (Random Breath Testing, Sobriety checkpoints, graduated licensing) (Y, N, N) Drink–driving penalties for fi rst offence (community service, detention, fi nes, license suspension, 100% 5/5 mandatory treatment, penalty points, vehicle impoundment) (Y, Y, Y, Y, Y, Y, Y) Drink–driving penalties for repeated offence (Y, Y, Y, Y, Y, Y, Y) 100% 5/5 F acilitate access to screening, brief interventions and treatment 13% 1.6/12.5 Access to screening and brief interventions (proportion of health services with screening and brief 0% 0/5 intervention)*(No data) Treatment for alcohol dependence (close to none <1% of health facilities) 26% 1.3/5 E nforce ban or comprehensive restriction on alcohol advertising, sponsorship and sales promotions 88% 22/25 Advertising restrictions Seven traditional media (TV/cable, national/local radio, print media, billboards, cinema, internet, point of sale)-B, B, B, B(PR-beer), 95% 4.8/5 B(PR-beer), B (PR-beer) In internet, social media, and point of sale (B, B, B) 83% 4.2/5 Restrictions on product placement 100% 5/5 on national TV/cable TV/fi lms and movies (B, B, B) Restriction on sale promotions 100% 5/5 from owners of pubs/bars, from producers, and from retailers (B, B, B) Restriction on alcohol sponsorship at sports and youth events (B, B) 100% 5/5 Arrangements for detection and penalties for marketing infringements (Y, N) 50% 2.5/5 R aise prices on alcohol through excise taxes and pricing policies 25% 6.3/25 Excise taxes on alcohol with an objective to reduce alcohol-related harms (Y, N) 50% 3/6 Taxes on traditional/indigenous alcohol (Bangla Mad, cholai Tari) (N) 0% 0/2 Use of duty paid/tax stamps on alcoholic beverages containers/bottles (N) 100% 2/2 Taxes adjusted regularly for changing infl ation and income level (N) 0% 0/2 Minimum price per unit of alcohol (N) 0% 0/2 Ban on volume discounts and below cost selling (N) 0% 0/2 Incentives for producing low content or non-alcoholic beverages at lower price (N) 0% 0/2 Earmarking of some alcohol taxes for health promotion including alcohol control (N) 0% 0/2 Source of data: Global Alcohol and Health Survey 2016; *WHO Atlas Substance Abuse survey 2014 <50% 50%-75% >75% † National Global School-based Health Survey, 2015 (13-17 years) Y-Yes; N-No; ND-No data; B-Ban; NA-Not available; a b in the past 12 months; among adult current drinkers in past 30 days NR-No restriction; V-voluntary; SR-Self restriction A policy card to reduce harmful use of alcohol MYANMAR
65.1% 27.6% 43% 4.6% Lifetime abstainers # Adult current drinkers a, # Heavy episodic drinkers b, # Adolescent current drinkers † Total score 56% 56.4/100 Policy component % Score S trengthen restrictions on alcohol availability 71% 17.8/25 Licensing/monopolies at different levels of alcohol market 100% 5/5 (import, production, distribution, retail sales)-(Y, Y, Y, N) On-premise sale restrictions 83% 4.2/5 (days, hours, outlet density, places, events, intoxicated persons) (N, Y, Y Y, Y, Y) Off-premise sale restrictions 50% 2.5/5 (days, hours, outlet density, place, events, petrol stations) (N, Y, N, Y, Y, N) Minimum purchasing age (national, 18 years) 50% 2.5/5 Restrictions on alcohol consumptions in public places (B-govt offi ce, educational/health facilities, places of 72% 3.6/5 worship, PR-others) A dvance and enforce drink-driving countermeasures 50% 6.3/12.5 Strictness of BAC% limit for general population (young/novice drivers, commercial professional drivers 50% 2.5/5 less than or equal to .05) [0.08, .08, .08] Deterrent & detection measures for drink–driving 50% 2.5/5 (Random Breath Testing, Sobriety checkpoints, graduated licensing) (Y, N, N) Drink–driving penalties for fi rst offence (community service, detention, fi nes, license suspension, 57% 2.9/5 mandatory treatment, penalty points, vehicle impoundment) (N, Y, Y, Y, N, N, N) Drink–driving penalties for repeated offence (N, Y, Y, Y, N, N, N) 43% 2.1/5 F acilitate access to screening, brief interventions and treatment 25% 3.1/12.5 Access to screening and brief interventions (proportion of health services with screening and brief 0% 0/5 intervention)*(No data) Treatment for alcohol dependence (very limited 1-10% of health facilities) 50% 2.5/5 E nforce ban or comprehensive restriction on alcohol advertising, sponsorship and sales promotions 92% 22.9/25 Advertising restrictions Seven traditional media 100% 5/5 (TV/cable, national/local radio, print media, billboards, cinema, internet, point of sale)- ban for all In internet, social media, and point of sale (PR for all) 50% 2.5/5 Restrictions on product placement 100% 5/5 on national TV/cable TV/fi lms and movies (B, B, B) Restriction on sale promotions 100% 5/5 from owners of pubs/bars, from producers, and from retailers (B, B, B) Restriction on alcohol sponsorship at sports and youth events (B, B) 100% 5/5 Arrangements for detection and penalties for marketing infringements (Y, N) 100% 5/5 R aise prices on alcohol through excise taxes and pricing policies 25% 6.3/25 Excise taxes on alcohol with an objective to reduce alcohol-related harms (Y, N) 50% 3/6 Taxes on traditional/indigenous alcohol (Bangla Mad, cholai Tari) (N) 0% 0/2 Use of duty paid/tax stamps on alcoholic beverages containers/bottles (Y) 100% 2/2 Taxes adjusted regularly for changing infl ation and income level (N) 0% 0/2 Minimum price per unit of alcohol (N) 0% 0/2 Ban on volume discounts and below cost selling (N) 0% 0/2 Incentives for producing low content or non-alcoholic beverages at lower price (N) 0% 0/2 Earmarking of some alcohol taxes for health promotion including alcohol control (N) 0% 0/2 Source of data: Global Alcohol and Health Survey 2016; *WHO Atlas Substance Abuse survey 2014 <50% 50%-75% >75% #National NCD STEPs survey, 2014 (25-64 years); †National Global School-based Health Survey, 2014 (13-17 years) Y-Yes; N-No; ND-No data; B-Ban; a in the past 12 months; b among adult current drinkers in past 30 days PR-Partial restrictions A policy card to reduce harmful use of alcohol NEPAL
72.2% 23.9% 28.4% 45.1% Lifetime abstainers # Adult current drinkers a, # Heavy episodic drinkers b, # Adolescent current drinkers † Total score 41% 40.5/100 Policy component % Score S trengthen restrictions on alcohol availability 62% 15.6/25 Licensing/monopolies at different levels of alcohol market 100% 5/5 (import, production, distribution, retail sales)-(Y, Y, Y, Y) On-premise sale restrictions 50% 2.5/5 (days, hours, outlet density, places, events, intoxicated persons) (N, Y, N, Y, Y, Y) Off-premise sale restrictions 34% 1.7/5 (days, hours, outlet density, place, events, petrol stations) (N, Y, N, Y, N, N) Minimum purchasing age (national, 18 years) 50% 2.5/5 Restrictions on alcohol consumptions in public places (B - Govt offi ces, workplace, sports, educational/ 78% 3.9/5 health care facilities, PR - Public transport, leisure events, V/SR - Parks and Streets) A dvance and enforce drink-driving countermeasures 66% 8.3/12.5 Strictness of BAC% limit for general population (young/novice drivers, commercial professional drivers 100% 5/5 less than or equal to .05) [zero tolerance] Deterrent & detection measures for drink–driving 50% 2.5/5 (Random Breath Testing, Sobriety checkpoints, graduated licensing) (Y, N, N) Drink–driving penalties for fi rst offence (community service, detention, fi nes, license suspension, 58% 2.9/5 mandatory treatment, penalty points, vehicle impoundment) (N, Y, Y, Y, N, Y, N) Drink–driving penalties for repeated offence (N,Y, Y, Y, N, Y, N) 58% 2.9/5 F acilitate access to screening, brief interventions and treatment 50% 6.3/12.5 Access to screening and brief interventions (proportion of health services with screening and brief 50% 2.5/5 intervention)*(20-25%) Treatment for alcohol dependence (very limited 1-10% of health facilities) 50% 2.5/5 E nforce ban or comprehensive restriction on alcohol advertising, sponsorship and sales promotions 26% 6.5/25 Advertising restrictions Seven traditional media 57% 2.9/5 (TV/cable, national/local radio, print media, billboards, cinema, internet, point of sale) - (B, B, NR, NR, NR) In internet, social media, and point of sale (NR, NR, B) 33% 1.7/5 Restrictions on product placement 67% 3.3/5 on national TV/cable TV/fi lms and movies (B, B, NR) Restriction on sale promotions 0% 0/5 from owners of pubs/bars, from producers, and from retailers (NR, NR, NR) Restriction on alcohol sponsorship at sports and youth events (NR, NR) 0% 0/5 Arrangements for detection and penalties for marketing infringements (N, N) 0% 0/5 R aise prices on alcohol through excise taxes and pricing policies 15% 3.8/25 Excise taxes on alcohol with an objective to reduce alcohol-related harms (Y, N) 50% 3/6 Taxes on traditional/indigenous alcohol (Bangla Mad, chola Tari) (N) 0% 0/2 Use of duty paid/tax stamps on alcoholic beverages containers/bottles (Y) 0% 0/2 Taxes adjusted regularly for changing infl ation and income level (N) 0% 0/2 Minimum price per unit of alcohol (N) 0% 0/2 Ban on volume discounts and below cost selling (N) 0% 0/2 Incentives for producing low content or non-alcoholic beverages at lower price (N) 0% 0/2 Earmarking of some alcohol taxes for health promotion including alcohol control (N) 0% 0/2 Source of data: Global Alcohol and Health Survey 2016; *WHO Atlas Substance Abuse survey 2014 <50% 50%-75% >75% #National NCD STEPs survey, 2019 (25-64 years); †National Global School-based Health Survey, 2015 (13-17 years) Y-Yes; N-No; ND-No data; B-Ban; PR-Partial restrictions; a in the past 12 months; b among adult current drinkers in past 30 days NR-No restrictions; V-voluntary; SR-Self restriction A policy card to reduce harmful use of alcohol SRI LANKA
67.6% 26.6% 32.4% 3.2% Lifetime abstainers # Adult current drinkers a, # Heavy episodic drinkers b, # Adolescent current drinkers † Total score 67% 67.3/100 Policy component % Score S trengthen restrictions on alcohol availability 99% 24.7/25 Licensing/monopolies at different levels of alcohol market 100% 5/5 (import, production, distribution, retail sales)-(Y for all) On-premise sale restrictions 100% 5/5 (days, hours, outlet density, places, events, intoxicated persons) (Y for all) Off-premise sale restrictions 100% 5/5 (days, hours, outlet density, place, events, petrol stations) (Y for all) Minimum purchasing age (national, 21 years) 100% 5/5 Restrictions on alcohol consumptions in public places (ban in govt offi ces, work place, educational building, 94% 4.7/5 health, public transport); PR (park/streets, sporting events) V/SR (worship, leisure events) A dvance and enforce drink-driving countermeasures 50% 6.3/12.5 Strictness of BAC% limit for general population (young/novice drivers, commercial professional drivers 50% 2.5/5 less than or equal to .05) [0.08, .08, .08] Deterrent & detection measures for drink–driving 50% 2.5/5 (Random Breath Testing, Sobriety checkpoints, graduated licensing) (Y, N, N) Drink–driving penalties for fi rst offence (community service, detention, fi nes, license suspension, 43% 2.1/5 mandatory treatment, penalty points, vehicle impoundment) (N, Y, Y, Y, N, N, N) Drink–driving penalties for repeated offence (N, Y, Y, Y, Y, N, N) 57% 2.9/5 F acilitate access to screening, brief interventions and treatment 50% 6.3/12.5 Access to screening and brief interventions (proportion of health services with screening and brief 100% 5/5 intervention)*(Most, 61-100%) Treatment for alcohol dependence (no data) 0% 20/5 E nforce ban or comprehensive restriction on alcohol advertising, sponsorship and sales promotions 100% 25/25 Advertising restrictions Seven traditional media 100% 5/5 (TV/cable, national/local radio, print media, billboards, cinema, internet, point of sale) - ban for all In internet, social media, and point of sale (B, B, B) 100% 5/5 Restrictions on product placement 100% 5/5 on national TV/cable TV/fi lms and movies (B, B, B) Restriction on sale promotions 100% 5/5 from owners of pubs/bars, from producers, and from retailers (B, B, B) Restriction on alcohol sponsorship at sports and youth events (B, B) 100% 5/5 Arrangements for detection and penalties for marketing infringements (Y, Y) 100% 5/5 R aise prices on alcohol through excise taxes and pricing policies 20% 35/25 Excise taxes on alcohol with an objective to reduce alcohol-related harms (Y, N) 50% 3/6 Taxes on traditional/indigenous alcohol (Toddy, Arrack, Kasippu) (Y for Toddy) 50% 1/2 Use of duty paid/tax stamps on alcoholic beverages containers/bottles (N) 0% 0/2 Taxes adjusted regularly for changing infl ation and income level (N) 0% 0/2 Minimum price per unit of alcohol (N) 0% 0/2 Ban on volume discounts and below cost selling (N) 0% 0/2 Incentives for producing low content or non-alcoholic beverages at lower price (N) 0% 0/2 Earmarking of some alcohol taxes for health promotion including alcohol control (N) 0% 0/2 Source of data: Global Alcohol and Health Survey 2016; *WHO Atlas Substance Abuse survey 2014 <50% 50%-75% >75% #National NCD STEPs survey, 2014 (18-64 years); †National Global School-based Health Survey, 2016 (13-17 years) Y-Yes; N-No; ND-No data; B-Ban; a in the past 12 months; b among adult current drinkers in past 30 days NR-No restrictions; V/SR=Voluntarily/Self restricted A policy card to reduce harmful use of alcohol THAILAND
57.2% 28.4% 41.9% 23% Lifetime abstainers # Adult current drinkers a, # Heavy episodic drinkers b, # Adolescent current drinkers † Total score 53% 53.3/100 Policy component % Score S trengthen restrictions on alcohol availability 76% 18.9/25 Licensing/monopolies at different levels of alcohol market 100% 5/5 (import, production, distribution, retail sales) - (Y for all) On-premise sale restrictions 67% 3.3/5 (days, hours, outlet density, places, events, intoxicated persons) (Y, Y, N, Y, N, Y) Off-premise sale restrictions 67% 3.3/5 (days, hours, outlet density, place, events, petrol stations) (Y, Y, N, Y, N, Y) Minimum purchasing age (national, 20 years) 100% 5/5 Restrictions on alcohol consumptions in public places 44% 2.2/5 (B - public transport, NR - leisure/sporting event, PR - other) A dvance and enforce drink-driving countermeasures 66% 8.3/12.5 Strictness of BAC% limit for general population (young/novice drivers, commercial professional drivers 100% 5/5 less than or equal to .05) [0.05, .05, .05] Deterrent & detection measures for drink-driving 50% 2.5/5 (Random Breath Testing, Sobriety checkpoints, graduated licensing) (N, Y, Y) Drink–driving penalties for fi rst offence (community service, detention, fi nes, license suspension, 57% 2.9/5 mandatory treatment, penalty points, vehicle impoundment) (N, Y, Y, Y, Y, Y, Y) Drink–driving penalties for repeated offence (N, Y, Y, Y, Y, Y, Y) 57% 2.9/5 F acilitate access to screening, brief interventions and treatment 0% 0/12.5 Access to screening and brief interventions (proportion of health services with screening and brief 0% 0/5 intervention)*(No data) Treatment for alcohol dependence (unknown) 0% 0/5 E nforce ban or comprehensive restriction on alcohol advertising, sponsorship and sales promotions 69% 17.3/25 Advertising restrictions Seven traditional media (TV/cable, national/local radio, print media, billboards, cinema, internet, point of sale) - ban for national/ 64% 3.2/5 local radio, PR for others In internet, social media, and point of sale (N, N, B) 50% 2.5/5 Restrictions on product placement 50% 2.5/5 on national TV/cable TV/fi lms and movies (PR, PR, PR) Restriction on sale promotions 100% 5/5 from owners of pubs/bars, from producers, and from retailers (B, B, B) Restriction on alcohol sponsorship at sports and youth events (PR, PR) 50% 2.5/5 Arrangements for detection and penalties for marketing infringements (Y, Y) 100% 5/5 R aise prices on alcohol through excise taxes and pricing policies 35% 8.8/25 Excise taxes on alcohol with an objective to reduce alcohol-related harms (Y, N) 50% 3/6 Taxes on traditional/indigenous alcohol (Oou, Krachae, Namtanmao, Sa-tho) (Y) 50% 1/2 Use of duty paid/tax stamps on alcoholic beverages containers/bottles (N) 100% 2/2 Taxes adjusted regularly for changing infl ation and income level (N) 0% 0/2 Minimum price per unit of alcohol (N) 0% 2/2 Ban on volume discounts and below cost selling (N) 0% 0/2 Incentives for producing low content or non-alcoholic beverages at lower price (N) 0% 0/2 Earmarking of some alcohol taxes for health promotion including alcohol control (Y) 50% 1/2 Source of data: Global Alcohol and Health Survey 2016; *WHO Atlas Substance Abuse survey 2014 <50% 50%-75% >75% # † National Tobacco and Alcohol Surveys, 2017 (15+ years); National Global School-based Health Survey, 2015 (13-17 years) Y-Yes; N-No; ND-No data; B-Ban; a b in the past 12 months; among adult current drinkers in past 30 days PR-Partial restrictions A policy card to reduce harmful use of alcohol TIMOR-LESTE
57.8% 36.8% 39.5% 15.1% Lifetime abstainers # Adult current drinkers a, # Heavy episodic drinkers b, # Adolescent current drinkers † Total score 31% 31.4/100 Policy component % Score S trengthen restrictions on alcohol availability 36% 8.9/25 Licensing/monopolies at different levels of alcohol market 83% 4.2/5 (yes for import, production (bear), distribution, retail sales) On-premise sale restrictions 22% 1.1/5 (days, hours, outlet density, places, events, intoxicated persons) (N, N, N, Y, N, N) Off-premise sale restrictions 0% 0/5 (days, hours, outlet density, place, events, petrol stations) (N, N, N, N, N, N) Minimum purchasing age (none) 0% 0/5 Restrictions on alcohol consumptions in public places (ban in Govt offi ce, educational building, health 72% 3.6/5 facilities, pub transport, PR in others) A dvance and enforce drink-driving countermeasures 93% 11.6/12.5 Strictness of BAC% limit for general population (young/novice drivers, commercial professional drivers 100% 5/5 less than or equal to .05) [0.05, .05, .05] Deterrent & detection measures for drink-driving 100% 5/5 (Random Breath Testing, Sobriety checkpoints, graduated licensing) (Y, Y, Y) Drink–driving penalties for fi rst offence (community service, detention, fi nes, license suspension, 86% 4.3/5 mandatory treatment, penalty points, vehicle impoundment) (N, Y, Y, Y, Y, Y, Y) Drink–driving penalties for repeated offence (N, Y, Y, Y, Y, Y, Y) 86% 4.3/5 F acilitate access to screening, brief interventions and treatment 0% 0/12.5 Access to screening and brief interventions (proportion of health services with screening and brief 0% 0/5 intervention)*(No data) Treatment for alcohol dependence (unknown) 0% 0/5 E nforce ban or comprehensive restriction on alcohol advertising, sponsorship and sales promotions 8% 2.1/25 Advertising restrictions Seven traditional media (TV/cable, national/local radio, print media, billboards, cinema, internet, point of sale) - (NR - TV,Cinema, 0% 0/5 Internet, V/SR for others) In internet, social media, and point of sale (N, N, B) 0% 0/5 Restrictions on product placement 0% 0/5 on national TV/cable TV/fi lms and movies (NR/ V/SR) Restriction on sale promotions 0% 0/5 from owners of pubs/bars, from producers, and from retailers (NR, NR, NR) Restriction on alcohol sponsorship at sports and youth events (NR, NR) 0% 0/5 Arrangements for detection and penalties for marketing infringements (Y, N) 50% 2.5/5 R aise prices on alcohol through excise taxes and pricing policies 35% 8.8/25 Excise taxes on alcohol with an objective to reduce alcohol-related harms (Y, N) 50% 3/6 Taxes on traditional/indigenous alcohol (Bangla Mad, cholai Tari) (N) 0% 1/2 Use of duty paid/tax stamps on alcoholic beverages containers/bottles (Y) 100% 2/2 Taxes adjusted regularly for changing infl ation and income level (N) 0% 0/2 Minimum price per unit of alcohol (Y) 100% 2/2 Ban on volume discounts and below cost selling (N) 0% 0/2 Incentives for producing low content or non-alcoholic beverages at lower price (N) 0% 0/2 Earmarking of some alcohol taxes for health promotion including alcohol control (Y) 0% 0/2 Source of data: Global Alcohol and Health Survey 2016; *WHO Atlas Substance Abuse survey 2014 <50% 50%-75% >75% # † National NCD STEPs survey, 2015 (18-69 years); National Global School-based Health Survey, 2015 (13-17 years) Y-Yes; N-No; ND-No data; B-Ban; NR-No restrictions; a b in the past 12 months; among adult current drinkers in past 30 days V/SR= Voluntarily/Self restricted
Alcohol use is responsible for more than 1 in 20 deaths globally and in the WHO Making South-East Asia safer South-east Asia Region. It causes more deaths than those caused by tuberculosis, HIV/AIDS, and diabetes, each. Notably, more than one in every ve deaths from from alcohol related harm: tuberculosis is attributed to alcohol use. The societal costs of alcohol a ecting the partners, children, families and communities of drinkers are estimated to be twice those Current status and way forward incurred by drinkers themselves. The per capita alcohol consumption has been increasing substantially in the South-East Asia Region since 2000. Bold policy actions and their e ective implementation are required to reverse the trends in increasing per capita consumption. WHO launched “SAFER” – an action package prioritizing ve high-impact policy action domains. The paper provides the current status of implementation of SAFER policy action package in WHO South-East Asia Region.
9 789290 227274