Regulating alcohol advertising for public health and welfare in the age of digital marketing: challenges and options

Abstract

Aims: This narrative review considers traditional strategies for regulating alcohol marketing and their applicability to digital media.

Method: Drawing on international research, case studies, and reports, we examine the applicability of (1) comprehensive or partial bans; (2) placement restrictions; (3) content restrictions; and (4) counter-advertising.

Results: Comprehensive bans on advertising are generally the most effective option. A partial ban applying to digital media would make some lesser contribution to reducing exposure, but will usually simply result in the promotional budget being shifted to whichever media remain less strictly regulated. Limits on the placement of marketing have more salience for traditional media than for most digital media, which can be individualized and targeted. Content restrictions play a limited role in reducing exposure as they are not concerned with marketing volume, but with the way in which alcohol is represented.

Conclusions: Although these traditional strategies have a role in regulating digital media and are applied in certain international jurisdictions, new regulatory approaches are needed. These may include the use of artificial intelligence for monitoring, transparency requirements, and privacy law rights and duties. Opportunities to regulate alcohol marketing online will need to be addressed and seized as they arise in the current volatile policy environment concerning the governance of social media.

Keywords:

• Alcohol marketing
• digital media
• social media
• internet
• regulation

Introduction

Alcohol advertising is a key causal driver of alcohol consumption. This has been documented particularly for young people (Sargent & Babor, 2020), but is also apparent more broadly (Babor et al., 2022, Chapter 9). With the advent of promotion via social media and other online platforms, this risk has compounded, and exposure to alcohol-related content online has been linked to increased alcohol consumption (Noel et al., 2017). Regulation is recommended to respond to these risks (Alcohol Focus Scotland, 2022; WHO, 2010, 2022) but recent analyses have pointed out that the regulation is lagging well behind the developments in online marketing methods and techniques (Boniface et al., 2021). One of the issues is that digital marketing poses new and distinct regulatory challenges that have confounded regulators. Digital marketing strategies are less publicly visible, less transparent, and more targeted and personalized than traditional media, and often deploy subtle strategies, such as funded influencers and user-generated content (Carah & Brodmerkel, 2021).

Globally, the regulation of digital marketing significantly lags behind the regulation of traditional marketing (e.g. print, television, radio, cinema, etc.). For instance, the World Health Organization (WHO, 2018, p. 106) reports that while most countries had some form of regulation in 2016 for traditional alcohol marketing, almost half had no regulations in place for the internet (48%) and social media (47%) marketing. Given the potentially adverse impact of uninhibited alcohol marketing—particularly on young individuals and heavy drinkers (Townshend & Duka, 2001)—regulating such advertising in online spheres has become an emerging health priority.

Digital marketing of alcohol

The marketing of alcohol has become increasingly globalized, with digital media being critical to that change. WHO’s Global Alcohol Strategy defines marketing as ‘any form of commercial communication or message that is designed to increase, or has the effect of increasing, the recognition, appeal and/or consumption of particular products and services’ (WHO, 2010). ‘Marketing’ is a broad term often captured by the ‘marketing mix’ concept (e.g. four Ps) and may include considerations about product (e.g. recipes, product lines, and packaging), place (e.g. location of sale), promotion (e.g. communication strategies), and price. In this paper, when using the terms ‘marketing’ or ‘advertising,’ we are solely concerned with the promotion of alcohol products, and thus, do not consider other aspects of marketing (e.g. product, place, or pricing). Although the promotion of alcohol continues in traditional media (such as television, radio, print, and cinema), the advent of the internet and the growth of e-commerce, data analytics, and social media have fundamentally changed alcohol promotion, amplifying the capacity of such marketing to reach and influence new audiences. This is true of other technological developments over the last two decades—most specifically mobile phone ownership—meaning alcohol promotion is always available and on hand. As social media platforms, such as Facebook and YouTube, became global phenomena, trans-national alcohol companies (TNACs), such as Diageo and Heineken, formed strong alliances with them; by 2011, one-fifth of Diageo’s marketing budget was with digital media, and for 2012 Diageo committed to spending $10 million on advertising on Facebook (Kelsey, 2020). Carah (2017) notes that since then no major alcohol company has revealed details of their partnerships with internet media giants.

Digital marketing uses distinctive methods and processes, taking a variety of forms, including apps, social media platforms, electronic games, search engines, and webpages (McCreanor et al., 2013; Paterson et al., 2021). In terms of social media (such as Facebook, Instagram, TikTok, Twitter), alcohol promotion may be ‘paid’ and targeted, and may occur via a brand’s account or ‘page,’ or through the sharing of branded content by users (Mayrhofer et al., 2020). The marketing may also be through a social media influencer (SMI) or user-generated, which poses significant challenges for the regulation of alcohol marketing (Atkinson et al., 2017). SMI marketing is considered a form of peer-to-peer marketing both because influencers are often perceived by followers as peers who are relatable and trustworthy, and because SMI content is often shared amongst peers on social media (Enke & Borchers, 2019; Hendriks et al., 2019; Jin et al., 2019). Recent studies suggest that SMIs regularly promote alcohol brands, and alcohol use more generally, and that social media often exposes young audiences to alcohol brands and positive alcohol portrayals (Hendriks et al., 2019; Niland et al., 2017). As found in an experimental study, while young adult audience members were somewhat skeptical about alcohol advertisements identified as such, they were caught off-guard and more likely to be persuaded to purchase by user-generated content (Mayrhofer et al., 2020). It can also be difficult to distinguish user-generated content that is sponsored or facilitated by the alcohol industry from that which is entirely private (Kauppila et al., 2019).

Although marketing has always sought to target consumers who will be responsive to their advertising and likely to purchase the featured product, digital marketing has enabled ‘targeting’ in a manner that has never been possible before. Rapid developments in computer science have meant that alcohol marketing is now increasingly ‘data driven’ and reliant on complex algorithmic processes (e.g. the use of artificial intelligence [AI]) (Carah & Brodmerkel, 2022). For instance, through the collection and analysis of a range of personal data (geographic, demographic, psychological, and behavioral characteristics of sub-groups of consumers) (Goyat, 2011), while utilizing AI technologies and predictive analytics, digital marketing enables more finely grained segmentation of customers and markets (Carah & Brodmerkel, 2021). For alcohol, digital technologies have enabled the targeting of heavy drinkers, and potential new consumers in Latin America (Robaina et al., 2020), Africa (Jernigan & Babor, 2015), and Asia (Esser & Jernigan, 2018), as well as targeting toward young people and women, including in low- and middle-income countries (Atkinson et al., 2019). At the same time as governments have shown increasing interest in overseeing and regulating the platforms’ gathering and stores of consumer data and how they are used (Room & O'Brien, 2021), the industries have sought to protect their commercially valuable web archives and algorithms from government oversight (Kelsey, 2020).

Alcohol marketing, consumption, and regulation

There is a substantial body of literature that links exposure to alcohol advertising to increased alcohol consumption, alcohol-related harm, and the initiation of alcohol use among adolescents (Anderson et al., 2009; Stautz et al., 2016). Econometric studies assessing the effect of alcohol advertising expenditure on alcohol consumption find that a 10% increase in advertising expenditure leads to an estimated 0.3% increase in alcohol use (Burton et al., 2017; Gallet, 2007). However, such econometric evaluations utilizing population-level alcohol consumption are not able to identify differences within sub-groups of the population, and thus may miss the benefits of marketing bans in particular subpopulations (Petticrew et al., 2017). There is evidence to suggest that some demographics—e.g. the young or less-educated (i.e. those without a college/university education)—may be more affected than other cohorts by particular media, and notably by online alcohol marketing exposure (He, 2018). Recently, research has been extended to find the effects of digital alcohol marketing exposure on patterns as well as levels of alcohol use, with some findings that engagement with marketing online—such as targeted Facebook content, liking and sharing alcohol-related content—is associated with increased consumption and risky drinking (Lyons et al., 2015; Noel et al., 2020).

Cross-sectional surveys have been conducted that demonstrate an association between the level of alcohol advertising restrictions and alcohol consumption. For example, Cook et al. (2014) assessed the effect of alcohol advertising restrictions on consumption in 15 low- and middle-income countries, using national survey data. Assessing beer, wine, and spirits advertising separately, they created an aggregate measure of the strictness of advertising restrictions, ranging from 0 (no restrictions) to 3 (for a ban for national TV, national radio, print media, and billboards). Overall, more restrictive policies were associated with reduced alcohol consumption. Using a similar measure of alcohol marketing restrictiveness, Noel (2020) assessed the impact of the strength of alcohol marketing regulations (including for the internet and social media) in 13 Latin American and Caribbean countries on alcohol advertising exposure. Despite generally weak restrictions across the 13 countries assessed, individuals from countries with more stringent restrictions were less likely to report advertising exposure. Given the limitations of cross-sectional survey data, the findings are only suggestive. Nonetheless, the studies do provide some support for the utility of regulation to restrict alcohol marketing exposure, even if restrictions are partial.

The current study

As there is a limited evidence base directly pertaining to the regulation of digital alcohol marketing, it is important to consider policy options that have been utilized in regulating and limiting alcohol advertising and promotion in traditional media, such as television, radio, and print media (in their non-digital forms), with attention to their potential applicability to the digital sphere. Measures that could be considered include (i) bans on alcohol marketing (either partial or comprehensive bans), (ii) restrictions on the placement of advertisements, (iii) content restrictions, and (iv) counter-advertising. Given the distinctive features of digital marketing, this narrative review seeks to explore the transferability of policy options for regulating alcohol marketing in traditional media to digital alcohol advertising, in terms of the potential effectiveness of these strategies in reducing alcohol consumption and associated adverse outcomes. For each of these four strategies, there is a discussion of the nature and recent history of the use of the measure, and the evidence on the measure’s effects and on the conditions of its effectiveness. Since the research literature in this area is not well developed, we consider case studies as well as any evidence from formal policy impact studies. Our focus in this analysis is on the capacity of government regulation (which generally involves the use of law) and its enforcement to address alcohol marketing and its harms. Commercial interests, including both the alcohol and media industries, have been successful in many instances in opposing government regulation of alcohol marketing (O'Brien et al., 2022) substituting ‘self-regulation,’ controlled by the industry, or at least ‘co-regulation,’ where the industry has a strong voice in the regulation. But, as discussed below, such industry arrangements are often very weak compared to government regulation (Jongenelis et al., 2021).

Methods

Given that the wide range of regulatory models covered in this paper precluded a systematic review, a broader narrative approach was adopted. We first identified for review four traditional regulatory models for controlling alcohol marketing:

1. Bans on alcohol marketing (comprehensive or partial bans)

2. Restrictions on the placement of advertisements

3. Advertising content restrictions, and

4. Counter-advertising

Following the selection of these regulatory models, a broad literature review was conducted for each. Databases, such as MEDLINE, PubMed, and PsycINFO were searched for empirical literature based on relevant search terms for each model (e.g. ‘content restrictions alcohol,’ ‘alcohol advertising partial bans’). Grey literature, including international inter-governmental (e.g. WHO) and governmental reports and case studies, were also included within our search parameters. After a database search, the reference section of relevant articles was scanned for additional articles that were not identified in our initial search. Studies were included if they explicitly discussed alcohol marketing and were relevant to each of the four identified marketing regulatory models. We then synthesized evidence from articles into four subsections—one for each regulatory model—and discussed the evidence of each measure’s effects, the conditions of its effectiveness, and its potential transferability to digital marketing.

Results

A comprehensive or partial ban on marketing of alcohol

Bans on alcohol marketing entail the prohibition, generally established via government legislation, of marketing techniques (e.g. sponsorship), or of marketing in all or some media (e.g. digital media). The WHO has concluded that such bans would be one of three ‘best buys’ for public health-orientated alcohol policy (Burton et al., 2017; WHO, 2017). We use the term ‘comprehensive ban’ here to describe a cross-media ban prohibiting alcohol marketing on all media types (including digital media) and in all forms, and we use the term ‘partial ban’ to refer to a ban in one or more, but not all, media types and forms (e.g. a ban on digital media but not on TV and radio marketing). Comprehensive bans are not common and most often occur in conjunction with severe restrictions on alcohol sales (at least for locals, if not always for foreign tourists), for instance in some Muslim-majority countries (such as Niger, Indonesia, or Azerbaijan) (see WHO, 2018).

Partial bans are more common and, in 2015, 32 WHO members were found to have a ban on alcohol digital marketing, 16 members had some lesser restrictions (such as restrictions on marketing content, or the places or times when the marketing could be published), marketing content, or the places or times when the marketing could be published in digital media),29 used self-regulatory or voluntary industry codes, and 82 had no restrictions on digital marketing (WHO, 2022). Most studies of marketing bans are on the effect of bans on particular media platforms (e.g. TV or radio or billboards) and often find no effect from the ban (Nelson, 2010; Saffer, 2020). A likely explanation is that despite a partial ban, the advertising budget of alcohol companies remains intact, and the advertising or other promotion simply proceeds in other media. A ban on one medium, indeed, may result in a greater effect from marketing in another medium. Thus, a study (He, 2018) assessing the extent to which allowing online alcohol advertising offset the efficacy of outdoor advertising restrictions in the US found a 31.4, 32.4, and 52.5% reduction in the efficacy of these restrictions for beer, liquor, and wine, respectively.

It has proven difficult to establish the efficacy of comprehensive bans in jurisdictions where alcohol is legally available. Bans on advertising are often implemented at the same time as a suite of other alcohol control policies (e.g. in Lithuania since 2018, Rehm et al., 2021), making it difficult to disentangle the relative effect of bans compared to other measures. Also, some of the effects of marketing bans are likely to be in the longer term, for instance in changes in the cultural position of alcohol drinking, and such longer-term effects are challenging to measure.

The strongest evidence of the effects of a comprehensive ban on alcohol advertising, including on digital media, comes from Norway. In 1975, Norway banned all alcohol advertising (subsequently encompassing new forms of advertising, such as online with the advent of widespread internet usage), for any beverages above 2.5% alc/vol. There was an immediate 3% reduction in overall sales and in the prevalence of drinking among 15–16-year-olds, and an interrupted time series analysis for 1965–2002, taking into account price and income, found an immediate and continuing reduction of 7% in alcohol sales (Rossow, 2021a, 2021b).

While the Norwegian case study speaks to the potential effectiveness of a comprehensive ban on alcohol advertising, including in the digital sphere, it may also be one of the most challenging options to implement in circumstances where it is not politically or socially viable. Partial bans may be a more attractive political solution, but evidence of effectiveness is limited when compared to an all-encompassing ban.

Placement restrictions on marketing

In comparison to comprehensive or partial bans discussed above, placement restrictions do not ban the appearance of marketing in any particular media format—rather, they place some limits on when and where the marketing can be displayed (e.g. on billboards/television/websites). As there is considerable concern that alcohol advertising causes a disproportionate level of harm for specific at-risk groups, this option typically aims to tailor the delivery of alcohol advertising to times and physical spaces that individuals from the specific groups are less likely to view them. This form of restriction has been applied extensively to traditional media, such as television and radio, but also has relevance to digital media.

In its application to digital media, such restrictions may aim to prohibit the presence of alcohol advertising on websites/platforms that mainly attract these individuals (such as sites with cartoons or games for children). Another formulation of a placement restriction relates to audience composition, such as in Australia where the industry’s self-regulatory scheme provides that alcohol marketing is only permitted in a marketing medium, including online, ‘where the audience is reasonably expected to comprise at least 75% Adults (based on reliable, up-to-date audience composition data, if such data is available)’ (ABAC, 2019).

In the age of stream-on-demand services, social media platforms, and the broader dissemination of content via the internet, regulating the ‘timing’ of alcohol marketing is quickly becoming an antiquated concept. Unlike television in 2000, for instance, advertisements can now be tied into content at any moment. This arguably makes the regulation of other aspects of advertising placement more important than it has ever been. The restriction of alcohol advertising on websites or pages or content directed to or targeted at minors or with a very significant proportion of minors as users are theoretically effective in preventing some of the more egregious alcohol marketing practices, such as the appearance of ‘banner ads’ for alcohol on young children’s cartoon or games websites (although there have been examples of these rules not being observed: Baker, 2010). However, many websites and much content have a mix of adult and young person users, so that minors continue to be exposed to alcohol marketing, either because the content is not solely or principally ‘targeted to’ or ‘directed at’ minors or because the minors, whilst making up a large part of the audience, do not exceed the audience composition limit. Such placement restrictions also do not account for the promotion that is purposefully targeted at younger individuals, such as via private social media accounts, that may include minors.

Placement regulation, as it has been understood in relation to non-digital media, also has serious limits in terms of its applicability to advertising in the form of funded influencers and user-generated content in digital media (Carah & Brodmerkel, 2021). Furthermore, the distinctive feature of digital marketing, especially via social media, is its personalized targeting of individuals with specified demographic, behavioral, and other characteristics. ‘Big Tech’ has been unwilling to share information about the sorting and selection of those targeted, including their protocols, source codes, and algorithms. The practices and intricacies of the placement of online alcohol marketing are thus obfuscated, rendering the design of effective placement regulation very difficult in the current online environment.

Content restrictions

Content-based restrictions do not ban or restrict alcohol advertising in all or particular media or at particular times or places but limit the ways in which alcohol can be portrayed in advertising, with restrictions sometimes differing by beverage type or strength. Advertising content restrictions have been widely implemented, including on digital media—either through government regulation or, very commonly, through industry or company self-regulatory codes (Babor et al., 2010). The aim of such content restrictions is usually to protect against marketing strategies that provide misleading or deceptive messaging about alcohol and is often extended to include attractive but problematic messaging, for instance, advertising that connects consumption to risky behavior (such as driving a car or boat) or that may be appealing to young people under the legal drinking age (e.g. the use of humor, cartoon characters or celebrity endorsement).

Even where the content of advertisements is required to be pre-approved by a regulator, it is common to find that content limitation become boundaries that are repeatedly challenged by advertisers. Thus, while the Alcohol and Gaming Commission of Ontario prohibited advertising that appealed to those below the drinking age, in practice, the restrictions did little to reduce youth exposure to alcohol advertising (Novak, 2004). Short of an absolute prohibition, or a very clear specification of what can be shown (which is also called the ‘positive list’ approach), limitations on content tend to be treated by advertising agency staff—working in a very ‘wet’ environment—as a challenge, with the boundaries to be continually tested.

The ‘positive list’ approach is seen in the Loi Evin in France. One of the stronger restrictions on alcohol marketing, at least as it was originally passed in 1991, the law combined both partial bans (see above) and content restrictions (EUCAM, 2022). It banned advertising on TV and in cinemas, and provided fairly stringent stipulations for the range of permitted content in alcohol advertisements in permitted media. There were two components to the content restrictions: (i) alcohol advertisements were limited to providing ‘factual information’ about alcohol products; and (ii) were to be accompanied by a health message stating ‘alcohol abuse is dangerous for health.’ Information that was permitted in advertisements included the alcohol product’s country of origin, alcohol volume, and means of production (Gallopel-Morvan et al., 2017). In effect, this regulation prohibited what is called ‘lifestyle advertising’—‘attractive advertisements with positive, evocative images and/or text associating alcohol with pleasure, glamour, success, etc.’ (Gallopel-Morvan et al., 2017). More recently, in 2009, the Loi Evin rules were extended to digital media, allowing limited information about alcohol products in online media (except on sports websites, websites targeting young people, or where the marketing is ‘surreptitious or hidden,’ such as through undisclosed influencer marketing), provided that required warning accompanies the information (Friant-Perrot & Garde, 2022). Surreptitious marketing, for instance by undisclosed influencers, is not allowed (Friant-Perrot & Garde, 2022).

Since the Loi Evin’s inception in 1991, it has been repeatedly watered down. Thus, it is not surprising that a recent study, which aimed to assess alcohol advertising exposure among adolescents, found high levels of exposure and concluded that the Loi Evin (in its 2015 formulation) is inadequate (Gallopel-Morvan et al., 2017). However, even in its current somewhat weakened form, as noted by the Pan American Health Organization (PAHO, 2016), the Loi Evin facilitates ‘an adjudication process that levies substantial fines and has been effective in removing ads in violation of the legislation.’ For instance, the Association Nationale de Prevention en Alcoologie et Addictologie (ANPAA) has taken action to ensure that alcohol brands which produce advertisements—both online and on traditional platforms—that violate the content restrictions are held to account (Movendi, 2020). While the law has its limitations, its use of a ‘positive list’ approach clearly has relevance and utility as a tool for regulating the online sphere.

Another form of content restriction is to limit the scope of advertising strategies, for instance prohibiting giveaways or competitions. Thus, with Finland’s 2015 law to limit the use of social media and other web platforms for alcohol marketing, one restriction was a prohibition on the online use of interactive games, competitions, and lotteries connected to drinking, and this provision was generally obeyed (Katainen et al., 2020). The 2015 Finnish law also provided that user-generated content could not be used on an alcohol advertiser’s social page and that alcohol brands should not encourage consumers to share alcohol advertising content (Kauppila et al., 2019).

The results of Finnish content restrictions on social media have been studied, in a comparison of changes in alcohol-involved content on social media in Finland and in Sweden between January 2014 and January 2017 (Katainen et al., 2020; Kauppila et al., 2019). The study focused on the Facebook, Instagram, Twitter, and YouTube accounts of 38 alcoholic beverage producers in Finland, and 52 in Sweden, examining the content published by these producers on their social media accounts in the month of January 2014, 2016, and 2017, comprising a total of 1,536 social media posts from Finland and 1204 from Sweden. Comparing countries and time points, the researchers analyzed the prevalence of user reactions, of the marketing content restricted by the 2015 Finnish law, and of the content restricted by the self-regulatory codes of the alcohol industry, and examined the ways in which producers aim to interact with consumers and appeal, especially to young consumers. The first analysis of the data (Kauppila et al., 2019) found that the number of alcohol marketing messages doubled in both countries from January 2014 to January 2016 but declined in January 2017. Comparing trends, the 2015 legal change in Finland seems to have had some effect on the content of alcohol marketing, particularly in terms of consumer-generated content. The proportion of posts with content that researchers coded as violating the 2015 Finnish law increased in Sweden from 28% in 2016 to 32% in 2017, while it fell in Finland from 26% in 2016 to 16% in 2017 (Kauppila et al., 2019, pp. 58, 61). The Finnish law had called for age-limit restrictions to be enforced on access to alcohol marketing messages; by 2017, 13% of the Finnish alcohol producer’s websites had introduced such age-limit controls, while none of the equivalent Swedish websites had.

While the Finnish case study found some differential changes in Finnish social media alcohol-involved posts, compared to Sweden, it also illustrated how much of a challenge regulating alcohol content on social media poses—even when what is being regulated is posted in a language that is the national language of only one country. Stepping back from their specific case study, the Finnish study researchers noted that ‘the regulation of social media marketing through national legislation is difficult, as social media service providers operate globally, and the platforms they provide are constantly developed to optimize the user experience and are difficult to monitor’ (Kauppila et al., 2019).

Counter-advertising

Counter-advertising is a strategy that involves the distribution of advertising material aiming to counteract or neutralize the effects of advertising and other promotion of a potentially harmful behavior. In the case of alcohol counter-marketing, the aim is to counter or at least balance the effects that exposure to alcohol advertising may have on alcohol consumption and alcohol-related problems (Agostinelli & Grube, 2002). Thus we do not include within ‘counter-advertising’ messages, such as ‘drink responsibly’ chosen and financed by alcohol industry interests as an exercise in public relations, for which there is no evidence of effects in the public health interest (Petticrew et al., 2018). The term ‘counter-advertising’ can be used in the narrow sense of a message specifically appearing on or in conjunction with a particular advertisement or product, or more broadly as messaging disseminated generally in the interest of public health and welfare to counter efforts to promote and market alcohol. In this broader frame, it is often discussed under the term ‘social marketing,’ which has been defined as seeking ‘to develop and integrate marketing concepts with other approaches to influence behaviors that benefit individuals and communities for the greater social good’ (AASM et al., 2013). Examples of counter-advertising include messages warning about potential physical, psychological, and social adverse consequences of alcohol consumption; messages targeting specific alcohol-related harms, such as drink driving; and messages advising on low-risk limits on levels of drinking. Warning labels on alcohol bottles and cans, or included in alcohol advertisements, can be seen as another form of counter-advertising. Counter-advertising can be widely distributed digitally with relative ease.

The primary frame for media-based counter-advertising concerning alcohol has often been anti-drink driving messaging disseminated broadly. While such efforts have often been ineffective campaigns, financed and directed by alcohol industry interests as a public relations ‘corporate social responsibility’ effort (Esser et al., 2016), examples can be found of relatively effective efforts by government agencies, such as the campaigns by Australian governments as part of successful broad multi-pronged efforts to reduce traffic casualties in the last decades of the 20th century (Johnston, 2006). A clear result can also be seen for broad counter-advertising on alcohol in Thailand. About 90% of the Thai population is Buddhist, a religion which generally disfavors drinking, and particularly so during the Buddhist Lent. An evaluation of a mass media campaign each year to discourage drinking during the Lent found that, while exposure of drinkers to alcohol advertising during that period encouraged them to continue drinking, being exposed also to the anti-drinking messages induced them to either drink less or stop drinking altogether during the Lent (Witvorapong et al., 2019). Thus, there is a growing literature on evaluations of social marketing efforts at ‘minimizing alcohol harm’ (Kubacki et al., 2015), and a meta-analysis covering alcohol interventions in comparison with interventions addressing smoking, physical activity, and eating, discussed below (Hung, 2017).

Systematic reviews related to alcohol counter-advertising have been primarily concerned with ‘social marketing’ and are limited in their conclusions. The review of studies aiming at minimizing harm by social marketing (Kubacki et al., 2015) found 23 interventions between 2000 and 2014 which had been evaluated but concentrated on how completely the studies had applied the social marketing model and on critiquing their methods, with little to say about their effectiveness. A dissertation that meta-analyzed and compared the effectiveness of social marketing interventions across topical areas included eight studies addressing alcohol (Hung, 2017). The mean effect size of the intervention for alcohol (0.08) was substantially less than the average for all studies (0.14), and less than the effect sizes for the other three behaviors addressed—healthy eating (0.32), smoking (0.18), and physical activity (0.15). The study concluded that social marketing interventions were effective for the other activities addressed, but that ‘those addressing drinking were not’ (pp. 41, 67).

Concerning counter-advertising in the narrower sense of counter-messaging, where it appears along with the industry advertisement or other marketing message, examples can be found of a variety of policy decisions requiring counter-advertising in contexts where an alcohol transaction or drinking is being thought about or engaged in—ranging from the Swedish requirement that 1/8 of the space in printed-media advertisements for alcohol consist of one of 11 rotating warning messages chosen by a public health agency, to the requirement in California of a warning sign on the risks of cancer and of birth defects from drinking at the entrance to any store selling alcoholic beverages (Wilkinson & Room, 2009). The most commonly studied of these counter-message requirements is required warnings on alcoholic beverage containers. A systematic review identified 15 articles studying the effects of warning labels on individual consumers between 2000 and 2015, 8 of them concerning the US warning label (Hassan & Shiu, 2018). The study found ‘mixed’ findings on the efficacy of the warning labels, and that there is ‘not enough evidence on which alcohol warning labels are more/less effective on behavioral compliance.’ Studies of reception of the US label found that, in comparison to trends among Canadians, survey responses of Americans indicated ‘modest effects on conversations and several precautionary behaviors related to risks of drinking’ (Greenfield et al., 1999). The strongest evidence of an effect is for the warning labels in Yukon Territory, Canada, which included a label warning of the risk of cancer—although the effect, in this case, may have been enhanced by the publicity over the alcohol industry’s successful effort to suppress the label (Zhao et al., 2020). An Australian study found good recognition of the ‘standard drinks’-equivalent logo on Australian beverage labels, with heavier drinkers more likely to recognize its meaning (Coomber et al., 2017).

By way of contrast, there is evidence that counter-advertising concerning tobacco has been effective. With tobacco, a ‘fairness doctrine’ imposed by US courts concerning issues on television was interpreted to mean that as of 1968 TV channels had to carry anti-smoking advertisements without charge if they carried tobacco advertising. The counter-advertising was seen as so effective that, within two years, the tobacco industry had accepted a legislative prohibition on advertising cigarettes on television (Hamilton, 1972). In California, a counter-advertising campaign paid for by the state, with somewhat in-your-face messages (e.g. ‘The tobacco industry is not in business for your health’), had a substantial effect in reducing cigarette consumption in the period before the tobacco industry succeeded in killing the campaign (Hu et al., 1995). A more recent review fitted the effectiveness of the California campaign, along with a subsequent successful campaign in Florida, into a more general framework of the review of counter-marketing efforts also for alcohol and unhealthy food. In this review, Palmedo et al. (2017) emphasize the importance of ‘denormalization of the health-damaging practices of the industry’ as a crucial element in the success of the anti-tobacco programs but note that it is absent from the less successful efforts concerning alcohol and unhealthy foods.

Perhaps the strongest evidence of the potential effects of alcohol counter-advertising is the amount of energy and resources the alcohol industry has spent seeking to alter, counteract or extinguish it. As the Yukon Territory case exemplifies, industry interests are particularly averse to messages about cancer or poisoning (Stockwell et al., 2020). At the other end of the spectrum, industry interests have pressed, often successfully, for anodyne messages, such as calls for ‘responsible drinking,’ pointing to the drinker rather than their product as the source of any problems (Jones et al., 2017).

If effectiveness with other comestibles potentially harmful to health is taken into account, it is clear that counter-advertising in both the limited and the broader senses can be an effective strategy for limiting harms from alcohol. But the messages in the counter-advertising need to be determined by public health and welfare interests, and shielded from influence by those with vested economic interests in alcohol sales. And means must be found for financing and placing the counter-advertising at a level commensurate with the advertising and other marketing which it seeks to counter. Various efforts have been made in one place or another to reset this balance, in the interests of public health and welfare. A government agency can pay for counter-advertisements. Media can be required to carry balancing counter-advertisements without charge, or a government can require counter-advertising messages to be included in the advertisement or on the product. Deductibility of alcohol advertising as a business expense could be disallowed, as was once recommended by a U.S. Surgeon-General’s workshop (U.S. Department of Health and Human Services, 1989), and the added government revenue from this devoted to counter-advertising. For effective counter-advertising, resources to pay for it are as important a consideration as its message and modes of dissemination.

An implicit limit in the literature on counter-advertising is that studies have been on advertising and counter-advertising within a particular national jurisdiction. Clearly, the cross-border nature of online media presently poses substantial difficulties for the enforcement of restrictions or conditions on online marketing, including any counter-advertising requirements. However, this situation is subject to substantial and continuing change (Room & O'Brien, 2021; WHO Europe, 2022) potentially offering opportunities for counter-measures for online marketing, such as counter-advertising.

Discussion

Restrictions on advertising and other promotion of legal products are difficult in an open society, particularly in a society with a general commitment to market freedom. Even before the advent of the internet and digital media, this was true. The greatest success in controlling advertising and promotion of alcohol has tended to be where the government had assumed substantial power and control in the market, for instance by a national government monopoly on key aspects of the market. The advent of the internet and digital media, along with the general neoliberal tendency of industry and market policies in recent decades, has made a public health approach to the regulation of problematic commodities, such as alcohol even more difficult. Even before the digital media revolution, the pushback of industry interests against the more restrictive marketing-control measures, such as France’s Loi Evin or the Ontario requirements for pre-approval of advertisements has been strong, sustained, and often successful.

The dominant regulatory model for alcohol advertising in many countries is ‘co-regulation’ or ‘self-regulation’ through voluntary codes at the industry or company level. But for politically powerful industries like those making and trading in alcohol, such a model does not serve the interests of public health and welfare. There is a clear consensus in the research literature that voluntary codes are ineffective in ‘meeting their intended aim of protecting vulnerable populations’ (Noel et al., 2017). The problems have become compounded in the digital era, with control of digital media content no longer a matter just for the national level, and the digital media giants seeking to ensure that their algorithms and other tools of their trade remain beyond the reach of national governments (Kelsey, 2020; Srivastava, 2021). Optimal outcomes for reduced alcohol marketing exposure, as well as reduced harm from alcohol marketing messages, are best achieved when regulations are statutory and legislated (Esser & Jernigan, 2018), as well as used in tandem with a suite of other policies, such as price-based approaches and availability restrictions (WHO, 2019).

For effective public health-oriented controls, the literature suggests that comprehensive bans across all media types, without exemptions, are undoubtedly the optimal policy option. We argue there are two main reasons for this. Firstly, comprehensive bans have the greatest impact on the volume of exposure to alcohol marketing—an important determinant of consumption and alcohol-related harm (Noel et al., 2020). Secondly, comprehensive bans are easier to implement and relatively easier to monitor and enforce, even when applied to digital media. Compared to partial restrictions (e.g. placement or content restrictions), comprehensive bans reduce the potential for ambiguity in the application of a regulation. In other words, it is much easier to identify and sanction violations if all alcohol advertisements are prohibited. As has occurred in France with the Loi Evin, partial restrictions result in the alcohol industry challenging the interpretation of legislation (e.g. what constitutes an appealing advertisement for children, etc.) and in a running battle over the dividing line of what is acceptable (Friant-Perrot & Garde, 2022; O'Brien et al., 2022).

In cases where a comprehensive ban is not feasible—for example, where it is not politically or socially viable—the next best alternative would be a partial ban on marketing in digital media. However, if marketing is banned in digital media but no other media, then advertisers will likely find other outlets, such as television, radio, outdoor media, and sponsorships, which remain significant marketing channels for alcohol in most countries. But these alternative outlets are associated with more transparency and less individual targeting than digital platforms, making them more open to monitoring, scrutiny, and accountability. They also do not carry the same peer-to-peer dimensions of social media, including issues surrounding virality and engagement, liking, and sharing that produce multiplier effects on the impact and reach of advertising.

Where a country does not institute a comprehensive ban or a partial ban on alcohol marketing in digital media, there still appears to be a case in the interests of public health for placement and content restrictions on digital marketing. While reducing the volume of exposure to alcohol marketing is a chief aim, it is also important to consider the way in which alcohol is portrayed. Content restrictions, such as those described above (e.g. France’s Loi Evin ‘positive list’ approach), can reduce the overall impact of alcohol advertising exposure. In other words, not all alcohol exposure is equally damaging. For example, it is particularly important to limit the content that is received by or which appeals to children and adolescents. Placement restrictions that apply to sites or content which are aimed at or appeal to children, including through an audience composition limit, have some value. However, the weaknesses of placement and content restrictions in traditional media transfer to digital media—they are poor in dealing with content and sources which appeal to both minors and adults. Furthermore, content and placement restrictions face new challenges in their application to digital media, especially in dealing with user-generated material. The results of the Finnish experience with the regulation of alcohol promotion on social media can be seen as holding some parallels with the experience with regulating the content of the advertising on traditional media: if any commercial promotion is allowed, very clear bright lines on the limits need to be drawn—if not an outright ban, then a clear and simple listing of what is allowed and what is not.

Further to this, it seems evident that industry-regulated models are unsatisfactory in achieving their intended outcomes, and that limits on advertising and promotion should instead be regulated and enforced by an independent agency, with substantial protection from industry pressures, and in the jurisdiction of a department with expertise in regulation for consumer protection. Recent experience in control of digital and other marketing in parallel areas could be drawn on, such as the regulation of gambling marketing. Such an agency needs broad investigative powers and the resources to monitor digital marketing.

The efforts of such an agency may be aided by artificial intelligence—specifically, the use of artificial intelligence to monitor and enforce regulatory controls of advertisement placement, whether present or future, or perhaps even as a standalone intervention against exposure to alcohol marketing. Bonela et al. (2022) and Kuntsche et al. (2020) describe the development of a deep learning (artificial intelligence) algorithm that can passively and automatically detect the depiction of alcoholic beverages (e.g. beer, wine, and/or spirits) in digital imagery. Norman et al. (2022) conducted preliminary testing of the accuracy of this algorithm on social media imagery containing alcoholic beverages. Despite highlighting improvements that need to be made before it can be effectively implemented, the authors describe two key practical implications for the use of such technology, one reactive and one proactive. Firstly, as a reactive strategy, the authors note that the automatic detection of alcoholic imagery (which would detect a substantial proportion of alcohol advertisements) could be used to centrally monitor advertisements on digital platforms (e.g. those heavily trafficked by individuals under the legal alcohol purchasing age), thus improving capacity to enforce regulatory standards. As this content is frequently targeted (i.e. shown to specific groups of people based on demographic or browsing characteristics), a workable monitoring system might involve the use of dummy accounts that exhibit specific characteristics of interest (e.g. mirroring a user below the legal drinking age). The algorithm might also trawl popular content (e.g. pages over a certain threshold of ‘likes,’ or that have high levels of regular engagement), flagging alcohol-related sponsored content for review. Such a strategy could be effective if used in conjunction with statutory regulation in the form of bans or content or placement restrictions on alcohol marketing. Secondly, as a proactive strategy, such technology could be used to actively screen and filter out alcohol-related content while browsing online (delivered through, for example, a web browser plugin). This could serve as an optional but additional layer of protection against advertisement exposure to at-risk cohorts.

Even where there is legislation limiting alcohol marketing and an independent regulator has the power to investigate alleged violations, alcohol marketers and web platforms may continue to violate restrictions, perceiving the relative benefits from violating regulations to outweigh the costs. In other words, sanctions may become just another cost of ‘doing business.’ Consequently, it is important that legislation includes provisions for fines that are commensurate with the size and power of the giant corporations which dominate this space, such as Meta/Facebook and ABInBev.

Our review also points to the need for novel approaches to the regulation of alcohol marketing in digital media. Traditional approaches of banning or restricting alcohol marketing content or placement have a role to play in regulating digital marketing, but there are features of digital marketing that are not accounted for by these traditional methods. Digital media’s collection of swathes of personal data, its design and application of algorithms that consolidate thousands of data points of information about users, its differential targeting of content to groups, and its fleeting and secretive nature are features to which traditional methods of regulation are not completely responsive. These differences point to the need to combine traditional approaches to alcohol marketing regulation with other regulatory strategies.

Of particular significance is a privacy approach that gives individuals more control over how digital media companies collect and use data from the individual’s activity online. A model is found in the EU’s General Data Protection Regulation which aims to provide individuals with greater control over their personal data and requires that websites seek consent from individuals to collect information (e.g. third-party cookies) (Hu & Sastry, 2019). Some of the noteworthy provisions in the GDPR include: (1) the right to access personal information and data, (2) the right to be forgotten (i.e. one can request the erasure of personal data), and (3) the right to object to the use of personal data for direct marketing purposes (Hoofnagle et al., 2019). In January 2019, the Commission Nationale Informatique et Libertés (CNIL), France’s Data Protection Authority, fined Google €50 million for breaching several articles of the GDPR (Tambou, 2019). Among other things, CNIL claimed that Google provided insufficient information about their data collection and privacy practices and was collecting and processing data for personalized advertising without ‘valid consent’ (Tambou, 2019). It was deemed that Google’s consent-gathering was ‘neither unambiguous nor specific’ because ‘pre-ticked boxes’ were used and ‘users need to click on the button ‘more options’ to see what the alternatives are’ (Tambou, 2019).

Other jurisdictions are pursuing or considering pursuing regulation that has similarities to the GDPR, such as Thailand, Canada, and California. A privacy approach promises more control for individuals over their online activities; however, it depends on individuals being proactive and does not necessarily hold promise as a population-level measure. Further mechanisms may be needed in conjunction with privacy laws, such as bringing harmful industry marketing within the remit of e-safety or online harms laws. Both Australia (e.g. Online Safety Act 2021) and the UK (Online Safety Bill, 2022) are seeking to increase regulation in these areas, and although their focus has been more on child pornography, terrorism and cyber-bullying, the regulation has the potential to be expanded to harmful industry marketing, such as alcohol.

A major issue for regulators is, as discussed above, being able to track what is happening in online environments, especially as consumers are exposed to marketing online that has a global reach and is no longer jurisdiction limited. Some improved increased transparency tools are urgently needed. In Canada, a proposed bill made provision for ‘algorithmic transparency,’ meaning ‘businesses would have to be transparent’ about how they use artificial intelligence systems ‘to make significant predictions, recommendations or decisions about individuals’ (Government of Canada, 2020). Transparency requirements could be applied to the digital platforms, as well as to the alcohol companies marketing their products. The Framework Convention on Tobacco Control obliges states which cannot implement a comprehensive ban on tobacco marketing to require tobacco companies to disclose details of their marketing practices and spend (WHO, 2005). Targeting major online platforms with such an approach may help ameliorate instances of current transnational unaccountability.

In intergovernmental discussions, governments should push for the inclusion of public health and welfare considerations in international agreements about the governance of the internet and of digital platforms, and for the ability of national governments to regulate the availability in their jurisdiction of all content deemed harmful to public health and welfare, including where the content is created in or disseminated from another jurisdiction. Digital marketing is inherently cross-border and, although states have the legal authority to regulate content reaching into their jurisdiction, it is critical that states work together to enforce applicable laws against companies outside the regulating states’ borders (WHO, 2022).

Conclusion

From a public health and welfare perspective, the message has become clearer in recent years. In terms of the health of the drinker, harmful effects outweigh any protective effects for most or all drinkers, and the harms to others from drinking are greater than for any other psychoactive substance (Bonomo et al., 2019). In addition to considering the alcohol marketing-specific measures reviewed in this paper, alcohol marketing should be included in any discussions about changes in the general regulation of social media and other digital media. The distinctive nature of digital marketing means that regulatory approaches applied to traditional media do not adequately address the problem of alcohol marketing in digital media. The existing strategies can be part of the response to the digital marketing of alcohol, but new ways of regulating alcohol marketing (e.g. algorithmic transparency, privacy approaches, and/or using artificial intelligence to identify and filter promotional material) will need to be introduced in the context of the broader policy environment concerning the governance of digital media.

Acknowledgments

The authors would like to thank the Foundation for Alcohol Research and Education for their contribution to this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).