According to The Lancet “alcohol use is a leading risk factor for global disease burden and causes substantial health loss”1. In fact, it is the seventh leading risk factor globally for mortality and disease finding that “the risk of all-cause mortality, and of cancers specifically, rises with increasing levels of consumption, and the level of consumption that minimises health loss is zero”2. These results suggest that alcohol control policies and regulations that have traditionally focused on “responsible” or “safe” alcohol consumption might need to be revised worldwide, refocusing on efforts to lower overall population-level consumption. Some states (eg. Australia) are currently reviewing their alcohol control regime and with The Lancet’s recent publication more jurisdictions are expected to follow. This howtoregulate article examines the international and national alcohol control regulations to determine good regulatory techniques that could assist states’ reviews of existing regulation.
A. International and supranational regulatory framework
I. World Health Organisation (WHO)
1. In 2010, the 193 Member States of WHO agreed on a global strategy to reduce the harmful use of alcohol (resolution WHA63.13). The strategy gives guidance to both Member States and to the WHO Secretariat on ways to reduce the harmful use of alcohol. The strategy has five objectives:
- raise global awareness of the magnitude and nature of the health, social and economic problems caused by harmful use of alcohol, and increased commitment by governments to act to address the harmful use of alcohol;
- strengthen knowledge base on the magnitude and determinants of alcohol-related harm and on effective interventions to reduce and prevent such harm;
- increase technical support to, and enhanced capacity of, Member States for preventing the harmful use of alcohol and managing alcohol-use disorders and associated health conditions;
- strengthen partnerships and better coordination among stakeholders and increased mobilisation of resources required for appropriate and concerted action to prevent the harmful use of alcohol; and
- improve systems for monitoring and surveillance at different levels, and more effective dissemination and application of information for advocacy, policy development and evaluation purposes.3
2. In addition, ten target areas were identified for action and intervention, including:
- leadership, awareness and commitment: focusing on adequately funded comprehensive and intersectoral national policies that clarify the contributions, and division of responsibility, of the different partners involved.
- health services’ response: prevention and treatment interventions to individuals and families at risk of, or affected by, alcohol- use disorders and associated conditions. Funding should be commensurate with the magnitude of the public health problems caused by harmful use of alcohol.
- community action: empowering communities and other stakeholders to use their local knowledge and expertise in adopting effective approaches to prevent and reduce the harmful use of alcohol by changing collective behaviour while being sensitive to cultural and value systems.
- drink–driving policies and countermeasures: strong evidence-based interventions exist for reducing drink–driving, including measures that reduce the likelihood of a person driving under the influence of alcohol, and measures that create a safer driving environment.
- availability of alcohol: public health strategies that seek to regulate the commercial or public availability of alcohol through laws are important ways to reduce the general level of harmful use of alcohol. Such strategies provide essential measures to prevent easy access to alcohol by vulnerable and high-risk groups.
- marketing of alcoholic beverages: reducing the impact of marketing, particularly on young people and adolescents, is an important consideration in reducing harmful use of alcohol and a precautionary approach to protecting young people against these marketing techniques should be considered.
- pricing policies: increasing the price of alcoholic beverages is one of the most effective interventions to reduce harmful use of alcohol. A key factor for the success of price-related policies in reducing harmful use of alcohol is an effective and efficient system for taxation matched by adequate tax collection and enforcement.
- reducing the negative consequences of drinking and alcohol intoxication: through enforcing laws against serving to intoxication, legal liability for consequences of harm resulting from intoxication caused by the serving of alcohol and responsible serving of beverages on premises and staff training in how better to prevent, identify and manage intoxicated and aggressive drinkers.
- reducing the public health impact of illicit alcohol and informally produced alcohol: consumption of illicitly or informally produced alcohol could have additional negative health consequences due to a higher ethanol content and potential contamination with toxic substances, such as methanol.
- monitoring and surveillance: local, national and international monitoring and surveillance are needed in order to monitor the magnitude and trends of alcohol-related harms, to strengthen advocacy, to formulate policies and to assess impact of interventions.
At the 2013 World Health Assembly Member States agreed to a voluntary target of reducing harmful use of alcohol by 10% by 2025, as part of the Global Monitoring Framework of non-communicable diseases. Although the target is voluntary, as a credible norm-setting agency, the WHO is effective in monitoring, reminding and assisting Member States of their commitments.
II. European Union (EU)
3. Europeʾs per capita alcohol consumption is the highest of all regions in the world, and EU countries make up 11 of the top 20 highest consumers of alcohol4. Although Member States of the EU are responsible for their national alcohol policy, the Treaty on the Functioning of the European Union sets the protection of public health as an overarching EU objective (Article 9) to be pursued across all policies and activities (Article 168). Although the 2006 EU alcohol strategy ended in 2012 many of its elements continue to support Member States in the regulation of harmful and hazardous alcohol consumption. The aim of the strategy was to reduce alcohol-related harm by coordinating measures between the individual national policies, tackling cross-border problems, increasing exchanges of information and identifying and disseminating best practice. The five focus areas of the EU strategy were to:
- Protect young people, children and the unborn child;
- Reduce injuries and death from alcohol-related road accidents;
- Prevent alcohol-related harm among adults and reduce the negative impact on the workplace;
- Inform, educate and raise awareness on the impact of harmful and hazardous alcohol consumption, and on appropriate consumption patterns;
- Develop and maintain a common evidence base at EU level.
4. The bodies established under the EU strategy also continued including the Committee on National Alcohol Policy and Action (CNAPA), made up of representatives of Member States which meets twice a year to facilitate cooperation and coordination between Member States and contribute to further policy development. The European Alcohol and Health Forum (EAHF) is made up of relevant stakeholders (eg. alcohol industry, public health organisations, scientists) that can address alcohol-related harms through ‘commitments to action’(list of EAHF members). The EAHF is currently restructuring, following the resignation of a number of public health organisations over their concern that the global alcohol industry is influencing policy in ways that favour their business interests at the expense of public health and well-being5. Notwithstanding this, the EAHF encourages and monitors voluntary commitments by the alcohol industry to reduce the harmful effects of alcohol consumption.
5. In 2015, Council Conclusions on an EU strategy on the reduction of alcohol-related harm were adopted, inviting the Commission to “adopt by the end of 2016, while fully respecting Member States’ competences, a comprehensive EU strategy dedicated to the reduction of alcohol-related harm and comprising actions across EU policies in order to tackle health, social and economic consequences of the harmful use of alcohol”6. At time of writing and based on the last Council conclusions about tackling the harmful use of alcohol of 22 December 2017, the Council repeated its invitation to the Commission to adopt “a strategy dedicated to the reduction of alcohol-related harm…[accounting for] the scientific, technological, economic and social aspects of the harmful use of alcohol and the developments in different policy areas having an impact on alcohol-related harm that have occurred since 2012”7.
6. The Audiovisual Media Services Directive (AVMSD) contains specific rules for audiovisual commercial communications for alcoholic beverages and Article 9 provides that Member States shall ensure that such communications are not aimed specifically at minors and shall not encourage immoderate consumption of such beverages. Article 22 provides that television advertising and teleshopping for alcoholic beverages shall comply with the following criteria:
- it may not be aimed specifically at minors or, in particular, depict minors consuming these beverages;
- it shall not link the consumption of alcohol to enhanced physical performance or to driving;
- it shall not create the impression that the consumption of alcohol contributes towards social or sexual success;
- it shall not claim that alcohol has therapeutic qualities or that it is a stimulant, a sedative or a means of resolving personal conflicts;
- it shall not encourage immoderate consumption of alcohol or present abstinence or moderation in a negative light;
- it shall not place emphasis on high alcoholic content as being a positive quality of the beverages.
Although the AVMSD is currently under review, the revisions proposed are likely to strengthen the protections for minors and likely to continue to discourage immoderate consumption of alcoholic beverages8.
B. Standards and industry initiatives
I. International Chamber of Commerce (ICC)
1. The ICC is the world’s largest business organisation working to promote international trade, responsible business conduct and a global approach to accelerate inclusive and sustainable growth to the benefit of all9. The ICC has developed an Advertising and Marketing Communication Practice Code that promotes high standards of ethics in marketing, where Article D5 provides that “websites devoted to products or services that are subject to age restrictions such as alcoholic beverages, gambling and tobacco products should undertake measures to restrict access to such websites by minors”10. This ICC Code has been adopted by the Asia Pacific Economic Cooperation Conference parties as a way to establish and implement effective advertising standards across the Asia-Pacific region.11 Alcohol is dealt with specifically in the ICC Framework for responsible marketing communications of alcohol, which sets general principles governing all marketing communications, and includes separate sections on sales promotion, sponsorship, direct marketing, digital interactive marketing and environmental marketing. The Framework dealing with alcohol contains 8 articles that concern basic principles such as decency, honesty, social responsibility, safety and health, children and young people and encourages parties to ensure such principles are included in contracts pertaining to advertising and other marketing communication.
II. World Federation of Advertisers (WFA)
2. The WFA is the only organisation representing marketers. According to the WFA website it “brings together the biggest markets and marketers worldwide, representing roughly 90% of all the global marketing communications spend…[it] champions responsible and effective marketing communications”12. The WFA assists alcohol producers in developing responsible commercial communications and specifically assists in the Responsible Marketing Pact (RMP) launched by the leading producers of beer, wine and spirits. The RMP is a self-regulatory tool for establishing a set of common rules about limiting minors’ access to and interaction with alcohol brand communications across all media, while avoiding primary appeal to them. The RMP works in the following way:
- Ensuring that common controls are in place so that advertisements are only placed in media where the audience is composed of at least 70% adults over the legal drinking age;
- Creating a black list of over 50 creative features that appeal to minors that will never be represented in advertisements; and
- Using a social media profile on main social networks composed of safeguards to limit minors’ access to alcohol brand communications13.
The RMP website states that the rules and commitments will be monitored by independent third parties every year and the result published on the website but at the time of writing, there were no results published.
III. International Alliance for Responsible Drinking (IARD)
3. The IARD is a not-for-profit organisation based in the US, dedicated to reducing harmful drinking and promoting understanding of responsible drinking. IARD includes the leading global beer, wine, and spirits producers, who want to be part of the solution in combating harmful drinking. IARD works with public sector, civil society, and private stakeholders, and the WHO, to achieve the target of reducing the harmful use of alcohol by at least 10% by 2025. The alcohol producers of IARD commit to:
- reducing underage drinking using education programmes and materials via lectures and seminars;
- strengthening and expanding marketing codes of practice, particularly through contracts with advertising agencies;
- providing consumer information and responsible product innovation such as symbols or words warning against harmful drinking;
- reducing drinking and driving through the delivery of drink driving prevention programmes;
- working with retailers to reduce harmful drinking through local responsible retailing initiatives.14
C. National regulations
Using the WHO’s ten target areas for intervention identified in the global strategy to reduce the harmful use of alcohol, national reference regulations will be presented to highlight some best practices from jurisdictions that have implemented alcohol control measures.
I. Leadership, awareness and commitment
1. When it comes to leadership, awareness and commitment no jurisdiction has been more progressive than Ireland15. Ireland’s Public Health (Alcohol) Bill 2015 is expected to be enacted in coming months and is currently at the the eighth step of an eleven step process that ends when the Bill is signed into law by the President16. Research undertaken in writing this article indicates that Ireland is the only jurisdiction to legislate (through this proposed Bill) international recommendations made by the WHO’s European action plan to reduce the harmful use of alcohol 2012-2020. The objectives of the Bill are to:
- ensure the supply and price of alcohol is regulated and controlled in order to minimise the possibility and incidence of alcohol related harm;
- delay the initiation of alcohol consumption by children and young people;
- reduce the harms caused by the misuse of alcohol; and
- reduce alcohol consumption to 9.1 litres of pure alcohol per person per annum by 202017.
The Bill proposes to achieve these objectives by introducing:
- a minimum unit price, price per gram of alcohol is set at 10 cents (section 10);
- health labelling of alcohol products (section 11 labelling);
- the regulation of advertising and marketing of alcohol (section 12 concerns content of advertising, section 13 prohibition on advertising in certain places, section 14 restriction son advertising during events, section 17 advertising in publications and section 18 advertising in cinemas);
- the regulation of sponsorship (section 15 concerns sponsorship where majority of individuals taking part are children);
- structural separation of alcohol products in mixed trading outlets (section 20 of the Bill); and
- the regulation of the sale and supply of alcohol in certain circumstances (section 21 of the Bill) 18.
II. Health services’ response
2. The UK revised its drinking (alcohol) guidelines in 2016 following an extensive three year process where three groups of independent experts considered the evidence on the health affects of alcohol. These guidelines had not been systematically updated since 1995 and the approach was “sensible drinking”. The Chief Medical Officerʾs Low Risk Drinking Guidelines 2016 (the drinking guidelines) emphasises that:
- people have a right to accurate information and clear advice about alcohol and its health risks; and
- government has a responsibility to ensure this information is provided for the public in a clear and open way, so they can make informed choices.
The drinking guidelines outlines a weekly drinking guideline that applies to adults who drink regularly or frequently; a guideline for single occasion drinking episodes; and a pregnancy and drinking guideline. In revising the drinking guidelines the report from the development group also provides detailed notes for medical practitioners on how to use the guidelines and explain alcohol-related risks to their patients19. The UK’s National Health Service provides free therapy or counselling for those who recognise they may have an alcohol-related problem and can self refer themselves20.
3. Sweden has the public health goal to reduce the use of alcohol and focuses on capturing “early-risk alcohol users” in adults21 but with a particular focus on teenagers22. In Sweden most employers monitor the health of their employees because unhealthy employees are less productive and the Swedish public health authority is encouraging employers to introduce motivational conversations with employees that begin to have absentee problems as an early prevention before addiction sets in23.
III. Community action
4. Hong Kong’s action plan includes comprehensive community action to reduce alcohol-related harm. It focuses on education campaigns aimed at the general public, parents, children, teachers, government departments, non-government organisations, academia, professional health bodies, private hospitals and enforcement agencies. The Hong Kong Department of Healthʾs website promotes its two alcohol reduction campaigns, “#alcoholfails” and “#youngandalcoholfree”, which contains many resources about alcohol and health, in both Chinese and English, including:
- letters to higher education institutions reminding them about controlling alcohol advertisements on campus and promoting the dangers of alcohol drinking;
- an online questionnaire to asses your alcohol and potential health effects within a minute including where to go for help;
- tool kits for the general public, heathcare professionals and those in the education field;
- holding regular events open to all about the prevention and treatment of alcohol such as monthly information evenings at a hospital, children school camps focused on anti-alcohol messages, youth conferences, alcohol-free fitness camps; and
- ways to say no under peer pressure: “No, I’m allergic to alcohol”; “No, my mum will be angry if I drink”; “Alcohol is expensive and unhealthy. Let’s have something else”; or simply walk away from the situation “Sorry, some urgent business has flashed through my mind” or “Sorry, my family is calling me” and walk away quickly.
IV. Drink-driving policies and countermeasures
5. According to the WHO the risk of involvement in a crash increases significantly above blood alcohol concentration (BAC) levels of 0.04 g/dl. Less than half of countries worldwide (88 countries) have drink-driving laws based on BAC limits that is equal to or less than 0.05 g/dl as recommended in the World report on road traffic injury prevention.24 Armenia, Azerbaijan, Croatia25, Czech Republic26, Ethiopia, Hungary, Nepal, Romania and Slovakia27 all have a zero limit for BAC while driving28. The Czech Republic, Hungary and Slovakia have had regulations for zero limit BAC for over 50 years, producing relatively good results in terms of alcohol related accidents/fatalities, which has meant high levels of support among their respective populations29. However, these relatively good results can be mostly attributed to a permissive social climate condemning drinking and driving, good reporting of alcohol accidents often including detailed information on BAC level, severe sanctions (high fines, withdrawal of driving licence) and good enforcement regime matched with broad police powers to stop, detain and acquire property. An outline of the enforcement powers of the police can be found in the Evaluation of the 0.0 BAC limit for drivers of road vehicles in Czech Republic, Slovakia, Hungary and Croatia, and good police powers can be summarised as:
- the power to detain the driver and vehicle;
- power to subject the driver to a breath test, and if necessary go to the hospital for further testing, eg. urine and hair samples;
- power to withhold the vehicle keys;
- power to withhold drivers licence;
- in Slovakia all police are equipped with breath testing equipment; and
- on the spot fine.
6. Some states of the US have ignition interlock laws, which requires first-time convicted drunk drivers to install an ignition interlock in their vehicle for a legally specified time. An ignition interlock requires the driver to breathe into the breathalyser before the vehicle starts, if the result is greater than the programmed BAC, the vehicle engine will not start. See the full list of US statesʼ ignitions interlock laws but some notable regulations include:
- harsher time periods for the ignition interlock where children were in the vehicle while the driver was above the BAC limit (Alabama §32-5A-191) ;
- for a first offence, offender’s license will be revoked for 9 months, with the option after 1 month, to install an ignition interlock device and receive a limited license (Colorado §42-2-132.5);
- for a first DUI offence, the driver is prohibited from operating the vehicle for 1 year, after the 45 day suspension period, without the ignition interlock device. For a second offence within 10 years, the driver may not operate a vehicle for 3 years, after the 45 day suspension period, without an approved ignition interlock device (Connecticut §53a-56b); and
- A person who tampers with or circumvents an ignition interlock device installed as required in this chapter and while the requirement for the ignition interlock device is in effect commits a serious misdemeanour [Iowa §§321J.9(2)(b) and 321J.20(6)].
7. The WHO global strategy to reduce the harmful use of alcohol recommends that Member States:
- conduct public awareness and information campaigns in support of policy and in order to increase the general deterrence effect; and
- running carefully planned, high-intensity, well-executed mass media campaigns targeted at specific situations, such as holiday seasons, or audiences such as young people.
A simple search on YouTube for “anti-drink driving campaigns” shows some examples of media campaigns used over the years.
V. Availability of alcohol
8. A number of state-run alcohol monopolies exist to enforce alcohol-related regulations, which by their nature have an effect on the availability of alcohol. Scandinavian countries, Iceland, Norway and Sweden have low per capita alcohol consumption because of their state-run alcohol monopolies. In Sweden a chain of government-owned liquor stores, known as Systembolaget. Systembolaget is expressly mandated to limit the harmful effects of alcohol by selling alcohol without a profit, this includes informing customers about the risks of alcohol and providing a responsible, high quality service. This mandate is governed by the Swedish Alcohol Act, Systembolaget’s contract with the government in its capacity as Systembolaget’s owner30. A multi-national, independent review of Swedenʼs Systembolaget revealed that:
abolishing Systembolaget would lead to significant increases in alcohol consumption and, as well, in the health and social problems caused by alcohol and in economic costs. This is because privatisation typically leads to a reduction in the minimum price of alcohol, an increase in the number of outlets selling alcohol, an increase in the trading hours of those outlets, and increased promotion and marketing of alcohol.31
Measures in Sweden´s Systembolaget that serve to limit the availability of alcohol include:
- Although the legal drinking age in Sweden is 18, a person must be 20 to buy alcohol from Systembolaget, and identification is asked of everyone that looks 25 or below;
- Opening hours of stores are also limited to 10.00 to 18.00 on Mondays to Fridays and 10.00 to 13.00 on Saturdays;
- Whistleblowing portal for incidents that undermine Systembolaget and its mandate;
- Selling to a person visibly under the influence;
- Not tempting customers into stores by displaying beverages;
- Not advertising;
- Never running promotional deals such as “three for two”;
- Encouraging alcohol-free drinks.32
9. Regulating a minimum legal drinking (for alcohol consumption or purchase) age (MLDA) also serves to restrict the availability of alcohol, particularly to children whose brains are still developing33. An overwhelming majority of countries have regulation setting the MLDA of 18 years34. For example, it is illegal in Brazil to sell, serve or supply any alcoholic beverage to a person under 18 years of age and the penalty underscores the importance of the restriction because the presidential law enacted on March 17, 2015 made any violation of the MLDA a criminal offence35. Any adult person in Brazil selling, serving, giving or supplying alcoholic beverages to a minor is punished with imprisonment of 2 to 4 years, a fine of R$3.000 to R$10.000 and a ban to operate any business selling or serving alcohol36. In Paraguay Art. 1° of the law to “ban on the sale of alcoholic beverages to minors”, it is illegal to serve or sell alcohol or to allow the consumption by minors under 20 years of age37. Furthermore, under Art 2° all public establishments selling alcohol must display a clearly legible notice in the sales area with the following text: “ESTA PROHIBIDA LA VENTA DE BEBIDAS ALCOHÓLICAS A MENORES DE VEINTE AÑOS DE EDAD” (It is illegal (prohibited) to sell alcoholic beverages to minors under 20 years of age)38.
VI. Marketing of alcohol
10. Many countries have some form of regulation for the advertising of alcohol products, but other forms of promotion such as sponsorships and product placements are much less regulated. Sri Lankaʼs National Authority on Tobacco and Alcohol Act is a model regulation for prohibiting all advertising of alcohol products. Sri Lankaʼs Act follows the WHO Framework Convention on Tobacco Control, see howtoregulate article on Tobacco control regulations, and some of the strict tobacco advertising regulations have been applied similarly to alcohol. Section 35 of the Act outlines the prohibition of tobacco or alcohol advertisements, including:
- A person shall not publish or cause to be published, or authorise the publication of, a tobacco advertisement or an alcohol advertisement (subsection 1);
- A person who contravenes the provisions of subsection (1) shall be guilty of an offence under this Act and shall on conviction after summary trial before a Magistrate be liable to a fine not exceeding two million rupees (subsection 3);
- “alcohol advertisement” means any distinctive writing, still or moving picture, sign, symbol or colours or other visual image or any audible message or any combination of the aforesaid that promotes or is intended to promote—
- the drinking of liquor;
- the purchase or use of an alcohol product;
- a trade mark registered in respect of any alcohol product or articles that include alcohol products;
- a brand name associated with an alcohol products;
- the name of the manufacturer of an alcohol products (subsection 4).
- “publish” in relation to a “tobacco advertisement” or “alcohol advertisement” includes the following:—
- the displaying, screening or playing, of the advertisement or anything containing the advertisement so that it can be seen or heard in or from any place or vehicle to which the public have access;
- the insertion of the advertisement in a newspaper, magazine, programme, leaflet, handbill, or other document that is available, or distributed, to the public or a section of the public;
- the inclusion of the advertisement in a film, video, radio programme or television programme or through the internet that is seen or heard, or intended to be seen or heard by the public or a section of the public;
- the sale, hire or supply or the offer for sale, hire or supply, of the advertisement or anything containing the advertisement to the public or a section of the public (subsection 4).
Section 36 prohibits the use of a brand name or trade mark associated an alcohol product, or the name of a manufacturer of a alcohol product in association, sponsorships connected with the promotion of any educational, cultural, social or sporting organisation, activity or event. The penalty for contravening section 36 is a fine not exceeding fifty thousand rupees or imprisonment not exceeding two years or both. Section 37 prohibits free distribution of alcohol products, including as prizes, gift, cash rebate, discount or the right to participate in any contest, lottery or game. The Sri Lankan National Authority on Tobacco and Alcohol has broad functions to ensure that alcohol is controlled according to the Act and comprehensive enforcement powers (11 in total) including:
- acquisition of property
- to sell or dispose of property
- to inquire and investigate
- generally, to do all such other things as are necessary to facilitate the proper discharge of the functions of the Authority.
11. Irelandʼs Public Health (Alcohol) Bill 2015 is a model legislation for regulating the content of alcohol advertising. Section 13, subsection 2 provides that alcohol product advertising must include in the prescribed form warnings about the danger of alcohol consumption, alcohol consumption during pregnancy, direct link between alcohol and fatal cancers, and details of a website providing public health information about alcohol consumption. Section 13, subsection 7 contains a list of the other items that may be contained in an alcohol advertisement in addition to the prescribed warnings, such as (not exhaustive as list contains 13 items) an image of the method of production, the price, brand name, objective description of flavour, alcoholic strength or calories. Subsection 9 prohibits advertising any service, or any product (other than an alcohol product), in an advertisement that includes an image of an alcohol product or a reference to alcohol use. The Irish Bill also prohibits advertising in certain locations such as open spaces maintained by a local authority, on a train, at bus or train stations, at schools, playgrounds or within a 200 metre perimeter of such grounds, to name a few (section 14). Restrictions also apply to advertising during events such as sports events, including at the arena (section 15). Sponsorship is prohibited for events where the majority participants are children or competitors are children or an event that involves driving or racing (section 16) Where a licence holder of an event exists that relates to events in section 16, the licence holder may not advertise or promote an alcohol product or brand (section 16, subsection 2). Other worthy regulations include:
- prohibition of children’s clothing, either manufactured in or outside Ireland, bearing the name or trade mark of an alcohol product (section 17);
- broadcast watershed of no television alcohol advertisements between the hours of 03.00 and 21.00, no radio alcohol advertisements on weekdays between midnight and 10.00 or 15.00 to midnight (section 20);
- No alcohol advertisements in cinemas for films classified for viewers below 18 years of age
- Clear regulations about the separation and visibility of alcohol products and advertisements for alcohol products in specified licensed premises (section 22).
12. In Sweden advertisements of beverages of 15% volume of alcohol or higher are prohibited39.
VII. Pricing policies
13. In May 2018, Scotland became the first jurisdiction in the world to introduce legislation on a minimum unit pricing (MUP) for alcohol following a successful ruling from the UK Supreme Court in response to a challenge by the Scotch Whisky Association. The Alcohol (Minimum Pricing) (Scotland) Act 2012 provides that from 1 May 2018 the MUP of alcohol will be 50 pence per unit and anyone with a licence to sell alcohol is prohibited from selling it cheaper than this. The MUP for alcohol applies to retailers that sell alcohol for drinking off premises (like supermarkets or newsagents) and places that sell alcohol for drinking on premises (like pubs, bars and restaurants). The aim of MUP is to ensure that alcohol products are not sold too cheaply such that it encourages over consumption, generally cheap alcohol products appeal to children and heavy drinkers. Prior to the enactment of the Scottish MUP it was possible to exceed the recently lowered risk guidelines for alcohol (14 units per week) for around £2.50. Evidently, an unacceptable position for Scottish legislators.
14. Irelandʼs Public Health (Alcohol) Bill 2015 also establishes a MUP of alcohol products, set at 10 cents per gram of alcohol and establishes a formula for the MUP of an alcohol product (section 11). The minimum price must also be enforced where alcohol products are sold in a two pack or in a meal deal.
15. In Alberta, Canada a private liquor retail model is used, whereby liquor retailing, warehousing and distributions are all privatised but the Alberta Gaming and Liquor Commission is the Government of Alberta´s crown commercial enterprise that imports liquor into Alberta, and sells imported liquor to licensees with a markup. The liquor markup goes to the General Revenue Fund to support programmes and initiatives for the population40. The markup is applied as a flat rate per litre depending on the product type and alcohol content (see Markup Rate Schedule).
VIII. Reducing the negative consequences of drinking and alcohol intoxication
16. The Alberta Gaming and Liquor Commission (AGLC) is the Government of Alberta’s Crown commercial enterprise and agency that oversees the gaming, liquor and cannabis industries in Alberta, Canada. The AGLC establishes the rules and regulations in Alberta for liquor sales, distribution and consumption. Its goal is to encourage a shift in Albertan drinking culture to one of moderation and reduce harms related to alcohol consumption by:
- Mandatory training for those that sell or serve liquor and those that provide security, are managers or supervisors in a licensed premise41. The training is designed to:
- Help licensees and staff fulfil social responsibilities;
- Help achieve a balance between creating a safe and enjoyable atmosphere for patrons and reducing liability;
- Help liquor industry workers understand and apply relevant liquor legislation;
- Promote the responsible sale of liquor in service and retail environments; and
- Provide the knowledge to identify signs of intoxication and the techniques to effectively refuse or discontinue service42.
- Licensee staff must provide proof of mandatory training at the request of an AGLC Inspector. Failure to present proof may result in disciplinary action43;
- Developing educational material44;
- Updating the DrinkSense website which contains information about health and where top get 24 hour help, pregnancy and alcohol, which bars are responsible servers, health tips and the low-risk drinking guidelines45; and
- Games and competitions that reward responsible service by licensees (Best Bar None) or drinkers (SADD Alberta)46.
- Regulating “happy hours” by establishing a minimum drink prices for liquor consumed on-premises and a limit on the number of drinks a patron can order or possess after 01.0047.
IX. Reducing the public health impact of illicit alcohol and informally produced alcohol
17. Tanzania regulates the sale of “local liquor” (WHO reference would be informally produced alcohol) through the Intoxicating Liquors Act 1968, which uses a licensing scheme for the production of local liquor. Private liquor for private consumption by the owner and his friends requires a licence and prohibits sale (section 97). A class A local liquor licence enables the holder to sell local liquor on and off premises but limits the sale of off premise liquor consumption to 16 gallons (~60 litres) (section 27). The opening hours of such local liquor licences are regulated and for class A licences the sale of local liquor for on premise consumption are:
- in urban areas, from 12:00 to 14:00 and 17:00 to midnight Mondays to Fridays. Saturdays to Sundays the hours are 11:00 to 14:00 and 18:00 to midnight.
- in rural areas, from 16:00 to 23:00 Mondays to Saturdays. On Sundays the hours are 14:00 to 23:0048.
The act also regulates local liquor markets through a licensing scheme (section 35). All licensees (including those of local liquor) are prohibited to sell to persons under 16 and to employ persons to sell or control liquor (sections 68 and 69). Licensees are guilty of an offence if they serve liquor to a drunken person or permits drunkenness or any disorderly conduct on the premises (section 71). Section 76 prohibits licensees from selling to police officers on duty and to “suffer” any police officer on the premises unless for the purposes of keeping or restoring order while on duty. Tapping of palm trees for palm wine is also regulated (section 80). Duly authorised officers have powers to enter and inspect licensed premises, detain property (requires a warrant), to close the premise in case of disorder.
X. Monitoring and surveillance
19. The WHO´s tenth target area in the global strategy to reduce the harmful use of alcohol (resolution WHA63.13) concerns:
- establishing effective frameworks for monitoring and surveillance activities including periodic national surveys on alcohol consumption and alcohol-related harm and a plan for exchange and dissemination of information;
- establishing or designating an institution or other organisational entity responsible for collecting, collating, analysing and disseminating available data, including publishing national reports;
- defining and tracking a common set of indicators of harmful use of alcohol and of policy responses and interventions to prevent and reduce such use;
- creating a repository of data at the country level based on internationally agreed indicators and reporting data in the agreed format to WHO and other relevant international organisations;
- developing evaluation mechanisms with the collected data in order to determine the impact of policy measures, interventions and programmes put in place to reduce the harmful use of alcohol.
20. Model jurisdictions for monitoring and surveillance include:
- Ireland: Department of Health.
- Sweden: The Public Health Agency of Sweden (Folkhälsomyndigheten) and Systembolaget Alcohol Research Council.
- Canada: Best Practices Portal on alcohol.
- Australia: Federal Department of Health and Public Health Association Australia.
D. What we missed
1. In many ways much of the regulation of tobacco we wrote about in Tobacco control regulations is relevant to the regulation of alcohol consumption as well, the study published in the Lancet states:
The most effective and cost-effective means to reduce alcohol-related harms are to reduce affordability through taxation or price regulation, including setting a minimum price per unit, closely followed by marketing regulation, and restrictions on the physical availability of alcohol. These approaches should come as no surprise because these are also the most effective measures for curbing tobacco-related harms51.
And yet measures to regulate labelling, advertising and availability still remain in their infancy in many of the jurisdictions researched. On labelling, the Handbook: How to regulate? contains many examples of labelling regulations and also the aforementioned howtoregulate article on Tobacco control regulations at part II, section E. The 2014 paper from the EU concerning the “State of play in the use of alcoholic beverage labels to inform consumers about health aspects” is also a useful guide on labelling regulations and their effectiveness. A missed opportunity to regulate availability of alcohol in petrol stations was absent in many jurisdictions researched52, particularly noting the problem of drinking alcohol and then driving. In terms of advertising regulations for alcohol products or brands, few jurisdictions prohibited alcohol advertising outright, and while many did have some form of regulation, much of it focused on self-regulatory systems. Jurisdictions that had identified alcohol consumption as a public health problem, probably need to move from a self-regulatory alcohol advertising model to a legislative based model, such as Ireland is doing.
2. As noted by the Lancet above, many of the tobacco-related measures are likely to be effective in curbing alcohol-related harms, and much of the tobacco regulation are enforced through legislation. Most of the alcohol regulation researched in this article are based on policies, with limited mechanisms for enforcement and sanction. Jurisdictions may need to reflect on the necessity for legislative empowerments for alcohol regulation and enforcement. Please see the Handbook: How to regulate? about how to create the necessary empowerments to enforce alcohol regulation and policy but also the two-part empowerments articles: Empowerments (Part I): typology and Empowerments (Part II): checklist. Specifically, jurisdictions could consider the following empowerments to better enforce alcohol regulation and policy:
- Sanctions and penalties, including: penalties for natural persons, financial sanctions for legal persons: direct sanctions and indirect sanctions like banning from receiving subsidies, public naming and shaming and withdrawing membership.
- Enforcement with the help of non-designated parties, including: establishing a complaints; alert or whistle-blowing portals or specific communication channels; and communicating with third parties to obtain further evidence and details.
- Enforcement via regional authorities, geographic entities or designated third parties, including: establishing minimum resource requirements for enforcement at the level of geographic entities or designated third parties; creating incentives for highly performing third parties, regional authorities or geographic entities; obliging to undertake certain enforcement activities (in some jurisdictions: to be specified); and obliging to inform about enforcement activities.
- Designation and supervision of public or private organisations entrusted to play a special role in the application of regulation, including: preselecting potential cooperating organisations in cases of high number of potential candidates; establishing selection criteria; selecting members of panels attributing subsidies, functions or other advantages; and taking discretionary decisions regarding the attribution of subsidies, functions or other advantages (which can exclude full legal control).
- Investigations and data, see full list at Empowerments (Part II): checklist as all are applicable in alcohol enforcement.
- Enforcement in general, see full list at Empowerments (Part II): checklist as all are applicable.
- Information, see full list at Empowerments (Part II): checklist as all are applicable in alcohol enforcement.
- Cooperation, including exchange of data with other jurisdictions or with international organisations, see full list at Empowerments (Part II): checklist as all are applicable in alcohol enforcement.
3. One of the WHO measures in the global alcohol strategy concerned reducing or stopping subsidies to economic operators in the area of alcohol but some thought also needs to be put into bilateral and multilateral trade deals that include removal of trade barriers for alcohol brands. It seems odd to enforce a strict alcohol consumption regime domestically, negotiate international trade deals advocating the liberalising of alcohol trade, particularly in developing countries and possibly then supporting development programmes for alcohol dependency.
4. The Organisation for Economic Development (OECD) report on Tackling Harmful Alcohol Use discusses the affect of social norms on alcohol consumption and while developing regulations to encourage social norms is complex, it cannot be under estimated the impact of revolutionary regulations, such as Irelandʼs stringent approach, to turn the regulatory landscape around. Often regulations that seek to introduce a stringent measure be it alcohol labelling with words warning of the link to cancer, outright prohibition of alcohol advertising and sponsorship or establishing a government monopoly on alcohol distribution, can be the stimulant for change of social norms around alcohol consumption. The OECD report also noted that harmful drinking is normally the result of an individual choice, but it has social consequence. Evidence of the magnitude of the risks associated with harmful alcohol use, and of the effectiveness of many regulatory options to address those harms, has never been so abundant and detailed as it is today53.
5. Below in Annex A it is listed all the suggested measures and interventions of the WHO global alcohol strategy.
This article was written by Valerie Thomas, on behalf of the Regulatory Institute, Brussels and Lisbon. Elvira Fernando provided research assistance on the Portuguese and Spanish speaking jurisdictions.
Leadership, awareness and commitment.
(a) developing or strengthening existing, comprehensive national and subnational strategies, plans of action and activities to reduce the harmful use of alcohol;
(b) establishing or appointing a main institution or agency , as appropriate, to be responsible for following up national policies, strategies and plans;
(c) coordinating alcohol strategies with work in other relevant sectors, including cooperation between different levels of governments, and with other relevant health-sector strategies and plans;
(d) ensuring broad access to information and effective education and public awareness programmes among all levels of society about the full range of alcohol-related harm experienced in the country and the need for, and existence of, effective preventive measures;
(e) raising awareness of harm to others and among vulnerable groups caused by drinking, avoiding stigmatisation and actively discouraging discrimination against affected groups and individuals.
Health services’ response.
(a) increasing capacity of health and social welfare systems to deliver prevention, treatment and care for alcohol-use and alcohol-induced disorders and co-morbid conditions, including support and treatment for affected families and support for mutual help or self-help activities and programmes;
(b) supporting initiatives for screening and brief interventions for hazardous and harmful drinking at primary health care and other settings; such initiatives should include early identification and management of harmful drinking among pregnant women and women of child-bearing age;
(c) improving capacity for prevention of, identification of, and interventions for individuals and families living with fetal alcohol syndrome and a spectrum of associated disorders;
(d) development and effective coordination of integrated and/or linked prevention, treatment and care strategies and services for alcohol-use disorders and co-morbid conditions, including drug-use disorders, depression, suicides, HIV/AIDS and tuberculosis;
(e) securing universal access to health including through enhancing availability, accessibility and affordability of treatment services for groups of low socioeconomic status;
(f) establishing and maintaining a system of registration and monitoring of alcohol-attributable morbidity and mortality, with regular reporting mechanisms;
(g) provision of culturally sensitive health and social services as appropriate.
(a) supporting rapid assessments in order to identify gaps and priority areas for interventions at the community level;
(b) facilitating increased recognition of alcohol-related harm at the local level and promoting appropriate effective and cost-effective responses to the local determinants of harmful use of alcohol and related problems;
(c) strengthening capacity of local authorities to encourage and coordinate concerted community action by supporting and promoting the development of municipal policies to reduce harmful use of alcohol, as well as their capacity to enhance partnerships and networks of community institutions and nongovernmental organisations;
(d) providing information about effective community-based interventions, and building capacity at community level for their implementation;
(e) mobilising communities to prevent the selling of alcohol to, and consumption of alcohol by, under-age drinkers, and to develop and support alcohol-free environments, especially for youth and other at-risk groups;
(f) providing community care and support for affected individuals and their families;
(g) developing or supporting community programmes and policies for subpopulations at particular risk, such as young people, unemployed persons and indigenous populations, specific issues like the production and distribution of illicit or informal-alcohol beverages and events at community level such as sporting events and town festivals.
Drink-driving policies and counter-measures.
(a) introducing and enforcing an upper limit for blood alcohol concentration, with a reduced limit for professional drivers and young or novice drivers;
(b) promoting sobriety check points and random breath-testing;
(c) administrative suspension of driving licences; (d) graduated licensing for novice drivers with zero-tolerance for drink-driving;
(e) using an ignition interlock, in specifi c contexts where affordable, to reduce drinkdriving incidents;
(f) mandatory driver -education, counselling and, as appropriate, treatment programmes;
(g) encouraging provision of alternative transportation, including public transport until after the closing time for drinking places;
(h) conducting public awareness and information campaigns in support of policy and in order to increase the general deterrence effect;
(i) running carefully planned, high-intensity, well-executed mass media campaigns targeted at specific situations, such as holiday seasons, or audiences such as young people.
Availability of alcohol.
(a) establishing, operating and enforcing an appropriate system to regulate production, wholesaling and serving of alcoholic beverages that places reasonable limitations on the distribution of alcohol and the operation of alcohol outlets in accordance with cultural norms, by the following possible measures:
(i) introducing, where appropriate, a licensing system on retail sales, or public health- oriented government monopolies;
(ii) regulating the number and location of on-premise and off-premise alcohol outlets;
(iii) regulating days and hours of retail sales;
(iv) regulating modes of retail sales of alcohol;
(v) regulating retail sales in certain places or during special events;
(b) establishing an appropriate minimum age for purchase or consumption of alcoholic beverages and other policies in order to raise barriers against sales to, and consumption of alcoholic beverages by, adolescents;
(c) adopting policies to prevent sales to intoxicated persons and those below the legal age and considering the introduction of mechanisms for placing liability on sellers and servers in accordance with national legislations;
(d) setting policies regarding drinking in public places or at official public agencies’ activities and functions;
(e) adopting policies to reduce and eliminate availability of illicit production, sale and distribution of alcoholic beverages as well as to regulate or control informal alcohol.
Marketing of alcoholic beverages.
(a) setting up regulatory or co-regulatory frameworks, preferably with a legislative basis, and supported when appropriate by self-regulatory measures, for alcohol marketing by:
(i) regulating the content and the volume of marketing;
(ii) regulating direct or indirect marketing in certain or all media;
(iii) regulating sponsorship activities that promote alcoholic beverages;
(iv) restricting or banning promotions in connection with activities targeting young people;
(v) regulating new forms of alcohol marketing techniques, for instance social media;
(b) development by public agencies or independent bodies of effective systems of surveillance of marketing of alcohol products;
(c) setting up effective administrative and deterrence systems for infringements on marketing restrictions.
(a) establishing a system for specific domestic taxation on alcohol accompanied by an effective enforcement system, which may take into account, as appropriate, the alcoholic content of the beverage;
(b) regularly reviewing prices in relation to level of inflation and income;
(c) banning or restricting the use of direct and indirect price promotions, discount sales, sales below cost and fl at rates for unlimited drinking or other types of volume sales;
(d) establishing minimum prices for alcohol where applicable;
(e) providing price incentives for non-alcoholic beverages;
(f) reducing or stopping subsidies to economic operators in the area of alcohol.
Reducing the negative consequences of drinking and alcohol intoxication.
(a) regulating the drinking context in order to minimize violence and disruptive behaviour, including serving alcohol in plastic containers or shatter -proof glass and management of alcohol-related issues at large-scale public events;
(b) enforcing laws against serving to intoxication and legal liability for consequences of harm resulting from intoxication caused by the serving of alcohol;
(c) enacting management policies relating to responsible serving of beverage on premises and training staff in relevant sectors in how better to prevent, identify and manage intoxicated and aggressive drinkers;
(d) reducing the alcoholic strength inside different beverage categories;
(e) providing necessary care or shelter for severely intoxicated people;
(f) providing consumer information about, and labelling alcoholic beverages to indicate, the harm related to alcohol.
Reducing the public health impact of illicit alcohol and informally produced alcohol.
(a) good quality control with regard to production and distribution of alcoholic beverages;
(b) regulating sales of informally produced alcohol and bringing it into the taxation system;
(c) an efficient control and enforcement system, including tax stamps;
(d) developing or strengthening tracking and tracing systems for illicit alcohol;
(e) ensuring necessary cooperation and exchange of relevant information on combating illicit alcohol among authorities at national and international levels;
(f) issuing relevant public warnings about contaminants and other health threats from informal or illicit alcohol.
Monitoring and surveillance.
(a) establishing effective frameworks for monitoring and surveillance activities including periodic national surveys on alcohol consumption and alcohol-related harm and a plan for exchange and dissemination of information;
(b) establishing or designating an institution or other organisational entity responsible for collecting, collating, analysing and disseminating available data, including publishing national reports;
(c) defining and tracking a common set of indicators of harmful use of alcohol and of policy responses and interventions to prevent and reduce such use;
(d) creating a repository of data at the country level based on internationally agreed indicators and reporting data in the agreed format to WHO and other relevant international organisations;
(e) developing evaluation mechanisms with the collected data in order to determine the impact of policy measures, interventions and programmes put in place to reduce the harmful use of alcohol.
1 GBD 2016 Alcohol Collaborator, “Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016”, Lancet 2018, published online Aug 23. http://dx.doi.org/10.1016/S0140-6736(18)31310-2.
3 WHO, Global strategy to reduce the harmful use of alcohol, May 2010, p. 8. http://apps.who.int/iris/bitstream/handle/10665/44395/9789241599931_eng.pdf?sequence=1.
4 Alcohol in the European Union – Consumption, harm and policy approaches, WHO Regional Office for Europe and the European Union, 2012.
5 Eurocare European Alcohol Policy Alliance, Euroecare suggestions for changes to the EU Alcohol anf Health Forum, 21 March 2014, p. 3. https://www.eurocare.org/media/GENERAL/docs/reports/eurocaresuggestionsforchangeseahf21stmarch2014.pdf.
6 Council Conclusions on an EU strategy on the reduction of alcohol-related harm (2015/C 418/03) 16 Dec 2015 para. 21. https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A52015XG1216%2801%29.
7 Council Conclusions on cross-border aspects in alcohol policy – tackling the harmful use of alcohol (2017/C 441/04) 22 Dec 2017 para. 33. https://eur-lex.europa.eu/legal-content/EN/TXT/?qid=1537264949877&uri=CELEX:52017XG1222(01).
8 European Commission Press Release, Audiovisual media services: breakthrough in EU negotiations for modern and fairer rules, 26 April 2018. http://europa.eu/rapid/press-release_IP-18-3567_en.htm.
9 International Chamber of Commerc About Us https://iccwbo.org/about-us/.
10 Article D5 of the ICC Advertising and Marketing Code, p. 33. https://cdn.iccwbo.org/content/uploads/sites/3/2011/08/ICC-Consolidated-Code-of-Advertising-and-Marketing-2011-English.pdf.
11 ICC News, ICC Marketing Code reaffirmed as global standard at APEC Conference, 24 August 2017, https://iccwbo.org/media-wall/news-speeches/icc-marketing-code-reaffirmed-global-standard-apec-conference/.
12 WFA About Us page https://www.wfanet.org/about/who-we-are/.
13 The RMP and how it works https://the-rmp.eu/how-it-works/.
14 IARD commitments http://www.iard.org/producers-commitments/.
15 See stakeholder contributions by public health organisations on the Technical Regulation Information System (TRIS) 2018/22/IRL (Ireland) Public Health (Alcohol) Bill 2015 )in so far as it related to the 3 additional specification to labelling, advertising and broadcast watershed). http://ec.europa.eu/growth/tools-databases/tris/en/search/?trisaction=search.detail&year=2018&num=22.
17 Explanatory and Financial Memorandum to the Public Health (Alcohol) Bill 2015 p. 1. https://data.oireachtas.ie/ie/oireachtas/bill/2015/120/eng/memo/b12015s-memo.pdf.
19 Alcohol Guidelines Review – Report from the Guidelines Development Group to the UK Chief Medical Officers, pp. 30-32. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/545739/GDG_report-Jan2016.pdf.
20 UK Alcohol Support page https://www.nhs.uk/live-well/alcohol-support/.
21 Public health information in Sweden, http://www.fhi.se/om-oss/Overgripande-mal-for-folkhalsa/.
22 Ibid. The teenager – the wisdom book for teenage parents http://www.fhi.se/Aktuellt/Nyheter/Tonarsparloren—klokbok-om-alkohol-for-tonarsforaldrar/.
23 Ibid. Hazardous use project http://www.fhi.se/riskbruksprojektet
24 WHO, Global Health Observatory: Blood alcohol concentration limit for drivers, http://www.who.int/gho/road_safety/legislation/situation_trends_alcohol/en/.
25 Croatia Road Traffic Safety Act NN 67/2008 https://narodne-novine.nn.hr/clanci/sluzbeni/2008_06_67_2224.html. Croatian website explaining the legal regulation that prohibits driving while alcohol is in the body http://stari.mup.hr/main.aspx?id=26496.
26 Czeck Republic Law no. 411/2005. http://www.zakony.cz/zakony/2005/401/zakon-411-2005-Sb-zakon-kterym-se-meni-zakon-c-361-2000-sb-o-provozu-na-pozemnich-komunikacich-a-o-zmenach-nektery-SB2005411.
27 Slovakia Law no. 315/1996 § 4 Povinnosti vodiča (3). https://www.noveaspi.sk/products/lawText/1/44639/1/2.
28 See list of Standard BAC Limits of the world by Rocakova, P and Eksler, Evaluation of the 0.0 BAC limit for drivers of road vehicles in Czech Republic, Slovakia, Hungary and Croatia, 2008, pp. 54-55. https://www.vtt.fi/files/sites/pepper/pepper_w41_wp4.pdf.
29 Rocakova, P and Eksler, Evaluation of the 0.0 BAC limit for drivers of road vehicles in Czech Republic, Slovakia, Hungary and Croatia, 2008, p. 20. https://www.vtt.fi/files/sites/pepper/pepper_w41_wp4.pdf.
30 The alcohol policy role of Systembolaget, https://www.omsystembolaget.se/english/our-way-of-working/our-alcohol-policy-role/.
31 Stockwell, T. et. al., What are the public health and safety benefits of the Swedish government alcohol monopoly, April 2017,Centre for Addictions Research of British columbia, University of Victoria, Canada, p. 10. https://www.uvic.ca/research/centres/cisur/assets/docs/Systembolaget-public-health-safety-benefits-April_2017.pdf.
32 Systembolaget Our Way of Working https://www.omsystembolaget.se/english/our-way-of-working/our-way-of-working/.
33 “Longitudinal neuroimaging studies demonstrate that the adolescent brain continues to mature well into the 20s”, Johnson, S. B., Blum, R. W., & Giedd, J. N. (2009). Adolescent Maturity and the Brain: The Promise and Pitfalls of Neuroscience Research in Adolescent Health Policy. The Journal of Adolescent Health : Official Publication of the Society for Adolescent Medicine, 45(3), 216–221. http://doi.org/10.1016/j.jadohealth.2009.05.016.
34 ProCon Minimum Legal Drinking Age in 190 countries https://drinkingage.procon.org/view.resource.php?resourceID=004294.
35 Brazil Lei Nº 13.106, de 17 de Março de 2015 http://www.planalto.gov.br/ccivil_03/_ato2015-2018/2015/lei/L13106.htm.
37 Paraguay Ley Nº 1642 / PROHIBE LA VENTA DE BEBIDAS ALCOHÓLICAS A MENORES DE EDAD Y PROHIBE SU CONSUMO EN LA VÍA PUBLICA http://www.bacn.gov.py/leyes-paraguayas/5076/prohibe-la-venta-de-bebidas-alcoholicas-a-menores-de-edad-y-prohibe-su-consumo-en-la-via-publica.
39 Sweden Alkohollag (2010: 1622) chapter 7, https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/alkohollag-20101622_sfs-2010-1622.
40 AGLC About liquor in Alberta https://aglc.ca/liquor/about-liquor-alberta.
41 AGLC Responsible liquor service https://aglc.ca/liquor/responsible-liquor-service.
42 Alberta ProServe Liquor Staff Training https://proserve.aglc.ca/Index.aspx?tabid=1.
44 AGLC Responsible liquor service https://aglc.ca/liquor/responsible-liquor-service.
45 DrinkSence http://www.drinksenseab.ca/.
46 AGLC Responsible liquor service https://aglc.ca/liquor/responsible-liquor-service.
47 AGLC Policy Update https://aglc.ca/news/responsible-liquor-service-focus-happy-hours-policy-change.
48 Section 33 of Tanzaniaʼs Intoxicating Liquors Act 28-1968, p. 15. http://www.tanzania.go.tz/egov_uploads/documents/The_Intoxiacating_Liquors_Act,_28-1968_en.pdf.
49 Alberta Gaming, Liquor and Cannabis Regulations AR 143/96, section 88. http://www.qp.alberta.ca/1266.cfm?page=1996_143.cfm&leg_type=Regs&isbncln=0779735234.
50 Alberta Gaming, Liquor and Cannabis Act 2000, section 86(2). http://www.qp.alberta.ca/1266.cfm?page=G01.cfm&leg_type=Acts&isbncln=0779721373.
51 Burton, R. and Sheron, N. “No level of alcoholic consumption improves health”, Lancet 2018, published online Aug 23, 2018 https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)31571-X.pdf.
52 For instance, only about half of OECD countries restrict sales of alcohol in petrol stations. P6 http://www.oecd.org/els/health-systems/Policy-Brief-Tackling-harmful-alcohol-use.pdf