Excess drinking is one of the most common preventable causes of global mortality, implicated in more than three million deaths each year. It's also one of the most neglected. That's due, in large part, to the efforts of alcohol industry, which is dominated by a small group of firms that generate more than $1.5 trillion in global sales.
The World Health Organization (WHO) has a small unit devoted to advancing rigorous, population-based policies to reduce excess drinking, and Juan Tello has been running it since 2020. He spoke with Think Global Health about their efforts, and what they are up against.
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Think Global Health: How did your office come about?
Juan Tello: The unit on alcohol was created specifically to look with a more global perspective at how we tackle alcohol.
The four main risk factors in this epidemic of NCDs [noncommunicable diseases] are tobacco use, lack of physical activity, wrong diet, and alcohol consumption. I moved to work on alcohol control in the last two years.
We at the WHO have adopted a new approach to alcohol. Our organization is looking at treating diseases but it's also trying to understand what causes the diseases. That's the shift that has taken place since the new WHO management took office, about six years ago.
Think Global Health: Can you tell me more about the change in approach?
Juan Tello: We have traditionally focused on people who drink, who have a problem. We treat them. We try to prevent them from beginning to drink. We also support their families. But now we ask, "Why are they drinking? What is driving the drinking in general?"
The alcohol industry learned from tobacco and uses similar marketing strategies to get younger people, women, drinking more.
Juan Tello, World Health Organization
Several drivers are behind the phenomenon. One is the price of alcohol. In the last few years, alcohol has become more accessible in terms of its price tag than it once was. People therefore buy more alcohol.
Another factor is availability. When you go to supermarkets, drugstores, outlets along the highways, you can buy alcohol. That didn't used to be the case.
Marketing campaigns are also aggressive. The alcohol industry learned from tobacco and uses similar marketing strategies to get younger people, women, to drink more.
Finally, alcohol is normalized in Western society. If we want to make a toast because we are happy, we drink alcohol. If we are sad, as we see in the movies, we drink alcohol. This is the cultural aspect of alcohol. Alcohol has been there forever so it's more accepted than tobacco in many countries. Thus it's more difficult for us to combat.
Think Global Health: Where does your office fit into the WHO?
Juan Tello: The WHO has three pillars: one is emergencies such as COVID-19. Another is the management and the treatment of diseases. And the new one is all related to the upstream work: commercial determinants of health, environment, all that creates healthier populations. And that's where this new unit sits.
Think Global Health: Some other health threats are influenced by natural conditions. What forces are your office up against?
Juan Tello: We are working against the alcohol industry. They sponsor big sporting events, which presents a contradiction: we are doing healthy things like playing sports but at the same time seeing beer or spirit ads in stadiums.
We know that the more advertising you do, the more you expose people to this normalization of "we drink, it's fine, drinking is fine." We also know that being exposed to advertisements of alcohol brings children to start drinking earlier — and then when they arrive at eighteen, they are already drinking beer, and when they are in their twenties, they transition to wine, to vodka, to heavy drinking.
That's what we are against. We want to avoid people being exposed. We want people to make informed choices of what they are drinking.
Think Global Health: What are some of the powers of your office?
Juan Tello: We can advise national governments to be aware of these dynamics. We confront them on choices they make. For example, many countries subsidize the alcohol industry because they think they are promoting economic development. The profits this industry earns, though, do not balance the harms it produces by pushing people to consume alcohol. We make governments aware of the conflict of interest they face on this.
Through lobbying or economic incentives, the alcohol industry tries to undermine the legislation we promote to avoid exposing children to alcohol advertisements, to have more informed choices, to index taxes so that the prices of alcohol will always be high.
We give countries five recommendations that are cost effective to implement, especially in middle-income countries: increase pricing, particularly through taxation; ban marketing and sponsorships advertising alcohol; decrease the physical availability of alcohol outlets; enforce checks and control of blood alcohol concentration; and treatment. We are well positioned to do this when countries are willing to move forward.
The profits this industry earns, though, do not balance the harms it produces by pushing people to consume alcohol.
Juan Tello, World Health Organization
Think Global Health: What's the level of interest from countries?
Juan Tello: The uptake is low. It's truly low. Depending on the political cycle, countries are keen to move one step at a time. Maybe some of them are keen to increase taxation. Others would prefer to offer more treatment. Others implement drunk-driving control measures. It is more difficult for countries to embark on a comprehensive approach because politically, of course, this has a cost.
The political cycle is short in most low- and middle-income countries. The interest of the industry and the lobbying that they do is high. At the moment, the WHO is supporting three or four countries that are moving forward in a comprehensive way on this issue.
Think Global Health: Here in the United States, the politics related to alcohol are contentious. Is it similar at the global level?
Juan Tello: Yes. If you say "we need to treat all people with addictions or with drinking problems," everybody would agree. If you talk with ministers of health or people working in the public health or social sphere, you will get a quick endorsement. These are not the people driving the commercial or the industrial or the economic agendas, however.
We see a common pattern across the industries of tobacco, alcohol, food, and other "unhealthy commodities." The way they behave is quite similar. We need an approach that is common to all of these unhealthy commodities. We need to think more broadly on what the well-being of the people is, or what development means.
Think Global Health: What are the trends in global alcohol consumption?
Juan Tello: High-income countries have strong governance mechanisms so it is easier for them to tackle the root cause of the problems. They are better to regulate the market, to say, "you are not going to advertise here." However, alcohol industries from high-income countries are moving toward low- and middle-income countries where these governance mechanisms are weaker.
What we see now is that high-income countries are steady in terms of consumption, many are decreasing, and that is excellent news. But we have a huge increase in Latin America, in Africa, and Southeast Asia. Countries in those regions are better off in terms of economic development than they were, so alcoholic beverages are affordable. They have younger populations, so they have a huge potential market. They are targeted in terms of marketing strategies. These younger generations are driving the consumption up, particularly women, because women are keen to drink more to show that they are equal to men.
Think Global Health: Should people who are working in global health feel pessimistic or optimistic?
Juan Tello: I think we have to be optimistic but realistic as well. For example, a huge movement of civil society organizations and academics are pushing for a framework convention against alcohol, similar to what we have for tobacco.
I don't think that will happen anytime soon because we are dealing with debates that are more complex. Tobacco was clear: one type of product. Here we have different types of products, from zero alcohol to low-alcohol to beer, wines, liquor. The variety is immense. Also, the evidence for each of these is quite different in terms of how much they harm health.
Overall, we have a better understanding that in any case it is not safe to drink alcohol. Not only because of violence or road safety. Ethanol is a carcinogenic substance; consumption is not safe, certainly when it comes to cancer. It is not recommended at any level by the International Agency for Research on Cancer. We are getting more clarity and seeing more evidence on how much it can harm.
Alcohol is embedded in our culture, however. We need to tackle the culture aspect of normalizing drinking. We need to keep pushing people to understand that it is not a shame to not drink. We are getting more coherent, more harmonized, not only the WHO, but also many other organizations working in this field.
As the alcohol industry learns to market, based on experience in the tobacco industry and in targeting women, the WHO, academia, civil society organizations are learning quickly how to frame the issues and to narrate a story in a way that people can understand.
That's where I think we are better off, and we stay positive. I have young kids so I want to make sure that they live in a better world.
Think Global Health: Are there success stories you would point to around the world?
Juan Tello: I love the ones that are driven by younger generations because they are fantastic and really creative.
In Norway, restrictions on marketing or selling to youth are high. Young volunteer "mystery shoppers" ran a campaign in which they attempted to buy alcohol to see whether anyone responded if they were caught. Seventy percent of the time, they managed, as minors, to get perfectly good and decent people to buy alcohol for them. They developed an approach and now have a huge related program. The government recently awarded them funds to use these methods as a surveillance for providers to not sell alcohol to minors.
Lithuania is a great case. They looked at big policy interventions and tackled all of them together. They passed significant, important laws. Now, in the face of industry lobbying, they are struggling to keep the laws in force.
Nepal, like Norway, banned advertising alcohol but companies advertise regardless. In February this year, the Supreme Court there said to the industry, your companies can't advertise, this is enforcement of law already in place.
Think Global Health: What would you hope the global community would do in the near future to better regulate alcohol?
Juan Tello: For a start, all 194 WHO member states endorsed a global action plan.
In terms of marketing, it's clear that a great deal can be done at the global level to prevent children from being exposed to this advertising. Ending sponsorships such as FIFA and many others is one possibility. Various intermediate steps are viable options, we think, to move toward a framework convention.
Think Global Health: Has anything changed recently in the alcohol business?
Juan Tello: Digital marketing is becoming at hot topic, for alcohol and also other unhealthy commodities. The regulation remains at the national level but these are cross-national phenomena. We don't have tools to address it, and there is a huge debate of what you can do to regulate the platforms, to regulate the advertising companies. That's still very much on the debate side of understanding what we can really do.
WHO is working on recommendations for governments to help regulate digital marketing. From a global health community perspective, this is something that we should tackle together because it affects not only alcohol, but many diseases that are linked to advertisement or digital marketing.
EDITOR'S NOTE: This interview was conducted via Zoom and has been edited for length and clarity.
