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Public Health and the Global Governance of
Alcohol
Paula O’BRIEN*
I
NTRODUCTION TO THE SPECIAL ISSUE ON PUBLIC HEALTH AND THE GLOBAL
GOVERNANCE OF ALCOHOL
In many cultures, alcohol is regarded as a food that is associated with festivities, leisure,
coming of age and success.1Alcohol industry marketing creates and reinforces these
cultural understandings, downplaying facts about the harms associated with alcohol
consumption.2Alcohol is also a drug, and its harm profile distinguishes it from
regular foodstuffs or other consumer items. Alcohol use is causally connected to
more than 200 diseases, conditions and injuries,3with at least 25 other diseases and
conditions entirely attributable to alcohol.4These harms include non-communicable
diseases (such as cancer), mental health problems (including alcohol dependence),
injuries from violence and accidents, and disabilities arising from foetal alcohol
spectrum disorders.5The burden of disease associated with alcohol use is
“unacceptably high”, amounting to 3 million deaths (5.3% of all deaths) and 132.6
million disability-adjusted life years (DALYs) (5.1% of all DALYs) worldwide in
2016.6The impacts of alcohol use also extend beyond health, and include social and
economic detriments.
Preventing harms from alcohol requires intervention at multiple levels –in
communities and organisations, and by governments acting at the national, regional
and global level. The articles in this symposium issue of the European Journal of
*Senior Lecturer and Director of the Health Law and Ethics Network, Melbourne Law School, University of
Melbourne, Australia; email: obrienpl@unimelb.edu.au; ORCID 0000-0002-6879-0489. I appreciate the support for
the symposium provided by the European Journal of Risk Regulation, and its editor, Professor Alberto Alemanno,
and managing editor, Cliff Wirajendi.
European Journal of Risk Regulation, 12 (2021), pp. 415–418
© The Author(s), 2021. Published by Cambridge University Press
doi:10.1017/err.2020.107
1K Mäkela, “The Uses of Alcohol and Their Cultural Regulation”(2016) 26 Acta Sociologica 21, 24.
2M Petticrew et al, “How Alcohol Industry Organisations Mislead the Public about Alcohol and Cancer”(2018) 37
Drug and Alcohol Review 293.
3J Rehm and KD Shield, “Global Alcohol-Attributable Deaths from Cancer, Liver Cirrhosis, and Injury in 2010”
(2013) 35 Alcohol Research: Current Reviews 175.
4KD Shield, C Parry and J Rehm, “Chronic Diseases and Conditions Related to Alcohol Use”(2014) 35 Alcohol
Research: Current Reviews 155.
5TF Babor et al, Alcohol: No Ordinary Commodity: Researchand Public Policy (2nd edn, Oxford, OUP 2010) 15–18.
6World Health Organization (WHO), “Working Document for Development of an Action Plan to Strengthen
Implementation of the Global Strategy to Reduce the Harmful Use of Alcohol”(2020) 4 <www.who.int/docs/default-
source/alcohol/working-document-for-action-plan-web-consultation-november-2020-final.pdf?sfvrsn=684393b8_0>
(last accessed 25 November 2020).
https://doi.org/10.1017/err.2020.107 Published online by Cambridge University Press
Risk Regulation focus on alcohol as a global health problem, exploring how alcohol is
governed at the global level, and how it could and should be governed to minimise and
prevent harm. This conceptualisation of alcohol is warranted, not just because of the
common experience of countries with alcohol consumption and harm, but because of
the increasingly global nature of the alcohol industry and its products. The production
and marketing of alcohol is now concentrated in the hands of a small number of
transnational corporations.7There is a strong global trade in alcohol. There is also
significant cross-border marketing of alcohol, particularly through social media.8The
treatment of alcohol in trade and investment agreements is impacting the capacity of
national governments to intervene and regulate alcohol in a manner protective of the
public’s health. At the same time, there is an emergent desire to explore how the
instruments of global health governance, including those available through the World
Health Organization (WHO) and the Codex Alimentarius Commission (Codex),
might be used to advance the public health project of reducing harms from alcohol. A
push for a treaty on alcohol –a Framework Convention on Alcohol Control (FCAC)
inspired by the success of the Framework Convention on Tobacco Control (FCTC) –
has not yet been successful. But in early 2020, the Executive Board of the WHO did
commit to the development of an action plan to improve the implementation of the
“Global strategy to reduce the harmful use of alcohol”(Global Strategy).9
The symposium opens with an article by Jürgen Rehm, Sally Casswell, Jakob
Manthey, Robin Room and Kevin Shield analysing how levels of alcohol use have
been used as an indicator of progress in several global instruments covering alcohol,
including the “Global Strategy”,the“Global Action Plan for the Prevention and
Control of NCDs 2013–2020”10 and the “Sustainable Development Goals”.11 Yet
even with the proliferation of these global commitments, the article finds that the
targets for decreased alcohol consumption and harm have not been met. This
conclusion directs attention to the key questions explored in the other articles in the
symposium: How adequate is the current global health governance of alcohol? What
reforms to the global governance of alcohol are needed, now and into the future, to
achieve the public health goal of preventing harm from alcohol consumption?
In the article by Robin Room, the history of alcohol’s handling by international
institutions and its limited inclusion in international instruments reveals “good
intentions, but little action”. Alcohol is not covered by the international drug
conventions. Institutions, such as the International Labour Organization and the
World Bank, have had only “sporadic”interest in alcohol. Room posits that only the
7See D Jernigan and CS Ross, “The Alcohol Marketing Landscape: Alcohol Industry Size, Structure, Strategies, and
Public Health Responses”(2020) s19 Journal of Studies on Alcohol and Drugs 13, 14–15.
8R Room and P O’Brien, “Alcohol Marketing and Social Media: A Challenge for Public Health Control”(2020)
Drug and Alcohol Review <doi.org/10.1111/dar.13160>(last accessed 25 November 2020).
9WHO Executive Board, “Accelerating Action to Reduce the Harmful Use of Alcohol”(7 February 2020)
EB146(14); WHO, “Global strategy to reduce the harmful use of alcohol”(31 May 2010) <www.who.int/teams/
mental-health-and-substance-use/alcohol-drugs-and-addictive-behaviours/alcohol/global-alcohol-strategy>(last
accessed 3 December 2020).
10 WHO, “Global Action Plan for the Prevention and Control of NCDs 2013–2020”(31 May 2013) <www.who.int/
publications/i/item/9789241506236>(last accessed 3 December 2020).
11 United Nations Department of Economic and Social Affairs, “Sustainable Development Goals”(2015) <sdgs.un.
org/goals>(last accessed 3 December 2020).
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WHO has had a constructive long-term agenda on alcohol. At the same time, the WHO’s
resources are stretched, governments are not fully supportive, industry has not been
excluded and the WHO’s mandate around health means that the many other non-
health impacts of alcohol are not fully addressed at the global level.
The article by Trish Hepworth, Sarah Ward and Lisa Schölin and the article by Clare
Slattery also explore how alcohol is treated by international institutions other than the
WHO. Hepworth, Ward and Schölin discuss the developments by Codex to fill a
“vacuum”around international labelling standards for alcohol products. Alcohol has
not been subject to Codex’s food labelling standards, nor has it been subject to the
labelling rules of the international drug conventions. The absence of a standard on
alcohol labelling has produced “a lack of consistency across jurisdictions”,buthas
also allowed international trade law arguments to be made against states seeking to
introduce progressive public health labelling measures. Hepworth, Ward and Schölin
advise that taking alcohol labelling outside the WHO and into Codex has the
potential for benefits in governance, but there are also risks if the involvement of
industry and recalcitrant governments results in a weak standard. In her article,
Slattery strikes a positive note and argues that “the human rights agenda can be used
to ensure accountability and mobilise action for alcohol control”. She details ways in
which human rights law instruments, mechanisms and processes have already been
used to advance alcohol control, but also argues that a human rights framing should
be brought more directly to bear in new global instruments around alcohol and public
health. She asserts that support for this approach is to be found in the successful use
of human rights in the tobacco control context and the FCTC.
The lessons to be drawn from the FCTC for alcohol are a common theme across a
number of papers in the symposium. The article by Paula O’Brien compares how the
Global Strategy and the FCTC have been used in discussions in the World Trade
Organization’s Committee on Technical Barriers to Trade (TBT Committee). It
concludes that the low utility of the Global Strategy in the TBT Committee, including
the fact that it has been deployed to oppose public health warnings on alcoholic
beverage labels, is explained by key differences between the Global Strategy and the
FCTC that are salient to future developments in the global governance of alcohol.
O’Brien concludes that the legal status of the instrument matters, that the instrument
must contain detailed guidance as to the use of evidence-based measures and that the
alcohol industry must be excluded from the negotiation and implementation of the
instrument.
The article by O’Brien is a segue to a set of papers about a treaty for alcohol. The article
by Suzanne Zhou maps the differences between binding and non-binding legal
instruments, drawing on experience from tobacco control and the FCTC. She sets out
the options for legal instruments negotiated under the auspices of the WHO and the
practical differences in these instruments. Although acknowledging the benefits of the
FCTC, she puts forward the argument that there is not necessarily a “bright line”
between binding and non-binding instruments, and that significant gains could be
made for alcohol control through a high quality non-binding instrument. There is
resonance between the article by Zhou and the article by Gian Luca Burci. Although
2021 Public Health and the Global Governance of Alcohol 417
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Burci considers that a FCAC would be “the most effective approach from a substantive
and institutional perspective in terms of a global regulatory instrument”, he does not think
such an instrument is feasible at the present time owing to political considerations and the
absence of “norm entrepreneurs”. He explores alternatives to a FCAC, including further
international “legalisation”in the new action plan presently being developed by the WHO
to strengthen the implementation of the Global Strategy. Such legalisation could serve to
improve alcohol control and public health, as well as to smooth the way for states to
commit to a treaty in the future.
The symposium concludes with an article by Robin Room and Jenny Cisneros
Örnberg, offering the first ever “concrete”proposal for drafting a FCAC, including a
text that could be used as a starting point for discussions. The draft text draws on the
FCTC and the international drug conventions as models for the content of a treaty on
alcohol that pursues public health goals. In explaining and justifying their draft
FCAC text, Room and Cisneros Örnberg sound a warning, which is common across
the articles in this symposium, about “building in protection for public health
interests from inappropriate commercial influence”.
Drafts of these articles were presented at the “Public Health and Global Governance of
Alcohol”conference held in Melbourne, Australia from 30 September to 3 October
2019.12 The conference was held under the auspices of the Kettil Bruun Society for
Social and Epidemiological Research on Alcohol, and hosted by the Centre for
Alcohol Policy Research at La Trobe University and the Melbourne Law School at
the University of Melbourne. The conference was generously supported by the
Foundation for Alcohol Research and Education and the Victorian Health Promotion
Foundation.
12 University of Melbourne, “Public Health and Global Governance of Alcohol: Thematic Meeting of the Kettil
Bruun Society: 30 September 2019–3 October 2019”(2019) <law.unimelb.edu.au/alcohol-globalgov-2019?>(last
accessed 26 November 2020).
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