The never-ending story of alcohol control policy

Lithuania during the past five years has done some very successful developments in alcohol control policy. Cheap and effective, evidence-based and favoured by the majority of the population.

Since 2016 significantly stricter alcohol control policy embracing all WHO “Best Buys” was implemented: a ban on alcohol sales in gasoline stations (since 2016), multiple increases in excise tax (2014-2017, 2019-2020), a full ban on alcohol advertising, legal buying age increased to 20 years and retail hours shortened (since 2018). And all was going well in the former Grand Duchy of Lithuania. Legal alcohol consumption per capita has dropped by nearly 3 litres – from 14,0 in 2015 to 11,2 in 2018.

Lithuanian society embraced changes in alcohol policy without much fuss, and population surveys registered an uptick in perceived positive changes in life due to reduced alcohol consumption and increasing support for the restrictive policy.

Many positive consequences happened as well: a significant reduction in alcohol-attributable mortality, fewer suicides, deadly traffic accidents, drownings, fires and workplace accidents, less violence, and fewer social problems. Lithuania even gained life expectancy, most significant for men, an increase of 2.4 years between 2015 to 2019 – a huge success. The money was flowing in: excise tax revenues continued to grow, while alcohol sales were going down. Lithuanian society embraced those changes without much fuss, and population surveys registered an uptick in perceived positive changes in life due to reduced alcohol consumption and increasing support for restrictive policy (especially legal age and advertising ban). Public health advocates rejoiced, confident that we have nailed it and more countries will join the club practising Nordic style alcohol policies. We were the evidence and churning out scientific publications confirming the very real public health benefits.

And then it stopped. The year 2019 came when legal consumption stalled at 11.1 litres. The Year of COVID-19 came and went with the consumption numbers curving upwards to 11.4 litres and growing indicators of alcohol-related harm. What happened? 

There are several factors that could have impacted the 2020 consumption level in Lithuania. The pandemic situation has severely disrupted cross-border shopping through travel restrictions. So, alcohol that otherwise would have been purchased abroad (primarily in Poland and Latvia), was bought and consumed locally. The increase of 0.3 litres corresponds well with the previous assessments by the Lithuanian statistics department and research by the Health Research Institute of the Lithuanian Health Sciences University regarding unrecorded alcohol consumption. Nonetheless, it is significantly lower than Norwegian estimates for the same year. But if the current increase only matches earlier invisible cross-border effects, we would not expect deterioration in public health indicators.

Alcohol-related mortality in 2020 increased by nearly 12% compared to 2019.

However, alcohol-related mortality in 2020 increased by nearly 12% compared to 2019. The pandemic year should be assessed with caution, but indicators suggest a net increase in population alcohol consumption. There could be several contextual reasons for that. Migration trends in 2019-2020 were atypical – both the return migration of citizens and foreign immigration have increased. A majority of the immigrants are men, who drink significantly more than women. There are also generic mechanisms: alcohol affordability and marketing pressure have increased during these past couple of years. Affordability increased due to state-mandated increase in minimum salary, pandemic economic support, and a general upward trend for population income, while price increase for alcoholic drinks has been flat.

There is also a massive campaign to circumvent existing marketing restrictions by flooding the perimeter with advertising for non-alcoholic beer and wine. During the first eight months of the ban in 2018, non-alcoholic product advertising increased 38 times according to Kantar TNS advertising monitoring department. This resulted in increased record sales of these products and may have slowed down the reduction in alcohol use. The marketing industry is experimenting with social media marketing and consumer-generated content, but their presence is strongest in all mainstream news portals, TV and city billboards bombarding all users with non-alcoholic beer ads. Pandemic also resulted in reduced access to addiction treatment services, AA groups, counselling, and support services – another potential contributing factor to alcohol-related harm.

The alcohol control policy maintenance cannot stop.

All of the above is a stark reminder that the alcohol control policy maintenance cannot stop. If the invisible elephant in the room – international alcohol and allied industries with a profit margin to defend – does not stop. In Lithuania industry influence continues to be very strong: funding dubious research, buying media focus and the friendly ear of politicians. The newly elected Parliament members in autumn of 2020 have launched a campaign to review and revoke some of the current alcohol policies, which they claim ‘do not work’. Now they focus on reducing the legal age to 18, liberalizing marketing and alcohol sales on Sundays.

If politicians and industry tacitly agree to do nothing, do little or just ignore the proper implementation of control policies – alcohol harm will soar, primarily for the vulnerable groups in society.

They might not need to bother. For those measures to continue producing public health benefits, they must be thoroughly implemented and strengthened. The current Government announced plans for further excise tax increases, but these increases need to stay ahead of the population income growth curve. Only then do they maintain their effectiveness. So, if politicians and industry tacitly agree to do nothing, do little or just ignore the proper implementation of control policies – alcohol harm will soar, primarily for the vulnerable groups in society.

Lithuania can boast many positive things on this part of a policy journey: the country lost the notorious first place for consuming most alcohol per capita; our young are drinking less, like their European counterparts; the advocacy community has learned a lot, strengthened the pool of scientific evidence on specific health benefits of restrictive alcohol policies. The Lithuanian NGOs keep vigilant, hopeful and continue working in defending and strengthening evidence-based control policy.

There is a clear and present danger that modern, yet opaque political processes will pick business interests over population health and public finance.

Yet the sobering lesson is that all that evidence, enthusiasm and effort of the public health NGOs and civil society stand to fail, once political will withers and fades. There is a clear and present danger that modern, yet opaque political processes will pick business interests over population health and public finance.  And not only in Lithuania. Despite the stated commitments to new international policy instruments such as the Cancer Plan – Europe is still the region with the highest alcohol consumption and related harm. Progress on reducing alcohol consumption has been stalling in older EU member states, and the most effective taxation measures have not been favoured. The EU continues to subsidize the alcohol and tobacco industries and has just recently cut off public health NGOs from operational funding. Lithuanian example reflects the fact that even countries with the most harm from alcohol have difficulty maintaining hard-won successes, without favourable international infrastructure. There is an urgent need to target corruption in political decision making, which are frequently leaving civil society out in the cold.

Nijole Gostautaite Midttun
Lithuanian University of Health Sciences
August 2021

Bio

Nijole Gostautaite Midttun is the president of the Lithuanian Tobacco and Alcohol Control Coalition and director of the non-profit “Mental Health Initiative”. She has a background in medicine, psychiatry and health psychology, and has worked in a variety of mental health services in Lithuania and Norway. For over a decade she has been actively involved in mental health advocacy, with a strong focus on alcohol and tobacco control policy. She is a board member in European Centre for Monitoring Alcohol Marketing (EUCAM), Nordic alcohol and drug policy network (Nordan) and Eurocare (European Alcohol Policy Alliance). She has 15 years of experience in educating health and social work professionals. Some of the recent projects involve WHO Quality rights implementation in residential psychosocial institutions, development of the brief smoking cessation intervention for schools, contributing to the development of the National substance control program, implementing of a training program for addiction counsellor services in Lithuania, and developing university mental health and counselling programs. Her research interests are in the field of mental health, alcohol control, subjective health, and quality of life.