ALCOHOL USE LITERATURE REVIEW

PREPARED FOR SOUL CITY BY:-

Prof. Melvyn Freeman

Prof Charles Parry

February 2006

Contact details.
Melvyn Freeman Charles Parry
Tel: 011 487 3413 Tel: 021 938 0419
Fax: 011 487 3413 Fax 021 938 0342
Cel: 082 578 4730
e-mail mfreeman@telkomsa.net e-mail cparry@mrc.ac.za

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INTRODUCTION

Alcohol is a complex health and social issue. There is little doubt that considerable
harm is done through its abuse - even the alcohol industry accepts this - but in
moderation drinking alcohol is an acceptable convention utilized by over 2 billion
people word-wide. While it is possible, even probable, that if alcohol was
“discovered” now it would be banned, prohibition is not on the agenda in South
Africa or in most other parts of the world (Muslim dominated countries being the
exception). The critical issue then is how does one effectively prevent and control its
abuse and minimize the associated harms?

This review provides background to questions such as why people consume alcohol,
who consumes it, how much and when. It then looks at health impacts (both through
direct biological effects and non-natural mortality and morbidity) as well as social and
psychological impacts. Special areas of concern in South Africa, such as Fetal
Alcohol Syndrome and impacts on sexual behaviour are briefly addressed. The review
then turns to outlining some of the benefits that accrue to the country from a vibrant
liquor industry but also some of the social and economic costs.

The review points to international best practices with regard to alcohol prevention and
asks how relevant such recommendations are for South Africa? Are there also other
important issues for prevention in South Africa? The controversial issue of
advertising and counter advertising is then addressed.

Brief examples of community based programmes in South Africa are given as well as
a summary of the current response of government to alcohol abuse. Finally some
barriers to prevention and control of alcohol abuse in South Africa that need to be
addressed are outlined.

1) WHY IS ALCOHOL CONSUMED?

Alcohol consumption has been part of human history since antiquity. There are not
only numerous biblical examples and ancient myths which refer to alcohol but local
oral history and archeological findings suggests that consumption has been part of
African culture, rituals, tradition and custom since “time immemorial”. But the fact of
enduring alcohol consumption and the passing down of this habit through generations
does not adequately explain why alcohol is consumed. Moreover patterns of alcohol
use have changed significantly over time and evidence suggests that the quantity used
now is far greater than in earlier times (See pg. 4). The WHO estimates that around 2
billion people worldwide consume alcohol (WHO 2004) and there is clearly no single
reason why they do or why different people drink to different extents. It is apparent
though that drinking is influenced by factors such as genetics, social environment,
culture, age, gender, accessibility, exposure and personality.

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1.1) Common reasons why alcohol is consumed
• Alcohol as a social lubricant
Alcohol assists people to relax, converse more easily and mix socially. It disinhibits
defenses and facilitates “good company”.
• Use of alcohol in ritual
Alcohol has a “mystique” not shared by non-alcoholic beverages and its use in
traditional rituals (locally and internationally) appears to add to the aura of special
occasions.
• Social sharing
Sharing an alcoholic drink with other people promotes a bonding and a connectedness
amongst consumers often not gained through sharing non-alcoholic beverages.
• Drinking alcohol is accepted - and even expected - behaviour
There is very little public criticism of people who drink alcohol – even to states of
drunkenness. On the contrary, in a number of cultures and situations it is expected that
one drinks – even to states of drunkenness. Obvious examples would be to see in the
new year or “the coming of age” of a young person. Drinking in many situations is
simply the “status quo”, i.e. that’s the way things are1.
• Taste and quality
Though an acquired taste, consumers of alcohol enjoy the taste of alcohol. Some
people develop sophisticated palates for alcohol and sincerely appreciate good
quality. Even traditionally made alcohol products vary in quality and demand is
mediated by this. What one drinks and how one drinks it is very often an indication of
culture and class.
• Alcohol as a reducer of stress
Alcohol is often used to reduce the tension of an event – impending or actual.
Research suggests that drinking can reduce stress in certain people and under certain
circumstances. Differences include a family history of alcoholism, personality traits,
self-consciousness, cognitive functioning and gender (Sayette, 1999).
• Drinking as a means of dulling “the pain of poverty” or other hardships of
life.
For many people life is simply intolerable. They live in abysmal poverty or in life
circumstances which produce unbearable emotional pain. Alcohol dulls that pain for
as long as they are drinking. (The fact that this leads into a cycle of ongoing poverty
or pain does not influence this pattern).
• Consumption as “macho” behaviour
(Mainly) men consume large amounts of alcohol as an indication of their strength and
manliness. Behaviours such as drinking more than anyone else or more quickly than
anyone else are often regarded as admirable masculine qualities. With changing
gender roles some women also “prove” themselves with binge drinking patterns.
• Consumption in youth
As children are usually prohibited from drinking alcohol, youth (again mainly males)
often see drinking alcohol as a state of adult behaviour to be aspired to.

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Though there is the beginning of a “culture” of not drinking and driving in South Africa, this is still at
a rudimentary stage. In any event most adults in South Africa are not drivers and are hence not affected
by this. The sanction against drinking and driving appears to not extend to drinking and walking (which
is the cause of a significant number of road deaths) nor usually to drinking in situations where other
social ills such as violence might arise

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 • Enjoyment of a state of intoxication
Many people simply enjoy the feeling of intoxication (from fairly mild to
“motherless”).
• Maintaining a state of inebriation
The state of inebriation is not maintained unless additional alcohol is consumed. This
may lead to more consumption and to states of drunkenness not necessarily intended
when starting to drink.
• Lack of information
Many people are ignorant of the facts regarding the impacts and effects of alcohol and
drink without knowing the dangers. “Counter advertising” and education around
alcohol in schools are limited (though see section 8.1 regarding the minimal evidence
of the effectiveness of this).

1.2)Pressure to consume alcohol

• Responding to peer pressure.
Many people, especially youth, may be, or feel, pressurized to drink alcohol as this is
regarded as the social norm or the norm of a particular age or social/cultural grouping.
The pressure to conform, especially amongst youth, is a well-documented
psychological phenomenon. People may be (or fear they may be) excluded from or
ostracized by the group if they do not partake in alcohol.
• Pressure from advertising/following role-models
While the alcohol industry claims that alcohol advertising is aimed solely at brand
switching and that it is not aimed at promoting additional consumption - especially
drinking amongst youth - evidence suggests that advertising does indeed increase
consumption (Snyder 2006). The association of role models depicted in adverts such
as sportspeople, attractive people, strong people, “outdoor” people, people who enjoy
life, people with “superior” tastes etc, etc encourage drinking behaviour in the belief
that emulating this behaviour makes one more like these “models”.

1.3)Alcohol as part of social control

Since the arrival of European settlers in South Africa, alcohol was used as a form of
social and economic control. At different periods it was used in barter for cattle, in
exchange for labour (including the “dop” system), the education of slaves and played
a pivotal role in “managing” labour in certain sectors of the economy such as mining
and agriculture (Parry and Bennetts 1998).

The history of alcohol in South Africa is an integral part of the history of apartheid
and segregation. During apartheid who was allowed to buy liquor, when, what types
and where were all determined by race and used to control the movements, social
habits and freedoms of black people. In townships, municipal beer halls were
established by local authorities to help finance township development and control the
behaviour of black people.

In response, many people turned to illegal liquor related activities - both brewing
traditional African beer and setting up illegal outlets (shebeens) where liquor was
sold. Importantly the growth of illegal shebeens in the second part of the 20th century
served not only as a way to increase access to alcohol, as a means for social mixing
and as employment for the owners and employees but also as a form of resistance to
apartheid policies. Moreover during the 1976 uprisings in Soweto and other

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townships, beerhalls were specifically targeted as they had come to symbolize white
domination and control.

This history of distribution, consumption and resistance is critical for understanding

current alcohol related behaviour

1.4)Alcohol dependence
The reasons why most people drink can probably be found in a combination of the
above factors, however for some people, drinking is allied with a disease - alcohol
dependence. This disease is characterized by craving, a strong need or compulsion to
drink; impaired control, the inability to limit one’s drinking on any given occasion;
physical dependence, withdrawal symptoms such as nausea, sweating and anxiety
when alcohol use is stopped after a period of heavy drinking; tolerance, the need for
increasing amounts of alcohol in order to feel its effects. It is a chronic and often
progressive disease. People need to drink despite negative consequences such as
serious job or health problems. It is influenced by both genetic and environmental
factors.

2) WHO CONSUMES ALCOHOL IN SOUTH AFRICA, HOW

MUCH AND WHEN?
Though alcohol has been consumed for thousands of years, the quantity and patterns
of alcohol consumption have changed significantly over the past 500 years. The most
important of these changes has been the replacement (or in some instances
complementing) of traditional and locally produced beverages with industrial
beverages – in particular Western-style commercially produced beer (Riley and
Marshall, 1999). As a result of this, regular heavy drinking has become a sustainable
pattern. Previously alcohol products did not last long – especially in warm climates –
and each batch was consumed within a relatively short period of time. The amount of
alcohol available was typically limited by the amount of agricultural surplus (Room et
al. 2002). Other factors which have substantially affected patters of drinking in
developing countries include urbanization, changes in gender and age roles, and high
intensity mass marketing and promotion of alcoholic beverages by mass multi-
national corporations. (Parry 2000).

In traditional African society the use of alcoholic beverages appears to have been well
regulated. Drinking did not occur on a daily basis and people did not drink alone or
just for the sake of drinking. Rather, drinking served a communal and ceremonial
purpose (Western Cape Department of Economic Affairs and Tourism, 2003).
However this changed with the social and economic developments mentioned. Life
for black people tended to be extremely hard and many people turned to drink to
alleviate their stress and sorrow.

Rates of drinking in countries with the highest consumption are decreasing while the
opposite is true of countries with lower consumption (corresponding generally to
more developed vs. less developed countries). It also appears that there is a link
between economic prosperity and rising alcohol consumption (e.g. Ireland and the
Nordic Countries).

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Recorded consumption
Data on country level alcohol consumption is usually measured in terms of “recorded”
alcohol derived from formal production and sales - the UN Food and Agriculture
Organisation collects annual figures directly from governments around the world –
and measured in terms of per capita alcohol consumption (15+) in litres of pure
alcohol.

The WHO Global Status report on Alcohol 2004 reported on alcohol consumption in
189 countries (WHO 2004). Consumption ranges from Muslim countries such as Iran
and Saudi Arabia were no alcohol is consumed (in terms of official production and
sales) to Luxembourg and Uganda who consume 17.54 and 19.47 litres of pure
alcohol per adult capita respectively. South Africa is the 47th highest consumer
with 7.81 litres per capita.

These figures do not, however, include “unrecorded” consumption or the consumption

of those who do not drink i.e. excluding adults who abstain from alcohol.

Unrecorded consumption
Unrecorded consumption includes traditionally brewed beverages (mainly brewed in
villages and homes), cross border trade, smuggling, tourist consumption and
beverages with alcohol below the legal definition of alcohol. Few countries have
been able to estimate the level of unrecorded alcohol consumed, though some
research has been done and estimates suggested. Countries in Africa with high levels
of estimated unrecorded alcohol use include Kenya (5.0 litres), Swaziland (4.1 litres.
Uganda (10.7 litres) and Zimbabwe (9.0 litres). South Africa was estimated to
consume an additional 2.2 litres per adult capita. Total alcohol consumption is
thus estimated to be around 10 litres per adult capita. Other estimates have suggested
12.4 per year

Locally made beverages are usually cheaper than mass or factory based products,
often brewed in rural areas and is consumed mostly by the poorer segments of society.
They are also often used as part of ceremonial occasions.

2.1)Who drinks in South Africa?

The adult per capita measurement of alcohol consumption assumes an average across
the population, but clearly not everyone consumes equal amounts. In 1998, as part of
the first South African Demographic and Health Survey (SADHS), an alcohol survey
was conducted to assess the extent of alcohol use, risky drinking, and alcohol
problems among South Africans in order to obtain estimates of consumption and risky
drinking and to inform intervention efforts (Parry et al, 2005). The SADHS was a
national household survey providing cross-sectional data on a representative sample
of the non-institutionalised population. Current and life time drinking from this survey
were as follows:-

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 Percentage of males and females (aged 15 years or older) reporting lifetime and
current use of alcohol.

Ever drunk alcohol Drink now

(Current drinking)
Background
Males Females Males Females
characteristics

Age
15-24 35.5 15.9 23.5 8.5
25-34 65.7 24.5 51.8 15.6
35-44 71.8 29.4 61.1 21.0
45-54 72.8 31.6 60.1 23.5
55-64 67.2 29.8 54.2 20.4
65+ 65.3 33.4 45.8 20.3

Geographic setting
Urban 59.9 29.2 46.7 19.2
Non-urban 55.0 20.1 41.4 13.2

Province
Western Cape 61.4 40.1 43.6 24.2
Eastern Cape 60.2 22.3 47.5 16.2
Northern Cape 63.4 34.3 48.5 23.1
Free State 66.4 31.6 56.2 24.5
KwaZulu Natal 54.4 17.9 39.8 11.5
North West 57.5 23.7 46.6 17.0
Gauteng 59.1 32.4 49.7 20.6
Mpumalanga 62.1 21.0 45.9 14.2
Northern 45.1 15.7 28.3 8.6

Education#
No education 70.3 33.5 54.6 22.9
Gr. 1 – Gr. 5 63.2 24.2 50.7 16.3
Gr. 6 – Gr. 7 55.2 20.5 42.0 13.2
Gr. 8 – Gr. 11 51.2 20.7 39.6 12.7
Grade 12 59.6 28.8 46.7 18.5
Higher 70.4 45.7 57.8 33.4

Population group
African 53.4 18.8 41.5 12.3
Afr. Urban 54.1 19.9 43.6 12.8
Afr. Non-urban 52.4 17.6 38.8 11.8
Coloured 63.6 40.4 44.8 23.2
White 84.9 69.8 71.4 50.5
Asian 64.6 14.7 37.4 9.0
Total 58.1 25.7 44.7 16.9

Just under half the men (45%) and one-fifth of the women (17%) 15 years and older
reported that they currently consume alcohol. Rates of current drinking differed
substantially by population group and gender, with the highest levels reported by
white males (71%), followed by white females (51%), and Coloured males (45%).
The lowest rates were reported by African and Asian females (12% and 9%
respectively). For both men and women higher rates of current drinking were
recorded in urban areas. For males the highest current drinking levels were reported in
the Free State and Gauteng (50% or more) and the lowest levels were reported in the
Northern Province (28%). For females, the lowest levels were also recorded in the
Northern Province (9%), with the highest levels being in the Free State, Western Cape
and Northern Cape (23%-25%). For both men and women the highest levels of
current alcohol use were recorded among persons in the 35-44 and 45-54 year age

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groups, and the lowest levels in the 15-24 year group. These figures are likely to be
underestimates given the nature of broad household surveys, where respondents may
be dishonest about behaviors which may be stigmatized or disapproved of in certain
communities and where inadequate attention may be given to setting respondents at
ease in asking sensitive questions (Gfroerer et al., 1997). Female drinking, in
particular, is often disapproved of in many African communities and as a result is
likely to be under-reported (Mphi, 1994; Siegfried et al., 2001).

From this survey it is evident that those who do drink, drink heavily – closer to 20.1
litres of pure alcohol per year. This is amongst the highest in the world (Rehm et al
2003).

2.2) Risky and problem drinking

Table 2. Percentage of males and females (aged 15 years or older) current

drinkers engaging in risky drinking
Current drinkers
CAGE ≥ 2
Risky drinking - Risky drinking -
(Alcohol problems) weekdays* weekends*

Males Females Males Females Males Females

Age
15-24 17.6 5.9 3.1 1.2 29.3 30.1
25-34 35.2 9.8 8.4 9.1 37.2 33.4
35-44 38.3 12.1 7.5 7.4 39.0 32.4
45-54 31.2 13.4 8.1 14.0 31.7 35.3
55-64 27.6 9.6 7.6 12.5 27.2 31.8
65+ 22.6 12.2 6.6 7.0 21.0 30.2

Geographic setting
Urban 27.6 10.3 6.4 7.1 30.0 29.5
Non-urban 28.2 9.3 8.3 12.9 38.0 39.3

Province
Western Cape 27.9 11.8 6.1 5.4 33.4 30.2
Eastern Cape 33.9 10.9 6.5 9.8 31.4 33.6
Northern Cape 38.8 18.7 6.2 7.7 38.1 48.7
Free State 34.5 11.9 5.6 5.6 27.3 30.0
KwaZulu Natal 22.9 6.9 8.5 14.2 31.7 37.8
North West 25.0 11.6 9.1 14.9 42.9 43.0
Gauteng 23.8 10.4 6.1 4.7 24.0 22.1
Mpumalanga 38.4 11.7 5.8 8.6 49.4 46.4
Northern 24.0 6.1 11.1 18.1 41.1 45.2

Education#
No education 33.5 17.1 6.9 14.6 36.0 38.6
Gr. 1 – Gr. 5 35.8 13.1 12.1 11.3 40.3 44.6
Gr. 6 – Gr. 7 32.2 11.3 10.5 9.5 42.9 44.9
Gr. 8 – Gr. 11 25.9 7.6 4.7 7.6 30.4 32.5
Grade 12 22.4 6.5 6.9 5.9 24.4 18.3
Higher 17.9 4.9 2.0 1.9 24.0 12.6

Population group
African 29.6 9.7 7.7 13.3 35.7 42.1
Afr. Urban 30.6 10.8 6.6 11.3 32.5 40.7
Afr. Non-urban 28.2 8.3 9.2 15.3 40.2 43.5
Coloured 33.8 18.7 9.3 4.3 39.2 34.2
White 10.0 6.1 3.4 2.7 18.7 14.0
Asian 20.4 1.8 1.5 0.0 6.1 0.0
Total 27.8 9.9 7.0 8.8 32.8 32.4

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Risky drinking was defined as drinking five or more standard drinks per day for men
and three or more drinks per day for women. Many people that do drink tend to binge
– especially over weekends. Rates of risky drinking amongst current drinkers were
very similar for male and female drinkers (remembering that far more males are
drinkers) and were approximately 4-5 times greater at weekends than on weekdays,
with one-third of current drinkers drinking at risky levels over weekends (Males 33%;
Females 32%). For both males and females, risky drinking at weekends appeared to
be highest among persons in the middle categories for age (35-44 years for males and
45-54 years for females), among persons residing in non-urban areas, with a low level
of education (grade 1 to grade 7), and amongst Coloureds and Africans. Weekend
risky drinking by males appeared to be highest in Mpumalanga, whereas for females
the highest levels appeared to be in the Northern Cape.

The screen for symptoms of alcohol problems (CAGE) found that overall almost a
third of males reported symptoms of alcohol problems. This translated to almost two
thirds of those who reported currently drinking alcohol. The proportion for females
overall was significantly lower. However, when considering the current female
drinkers, the proportion who scored two or more on the CAGE screen was virtually
equal to that of the males.

The apparent relationship between socio-economic status and an increased risk for
alcohol-related problems, with wealthier persons having lower levels of alcohol
problems, is confirmed by international studies (Khan et al., 2002). For example, a
study conducted in Nepal (Jhingan et al., 2003) also found that lower levels of
education were linked to higher scores on the CAGE Questionnaire and that
symptoms of alcohol problems seemed to peak in the older age groups (45-54 years
for both genders in the Nepal study, versus 35-44 years for males and 45-54 years for
females in this study).

The rates of ‘current drinkers’ found in this survey were lower than those reported for
other developing countries, including Mexico (males 77%, females 44%), Chile
(males 77%, females 44%), Thailand (males 71%, females 46%), and Namibia (males
61%, females 47%) (Room et al., 2002). Although risky drinking was fairly
uncommon during weekdays, it increased significantly over weekends, coinciding
with findings from other developing countries, such as Zimbabwe (Room et al., 2002).
Interestingly, male and female drinkers were equally likely to engage in risky drinking
over weekends, which does not appear to be the case in other developing countries
(Room et al., 2002). In most other developing countries males are more likely to
engage in risky drinking than females. The similarly high levels of risky drinking
between males and females found in this study also differs from that found in most
developed countries where levels of risky drinking are much higher among males
(Babor et al., 2003).

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 Harmful drinking patterns amongst South Africans was also reported in the 2002
World Health Report (WHO, 2002) where South Africa fell into the group of
countries exhibiting the most harmful pattern of drinking2.

2.4)What do people drink?

By far the largest quantity of alcohol consumed is beer, followed by African
traditional Beer, wine, brandy, other spirits, alcoholic fruit beverages, whisky,
fortified wine and sparkling wine.

Beer Brandy Other Alco Whisky Fortified Spark Tot

Trad Wine
beer spirits Fruit wine wine
bev
2004 43.3% 24.7% 12.3% 6.5% 4.4% 3.4% 2.7% 2.4% 0.3 100%

2.5)Alcohol consumption in Youth

There have been few studies that have documented prevalence rates of substance
abuse amongst young people in South Africa. In 1990 Rocha-Silva et al (1996) found
that 34% of black youth aged 10-21 had used alcohol in the previous 12 months. In
1993 Flisher et al found that 27% of school going youth had engaged in binge
drinking in schools in the Cape Town. A later study by Flisher et al (2003) found:-

Grade 8 Grade 11
Black Coloured White Black Coloured White
Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
Life 34.7 16.2 39.7 32.5 49.8 52.8 55.4 18.3 69.0 55.6 72.9 75.7
Time
Past 16.1 6.7 22.6. 18.5 33.9 39.8 35.6 9.6 54.3 41.3 62.3 64.1
year
Past 17.7 7.7 21.9 20.5 22.5 25.0 37.6 8.4 47.7 33.2 54.7 56.8
month

An important finding of this study was that black female adolescents consumed
significantly less alcohol than either their male counterparts of females of other races.
Another important finding was that the numbers of days absent from school correlated
with alcohol use. Whether this is a causal relationship or related to another variable
such as “unconventionality” (ie the same people tend to more rebellious type
behaviours due to personality of other factors) cannot be gleaned from this study. A
community survey in Cape Town in 2002 found that more than 10% of 11- to 17- year
olds had been drunk more than 10 times. The median age of first use of alcohol was
14 years. Adolescents who reported having been drunk were more likely to live in
communities where youth have easy access to alcohol and where they are exposed to
public drunkenness. Older adolescents and adolescents whose friends drink were
more likely to have been drunk at least once. Risks of having been drunk were being
white and being exposed to public drunkenness on a daily or at least weekly basis.

2
Harmful drinking was indicated by the level of the population drinking first thing in the morning,
drinking to intoxication, drinking apart from meals etc.

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Attendance at religious services was found to be a significant protective factor against
drunkenness.

In the 2002 National Youth Risk Behaviour Survey half of learners (49.1%) between
grades 8 and 11 had drunk at least one drink of alcohol in their lifetime. In the 30 days
preceding the survey 31.3% used alcohol on one or more days while 23% reported
binge drinking (five or more drinks within the space of a few hours) on one or more
days (29% of males and 18% of females). Significantly higher percentages of white
and coloured learners had ever drunk alcohol. Rates of using alcohol (including binge
drinking) increased with age and grade.

Comparisons of data across different studies suggests that over time there has been an
increase in the proportion of people drinking amongst South Africans with particular
increases among young, black African males and females.

3)HEALTH IMPACTS OF ALCOHOL

In 2000 alcohol was responsible for 4% of the global burden of disease – more or less
equal to the damage caused to society by tobacco use (4.1%). Alcohol was estimated
to have caused 1.8 million deaths, or 3.2% of all deaths globally. Contribution to the
global burden of disease was considerably higher in developed (9.2%) than
developing countries, in part due to the greater consumption of alcohol in these
countries and in part due to the high burden from other diseases in developing
countries (such as AIDS, Malaria, childhood illnesses etc). Alcohol consumption
contributes to disease, injury, disability and premature death more than any other risk
factor in developing countries with low mortality, where alcohol is responsible for
6.2% of disability adjusted life years lost. In high mortality regions including Afro
Region E the GBD was calculated to be 1.6%. For South Africa the estimated burden
due to alcohol (death and disability) has been calculated to be 7.0%, 10.5% for males
and 3.1% for females (Schneider et al., personal communication).

Moreover there are many other negative consequences of alcohol that are not taken
into account in analysing global burden of disease, such as the effects on families,
communities and society as a whole.

3.1)Direct biological Impacts

Both acute intoxication and chronic/long term excessive drinking may have adverse
effects on the brain, central nervous and muscular system, liver, heart (though there
are also some positive effects for certain groups of people), blood cells,
gastrointestinal system, respiratory system, reproductive system as well as the
immune system. Its use contributes to more than 60 diseases and conditions. The
following conditions are some of the most important. The prevalence rates of most of
these diseases in South Africa is generally not known and unless specifically stated
rates refer to international figures.

Alcoholic liver disease

Alcohol is absorbed quickly into the blood system, passes through organs where is
oxidises slowly and can cause damage. The most common organ affected is the liver.

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Mortality studies have consistently demonstrated that heavy drinkers die from liver
disease at a much higher rate than the general population. Types of alcoholic liver
disease include alcoholic fatty liver (prevalent in about 20% of heavy drinkers);
alcoholic hepatitis; and alcohol cirrhosis (about 10-15% of people with alcohol
dependence develop cirrhosis). Alcohol also increases the risk of developing liver
cancer.

Alcohol hepatitis is characterised by inflammation (necrosis) of the liver, jaundice and

abdominal pain. Scar tissue may replace healthy tissue leading to a process of
“fibrosis”. The condition is reversible with abstinence.

Alcohol cirrhosis is the most advanced form of liver disease. The liver is characterised
by extensive fibrosis that stiffens blood vessels and distorts the internal structure of
the liver. This damage results in severe functional impairment and may result in
secondary malfunction of other organs including the brain and kidneys. The amount
of alcohol consumed and the duration of that consumption are closely associated with
cirrhosis. Importantly, as consumption increases the risk of cirrhosis is greater for
women than for men. Moreover consumption of alcohol without food results in
higher risk than with food. Cirrhosis can stabilise with abstinence.

While alcoholic fatty liver, alcohol hepatitis and cirrhosis have been considered to be
sequentially related, i.e. progressing in this order, this is not always the case. Some
cirrhosis develops without hepatitis and hepatitis may have a sudden onset and a rapid
course resulting in death even before cirrhosis can develop.

Effects on the heart

Alcohol can be beneficial or harmful to the cardiovascular system depending on the
amounts consumed and the characteristics of the consumer.

Low to moderate consumption has been shown to have coronary benefits for people
who are 40 years and older. However according to the WHO “ in some industrialised
countries where the condition is common and injuries and violence are rare, alcohol
consumption may prevent about as many deaths as it causes in some segments of the
population. The patterns of drinking in many countries, however, often with heavy
episodic consumption, are likely to increase rather than decrease the occurrence of
coronary heart disease” (WHO, 2005).

Importantly, questions have also been raised regarding the transferability of the
finding of the benefits to developing countries. As coronary heart disease is associated
with diet, lifestyle and age and given that the diet of many traditional developing
countries is relatively low in fat and high in fibre (a factor that is often given as one of
the reasons for the comparatively low incidence of heart disease in developing
countries) the findings of the protective effects may not be applicable.

Moreover even if moderate drinking is protective, heavy alcohol consumption could

damage the cardiovascular system causing heart muscle disorders, irregular heart
rhythms, high blood pressure and strokes.

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Effects on blood cells
Alcohol has numerous adverse effects on blood cells and their functions. For example
heavy drinking can cause generalised suppression of blood cell production and the
production of abnormal blood cell precursors that cannot manufacture cells.

There is evidence that blood pressure increases with increased drinking. A study in
India found alcohol consumption to be a significant risk factor for hypertension. A
meta-analysis found that 11% of cases of hypertension in males and 6% in females
could be directly causally attributed to alcohol.

Gastrointestinal and respiratory systems

Alcohol can interfere with the structure and function of the gastrointestinal tract. For
example alcohol can impair the muscles separating the oesophagus from the stomach
increasing the risk of cancer. Alcohol interferes with the muscle movement of the
small and large intestines and the absorption of nutrients into the body.
Epidemiological research in developing countries has found a causal link between
heavy alcohol consumption and pancreatitis. 84% of cases of chronic pancreatitis
were attributable to alcohol.

A meta analysis of more than 200 studies found that alcohol strongly increased the
risks of various types of cancers (oral cavity, pharynx, oesophagus and larynx) and
found statistically significant increases in risk for cancers such as stomach, colon,
rectum, liver, breast and ovaries.

Reproductive system
In men alcohol can result in loss of libido, reduced potency, shrinking in size of testes
and penis, reduced or absent sperm formation and so infertility. In women alcohol has
been found to result in menstrual irregularities, shrinking of breast and external
genitalia and sexual difficulties. It also affects female reproductive capacity.

Immune system
From animal and in-viro studies it is evident that alcohol impairs various aspects of
the immune system and, particularly, increases the susceptibility to HIV infection. It
may also interfere with adherence to anti-retroviral treatment. Some evidence also
suggests that alcohol may lead to accelerated progression of the disease.

Effects on the brain and central nervous system.

Alcohol directly affects brain function in a number of ways. On a behavioural level

neurological disorders resulting from alcohol can result in changes in emotions,
personality, impaired perception, learning and memory. The detrimental effects of
alcohol on the brain may be similar to Alzheimer’s Disease.

From autopsies it has been established that the brains of people with severe alcohol
dependency are smaller, lighter and exhibit greater atrophy than non-alcoholics.

Neuropsychological studies with people with chronic alcohol dependence have

reported cognitive deficits including problems with problem solving, organising,
planning and abstraction (frontal lobe functions); short and long term memory loss;

13
verbal fluency, learning, and visio-spacial perceptions. Impaired co-ordination and
balance have also been found.

Co-morbidity
Psychiatric co-morbidity is common in individuals with a history of alcohol abuse and
dependence. Schizophrenia, bi-polar disorder, depression, attention deficit disorder,
anxiety disorder and eating disorders have all been associated with abuse of alcohol
though it is not always clear which condition preceded which.

Depression
According to the WHO Global Status report on Alcohol (WHO 2004) there is now
evidence to assume that alcohol has a causal role in depression. Not only do alcohol
dependence and major depression co-occur disproportionately but also higher
volumes of alcohol consumption are associated with more symptoms of depression.
While it has often been postulated that people suffering from depression “self
medicate” with alcohol (and in some cases this is no doubt true), the question of
which precedes the other is not yet fully resolved and/or whether there may be a third
variable (such as neurobiological mechanisms or genetic predisposition) which causes
both to occur. Nonetheless evidence of a causal link from alcohol to depression is
growing. Reversibility (remission during abstinence) is a key indicator for causal
effect of alcohol dependence on depressive disorder and there is good evidence that
abstinence substantially removes depressive disorders within a short time frame.

Alcohol dependence
The ICD-10 defines alcohol dependence syndrome as being a cluster of physiological,
behavioural and cognitive phenomena in which the use of alcohol takes on a much
higher priority for a given individual than other behaviours that once had greater
value. A central descriptive characteristic is the desire (often strong, sometimes
overpowering) or sense of compulsion to take alcohol.

In the WHO Global Status Report on Alcohol 2004, of 35 countries reporting levels
of alcohol dependence amongst the adult population, South Africa had the highest
reported figure i.e. 27.8% of males and 9.9% of females. This should, however be
interpreted with great caution as for example instruments and timeframes used were
not standardised.

Alcohol dependence is consistently the substance of abuse in people receiving help

for substance related problems in South Africa. In the first half of 2005, between 47%
(Cape Town) and 74% (Durban) of patients receiving treatment had alcohol as a
primary or secondary drug of abuse (Sacendu 2005). Though the proportion of people
reporting alcohol as the primary drug of abuse is decreasing as pressure on treatment
slots increases from other drugs, this still remains the major cause of people receiving
treatment. The proportion of patients older than 20 seeking treatment for alcohol
problems is substantially higher than for younger patients.

3.2)Non-Natural Mortality And Morbidity

Unintentional and intentional injuries are responsible for up to 10% of the global
burden of disease. Internationally alcohol use accounts for 13% of DALYs lost due to

14
unintentional injuries and 15% due to intentional injuries. The amount of alcohol
consumed is a major determinant of both risk and severity of injury.

Alcohol plays a major role in traffic and other accidents as well homicides,
interpersonal injury and suicide. High rates of alcohol have been found in both the
“perpetrator” and the “victim”3.

The largest number of non-natural deaths is South Africa is due to violence (48%)
followed by transport fatalities (30%). Both violence and transport deaths are closely
linked with alcohol.

Alcohol related mortality

Data from the Non-Natural Mortality Surveillance System (NNMSS) in 2002
indicated that 46% of non-natural deaths in South Africa involved persons with blood
alcohol concentrations (BACs) greater than or equal to 0.05g/100 ml (Matzopoulos et
al., 2003). NNMSS data for 2003 indicated that for all causes of death, 49% had
positive BACs and the mean BAC overall was 0.18g/100ml (Harris et al., 2004).
Levels of BAC positivity were high for homicides (51% positive, with a mean BAC
of 0.17g/100ml), suicides (35% positive, with a mean BAC of 0.15g/100ml) and
transport related deaths (53.3%).

The majority of transport related deaths in South Africa are of pedestrians 38.8%,
followed by unspecified (21%), driver of a motor vehicle (17.7%) and passenger
(12.2%) of deaths. While in all categories of transport related death, high alcohol
blood levels was prevalent, this was highest amongst pedestrians (61%).

This means that by far the largest number of transport related deaths in South Africa
are of intoxicated pedestrians. Despite this, campaigns almost always focus on
drinking and driving and not on drinking and walking!

Alcohol related trauma

In 2001 39% of trauma patients in Cape Town, Durban and Port Elizabeth had breath
alcohol concentrations (BrACs) greater than or equal to 0.05g/100 ml (Plüddemann et
al., 2004). Levels of alcohol positivity were particularly high for persons injured as a
result of violence (73% for Port Elizabeth, 61% for Cape Town and 43% for Durban).
In data gathered from a wide variety of facilities in the Cape Metropol, Peden
reported that 70% of domestic violence cases were alcohol-related (Peden, 1995).
From research conducted by the Department of Transport the national daily average
of persons driving under the influence of alcohol has been found to have increased
from 1.8% in 2002 to 2.1% in 2003 (Arrive Alive, 2005).

3
The differences between perpetrator and victim are not always clear. For example victims may
include people involved in fights who happened to be the one injured/killed or the drunk driver of a
motor vehicle injured or killed in an accident.

15
4)SOCIAL AND PSYCHOLOGICAL IMPACTS
Social and psychological impacts of alcohol are even more difficult to measure than
the physical health impacts. One can, however for example, look at substantive
impacts on crime, patterns of interpersonal violence and family and work problems.

4.1)Alcohol and crime

A national study of prisoners and parolees in 1996 found that just under half had
taken alcohol or other drugs just prior to the crime for which they were incarcerated
(Rocha-Silva & Stahmer, 1996). Drinking was especially linked to rape and
housebreaking offences. Subsequent research in Cape Town, Durban and
Johannesburg in three phases between 1999 and 2000 (Parry et al., 2004) found that
overall 15% of arrestees indicated that they were under the influence of alcohol at the
time the alleged offence took place. Regarding violent offences, arrestees indicated
that they were under the influence of alcohol for 25% of weapons related offences,
22% of rapes, 17% of murders, 14% of assault cases and 10% of robberies. Levels of
alcohol-related crime were particularly high for family violence offences at 49%.
Arrestees also indicated that they were often under the influence of alcohol in cases
involving property offences, for example, 22% of cases involving housebreaking and
12% of cases involving the theft of a motor vehicle. When asked why they consumed
alcohol or other drugs in relation to crimes, many arrestees indicated they consumed
these substances in order to give them courage to commit the crimes (Parry et al.,
2004).

4.2)Interpersonal violence.

Numerous studies have found an association between alcohol consumption and

aggressive behaviour though clearly not everyone who consumes alcohol gets
aggressive. People with anti-social personality disorder appear to be particularly
susceptible to alcohol related aggression. People who have previously been violent
under the influence of alcohol are the most likely to become aggressive when drinking
again.

Internationally alcohol has been associated with numerous acts of interpersonal

violence which include physical and sexual abuse, emotional and psychological abuse
and neglect. The WHO (draft paper 2005) has identified the following 5 major areas
of interpersonal violence (with examples of each).

16
 Box 1: Alcohol and interpersonal violence

• Among 18-24 year old males, those who binge

drink* are more than twice as likely to have
Youth violence
committed a violent crime in the previous year
Violence committed by young people
than regular but non-binge drinkers (England
and Wales)
Child abuse
• Parental alcohol or drug use was reported in 34%
Violence and neglect towards children
of child welfare investigations (Canada)
by parents and carers
• 71% of female victims of intimate partner
Intimate partner violence violence stated partner alcohol use as the main
Violence occurring within an intimate cause of their assault, and 22% reported using
relationship alcohol following the event as a mechanism for
coping (Iceland)
Elder abuse
• 44% of male and 14% of female abusers of
Mistreatment or neglect of older people
elderly parents (age 60+) were dependent on
by family, carers or others where there is
alcohol or drugs, along with 7% of victims (USA)
an expectation of trust
Sexual violence • A fifth of offenders arrested for rape reported
Including sexual assault, unwanted that they were under the influence of alcohol at
sexual attention and sexual coercion the time of the crime (South Africa)

Alcohol consumption by perpetrators of violence

• In the USA, among victims that were able to report whether their attacker
had been drinking alcohol, around 35% believed the offender had been
drinking.
• In England and Wales, 50% of victims of interpersonal violence reported
the perpetrator to be under the influence of alcohol at the time of assault.
• In Russia, more than two thirds of individuals arrested for homicide had
consumed alcohol before committing the crime.
• In South Africa, 44% of victims of interpersonal violence believed their
attacker to be under the influence of alcohol or drugs at the time of the
incident.
• In Tianjin, China, a study of inmates found that 50% of assault offenders
had been drinking alcohol prior to the incident..

4.3)Family and work problems

Drinking can impair functioning as a parent, as a spouse and as a contributor to

household functioning (Mulaudzi et al 2003).

Most drinking requires time (often spent with drinking colleagues) and this competes
with time needed to carry on family life (e.g. time spent with children, doing
household chores etc).

Drinking costs money. Drinking money often takes precedence over other household
needs, often leaving the family unable to afford even basic goods and services.

17
Drinking leads to a spiral of poverty in which the drinking behaviour inhibits income
capacity (through absenteeism, lack of motivation, poor quality of work, loosing
employment) while any income earned is then spent on drink – at times drowning
sorrows regarding not having work or only having a poorly paid job. A study in Delhi,
India, compared families where the husband drank at least three times a week
compared to those where the husband drank only once a month. In the first group 24%
of household income was spent on alcohol compared with 2% in the other families.
The family with the drinker had significantly more debts (60% vs. 42%) and these
debts were twice as large (Saxena in Mulaudzi, 2003).

While continuing patterns of drinking threaten family subsistence, events that take
place when a family member is intoxicated can also have lasting consequences –
mainly through injuries and family violence.

The psychological toll on the family is often great. For example in interviews with
family members of heavy drinkers in Mexico 73% reported feelings of anxiety, fear
and depression, 62% reported physical or verbal aggression and 31% reported family
disintegration. For many mothers, the inability of the fathers to bring in adequate
incomes due to their drinking habits, and therefore being unable to feed and clothe
their children led to depression in the mothers (Rosovosky in Mulaudzi, 2003).

Violence against women and children often has severe psychological consequences
for the victim (WHO 2001).

Alcohol can impair work performance through decreased efficiency and can lead to
poor workplace safety. For example intoxication can result in errors of judgement,
accident proneness and putting other lives at risk. Alcohol misuse also results in
greater absenteeism from work and increases the risk of dismissal from work. In
Costa Rica it was found that 30% of absenteeism and workplace accidents were
caused by alcohol dependence. In India 15-20% of absenteeism and 40% of accidents
were due to alcohol.

Among grade 8 and 11 learners in Cape Town a significant association was found
between past month use of alcohol and the number of days absent from school and
repeating a grade. The odds of repeating a grade were 60% higher for learners who
consumed alcohol. (Whether this relationship was causal, which way, or occurred
through another factor was not established).

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5)SPECIAL AREAS OF CONCERN IN SOUTH AFRICA
Two areas regarding alcohol in South Africa need special mention. These are Fetal
Alcohol Syndrome (FAS) and HIV/AIDS.

5.1) Fetal Alcohol Syndrome (FAS).

Drinking alcohol during pregnancy may lead to damage to the foetus. This could be in
the form of Fetal Alcohol Effects or full-blown Fetal Alcohol Syndrome. FAS is
characterised primarily by damage to the brain and central nervous system which
results in hyperactivity, attention problems, learning disabilities (e.g. problems of
memory, abstract reasoning), lack of judgement and fits. Other organs such as the
heart, kidneys and growth may also be affected. As there is no cure for FAS, as most
FAS children are unable to cope with normal schooling and as many FAS children are
part of “alcoholic families” who are unable to give them the special care and attention
they need, many FAS children drop out of school early, are not easily employable and
are susceptible to gangs, crime and peer-pressure.

South Africa has the highest reported rate of FAS in the world. (It must be noted
though that most poorer countries have never conducted epidemiological research into
FAS and thus rates in these countries are not known). In poorer areas of the Western
Cape prevalence of FAS among Grade 1 learners was found to be 46 per 1000 in 1997
and increased to 75 per 1000 in 1999. In the Northern Cape rates of 103 and 75 per
thousand were found in different areas. Prevalence in three poor areas in Gauteng
found rates of 12, 22 and 37 per 1000. While the Gauteng rates were lower than areas
of the Cape they are still far higher than even the most at risk communities in
developed countries - such as the urban poor or native settlement areas in the USA. In
studies in the USA and France rates of 0,5 and 3,0 per 1000 were found.

Mothers who drink alcohol in a binge fashion while pregnant and exceed 5 drinks per
week per occasion (ie More than 90mls of absolute alcohol) are especially at risk for
FAS. Thus one heavy bout of drinking may be enough to cause FAS. (FARR, 2005)

5.2)Risky sexual behaviour

The misuse of alcohol is increasingly being recognized as a key determinant of sexual

risk behaviour, and consequently, an indirect contributor to HIV transmission in sub-
Saharan countries (e.g. Fritz et al., 2002). According to Morejele et al (2004)
numerous cross-sectional investigations conducted among adults in this region have
shown consistently that alcohol use is associated with HIV infection (Campbell,
Williams, & Gilgen, 2002; Clift et al., 2003; Fritz et al., 2002; Hargreaves et al.,
2002; Mbulaiteye et al., 2000; Mnyika et al., 1996), as well as with sexual risk
behaviours, such as having multiple sexual partners (Mnyika, Klepp, Kvale, & Ole-
Kingori, 1997; Trigg, Peterson, & Meekers, 1997).

Three different but related explanations are proposed to account for the relationship
between alcohol use and sexual risk behaviour. Firstly that alcohol consumption may
represent other behavioural, lifestyle, contextual and/or personality factors which are
associated with engagement in high-risk sexual behaviour (e.g. Hargreaves et al.,
2002; Plant, 1990). Secondly, ethanol acts on the central nervous system, reduces

19
inhibitions, and consequently, increases people’s likelihood of engaging in risky
sexual and other behaviours (Plant, 1990). Thirdly people’s alcohol expectancies (i.e.
their expectations about how alcohol will influence their behaviour), can also
influence their actual behaviour (Brown, Christiansen, & Goldman, 1987).

In both qualitative and quantitative studies conducted by Morojele et al (2004) in a

black township in South Africa amongst adults 22-45 it was found that there were
strong relationships between various measures of alcohol use and risky sexual
behaviour. In the quantitative study two main types of effects were that alcohol
consumption may have on sexual behaviour were identified; drinking seems to
increase the appeal of sexual episodes and reduce people’s control with respect to
sexual encounters. The variables which were found to be associated with the reported
increased sexual appeal due to drinking were being younger, not being married, being
employed, drinking more, being a problem drinker, having more sexual partners and
engaging in regretted sex. This profile seems to suggest that inexperienced, younger,
heavier drinking adults are at greatest risk of having alcohol-related risky sexual
encounters.

Those who reported being less able to have control over their condom use after
drinking were less likely to have used condoms in their lifetime. It seems that those
who are usually not inclined to use condoms may become even less inclined to use
them after drinking; on the other hand, other individuals who are most strongly
committed to condom use become even more vigilant when drinking.

Men appear to be at greater risk of engagement in alcohol use-related sexual risk

behaviour than women. Men seem to be more likely to drink at all and drink larger
quantities than women. They are also more likely to report that they engage in sex
under the influence of alcohol, that drinking increases their desire to have sex with a
casual partner and that drinking worsens their ability to resist unwanted sexual
advances.

6)BENEFITS ARISING FROM THE LIQUOR INDUSTRY

Despite the above there are important benefits, which accrue from the alcohol
industry. The industry, through alcohol producing companies, acting independently
and through the Industry Association for Responsible Alcohol Use (ARA), aim to
promote the responsible use rather than the abuse of alcohol. It is argued that the
majority of people who consume alcohol in South Africa do so without damaging
consequences and that this trend should be encouraged. They also argue that the
industry does far more good for the country than harm. Some of the contributions
which the industry make (aside from the “enjoyment” that people get) are:-

Employment creation: South African Breweries (including ABI) employs 8 232

people (2005 web page). Salaries and wages amounted to around R2.2 billion. It is
estimated that more then 1 million people are employed in the beer and soft drink
value chain.

The wine industry estimates that 197 579 jobs were directly and indirectly supported
by the industry in 2003. 108 679 of these were directly employed. They estimate

20
further that if the tourism industry is taken into account, a grand total of 256 908
employees were directly and indirectly supported in the Western cape alone.

Contribution to the fiscus: The industry contributed around R10.3 billion in terms of
taxes. From beer production around R8billion was paid 2004. (This was more than all
the mining companies put together). Taxes on spirits were levelled at around R50 per
litre and wines between R1.40 and R3.80 per litre. VAT at 14% was also charged on
top of this.

Community partnerships and sponsorships: The South African breweries spend

around R120million in community partnerships and sponsorships per annum. This
includes a number of partnerships to combat and treat alcohol abuse. For example
contribution were made to “Arrive Alive”; the “there is so much to live for”
campaign; living responsibly on campuses; prevention on underage drinking
campaigns; a rock challenge, and research into alcohol abuse (including research into
FAS). SAB also sponsors the work of the South African National Council on Alcohol
and Drug Dependence (SANCA) and a Life Skills Education Programme. Other
industry players also support a number of initiatives to assist against the abuse of
alcohol and treatment and rehabilitation centres.

Black Economic Empowerment: The liquor industry has been active in BEE
programmes which help to redistribute wealth in South Africa. This has ranged from
large corporate based deals to empowering emerging farmers who supply the industry.
For example The SAB supports 178 emerging barley producers through its
empowerment programme. The wine industry also supports a range of small and
medium empowerment business initiatives.

Spending on advertising: The advertising industry is highly dependent on revenue

from liquor companies and numerous jobs depend on this. In 2004/5 the industry
spent close to R560 million on advertising (2005 Alcoholic Beverage Review). The
majority was spent on TV advertising, followed by print and radio ads.

7)ECONOMIC AND SOCIAL COSTS

Social costs are the negative economic impact of alcohol consumption on the material
welfare of society (WHO, 2004). Direct costs refer to the value of goods and services
actually delivered to address harmful effects of alcohol consumption while indirect
costs represent the value of personal productive services that are not performed
because of the adverse consequences of drinking.

A conservative estimate of the economic costs of alcohol abuse based on research

studies conducted in other countries is 1% of gross domestic product (GDP). For
South Africa this would work out at about R8.7 billion per year, an amount almost
twice that received in excise duties on alcoholic beverages in 2000/1.

21
8)PREVENTION, TREATMENT AND CONTROL MEASURES
In this section we look at various public health initiatives to decrease alcohol
consumption and abuse. We examine international best practice and its relevance to
South Africa as well as specific initiatives which may assist in addressing the
problem. We also look at treatment as a public health intervention.

8.1)Review of policy-relevant strategies to address the burden of alcohol use

(This section is taken verbatim from Parry CDH, A Review of policy-relevant
strategies and interventions to address the burden of alcohol on individuals and
society in South Africa. S Afr Psychiatry Rev 2005;8, 20-24)

Unfortunately there is no single strategy or “magic bullet” by which to reduce or

eliminate the burden of alcohol misuse to individuals and society. According to WHO
what is required are a mix of individual- and population-based approaches that target
high risk groups and reduce per capita consumption in general.2 Babor et al.,1 in a
project sponsored by WHO, reviewed 32 commonly used strategies available to
policy-makers for addressing the burden imposed by alcohol on individuals and
society. These strategies were divided into seven categories: regulating physical
availability (8 strategies), taxation and pricing (1), altering the drinking context (6),
education and persuasion (4), regulating alcohol promotion (2), drinking and driving
countermeasures (7), and treatment and early intervention (4). Of these 10 were rated
highly by the authors based on various dimensions: evidence of effectiveness, strength
of research support, cross-cultural testing, cost to implement and target audience.

Strategies indicated by Babor et al. as having proven effectiveness

Specific strategy Effectiveness Breadth of Cross cultural Cost to Target
research support testing implement group
Regulating physical availability
Changes in minimum legal +++ +++ ++ Low B
purchase age
Government monopoly on +++ +++ ++ Low A
retail sales
Restrictions on hours/days of ++ ++ ++ Low A
sale
Outlet density restrictions ++ +++ ++ Low A
Alcohol taxation
Increase excise taxes on +++ +++ +++ Low A
alcohol
Drinking/driving counter-measures
Sobriety checkpoints ++ +++ +++ Moderate A
Lowered BAC limits +++ +++ ++ Low A
Administrative license ++ ++ ++ Moderate C
suspension
Graduated licensing for novice ++ ++ ++ Low B
drivers
Brief interventions
Brief interventions for ++ +++ +++ Moderate B
hazardous drinkers
A-general population, B-high risk drinkers or groups considered to be vulnerable to the effect of
alcohol, C-persons already manifesting harmful drinking and alcohol dependence; ++-moderate, +++-
high

22
In the paragraphs that follow these 10 strategies are described in more detail and a
subjective analysis given regarding whether their implementation is likely to be
feasible in South Africa. Four of the “effective” strategies involve regulating the
physical availability of alcohol.

i. Changing the minimum legal purchase age

Babor et al. (2003) point out that raising the minimum legal age for purchasing
alcohol can have substantial effects on youth drinking, particularly in reducing levels
of drinking-driving, single vehicle night-time crashes and fatal crashes involving
young drinking drivers. However, they acknowledge that it does not eliminate
underage drinking. This strategy is regarded as being effective with minimal
enforcement, but enforcement substantially increases its effectiveness. In South
Africa it would be difficult politically in the short- to medium-term to raise the
drinking age to 21, but this strategy might be worth considering in the longer-term.

ii. Instituting a government monopoly on retail sales

According to the WHO Global Status Report on Alcohol Policy (WHO 2004) state
monopolies for off-consumption retail sales for one or more alcoholic beverages exist
in 15% of countries. The evidence is quite strong that off-premise monopoly systems
limit alcohol consumption and alcohol-related problems. Typically the density of
outlets in a government-operated system is low and the opening hours limited.
Elimination of a profit motive also facilitates the enforcement of rules against selling
to minors or persons already intoxicated. According to Babor et al., however, such
monopolies are effective only if operated with public health and public order goals.
With regard to South Africa, given the movement of the state sector out of the retail
liquor trade in the 1970s and 1980s and the government’s push for the development of
small and medium micro enterprises, there would be very little support for
reintroducing a government monopoly in this area.

iii. Instituting restrictions on hours/days of sale

Babor et al. (2003) cite evidence from a variety of countries to indicate that having
reduced hours and days of sale of alcohol can reduce alcohol consumption and
problem levels, with the effects concentrated during the time of closure. With regard
to South Africa, efforts in this area are unlikely to be fruitful if not accompanied by
innovative efforts to draw in the many unregulated outlets into the regulated market.
Also important will be strengthening community input in the process of allocating
liquor licenses and dealing with complaints, ensuring improved enforcement and
handling of complaints, and providing increased access to information and
accountability by those agencies tasked with monitoring and enforcing regulations on
hours and days of sale.

iv. Instituting restrictions on outlet density

Restricting the number of outlets in an area may affect levels of drinking and alcohol-
related problems due to an increase in the opportunity costs associated with obtaining
alcohol. Babor et al. (2003) acknowledge that policy changes in this area require a
longer time course for implementation when drinking establishments have become
concentrated due to vested economic interests. This is likely to be the case in South
Africa, where more than 80% of retail outlets for alcohol operate outside the regulated
market (often from within residential areas) and there is estimated to be one outlet for
every 190 adults. In this country it will first be necessary to encourage existing

23
unlicensed outlets to become licensed and to move to business nodes or corridors
within residential areas and to place greater restriction on those outlets not operating
in business nodes or along business corridors or operating near educational
institutions before tackling the issue of outlet density. Perhaps subsidies or other
incentives could be offered to existing liquor outlets that are willing to move out of
areas where there are already too many outlets.

The fifth “effective” strategy involves decreasing the accessibility of alcohol through
increasing its price via raising excise taxes.

v. Increasing excise taxes on alcohol

The primary reasons for increasing excise taxes on alcohol are to correct for the
external costs associated with alcohol consumption and to raise revenues for
programmes aimed at reducing the social burden of alcohol misuse. Research suggests
that price also influences the behaviour of heavy drinkers and that young drinkers are
especially responsive to price. Increases in alcohol taxes have been shown to be
associated with reductions in motor vehicle fatalities, crime, cirrhosis mortality,
industrial injuries and dropping out of school. The effectiveness of policy changes in
this area depends on government oversight and control of alcohol production and
distribution. High taxes can also lead to smuggling and illicit production. The
National Treasury has set as its target increasing the total tax on beer, wine and spirits
to 33%, 23% and 43% of the retail sales price. This is a step in the right direction, but
is still less than international averages and taxes should be increased by three to five
percentage points. Furthermore, South Africa has fallen behind in terms of taxing
sorghum beer.

The next four “effective” strategies outlined by Babor et al. involve various drink-
driving countermeasures.

vi. Sobriety checkpoints

At sobriety check points only motorists who are judged by police to have been
drinking are asked to take a breath test. Such checkpoints are part of a strategy to
increase the frequency and visibility of enforcement of drink-driving laws and the
certainty of apprehension and punishment. While there is a considerable breadth of
research support for such measures across various cross-cultural settings, the
effectiveness of such checkpoints is moderate. An alternative to sobriety checkpoints
is random breath testing (RBT) where the alcohol levels of motorists are checked at
random, even if they are not suspected of driving under the influence of alcohol. The
effectiveness of RBT based on research studies was judged as being greater than for
sobriety checkpoints, but the breath of research and the degree of cross-cultural
testing has been less. RBT was also judged as being more costly to implement.
According to Babor et al., (2003) the effects of police campaigns are typically of short
duration unless sustained. With regard to South Africa, consideration should be given
to increasing the level of RBT, and strategies would need to be sought for processing
cases quickly and not clogging up the court system.

vii. Lowering BAC limits

Here the emphasis is on passing legislation to lower allowable BAC levels for drivers.
While policy changes in this area have been shown to be highly effective, are
supported by cross-cultural research, and to be of low cost to implement, Babor et

24
al.(2003) acknowledge that there are diminishing returns when lowering already low
BAC limits. With a BAC limit for ordinary drivers of 0.05g/100ml in South Africa,
efforts in the short-term would probably be better spent on enforcing existing limits.
This might, however, be a strategy worth revisiting in the longer term.

viii. Administrative license suspension

Administrative license suspension refers to the immediate revoking of a driver’s
license for a period of time (e.g. six months) without a court hearing following a
drink-driving offence. This action is permitted in 80% of US states and has been
shown to reduce alcohol-involved crashes by 5%. A key motivation behind this
strategy is to dramatically decrease the time between the drink-driving event and the
proximity of punishment. With the over-crowded court system in South Africa, this is
certainly something worth considering, although strategies would also need to be
instituted to deal harshly with suspended drivers who drive without a license.

ix. Graduated licensing for novice drivers

Another counter-measure that has been applied to reduce rates of driving-related
problems is to place certain restrictions on young/inexperienced drivers. Among the
restrictions that are relevant to drink-driving are having lower BAC limits for such
drivers (i.e. 0.01 or 0.02g/100ml) and placing curfews on their driving at night.
Graduated licensing schemes, which can incorporate all of these strategies within one
system, have been shown to show safety benefits. Implementing such a strategy
would be very feasible in a country like South Africa, and given the strong link
between alcohol use and injury among young drivers, is likely to receive widespread
support.

The final strategy indicated by Babor et al. as having proven effectiveness is that of
brief interventions for hazardous drinkers.

x. Brief interventions for hazardous drinkers

Brief interventions are characterized by their low intensity and short duration and
usually comprise one to three sessions of counselling and education. The goal is to
provide early intervention. Randomised control trials to assess the efficacy of such
interventions have generally been positive, but one problem with implementing such
approaches is that primary care practitioners lack the training and time to conduct
screening and brief interventions. In South Africa one pilot study involving various
categories of health workers in Cape Town has highlighted the need for further
demonstration projects in this area.

Various other strategies were reviewed by Babor et al. (2003) that currently are not
yet as strongly supported by research but which probably have some effect. These
include (1) regulating physical availability by allowing server liability whereby
alcohol servers and owners of liquor outlets can be held civilly liable for damages in
cases where they have served persons who were clearly intoxicated and who went on
to hurt themselves or others; (2) regulating alcohol promotions by instituting
advertising bans (e.g. banning alcohol advertising via billboards, or restricting it on
radio/TV till after 9 pm, or not permitting sports sponsorships where more than 25%
of the audience are expected to be under the legal drinking age); (3) facilitating
community action approaches, such as community mobilization against the
granting/renewing of particular liquor licenses; (4) altering the drinking context by

25
training alcohol servers and managers not to serve intoxicated patrons and to
prevent/manage aggression, and backing this up by enforcing on-premise regulations
and legal requirements; and (5) supporting other forms of treatment and early
intervention (e.g. 12-step approaches, motivational enhancement therapy and
cognitive behavioural therapy), attendance at mutual help/self-help meetings and
mandatory extended treatment of repeat drinking-drivers. With regard to these
strategies, mandating server liability is probably only likely to work in the formal
market and should perhaps only be pursued in the medium- to long-term.
Considerations should, however, be given to promoting the other strategies listen in
this paragraph.

Alcohol polices identified as having not been shown empirically to be effective

include, (1) regulating physical availability via voluntary codes of bar practice, (2)
education and persuasion strategies such as alcohol education in schools and public
information campaigns, (3) alcohol-free activities, and (4) regulating alcohol
promotion via advertising content regulations and warning labels. With regard to
school-based education and persuasion programmes there are things that can be done
to enhance their effectiveness, including starting them in primary school; involving
parents and the community; including peer education; having intensive long-term
programmes; incorporating life skills, resistance training and normative concepts; and
ensuring developmental, cultural and local relevance. The effectiveness of warning
labels is likely to be enhanced if they are rotated, easy to read and conspicuous. In
addition, for a country with relatively low rates of adult literacy it might be useful to
include provocative pictures. In general, however, far greater emphasis should be
placed on more active forms of counter-advertising using all forms of media.

Strategies missing from the review that would need to be considered in South Africa
include work-place interventions, broad-based community development initiatives,
and specific interventions aimed at drunk pedestrians. In addition consideration
should be given to implementing various product restrictions such as restricting the
size of beer, wine and spirits containers (e.g. only 340ml containers of beer, and no
sachets of spirits or 5 litre papsakke), requiring the inclusion of the number of
standard drinks on container labels together with calories and other ingredients.
Products with a clear youth appeal should be restricted and special labelling and
bottling requirements should be required so that alcohol products are distinguishable
from non-alcoholic products.

8.2)Treatment and personal intervention

Strategies to change the “environment” in which drinking takes place are possibly
more effective than trying to change personal behaviour directly. However people
with drinking problems (alcohol dependence as well as regular binge drinking)
contribute by far the largest proportion of the alcohol related burden of disease. As
alcohol dependence is a chronic disease, not treating the problem significantly
increases the prevalence - and consequent problems increase. For example probably
the best predictor of whether a mother will give birth to a child with FAS is if she
already has a child with FAS. However if the mother stops drinking she can have a
healthy baby. In other words lack of treatment (or more specifically lack of a change
in behaviour) probably gives rise to at least a doubling or trebling of the number of
FAS children. Or if a person with a drinking problem who assaults his intimate
partner is not treated for the problem, he is likely to continue to engage in such violent

26
behaviour. Hence from both an individual and a public health perspective redressing
personal alcohol problems is critical.

Access to treatment in South Africa is limited by both the availability of treatment

sites and facilities and by stigma associated with being an “alcoholic” or having an
alcohol problem.

Treatment for alcohol problems is available to different extents in different provinces

and regions in state health facilities, in private non-profit organisations, through
NGOs and in private for profit institutions. Services are available for outpatients as
well as inpatients.

Myers and Parry (2005) state that although there has been a growing demand for
substance abuse treatment services, several socio-political factors have hampered
access to treatment in South Africa. Racial inequities from the Apartheid era remain,
and according to these writers, the number of beds available in state hospitals for
substance abuse disorder has been reduced since 1994. The South African Community
Epidemiological network on Substance Abuse (SACENDU) has consistently found
that black clients have been significantly underrepresented in specialised treatment
centres. Myers and Parry say that rather than reflecting lower levels of substance
abuse, this probably reflects the limited accessibility of treatment services to black
South Africans. Barriers to treatment include cultural and linguistic difficulties,
stigma associated with seeking treatment, affordability of the treatment itself and
difficulties in paying for transport to facilities, which are mainly in urban areas.

Myers & Parry (2004 – Curationis) also highlight lack of access to treatment for
women in SA – and provide some reasons for this.

Denial of an alcohol problem is very common amongst people with alcohol problems.
This is in part related to the social stigma of having an alcohol problem, the perceived
weakness of not being able to simply stop or cut down on drinking and fear of how
they will cope without alcohol. It is one of the first steps in a number of alcohol
rehabilitation programmes (such as Alcoholics Anonymous) to acknowledge that one
has an alcohol dependence problem.

Having accessible, affordable and culturally appropriate treatment facilities available

and shifting community attitudes towards understanding and accepting people with
alcohol problems rather than judging and blaming them are important public health
shifts needed to deal with alcohol problems.

After treatment, gains tend to be better maintained if the person becomes actively
involved in a recovery support group (such as Alcoholics Anonymous) and develops
family and peer relationships that are supportive to recovery.

27
9)ADVERTISING AND COUNTER ADVERTISING

Advertising
Despite the claim from the alcohol industry that alcohol advertising is aimed only at
brand promotion and brand change rather than encouraging greater alcohol
consumption, many policymakers and members of the public are concerned about the
potential effects of alcohol advertising on alcohol consumption and problems –
especially among children and adolescents.

Until recently a causal relationship between alcohol advertising and alcohol

consumption, especially amongst youth had not been conclusively established.
However, in a large scale longitudinal study in the USA Snyder found that the amount
of advertising expenditures in the media environment of 15-26 years olds and the
amount of advertising recalled related to greater youth drinking. Youth younger than
the legal drinking age showed the same pattern of advertising effects as the older
group. Youth who saw more alcohol advertising on average drank more with each
additional advertisement seen increasing the number of drinks consumed by 1%. The
study also found that youth drank 3% more per month for each additional dollar spent
per capita in their market.

According to a WHO survey some kind of regulation of alcohol advertising exists in

at least 37 countries. Many of the regulations are designed to protect young people
from seeing alcohol advertisements. Nine countries (Brazil, Colombia, Costa Rica,
Ecuador, Mexico, South Korea, the USA, Venezuela, and Zimbabwe) require warning
labels on alcohol advertisements. More common strategies for regulating the
advertising of alcohol products are the use of voluntary codes and the outright
banning of advertising for certain or all alcoholic beverages in some or all media
outlets. The WHO report indicates that at least 29 countries have implemented bans
on alcohol advertising in at least one medium, and most bans cover beer, wine and
spirits on at least television or radio. There are a further 10 or more countries that
have imposed partial restrictions on alcohol advertising including banning advertising
during daytime and early evening hours when young people are likely to be more
exposed. Various countries, including Croatia, Iceland, India, most states in
Malaysia, Portugal, and Turkey, have banned billboard advertising. Alcohol
advertising is reportedly banned in several countries, including Egypt, Poland, and the
Russian Federation.

Other countries, including South Africa, have content restrictions on alcohol

advertising, for example, prohibiting advertising that is seen as promoting
drunkenness. Mauritius and Norway, ban sponsorship of sporting events by alcohol
companies. The Netherlands’ alcohol advertising code, recently negotiated between
the Health Ministry and the drinks industry, covers all media and public events, and
bans alcohol advertising or sponsorship where more than a quarter of the viewers,
readers, listeners, or visitors are under 18 years. Alcohol advertisements on the music
channels MTV and TMF and on a pop radio station will be scrapped.

Counter-advertising
As a balance to the marketing of alcohol, many countries and organizations have
introduced mechanisms to address and counteract the persuasiveness of alcohol
advertising - (though counter-advertising may be used to give factual information and

28
messages around alcohol abuse or appropriate behaviour which do not necessarily
have to “counter” positive messages as such). “Counter” advertising generally takes
two forms. 1)broadcast (e.g. television and radio), outdoor (e.g. billboards) and print
media and 2)product warning labels. In evaluating the effectiveness of counter
advertising or Public Service Announcements (PSA) is was found that the PSAs tend
not be marketed in as attractive a way as adverts selling alcohol and hence may have
less appeal. Counter advertising by the alcohol industry, e.g. don’t drink and drive
adverts sponsored by alcohol companies, were viewed with some skepticism by an
American audience. In fact it has been argued that by creating an impression of
responsibility drinking in risky situations is justified and alcohol sales are promoted
more generally (Atkin et al 1994)

Audience factors such as gender, age, whether the recipient of the message is a heavy
or light drinker etc all influence the impacts of counter adverts.

Saffer (1996) has used econometric studies on the effect of cigarette counter-
advertising to reduce cigarette consumption to argue that counter-advertising is likely
to reduce alcohol consumption. The primary purpose of counter advertisements is to
challenge the dominant view that public health problems reflect a personal health
habit rather than a social or community problem.

New Zealand and Costa Rica are two countries that have supported the placement of
counter advertisements in the media. In New Zealand health and safety messages
were flighted before or after alcohol advertisements.

The research on the impacts of warning labels is mixed. The impacts are likely to be
influenced by design factors (e.g. size of the label, whether messages are changed
regularly) the specific content and whether it evokes a visceral avoidance response
and audience factors (heavy or light drinkers etc).

Public attitudes to advertising/counter advertising

In a study of attitudes towards advertising/counteradvertising in South Africa Parry
(2002) found that about one in three respondents (33.4%) felt that there should be no
restrictions on radio/TV advertising of alcohol products, but a similar percentage
(36.7%) indicated support for a complete ban on radio/TV advertisements of alcohol.
A further 29.9% felt that advertising should only be allowed after 9 pm. Three-
quarters (74.2%) of respondents agreed with the position that alcohol manufacturers
should be required to place warning labels on alcohol containers. About half (53.3%)
of respondents felt that there should be no ban on sports sponsorships by alcohol
companies, but over a quarter (27.1%) supported such a ban, and almost one in five
(19.6%) felt that sponsorships should be banned only for events attended or watched
by an audience comprising persons under 18 years of age. Almost half (45.1%) of
respondents supported that statement that the government should ban billboard
advertising of alcohol products. (In the USA 67% of adults supported banning of
liquor adverts on TV).

29
10)COMMUNITY BASED ACTIVITIES

A number of community based and other non-governmental organisation are involved

in programmes for the prevention of substance abuse in South Africa. For example:-
• SANCA. The South African National Council on Alcohol and Drug
Dependence runs programmes such as TADA (Teenages Against Drug
Abuse); Peer Counsellors (Youth to Youth); Poppets (Puppet education for
pre-school and early school children); Life Skills Education in Schools; Pupil
Support programmes.
• Dopstop. While “dopstop” was started initially to stop the system of payment
of wages in alcohol (dop system) they have since extended their activities to
include alcohol awareness programmes with farm workers; they conduct
community rehabilitation programmes; run a programme to stop the cycle of
alcohol abuse during pregnancy and hence reduce the number of children born
with Fetal Alcohol Spectrum Disorders; train community health workers on
farms and assisting police to better deal with alcohol related crime. While
“Dopstop” initially saw the farmers as the problem, they are now working
together with the farmers who have become “part of the solution”.
• FARR. The Foundation for Alcohol Related Research is primarily a research
organisation but is also involved at a community level to reduce alcohol
related problems. For example they have set up a “Safe House” in a high FAS
prevalence area of the Northern Cape. This allows people to get away from the
environment where they find it impossible not to drink. They are offered
encouragement, help, education, advice and treatment. The house is also
available for other community activities such as adult literacy and life skills
programmes.
• Arrive alive. This is a community and government based initiative to reduce
drinking and driving.
• Soul City. Soul city has previously run a 14 part drama series on TV, 60 part
radio series and three 36 page booklets focussing on substance misuse.
• Religious based organisations. A number of religious based organisations
teach and support their own congregants to abstain from alcohol
• The Sensible Drinking Project is a community level initiative aiming to reduce
the high rates of trauma as a result of alcohol problems in communities. As
part of a multifaceted prevention programme a pilot training of health workers
in brief interventions was conducted and evaluated. It was found that the short
course was very relevant and well presented, and that the participants
experienced a shift in their attitudes towards screening and counseling people
with alcohol problems.

Involvement of people at a community level in combating alcohol abuse can be highly

effective. For example in Geelong, Australia, an initiative to reduce alcohol related
crime involved a collaboration of the police, local licensed premise operators, the
Liquor Licencing Commission and representatives of community based organisations
and concerned individuals. Some of the achievements of this initiative included the
licensing of all crowd controllers to check underage persons entering licenced
premises; improving the training or bar staff, security personnel and new licencees;
offering all operators a mechanism of referral for dealing with young persons who
pass false or altered identification to gain entry into licenced premises; establishing
alcohol-free entertainment (e.g. discos); allocating hotels and nightclubs to specific

30
police officers to assist with any alcohol related problems; having the local authority
enact a by-law prohibiting persons from having open containers of alcohol in public
places. Since the adoption of the “Local Industry Accord” crime and violence
associated with intoxicated parties decreased significantly.

People within the industry themselves can also be effective in regulating alcohol
misuse. For example in Meadowlands, Soweto, shebeen owners joined together to
form the Tavern Owners Against Crime (TOAC) group (Mkhuma, 2001). A code of
conduct for tavern owners was drawn up, restricting, among other things, the sale of
alcohol to minors and intoxicated persons. Through this initiative, the number of
assaults reported in the area is reported to have decreased significantly. Three
neighbouring township areas have since adopted the strategy (Mkhuma, 2001).

11)GOVERNMENT RESPONSE AND CO-ORDINATION

11.1)Liquor legislation
The main legislative framework for alcohol in South Africa is the Liquor Act (Act 59
of 2003). A number of provincial Acts are currently being finalised. The objectives of
the Act are to:-
a)Reduce the socio-economic and other costs of alcohol abuse by:-
- setting essential national norms and standards in the liquor industry
- regulating the manufacture and wholesale distribution of liquor
- setting essential national norms and standards for the regulation of the
retail sale and micro-manufacture of liquor and
- providing for public participation in the consideration of applications
for registration and
b)to promote the development of a responsible and sustainable liquor industry in a
manner that facilitates:-
- the entry of new participants into the industry
- diversity of ownership in the industry and
- an ethos of social responsibility in the industry.

Some of the more important health related clauses in the Act include restrictions on
advertising which targets minors, sale of liquor to minors and the banning of liquor as
part of payment for work (dop system). Provincial Liquor acts are in various stages of
completion and provide detail on various licencing requirements and procedures and
mechanisms for controlling sale and consumption of liquor (aimed at both spreading
legal outlets and restricting alcohol abuse). For example the Western Cape draft
Liquor Bill (2005) addresses issues such as the sale of liquor in residential areas (eg
that the licencee is responsible to ensure the restriction of noise, there is no loitering,
parking is available etc); involvement of community members in the location, hours
of trade and other matters regarding outlets; designation of liquor officials in each
police station; culpability for sale of liquor to a drunk person and so on.

11.2)Central Drug Authority.

Government has recognised that preventing and controlling the negative impacts of
alcohol use requires intersectoral collaboration. Government departments centrally

31
involved include Health; Social Development; Safety and Security, Education; Trade
and Industry; Finance; Labour; Correctional Services and the South African Revenue
Services. It also requires the inputs of researchers, NGOs, youth organisations and
business.

In order to co-ordinate initiatives government created the Central Drug Authority.

One of the tasks of this body has been to develop a “Drug Master Plan”. This plan
aims to summarise national policies, define priorities and apportion responsibilities
for drug control efforts. While the role of alcohol is somewhat ambiguous in this
document as the term “drug” excludes alcohol in the draft document, alcohol is
included as part of “substance abuse” – a term regularly used in the draft plan and
many of the objectives of the plan include alcohol.

To achieve its aims, the National Drug Master Plan has identified eight main areas of
focus, namely: ● Crime ● Youth ● Other vulnerable groups (such as children-in and
out of street, workers, women, people with disabilities, elderly, unemployed persons
and persons affected by HIV/AIDS) ● Community health and welfare ● Research and
information dissemination ● International involvement. ● Communication
(crosscutting area) ● Capacity building

The full draft DMP, which is a rework of the 199-2004 plan, is included as Appendix
1, however it is important to outline relevant strategies/objectives in four of the
relevant areas covered i.e. youth, other vulnerable groups, community health and
welfare. The draft plan states:-

Youth
Specific treatment services need to be targeted at young people, as their needs are
likely to be different from those of adults. For example, young people hold a
dependent position in family and society; they are more influenced by peers and
popular culture; they often need education or vocational training; and are more likely
to be using other drugs. The CDA will ensure that annually, information on substance
abuse reaches parents of learners and that they should take responsibility in
monitoring substance use and alleviating drug use among their children. Children are
not born drug abusers and it remains the task of parents to teach their children values
during the early formative years before peer pressure and other influences intervene.
The CDA acknowledges that major gaps still exist with regard to a comprehensive
approach to the prevention of substance abuse among youth, especially in the rural
areas. Intervention programmes on the prevention and treatment of substance abuse
should be made accessible to all the youth of South Africa.

The following are the objectives for the youth priority area:
● motivate youth to refrain from abusing substances
● improve responses regarding links between substance abuse and crime through the
use of restorative justice principles
● enforce the law on the sale of alcohol, tobacco and other drugs to youth
● ensure that schools offer effective programmes on drug education; giving pupils the
facts, warning them of the risks, and helping them to develop an attitudes to resist
abusing substances
● promote a healthy life style through awareness programmes

32
● develop effective national and local public education strategies focusing particularly
on young people
● ensure that young people have access to life skills and other programmes
that promotes a healthy life style.

Other vulnerable groups

Besides youth, there are a number of other groups that have been known to be
particularly vulnerable to the use of substances and/or their effects: e.g. people
affected by substance abuse and HIV and AIDS, unemployed, children, street
children, orphans, workers, women, musicians, people with disabilities older persons
etc.

The following are the objectives for the priority area other vulnerable groups:
● ensure that all government departments are responsible for preventing and
combating substance abuse and offering effective programmes on Information,
Education and Communication (IEC) to facilitate vulnerable groups to make informed
decisions.
● Increase awareness among community members, on issues related to substance use
and abuse among the vulnerable groups
● ensure that vulnerable groups who abuse or become dependent, have increased
access to a range of: advice, counselling, treatment, rehabilitation and after-care
services.
● empower all vulnerable people, so that they may know their rights under the RSA
Constitution and can access support and/or avoid future victimisation.

Community health and welfare

Substance abuse has a negative impact on many areas of individual and community
life including health, security and the economy. Special areas of concern here are the
high rate of substance abusers that are still at the childbearing age. Issues such as
teenage pregnancy, the Foetal Alcohol Syndrome, MDR, STIs including HIV/AIDS
merit attention. (Substance abuse)…affects important areas such as school
performance, health, family life, productivity, and safety and security. Primary
Prevention and treatment programmes should consider efforts in harm reduction too.

The following are the objectives of the community health and welfare priority
area:
● protect communities from health risks and other harms associated with substance
use, including the spread of communicable diseases, related injuries and premature
death
● ensure that individual substance users have access to information, treatment and
counselling, rehabilitation and aftercare services
● ensure that individuals, and significant others have accredited treatment and support
services
● acknowledge the link between HIV/AIDS and substance use and devise health and
welfare programme
● ensure that persons suffering from mental illness and substance abuse morbidity
(dual diagnosis) receive appropriate and accredited treatment

33
Communication
For successful implementation of the National Drug Master Plan, it is required that
the public must be well informed on substance abuse issues and practitioners must
have access to information on the burden of substance abuse and an intervention
strategy that is effective. Extensive research is required to fill the gaps which still
exist in areas such as: knowledge in important areas such as the prevalence of drug
use by different groups in different parts of the country; the economic costs of
substance abuse to the country; the relationship between substance abuse and
important national issues (e.g. HIV/Aids, TB, crime, youth development and poverty);
effective community-based intervention approaches and the impact of current
policies.

The following are the objectives of the communication priority area:

The overriding and overarching objective of the National Drug Master Plan is to
ensure that all educational material and other information disseminated, is
contextually correct in a form and language appropriate to the culture, language, level
of education and socio-economic background of its intended recipients. Material
should be produced in all the official languages and signs appropriate for those who
are illiterate (pictures), or have disabilities for example, visual impairment (Braille).
● ensure that all educational material and other information disseminated to the public
is contextually correct
● ensure that information reaches the public in all languages and an appropriate mode
of communication, for groups such as illiterate and/or blind persons
● ensure that facilities for information dissemination are accessible to everyone

11.3)Recent prevention campaigns/initiatives

Government has recently combined with the UNODCCP in a media campaign termed
“Ke Moja” – “No thanks, I’m fine”. A recent evaluation found that while there were a
number of positive responses to the content, it’s effectiveness was somewhat limited
to urban areas.

The Department of Health flighted TV adverts against drinking and driving over the
2005/06 festive season.

In the 2006 budget Trevor Manual announced increased taxes on alcohol products
(excluding sorghum beer) ranging from 9%-20% (4.8% - 15.8% in real terms). This
above inflation increase is important for reducing consumption levels (though the tax
proportion still lags behind many countries internationally).

12)BARRIERS TO PREVENTION AND CONTROL OF

ALCOHOL PROBLEMS
Differences between the industry and health and social service lobbyists and
researches. Though the liquor industry (and the Industry Association for Responsible
Alcohol Use) argue vociferously that they are as anxious about alcohol abuse as lobby
groups and researchers concerned with the health and social consequences of alcohol,
there are a number of differences of opinion between these groups. For example there
are differences with regard to alcohol advertising, the extent of taxes that should be
paid, warning labels, hours that outlets should be allowed to open, the positive effects

34
of moderate drinking, where and how many outlets should be allowed and so forth.
Critically, while all groups are concerned with the abuse of alcohol, industry is
equally concerned with sales and profit. The industry also argues that it makes a very
large contribution to the society in terms of jobs, social responsibility programmes,
supporting the advertising industry, BEE etc. More sales and greater profits are, in
their view, good for the economy.

Competing priorities within government. Government finds itself in a position of

having to balance its own priorities. On the hand there are large and obvious health
and social impacts from alcohol abuse. On the other hand economic growth and
development - which supports poverty alleviation - and Black Economic
Empowerment are central policy priorities and the alcohol industry, including the
growth of the industry, plays a large part in this. Moreover due to the history of
alcohol sales it is necessary for government to bring the system of illegal shebeens
into a licensed regulatory process. This doesn’t fit particularly well with reducing
accessibility through ‘dedensification” of outlets, not having outlets near schools etc.
Decisions around alcohol get made in this context of competing health, social and
economic objectives.

Resistance from drinkers themselves. Consumers of alcohol are also public citizens
and voters. Controls on the price, availability and distribution of alcohol often meet
with strong public resistance (for example raises in “sin” tax of alcohol, or closing
shebeens which do not meet the requirements of the liquor act). While it appears that
accessibility (price and geographic) is probably not currently a major voting issue it
could easily become so if stringent actions were taken which directly affected the
public.

Problems with enforcement: having laws and regulations around alcohol means very
little unless they are enforced. Currently many laws are not adequately imposed. For
example sales to minors and sales from unlicensed outlets are common. This is a
major barrier to control of alcohol abuse.

Delays resulting from bureaucratic processes: Government processes often work very
slowly. This not only results in things not getting done on time but key people loose
interest and initiatives do then not have their optimal impact. For example though the
Prevention and Treatment of the Drug Dependency Act, (Act 14 of 1999, Section 2),
makes provision for a Central Drug Authority which would draw up a Drug Master
Plan, no plan has yet been approved. The draft five-year plan for 2005-2009 has
already lost a year in which very little has been done. Though the CDA has been in
existence for more than ten years one of its main tasks is monitoring the Drug Master
Plan - but in the absence of an approved plan, their task becomes somewhat
superfluous. Moreover the term of the current CDA ended in November 2005 but new
members have not been appointed.

CONCLUSION
Preventing alcohol related harm is a critical health priority. It requires a combination
of legal and regulatory interventions, enforcement, community based programmes and
actions, better health and social services which focus on alcohol, personal behaviour
change and shifts in community attitudes.

35
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