Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2019-001958 on 16 April 2020. Downloaded from Advancing alcohol research in low- income and middle- income countries: a global alcohol environment framework 1 2 3,4 4 Helen Walls , Sarah Cook, Richard Matzopoulos, Leslie London To cite: Walls H, Cook S, ABSTRACT Summary box Matzopoulos R, et al. Advancing Alcohol- related harm has gained increased attention alcohol research in low- income in high- income countries (HICs) in recent years which, ► In recent years, alcohol consumption has reduced in and middle- income countries: alongside government regulation, has effected a reduction a global alcohol environment high- income countries. in alcohol consumption. The alcohol industry has turned its framework. BMJ Global Health ► The alcohol industry has turned its attention to low- attention to low- income and middle- income country (LMIC) 2020;5:e001958. doi:10.1136/ income and middle- income countries. markets as a new source of growth and profit, prompting bmjgh-2019-001958 ► Critical need to understand how the alcohol industry increased consumption in LMICS. Alcohol use in LMICs is shapes local alcohol use. also increasing. There is a need to understand particularly Handling editor Eduardo ► We propose a conceptualisation of the ‘alcohol envi- in LMICs the impact of industry strategy in shaping local Gómez ronment’ to help do this. contexts of alcohol use. We draw on conceptualisations ► Our conceptualisation includes alcohol provision, ac- Received 27 September 2019 from food systems research, and research on the quisition and consumption. Revised 3 March 2020 commercial determinants of health, to develop a new ► This, critically, includes advertising and marketing Accepted 27 March 2020 approach for framing alcohol research and discuss activities. implications for alcohol research, particularly in LMICs, ► The conceptualisation also includes political, eco- focusing on South Africa as an illustrative example. We nomic and regulatory context of alcohol industry. propose a conceptualisation of the ‘alcohol environment’ ► This new conceptualisation provides an approach for as the system of alcohol provision, acquisition and framing alcohol research. consumption—including, critically, industry advertising ► Research of alcohol environments is vital to inform and marketing—along with the political, economic and effective regulation. regulatory context of the alcohol industry that mediates people’s alcohol drinking patterns and behaviours. While each country and region is different in terms of its context http://gh.bmj.com/ of alcohol use, we contrast several broadly distinct industry has been accompanied by reductions features of alcohol environments in LMICs and HICs. © Author(s) (or their in alcohol consumption in high-income coun- Improving understanding of the full spectrum of influences 1 employer(s)) 2020. Re- use tries (HICs). The industry has responded permitted under CC BY- NC. No on drinking behaviour, particularly in LMICs, is vital to by developing new sources of growth and inform the design of interventions and policies to facilitate commercial re- use. See rights profit, particularly in low-income and middle- and permissions. Published by healthier environments and reduce the harms associated 3 on September 30, 2021 by guest. Protected copyright. BMJ. with alcohol consumption. Our framework for undertaking income countries (LMICs), and expansion 1 alcohol research may be used to structure mixed methods into Africa is an explicit part of the industry’s Department of Global Health 4 and Development, Faculty of empirical research examining the role of the alcohol growth strategy. Relatedly, alcohol use has 1 Public Health and Policy, London environment particularly in LMICs. been shown to be on the rise in many LMICs. School of Hygiene & Tropical South Africa is a particular target of alcohol Medicine, London, UK industry efforts to develop new markets in 2Department of Community Medicine, UiT The Arctic Africa. Its large population, low rates of University of Norway, Tromsø, INTRODUCTION drinking among some population groups and Norway Hazardous alcohol use is a major public connectedness globally and regionally makes 3Burden of Disease Research health concern worldwide, increasing risk it an attractive base from which to expand Unit, South African Medical of many non- communicable diseases, infec- into other parts of Africa.5 Overall consump- Research Council, Cape Town, South Africa tious diseases, mental health problems and tion of alcohol in South Africa is high, despite 4School of Public Health and harm from external causes such as injuries current drinkers being in the minority. This is 1 Family Medicine, University of and violence. This alcohol- related harm has due to drinkers’ propensity to engage in heavy Cape Town, Cape Town, South gained increased attention in recent years, episodic drinking, which increases sales and Africa evidenced by a focus on addressing alcohol profitability. Industry marketing has focused Correspondence to consumption in the Sustainable Development on encouraging uptake of drinking among 2 Dr Sarah Cook; Goals. The increasing recognition and asso- women, who generally have low drinking sarah. cook@ uit. no ciated government regulation of the alcohol rates in Africa currently,6 and young adults, Walls H, et al. BMJ Global Health 2020;5:e001958. doi:10.1136/bmjgh-2019-001958 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001958 on 16 April 2020. Downloaded from in the hope that they will adopt heavy drinking patterns. taxation)14 and has mostly been conducted in HICs, This targeting is done in various ways, for example, despite the context of alcohol acquisition and consump- through development of flavoured products thought to tion, including advertising and marketing strategies, be favoured by women, such as alcopops, and through differing significantly in LMICs. The alcohol industry is marketing that promotes an association between alcohol a key determinant of alcohol consumption and related and women’s independence.6 harms in LMICs too and requires careful monitoring Evidence of alcohol’s health impact in LMICs is and effective regulation.15 However, there is also a need emerging, with alcohol consumption a leading health to understand the impact of industry strategy in shaping risk factor in Southern Africa, as demonstrated in the local contexts in which alcohol is used and interactions Global Burden of Disease Study.3 In South Africa, 7% of with broader relevant sociocultural factors. Analyses of disability- adjusted life years are attributable to alcohol.7 industry strategy, as have also been advocated for and However, South Africa’s harmful alcohol use has socio- conducted in other areas of health including regarding economic dimensions; high-income earners have the tobacco and ultraprocessed food and beverages, can highest drinking prevalence, but low-income earners on particularly assist with informing the development of average consume more alcohol, spend a greater propor- effective public health advocacy and regulation.16–18 tion of household income on alcohol and experience a While the difficulty of attributing policy change to any higher burden of alcohol- related harm.8 9 particular analysis has long been noted,19 the evolution Higher rates of alcohol-related illness, injury of tobacco control policy could be cited as policy change and mortality among the poor in South Africa8 are resulting to a significant extent from the large body of compounded by the inequalities in the health and social work analysing industry impact and strategy.20 21 systems—a legacy of the country’s history of colonial In this paper, we draw on theories and conceptualisa- subjugation, apartheid dispossession and prevailing tions from food systems research to propose a concep- dysfunction of the postapartheid period.8 Related to this tualisation of what we term the ‘alcohol environment’. are the deep roots that harmful alcohol use has in polit- We then discuss the implications of the alcohol environ- ical systems of control under apartheid. The ‘dop’ system ment conceptualisation for alcohol research in LMICs, was a practice which, despite being officially illegal, saw with a particular focus on South Africa as an illustrative farm workers given alcohol as a benefit of employment.10 example. We recognise the heterogeneity of contexts of With the rise of the gold mining industry in Southern LMICs, and thus while the themes emerging from South Africa, the availability of cheap alcohol to workers on Africa are indicative, there is a need to replicate this anal- the mines helped to facilitate retention and stability of a ysis in other LMIC settings. Such research is critical to migrant work force. However, by the turn of the century, identify points of intervention and to inform the devel- mining’s requirement for consistent worker productivity opment of effective regulation. was threatened by uncontrolled alcohol distribution to and consumption by workers. As a result, mining interests http://gh.bmj.com/ sought to establish better control over merchant retailing CONCEPTUALISING THE ‘ALCOHOL ENVIRONMENT’ of alcohol to workers or to support total prohibition of Our conceptualisation of the ‘alcohol environment’ the supply of alcohol to African workers. In contrast, agri- builds on research into the food environment, which cultural employers in Western Cape Province continued is informed by socioecological theories