A health promotion approach for reducing youth exposure to alcogenic environments

A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS BRIEF SNAPSHOT SERIES ON ALCOHOL CONTROL POLICIES AND PRACTICE SNAPSHOT SERIES ON ALCOHOL CONTROL POLICIES AND PRACTICE BRIEF A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS A health promotion approach for reducing youth exposure to alcogenic environments. Brief 12 (Snapshot series on alcohol control policies and practice) ISBN 978-92-4-007329-6 (electronic version) ISBN 978-92-4-007330-2 (print version) © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Layout and design: Alberto March iii About the series iv Acknowledgements v Brief at-a-glance vi Living in alcogenic environments increases alcohol consumption 01 Alcohol consumption among young people remains a global concern 01 Why reduce exposure to alcogenic environments? 02 What does this brief seek to achieve? 02 Drivers of alcogenic environments 03 Acceptability of alcohol consumption driving alcogenic environments 03 Availability of alcoholic beverages driving alcogenic environments 03 Affordability of alcoholic beverages driving alcogenic environments 04 Alcogenic environments result from interactions among availability, acceptability and affordability 04 Interventions to reduce alcogenic environments 06 Banning alcohol sachets to address youth access to alcohol in Uganda 06 Tackling alcogenic environments through policy and community-based initiatives in Nigeria 07 Ensuring enjoyable football games, Sweden 08 Understanding the alcohol landscape to advocate for stronger alcohol policies in Lebanon 09 Addressing underage access to alcohol through a mystery shopper campaign in Norway 09 Working together to protect children and adolescents from alcohol harm in Colombia 10 Increasing alcohol taxes through community efforts in Alaska, United States of America 10 Implementing alcohol-free festivals in Thailand 11 Opposing the government’s pro-alcohol initiative in Japan 12 The way forward 13 Takeaway messages 14 References 15 Contents A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 12iv About the series In 2023, more than a decade after adopting the WHO global strategy to reduce the harmful use of alcohol, attention has been called to accelerate the implementation of high- impact interventions for alcohol control. A global action plan for 2022–2030 aims to leverage the available evidence and policy know-how and quicken progress in tackling alcohol consumption and its effects. Making evidence accessible and spotlighting real-world experiences is a core component for advancing the implementation of effective policy interventions. Doing so requires a multipronged approach that addresses the social and cultural acceptability of alcohol consumption, its availability and affordability. In 2021, WHO launched a series of advocacy briefs about blind spots related to reducing alcohol consumption. The resulting topic-specific briefs were considered starting-points for navigating the evidence and its use in practice, forming the first edition of the Snapshot series. Topics covered included socioeconomic inequalities, unrecorded alcohol, conflicts of interest, labelling, digital marketing and per capita alcohol consumption. In 2022, the series continues its aim to create topical “snapshots”, serving as a compass for navigating critical topics related to high-impact and innovative interventions to accelerate progress in reducing alcohol consumption. The second edition of the series provides a portfolio of policy, system and practice guidance for tackling the determinants driving the acceptability, availability and affordability of alcohol. It explores, among other topics, no- and low-alcohol beverages, alcogenic settings and adolescents, gender- responsive alcohol control policies and policy options to respond to emergencies and pandemic situations. How was this brief developed? The series has evolved in its approach to best meet the information needs of its readership, applying a four-step Protect consumers Promote healthier settings Build resilient societies Acceptability Availability Aordability Public health objectives Raising awareness, e.g. labelling Mediating licensing, e.g. outlet density and location, online sales Health promotion interventions Increasing prices and excise taxes, ending nancial incentives and subsidies Banning or comprehensively restricting alcohol marketing, advertising, sponsorships and promotion Promoting healthy settings and a pro-health environment, e.g. schools, stadiums Tackling unrecorded alcohol production and consumption Addressing commercial determinants and conict of interests process to explore each topic. First, leading experts were engaged in searching and consolidating the available scientific evidence. Second, the first-hand experiences of countries related to the topic were sampled and documented. Third, stakeholders were brought together in webinars to discuss the evidence and country experiences. Lastly, the literature, experiences from countries and insights from discussions were synthesised in a brief report that forms the varied issues of the Snapshot series. Audience The series is intended for a wide audience, including people working in public health, as well as those working in local and national alcohol and tobacco policy; policy- makers from national, regional and local administrations; government officials; researchers; civil society groups; consumer associations; the mass media; and people new to alcohol control policy, research or practice. What is a health promotion approach to reducing alcohol consumption? Alcohol use has multidimensional connotations. Robust and growing evidence demonstrates that cultural, social and religious norms influence alcohol consumption, as well as its acceptability, ease of purchase (availability) and price (affordability). Addressing this multidimensional causality chain requires a portfolio of health promotion interventions to moderate the determinants driving alcohol consumption and, in turn, enable populations to increase control over and improve their health to realise their full potential. Interested in other topics? Visit the Less Alcohol webpage for other briefs in this series and upcoming webinars. Subscribe to our newsletter to be informed about releases of new briefs and notified of webinars to take part in these conversations. If you have a suggestion for a topic that has yet to be explored, contact the team at lessalcohol@who.int ■ Determinants driving the consumption of alcohol vAcknowledgements Contributors Lilian Ghandour, American University of Beirut, Lebanon Juan Tello, World Health Organization Rüdiger Krech, World Health Organization Pierre Andersson, Movendi International Erica Barbazza, World Health Organization Maik Duennbier, Movendi International Emeka Dumbili, Nnamdi Azikiwe University, Nigeria Tobias Elgán, Stockholm Prevents Alcohol and Drug Problems, Sweden Johanna Gripenberg, Stockholm Prevents Alcohol and Drug Problems, Sweden Tiffany Hall, Recover Alaska, United States of America Taisia Huckle, SHORE & Whariki Research Centre, New Zealand Sarah Fabricius Blom Jul-Rasmussen, Juvente, Norway Tomomi Imanari, Alcohol Citizens Association, ASK Japan Rogers Kasirye, Youth Development Link, Uganda Andrés Vélez Serna, Red PaPaz, Colombia Kristina Sperkova, Movendi International Visanu Srithawongse, Stop Drink Network, Thailand Kerry Waddell, McMaster University, Canada David Wahlund, IQ-Initiativet, Sweden Theertham Wutthiwatchaikaew, Stop Drink Network, Thailand This work has been made possible thanks to the financial contribution of the Government of Norway. A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 12vi Brief at a glance THE PROBLEM. Alcohol consumption among young people remains a global concern given its negative effect on brain development, decreased educational attainment, low mental well-being, greater alcohol consumption throughout the lifespan, higher likelihood of binge drinking and increased risk of alcohol use disorders as well as increased risk for social problems, such as violence and crime and earlier development of liver cirrhosis. The environment in which young people live, learn and play significantly affects their decisions about whether to consume alcohol. Environmental factors are the main risk factors driving alcohol consumption and related harm among young people. Environments that normalize alcohol consumption – termed alcogenic environments – include contexts with unregulated advertising and marketing of alcoholic beverages, higher alcohol outlet density, products designed to facilitate affordability and low prices of alcoholic beverages. THE EVIDENCE. A recent body of research evidence has emerged related to the measurement, functional significance and consequences of living in alcogenic environments. This includes findings on the complex and bidirectional interactions among alcohol acceptability, availability and affordability and how they create and perpetuate alcogenic environments. THE KNOW-HOW. Comprehensive and enforced alcohol control policies are effective at delaying the age of onset and lowering alcohol prevalence and frequency among young people. Experience from Colombia, Japan, Lebanon, Nigeria, Norway, Sweden, Thailand, Uganda and the United States of America elucidates how alcogenic environments normalize alcohol consumption and increase the exposure of young people to alcoholic products and how the initiatives of civil society organizations and whole-of-society approaches have counteracted alcohol industry interference. THE WAY FORWARD. Evidence consistently confirms the effectiveness of designing and implementing alcohol control policies that regulate upstream the drivers of an alcogenic environment, including alcohol availability, acceptability and affordability. These policies need to be multipronged and address the complex interactions between these drivers and the local alcohol culture. Civil society organizations and other community partners can be powerful associates in pursuing structural reforms, especially in garnering public support for strengthening alcohol control policies ■ 1Alcohol consumption among young people remains a global concern Alcohol consumption among young people remains a global concern, given its negative effect on brain development and increased risk of alcohol use disorders (1, 2). For young people, alcohol carries significant health risks (3). Numerous adverse health and social consequences of alcohol use in young people have been identified, including decreased educational attainment, low mental well-being, increased risk for social problems, violence and crime, a higher likelihood of binge drinking later in life and earlier development of liver cirrhosis (4, 5). Minimizing alcohol consumption among young people needs to be addressed if global health loss attributable to alcohol is to be substantially reduced (3). The environment in which young people live, learn and play significantly affect their decisions about whether to consume alcohol. Environments that normalize alcohol consumption – termed alcogenic environments – increase young people’s exposure to alcohol. Box 1 provides a proposed description. The harmful consequences of alcohol consumption and the influence of alcogenic environments on young people could be reduced through policies that restrict exposure to marketing and advertising and reduce the accessibility of alcohol to young people (6). Declining trends in alcohol consumption in several, but not all, high-income countries may point to increased public support for and strengthening of alcohol policies (7). Understanding what policy approaches have been successful and could be applied globally is critical to counteract industry influence on young people (8). Living in alcogenic environments increases alcohol consumption This section provides a brief overview of why alcogenic environments matter to the health of populations and why they need to be further examined within the global alcohol policy Box 1. The challenges in the European Union Alcogenic environments describe settings in which alcohol is easily accepted, available and affordable. Settings with aggressive advertisement practices that promote the normalization of alcohol consumption, a high number of alcohol outlets in gathering spaces, targeting young women with dedicated campaigns, selling inexpensive alcoholic beverages and alcoholic products designed to facilitate their affordability are all examples of components that interact to conform alcogenic environments. Alcogenic environments refers to any context or environmental configuration, such as schools, residential areas, youth centres and activity spaces for young people. Why reduce exposure to alcogenic environments? Cultural, social, political and economic factors influence and shape the motivations and decisions of individuals (9, 10). Since individuals are embedded in ecosystems that contain environmental cues, contextual factors are important to consider when developing strategies and interventions given their influence and effect on behavioural choices and subsequent health and social outcomes (11). Elements of an alcogenic environment, mainly alcohol outlet density, advertising and affordability, increase the exposure (12) and frequency of alcohol A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 122 consumption (13) and its associated problems (14). These environmental factors are the main risk factors driving alcohol consumption and harm related to alcohol in young people (14, 15). Combined with alcohol advertising and marketing targeting young people, increased density results in the normalization of alcohol consumption and the fostering of pro-alcohol personal attitudes (16, 17). The difference in normalization becomes apparent in comparing barriers reported between wet cultures and dry cultures. In wet cultures, alcohol is integrated into daily life, widely available and accessible. In contrast, dry cultures have a strong tradition of abstinence. In wet cultures, students report external barriers to moderate alcohol consumption, such as a culture of alcohol use, living environment, social norms and fear of missing out. In contrast, students residing in dry cultures report internal barriers such as feelings, habits and self-control (18). Thus, students residing in wet cultures could benefit from an ecological rather than an individual prevention approach (19), disrupting or reconfiguring social practices rather than individual behaviour (20). Pro-alcohol attitudes and social norms could be disrupted by social and environmental initiatives that, for example, restrict alcohol and its marketing within living and working environments, dissociate alcohol consumption from having fun and promote other alcohol-free activities (18). Alcohol outlet density affects young people’s alcohol consumption by normalizing alcohol consumption and providing additional opportunities to purchase alcohol. The higher outlet density affects the affordability of alcoholic beverages and is associated with binge drinking (21). Alcohol outlet density could also create competition and thus reduce alcohol beverage prices (22). A higher density of retailers makes purchase more convenient (23). This is especially of concern when no minimum pricing or restrictions on sale promotion policies are in place. What does this brief seek to achieve? This brief seeks to synthesize relevant evidence on the links among alcogenic environments, increased alcohol consumption and major related harm among young people. It provides an overview of examples used to reduce young people’s alcohol cues in various environments, such as school settings, residential areas, youth centres and activity spaces. The brief concludes by providing actionable policy options to identify and target all drivers of alcogenic environments ■ 3Living in settings characterized by high spatial availability of alcohol – also referred to as having high alcohol outlet density – has been termed Tiving Living in settings characterized by high spatial availability of alcohol – also referred to as having high alcohol outlet density – has been termed living in an alcogenic environment (13). The research that has emerged since then has focused on measuring the alcogenic environment (14), the functional significance of alcogenic environments (24) and the consequences of living in an alcogenic environment (25-27). A high number of alcohol outlets and alcohol advertisements constitutes the main driver for creating an alcogenic environment (14). Acceptability of alcohol consumption driving alcogenic environments Advertising and marketing drive the acceptability and the normalization of alcohol consumption at the individual and community levels. At the individual level, viewing alcohol advertisements increases immediate alcohol consumption (28). Possible mechanisms for the influence of alcohol advertising and marketing include normalizing alcohol consumption by depicting positive images associated with its use and cultivating personal pro-alcohol attitudes (16, 17). Social networking systems that normalize (29, 30) and promote a culture of alcohol consumption among young people (31) have shown similar findings. Social networking systems increase the speed, reach and efficiency of pro-alcohol advertisements established as social norms and practices among young people (32). Actions led by the alcohol industry as well as user- generated alcohol content, such as photos of individuals consuming alcohol or getting drunk on personal profiles, contribute to an online intoxigenic social identity (33). At the community level, the same advertisements, social networking and individual behaviour contribute to establishing a culture of alcohol use. Alcohol culture refers to the norms, patterns, practices, values, settings and occasions in which alcohol is consumed. It also refers to the modes of social control used to enforce and retain these norms and practices (34). Alcohol cultures can reinforce behaviour. This can be difficult to identify, since it is often made invisible and seen as acceptable or appropriate, despite having significant health risks. For example, focus group discussions with young people from Australia confirm this link because saying no to consuming alcohol when offered is considered rude (35). Alcohol consumption is ingrained in many other social habits, including attending drinking gatherings after working hours. The presence or absence of an alcohol culture plays a critical role in increasing exposure to alcogenic environments, suggesting a bidirectional relationship with alcohol consumption (31). Availability of alcoholic beverages driving alcogenic environments In 2008, a study described residing in areas with higher alcohol outlet density as living in an alcogenic environment (13). These environments significantly affect the amount of alcohol consumed and the patterns of alcohol consumption (24). This increases the health risks for all community members, especially children and young people (36). The 2008 study also showed that living within a 10-minute drive of multiple alcohol outlets was associated with more alcohol consumed by young people (13). The effects of alcohol outlet density on young people’s alcohol consumption could result from either the proximity effect, with outlets facilitating access to alcohol, or the amenity effect, with outlets influencing the Drivers of alcogenic environments This section provides an overview of what is known about alcogenic environments, implementation considerations for various settings and any gaps in the existing knowledge base A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 124 characteristics of the surroundings within a community (37). The proximity effect can be associated with the availability theory (38), which postulates that high outlet density increases the harm caused by alcohol, with or without increasing consumption, by increasing its accessibility and shaping young people’s pro-alcohol consumption routines, attitudes and social norms (23). The amenity effect offers an alternative explanation in which individuals are attracted to come and consume in high- density areas and alcohol outlets are seen as attractors, increasing alcohol consumption by redistributing where consumption takes place (37). Affordability of alcoholic beverages driving alcogenic environments Little is known about the relationship between alcohol prices and the decision to initiate alcohol consumption (onset). Evidence for other psychoactive substances, such as tobacco, suggests that higher prices may deter or defer the decision to initiate (39-42). However, alcohol prices change the pattern of alcohol consumption and health. According to studies conducted in Chile and Thailand, an increase in alcohol taxation reduces lifetime prevalence initiation and binge drinking (43, 44). The affordability of alcoholic beverages interacts with alcogenic environments in different ways – the high retail density is a hallmark of these environments. The high outlet density reduces the convenience cost of obtaining alcohol and, in addition, creates competition, resulting in lower prices of alcoholic beverages (22). In British Columbia, Canada, the increased density of liquor stores was associated with lower average prices of beer and alcohol aggregated across brands (45). The affordability is also driven by designing products that lead to cheaper and more accessible alcoholic beverages for young people. Many African countries experience alcoholic product packaging in small sachets or small-volume polyethylene or glass bottles, resulting in relatively inexpensive and more accessible products for young people (46-48). As a result, young people experience the effect of alcohol consumption at early stages in life, often when underage. Consuming alcohol underage affects all countries. In the United States, it accounts for 8.6% of the market (49). Affordable alcohol puts young people at risk of higher consumption. The affordability of alcohol has a cyclical relationship in fostering an alcogenic environment. Affordable alcohol combined with high retail density and significant advertisement drives alcogenic environments, further reducing the price of alcohol in these areas.uce the levels of alcohol by volume and may lead to more considerable reductions in alcohol consumption than those based on the volume of the beverage (16). Alcogenic environments result from interactions among availability, acceptability and affordability Higher alcohol outlet density and greater exposure to alcohol advertising are established risk factors for increased alcohol consumption, especially among adolescents (15). This has been confirmed for young people in high- income and middle- and low-income countries (50, 51). Alcogenic environments indicate the interactions among the availability, acceptability and affordability driving alcohol consumption. These elements work synergistically to create an alcogenic environment that significantly increases the odds of problems related to alcohol use (14). The complex dynamics between alcohol users, consumption behaviour and contextual factors delineate specific features of alcogenic environments that encourage young people to consume and increase occurrences of alcohol use (24). These features include access to alcohol, such as physical location, opening times and regulations; consumption of alcohol while participating in social interactions, such as consuming food, communicating with others, dancing, enjoying music and playing games; and promotion of alcohol, such as happy hours (24). Fig. 1 illustrates the complex and bidirectional relationships among alcohol acceptability, availability and affordability. It depicts their collective impact on creating alcogenic environments, which affect the alcohol consumption behaviour and patterns of young people. 5Fig. 1. Alcogenic environments and potential effects on young people Acceptability • Social norms • Marketing • Advertising • Sponsorship Availability • Outlet density • Stores location • Online purchase • Home delivery • Minimum purchasing age Aordability • Low price • Convenience cost • Product design • Happy hours • Promotions • Early onset • Binge drinking • lncreased amount • Frequency • School absenteeism • School dropout • Social exclusion • Alcohol use disorders • Mental health disorders • Injuries to self • Injuries to others • Violence • Crime • Reduced performance • Unemployment Disabilities Consequences A lc og en ic e nv ir on m en ts Patterns of alcohol use Source: adapted from Martineau et al. (52). Addressing the multidimensional effects of alcogenic environments requires multipronged and comprehensive interventions (53). These interventions recognize the need for coordinated actions (54). A portfolio of health promotion and population-wide interventions that take a systems approach is needed to tackle the determinants driving alcohol consumption and enable populations to increase control over and improve their health to realize their full potential ■ A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 126 The prevalence and patterns of alcohol consumption among young people across and within countries vary according to their alcohol control policies and the culture surrounding alcohol consumption (55). Comprehensive and enforced alcohol control policies are effective at avoiding binge drinking, delaying the age of onset and lowering alcohol prevalence and frequency among young people globally, including in low- and middle-income countries (22, 52, 56–58). Evidence consistently confirms the effectiveness of implementing Interventions to reduce alcogenic environments This section illustrates opportunities and challenges for reducing exposure to alcogenic environments. Although some of the outcomes were not evaluated, the process of these novel civil society organization initiatives may inform and inspire efforts in other settings regulatory and statutory enforcement of alcohol control policies that regulate upstream the sources of damage (57) and main drivers of alcogenic environments, including alcohol acceptability, availability and affordability (52). Conversely, interventions targeting solely families, communities and schools provide inconclusive and mixed evidence about effectiveness (52). Box 2 provides resources for designing and enforcing comprehensive alcohol control policies. Restricting exposure to alcohol advertising and physical availability of alcohol and increasing excise taxes on alcoholic beverages yield the second highest return on investment per dollar invested (US $8.32) (59). The WHO SAFER technical package promotes the five high-impact and cost-effective population-wide interventions to reduce alcohol consumption (60). Other WHO-recommended interventions are highly effective (61). The global action plan 2022–2030 to effectively implement the Global Strategy to Reduce the Harmful Use of Alcohol as a Public Health Priority was approved by the World Health Assembly (62). A WHO series on policies and practices provides a portfolio of policy options (63). Box 2. WHO resources for designing comprehensive alcohol control policies The country cases described in this section shed light on the multiple channels in which the alcohol industry interferes and lobbies to increase young people’s exposure to alcogenic environments, whether through making accessible alcohol sachets and bottles, such as in Uganda, through gendered marketing strategies encouraging girls to consume alcohol, such as in Nigeria, or through sponsoring events and sports activities, such as in Lebanon, Sweden and Thailand. The cases illustrate whole-of-community approaches in practice and underscore the role of civil society organizations in collecting and disseminating data to increase public awareness, such as in Uganda; changing alcohol consumption norms, such as in Thailand; disrupting industry interference with policy-making progress and policy implementation, such as in Lebanon, Nigeria, Norway and the United States of America; and, ensuring that government initiatives to increase revenue do not conflict with public health objectives, such as in Japan. Banning alcohol sachets to address youth access to alcohol in Uganda Nearly a third of young people living in the slums of Kampala, Uganda consumed alcohol in the past year (64). This population is at high risk for violence, child maltreatment, sexual exploitation and HIV (64). Much of the alcohol manufactured in Uganda has traditionally been sold in small plastic sachets. These sachets were very inexpensive and easy to access. The size and shape of the sachets made them easy to conceal in bags or 7pockets. Also, spirits with high alcohol content were sold this way. Civil society organizations raised awareness that children brought alcohol sachets to school and advocated banning alcohol in sachets for nearly 20 years. As part of this effort, collecting data and providing evidence about the harm of alcohol sachets has been a critical focus. For example, reports and policy briefs were compiled and circulated to the media, population and other key stakeholders to advocate for banning alcohol sachets. Although the alcohol industry continually lobbied against it, the government banned the sale of alcohol in sachets in 2016. The deadline for manufacturers to comply was 30 September 2017 (65). In 2019, only 11 of 26 manufacturers did not comply with the ban (66). In 2022, sachets were no longer used to sell alcohol. However, the alcohol industry now promotes small 100- mL plastic bottles, an accessible alternative. For this reason, the government plans to set a 200-mL minimum package size. Tackling alcogenic environments through policy and community-based initiatives in Nigeria In Nigeria, evidence shows that alcohol is readily available, easily accessible and affordable due to sociocultural factors, lack of alcohol control policies and the practice of multinational alcohol corporations. However, the National Agency for Food and Drug Administration and Control and civil society organizations seek to address the determinants of alcogenic environments and disrupt industry practices through surveillance. Advertising, sale promotions and sponsorships of social events carried over by multinational alcohol corporations facilitate the availability, accessibility and affordability of alcoholic beverages. For more than 14 years, foreigner- owned Nigerian breweries sponsored Star Music Trek concerts in stadiums and event centres nationwide to promote local beer (67). At Star Music Trek concerts, only the sponsor’s beer is sold. Adults and young people attending the concert must purchase at least one bottle of beer to be admitted into the venues (67). The company has also sponsored a TV reality show to promote the beer targeting young men and, more recently, women (68, 69). More recently, a gendered marketing strategy employs young women to promote specific beer brands in alcohol outlets (70). The gendered promotion marketing practice leverages the sexual appeal of women, bringing brands closer to bar customers, reducing prices and using free drinks as promos to drive the availability, accessibility and affordability of alcohol (70). The strategy exposes women and young people, in general, to initiate alcohol consumption or consume more if they already use alcohol, primarily due to the accompanying promotions, such as buy three and get one free (70). Another factor that supports alcogenic environments in Nigeria is new product development. Alcohol corporations have focused on producing inexpensive sachet and small- bottle alcoholic beverages. Recently, herbal alcoholic bitters, such as Orijin, and women-friendly flavoured alcoholic beverages were introduced (71, 72). Available evidence shows that this gendered strategy targeting women exposes them to alcogenic environments, alcohol consumption and related harm (71, 72). Recent evidence shows that alcogenic environments seriously affect alcohol consumption in Nigeria. Many young people who were abstainers are beginning to consume alcohol, and those who already consume alcohol are drinking large quantities (73, 74). The mid-year report of the four major breweries revealed that Nigerians consumed beer for 599.11 billion naira (equivalent to US$  1.36 billion) between January and June 2022 (75). The report shows a 31% growth rate compared to the companies’ growth in 2021 (75). Nigeria currently ranks first for heavy episodic drinking in Africa (71, 76). In 2020, the National Agency for Food and Drug Administration and Control announced that it would no longer register plastic sachets and bottles of alcohol products, reducing the production capacity by 50% (77). In January 2022, the Agency banned the registration of alcoholic beverages in a sachet or glass bottles of less than 200 mL. The Agency also announced that it would completely phase out the production of such products by January 2024. Consequently, promoting and selling such alcoholic products would be stopped (77). The Association of Advocates against Alcohol Harm in Nigeria (ASAAHN) (78), an affiliate of the West Africa Policy Alliance, is a coalition of civil society organizations that advocates for adopting and implementing an alcohol policy and monitors the alcohol industry’s interference in the policy process (78). Every 2 October, civil society organizations under ASAAHN raise awareness about the harm produced by alcohol use through a walk with students and other young people across various regions of Nigeria. According to Franklin Umenze, secretary of ASAAHN, on 2 October 2021, the David Folaranmi Foundation – an ASAAHN affiliate – organized a similar campaign and seminars A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 128 in three regions and participated in Radio Talk in Lagos to raise awareness about factors that encourage alcohol availability, consumption and related harm. According to Angela E. Bekederemo, KARIS Family Development Initiatives Lead, in 2022, ASAAHN massively engaged in social media campaigns and awarded a grant to KARIS Family Development Initiatives, a nongovernmental organization in Lagos, to train primary health care nurses who attend to pregnant women and coach students to avoid peer pressure to consume alcohol. Ensuring enjoyable football games, Sweden In 2015, violence at football games in Sweden was widely described and debated in the media. In 2017, a study showed that 10% of spectators to Stockholm football matches were highly intoxicated, with blood alcohol concentrations exceeding 0.1% (79). The IQ-Initiative and Stockholm Prevents Alcohol and Drug Problems (STAD), jointly with the three most prominent football clubs in Stockholm, launched a project to reduce binge drinking and the number of intoxicated spectators in the stadiums. This was intended to create safer and more enjoyable football games for all. IQ-Initiative is an independent subsidiary of the government retail alcohol monopoly, Systembolaget, aiming to change norms and attitudes related to alcohol use. STAD is a centre for alcohol and drug prevention connected to Karolinska Institutet and Region Stockholm. The project, based on a successful model initially used for alcohol and drug prevention in bar environments, was based on (1) mobilizing critical actors and models of cooperation, (2) training, (3) increasing supervision over bar licensing and (4) improving policies. A new dimension adapted the model to football stadiums regarding the communication about what and why was being done targeting clubs and external audiences. Personnel and volunteers from the football clubs were trained, focusing on entrance hosts. Personnel in bars – both in the stadiums and around them – were trained. In parallel, the City of Stockholm increased control and supervision over alcohol sales at the stadiums. Alcohol control actions for the football clubs included covering areas such as serving alcohol at the stadium, marketing and alcohol harm prevention among personnel. Since the start of the project, the percentage of heavily intoxicated spectators declined from 10% to 6%, and the number of spectators who were denied access to the stadiums due to intoxication increased by 154%. Serving personnel prevent intoxicated spectators from purchasing alcohol almost twice as often as before the project was initiated (80, 81). Table 1 shows the baseline and evaluation after the initiative was implemented. The communication campaigns reached a broad audience and won several awards. Surveys – including showing a robust public consensus for policies to reduce alcohol sales and intoxication at football games (82) – were broadly reported in the media. According to Johanna Gripenberg of STAD, the three Stockholm-based football clubs that were part of the initial project still apply it and have recently sought to intensify the initiative. Other clubs in Sweden have expressed interest in introducing similar initiatives. A baseline survey has been conducted in one other city. However, it has been identified that the main challenge in rolling out the project is its funding. A study conducted in Belgium, Finland, Italy, Poland, Slovenia and the United Kingdom found insufficient knowledge and regulation enforcement in sports settings. The study Table 1. Blood alcohol concentration of volunteer stadium spectators, 2015 and 2017 Blood alcohol concentration of stadium spectators 2015 2017 Before the project After the project >0 50% 43% Average (among those >0) 0.63% 0.57% >0.1% 10% 6% Source: STAD and IQ-Initiative (83). calls for cross-sectoral efforts to implement regulations on advertisements, sponsorships, alcohol selling and serving, including consumption by young players (84). 9Understanding the alcohol landscape to advocate for stronger alcohol policies in Lebanon Lebanon is a multi-faith Arab country with a long tradition of a free market and minimal state interference in public policy (85). The country produces alcohol, mainly wine and arak, a grape spirit flavoured with anise. Alcohol is inexpensive. Currently, local beer is sold at about US$  0.40 per bottle, the same price as a can of soft drink. Beer and other alcoholic beverages are easily accessible in supermarkets. There is no enforcement of the minimum legal drinking age to prevent minors from purchasing alcohol. Drive-through drinking shacks exist in Christian and Muslim areas, enabling the quick purchase of inexpensive high-ethanol alcoholic beverages and increasing the likelihood of driving under the influence in the absence of enforced drunk-driving policies. Advertising of alcohol on mainstream media channels heavily targets young people, often featured in advertisements. In such an alcogenic environment, young people commonly and increasingly consume alcohol, especially women (86). Time-trend data has been confirmed by the perceptions of young people, who have described alcohol consumption as a pervasive public health problem facilitated by lax policies (87). In 2013, academics embarked on a multidisciplinary research project to generate evidence to advocate and develop a national alcohol policy in Lebanon. The project had the financial support of the International Development Research Centre. An initial step showed only 81 peer-reviewed alcohol-related studies across 22 countries, including Lebanon and the Arab region and over two decades (85). The research presented evidence-informed recommendations and possible future directions tailored to each Arab country’s current stance on alcohol legislation and epidemiological data on consumption (85). Following the policy content analysis, data confirmed general observations on alcohol advertising, availability and affordability. Geographical mapping of alcohol outlets in four residential neighbourhoods in Beirut noted a high density of outlets selling alcoholic beverages near schools, universities and places of worship (88). Local simulations showed that increased taxation and higher minimum unit pricing of alcoholic beverages would significantly reduce alcohol consumption among young people (89, 90). More than 30 interviews with stakeholders in governmental and nongovernmental decision-making positions exposed several challenges to adopting a national harm-reduction policy, including weak governance, diversion of responsibility towards other stakeholders and industry resistance to change (91). The research outputs significantly informed, shaped and improved the quality of the debate around alcohol control policies. Its success was based on (1) the multidisciplinary nature of the team; (2) the participatory public health approach of the project, engaging from the start essential stakeholders as advisory board members, which brought in a fresh and grounded perspective throughout the research process; (3) mobilizing and sensitizing allies, including civil society organizations, on issues relevant to conflict of interest and industry interference; (4) the ongoing discussion of research findings with international scholars, which was critical for exchanging ideas and lessons learned; and (5) disseminating research findings to policy-makers via a policy brief (92) and to the lay public via several media appearances to engage societal members beyond the scientific community. This and other local research informed an interministerial national substance use strategy. Since 2019, multiple crises have shifted the priorities of the government and stakeholders: for example, the civil unrest in October 2019, the COVID-19 pandemic in February 2020, Beirut’s port blast in August 2020 and the deterioration of the local currency. These added to other common challenges, such as limited research funding and continued alcohol industry interference. Recent data show that the consumption of alcohol and other substances has increased during the crises and that market data predict that alcohol sales may increase as lower-priced local products continue to emerge (93). The need for alcohol control policies to reduce the alcogenic environments remains a priority in Lebanon. Addressing underage access to alcohol through a mystery shopper campaign in Norway In Norway, the alcohol law forbids the sale of alcoholic beverages to minors. Although the law should be easy to comply with, Juvente – a Norwegian youth nongovernmental organization – has uncovered thousands of sales to minors. For more than 15 years, Juvente has been testing the compliance of grocery stores with the minimum age for selling alcohol to minors. In 2019, Juvente conducted mystery shopping tests nationwide. In almost every fifth attempt, Juvente’s minors – as young as 13 years – could purchase alcoholic beverages. During the compliance tests, a minor enters a store, collects alcoholic beverages and other groceries and A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 1210 queues to pay for these items at checkout. Young people who participated in Juvente’s compliance tests did not attempt to appear older than they were by adapting their appearance or purchasing typical adult goods, such as diapers. Juvente’s mystery shoppers behave like normal teenagers, and if asked, they do not lie about their age nor use false credentials. The compliance tests are thus a test of a store’s routines without using tricks or manipulations. Year after year, Juvente documents that minors purchase alcohol in shops across Norway, including the government-run retail alcohol monopoly, Vinmonopolet. In 2019, 18.5% of attempts resulted in the purchase of alcoholic beverages. An underage girl is 63% more likely to succeed in purchasing alcohol than a boy (94). However, sales to minors have decreased since the start of the project. The current system of store-employee discretion does not prevent sales to minors and therefore requires revision. Standard identification for everyone, regardless of age, could be a solution. Young people are particularly vulnerable to the negative consequences of alcohol consumption and thus have the right to strengthened protection. Working together to protect children and adolescents from alcohol harm in Colombia Rappi is an on-demand delivery company based in Bogota, Colombia with a presence in 250 cities across nine countries in Latin America. It operates through an app that connects customers with retailers of a vast catalogue of products and services. The service is provided by delivery personnel known as Rappitenderos. Rappi has weak mechanisms to protect children and adolescents from purchasing products limited to adults, such as alcoholic beverages. In October 2019, a parent reported that his 15-year-old son, alongside some friends, ordered two bottles of vodka through Rappi. When the product was delivered, the delivery person did not verify their age as required by law. In November 2019, another parent reported advertising in Rappi directed to a 16-year-old that referred to discounts on alcoholic products. The parents reported these cases to the hotline Te Protejo administered by Red PaPaz. The latter filed a complaint with the police that was redirected to the Superintendence for Industry and Commerce (95). In December 2020, the Superintendence pressed charges against Rappi for breaching Articles 23, 29 and 30 of the Consumer Statute, which requires that consumers be informed about the harm of products and the need to consult the conditions for their correct use and contraindications. It also determined that Rappi had not complied with Articles 50 and 52 for electronic commerce, which required effective measures to protect children and adolescents. In March 2022, the Superintendence resolution no. 10098 imposed Rappi a fine of 1245 minimum legal wages, equivalent to about US$ 260 000. Following the appeal, the sanction was confirmed on 21 March 2023 by Superintendence. This decision cannot be appealed further. This is the first time an on-demand delivery company has been required to adopt strict measures to comply with the advertising alcoholic products and prevent the sale of alcohol and other restricted substances to minors in Colombia. It constitutes a significant milestone for protecting the rights of children and adolescents. Increasing alcohol taxes through community efforts in Alaska, United States of America Since 1994, several attempts to increase alcohol taxes have been made in Anchorage, Alaska. Under the leadership of Recover Alaska – a multisectoral action group working to reduce the harm caused by excessive alcohol consumption – Anchorage communities explored the main obstacles faced during the previous attempts to increase alcohol taxes. The alcohol industry’s campaigns against alcohol taxes were identified as the main barrier. These campaigns aimed at creating doubts among voters about the government’s intentions regarding how to invest the revenue from the alcohol tax. In parallel, communities were asked to elicit their preferences about how the government should invest the alcohol tax revenue. Treatment of substance use disorder, behavioural health and response to homelessness were among the top priorities. After considering the two primary ways that governments tax alcohol and the mix of taxes on alcohol at the different levels in the country, communities identified that it would be helpful to obtain an increase in sales taxes in their city (96). The communities developed a robust advocacy campaign that underlined the multiple benefits of the alcohol tax increase (97). The main components of the strategy were polling, identifying allies, identifying assembly champions, proposing the activities that the revenue should support, defining 11 regulatory boundaries that were important for the communities, such as demanding mandatory annual reporting, and establishing that public processes could determine the utilization. In 2020, in the Anchorage municipal elections, citizens voted in favour of a 5% tax increase on alcohol. The voters approved the alcohol tax revenue to be invested in core areas of public safety, preventing child abuse, sexual assault and domestic violence, preventing and treating substance use disorders, homelessness and mental health emergencies. More than 200 individuals and organizations collaborated to develop a positive change for Anchorage. They remain alert to ensure the government stays true to the initial vision for the investments to be made with the revenue from the alcohol tax. Sponsorship replacement Sponsorship replacement is used to prevent alcohol companies from sponsoring the festivals. The Thai Health Promotion Foundation contributes with a sponsorship replacement programme, and SDN commits as a strategic partner for the host of festivals and policy-makers to drive the alcohol-free festival. Social awareness SDN increases social awareness by using public relations advertisements, announcements and campaign booths about the event. Strict enforcement SDN promotes strict enforcement under the Alcoholic Beverage Control Act B.E. 2551 (A.D. 2008), which prohibits the sale and consumption of alcohol in public parks. SDN invites relevant stakeholders to a meeting to plan the enforcement of this provision. Teamwork SDN strengthens the efficiency of working teams. SDN conduct meetings for working and building relationships supporting teamwork across the many stakeholders collaborating in alcohol-free festivals. SDN also collects data to show the benefits of alcohol-free festivals for increasing their engagement in promoting alcohol-free festivals. Social learning SDN supports social learning, especially in communities, by sharing knowledge about the proper value of festivals, the reasons alcohol should be controlled and the benefits of alcohol-free festivals. The alcohol-free festivals have increased public awareness about the Alcoholic Beverage Control Act and the regulation establishing that public parks, temples and festivals are expected to be alcohol-free. Alcohol-free festivals have reduced violence, reduced road crashes and increased people’s satisfaction with the festivals (98). In eight of 76 provinces, all cultural activities are alcohol-free now. Implementing alcohol-free festivals in Thailand Thailand has a long tradition of cultural festivals. Regions and towns regularly hold festivals connected to the local traditions. The alcohol industry has sponsored festivals and promoted travel packages for visitors. Since 2014, Thailand’s Stop Drink Network (SDN) has been running annual alcohol-free festivals in 213 places across Thailand. An alcohol-free festival is a whole-of- community approach involving various stakeholders, such as municipalities, police, cultural office, religious leaders, tourism authorities, hospitals and health centres, insurance commissions, employment service offices, technical colleges, media associations, education offices and children and youth councils. The approach has five main strategies. SDN strives to support alcohol-free festivals across the country. In addition, it increases awareness to support community development and analyse the root causes of alcohol consumption, including documenting the cultural and social inequalities. It also provides solutions, such as promoting creative activities and raising alcohol literacy among young people, examining the social A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 1212 return on investment from alcohol-free festivals and collaborating with stakeholders to make alcohol-free festivals part of the alcohol control policies. Opposing the government’s pro-alcohol initiative in Japan The attitudes of young people towards alcohol use are changing, and alcohol consumption among young people in Japan is declining. During the COVID-19 pandemic, many people reconsidered their habits and questioned the need to consume alcohol when seeking to connect with colleagues at work. The declining alcohol use in Japan has led to decreased tax revenue from alcohol. In 2020, taxes on alcohol accounted for 1.7% of tax revenue versus 3% in 2011 or 5% in 1980. In August 2022, the National Tax Agency of Japan announced a contest for ideas on stimulating alcohol consumption among young people to raise declining sales and tax revenues. The competition called for new products and designs as a way to promote home alcohol consumption, also exploring the metaverse (99). ASK Japan – a local non-profit organization to prevent problems related to alcohol use and other addictions – together with nine other civil society organizations that engage social workers in the field of mental health promotion and addiction, requested that the National Tax Agency and the Ministry of Health, Labour and Welfare of Japan suspend the campaign. Civil society organizations described the current positive trend in declining alcohol consumption and recall that young people are identified as a group for special consideration in the national plan to prevent health disorders related to alcohol use (100). The National Tax Agency was a stakeholder in developing that national plan. One month after the request, the civil society organizations met with the representatives of the National Tax Agency. During the meeting, the representatives of civil society organizations brought up several evidence-informed arguments to stop the campaign that was harming public health, sought to increase young people’s consumption of alcohol and put the most vulnerable youth, including young women, at greater risk. The conflict of interest and policy incoherence was also discussed. Although the National Tax Agency’s intention was not to encourage young people to use alcohol, more than 290 applications were received by November 2022. All aimed at promoting more alcohol use. Of the many submissions, two were ultimately the winners. The first one involved adding alcohol to foods and other items. The idea was to “help people with a negative perception of alcohol see it as something delicious and enjoyable”. The proposal included illustrations of small, colourful packages of alcohol that were meant to be added on top of a cake. The second winner’s idea was about creating a “new and unique craft gin brand” to attract young people with the “sustainable gin”. Civil society organizations in Japan and worldwide remain concerned about the contest and effort to promote alcohol to youth when young people are reducing or quitting alcohol use or staying alcohol-free longer. This case shows that policy coherence can be achieved when adopting a public health perspective. It also shows that civil society organizations play an essential role in holding the government to account for public health objectives ■ 13 The way forward This section provides directions to ensure that the conversation continues beyond this brief T ackling the challenges laid out in this brief requires a multistakeholder approach, with each partner playing to its comparative advantage towards common goals. A partnership among stakeholders outside the health sector is critical to advocating, legitimating, adopting, implementing, enforcing and sustaining local alcohol policies and initiatives (101). Illustrative actions for policy- and decision-makers, civil society and community-based organizations, researchers and research institutions are provided below. Policy- and decision-makers Government policy- and decision-makers should give priority to approaches to safeguard young people from exposure to alcogenic environments. Government policy- and decision-makers should reach beyond the health sector to develop whole- of-government approaches to strengthening alcohol control policies, especially those that address upstream sources of damage. Government policy- and decision-makers should consider adapting and implementing cost-effective and high-impact WHO interventions to tackle the harm produced by alcohol consumption. Government policy- and decision-makers should partner with civil society and community-based organizations on campaigns and approaches that garner public support for strengthening alcohol control policies. Civil society and community-based organizations Civil society and community-based organizations should continue to raise public awareness and advocate for more robust alcohol control policies that safeguard young people from the harm related to alcohol consumption. Civil society and community-based organizations should partner with other civil society and community-based organizations across the globe to share lessons learned and successful approaches that have been used to curb the effects of alcogenic environments. Researchers and research institutions Researchers and research institutions should fill the knowledge and practice gaps by evaluating public policies that address the influence of alcogenic environments on young people. Researchers and research institutions should monitor and evaluate the effects of actions increasing exposure and targeting young people taken by the alcohol industry ■ A HEALTH PROMOTION APPROACH FOR REDUCING YOUTH EXPOSURE TO ALCOGENIC ENVIRONMENTS. BRIEF 1214 Takeaway messages The environment in which young people live, learn and play significantly affect their decisions about whether to consume alcohol. Environmental factors have been described as the main risk factors driving alcohol consumption and related harm among young people. Alcogenic environments promote the normalization of alcohol consumption, leading to adverse effects on brain development, decreased educational attainment, low mental well-being, increased risk for social problems such as violence and crime, earlier development of liver cirrhosis, higher likelihood of binge drinking, increased risk of alcohol use disorders, earlier onset and greater of alcohol consumption throughout the lifespan. Policy-relevant research should be conducted to understand further what approaches are effective in reducing the effects of alcogenic environments, including conducting evaluations on existing policy choices. Interventions that focus on single settings, such as those solely targeting schools or families rather than the whole environment, provide inconclusive evidence about their effectiveness in decreasing the harm derived from consuming alcohol. Multipronged interventions that tackle the acceptability, availability and affordability driving alcohol consumption are most effective in reducing young people’s exposure to alcogenic environments. Partnerships among many stakeholders ensure widespread advocacy, design, implementation and enforcement of initiatives that address upstream the causes of the harm caused by alcohol consumption. 4 6 7 1 2 5 15 References 1. Meister SR, Barker B, Flores Pajot MC. 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Business Contest for the Development and Promotion of Japanese Alcoholic Beverages” targeting young people. Tokyo: ASK Japan; 2022 [unpublished]. 101. Babor TF. Public health science and the global strategy on alcohol. Bull World Health Organ. 2010;88(9):643. doi:https://doi. org/10.2471%2FBLT.10.081729. The environment in which young people live, learn and play significantly affects their decisions about whether to consume alcohol. Environmental factors are the main risk factors driving alcohol consumption and related harm among young people. Environments that normalize alcohol consumption – termed alcogenic environments – include contexts with unregulated advertising and marketing of alcoholic beverages, higher alcohol outlet density, products designed to facilitate affordability and low prices of alcoholic beverages. A recent body of research evidence has emerged related to the measurement, functional significance and consequences of living in alcogenic environments. This includes findings on the complex and bidirectional interactions among alcohol acceptability, availability and affordability and how they create and perpetuate alcogenic environments. Comprehensive and enforced alcohol control policies are effective at delaying the age of onset and lowering alcohol prevalence and frequency among young people. Evidence consistently confirms the effectiveness of designing and implementing alcohol control policies that regulate upstream the drivers of alcogenic environment, including alcohol availability, acceptability and affordability. These policies need to be multipronged and address the complex interactions between these drivers and the local alcohol culture. Less Alcohol Unit Department of Health Promotion Website: https://www.who.int/teams/health-promotion/ reduce-the-harmful-use-of-alcohol E-mail: lessalcohol@who.int connect, share, practice #WHOdrinksless More taxes Less availability No advertising