There has been little progress in implementing comprehensive alcohol control strategies in Africa

ABSTRACT

Alcohol is the most common substance of addiction and a threat not only to health but also to sustainable human development. Consequently, at least a 10% relative reduction in the harmful use of alcohol has been advocated by the World Health Organization (WHO). This perspective describes alcohol use in Africa, strategies to reduce harmful alcohol use, and the ability of African countries to meet this target. Although alcohol consumption in Africa was intermediate compared to other world regions, the total alcohol per capita among alcohol consumers was the second highest (19.5 liters); 19% of Sub-Saharan African men could be classified as binge drinkers. The alcohol industry is the key driver behind the uptake of alcohol use and misuse. The most cost-effective ways to reduce alcohol-related harm is to make alcohol less available and more expensive and to prohibit alcohol advertising. Most African countries have alcohol excise taxes, but these are not adjusted for inflation, meaning that the effectiveness of these taxes will likely decrease with time, leading to greater affordability. The majority of African countries do not have legally binding regulations for alcohol marketing. Alcohol misuse in Africa is not being addressed at a time when available strategies can efficiently and cost-effectively control alcohol-related harm.

KEYWORDS:

• Alcohol control
• alcohol policy
• alcohol regulation
• Africa

Alcohol use in Africa

The WHO Africa Region, comprising over 927 million inhabitants in 47 countries (1), is a large and diverse region with many languages, cultures, and religious beliefs. It is undergoing rapid urbanization and economic growth, and has a growing young population arising from declining childhood mortality (2); 42% of its population is under 15 years of age while another 53% is aged 15–59 (1).

In Africa, alcohol is responsible for about 271000 premature deaths annually, almost twice that from tobacco use (3). Alcohol use is strongly related to many noncommunicable diseases (NCDs) (4), as well as infectious diseases such as tuberculosis and HIV/AIDS. Indeed, when taking into consideration the impact of alcohol use on HIV/AIDS, alcohol use contributed to 6.4% of mortality and 4.7% of DALYS in Africa in 2012 (5).

Alcohol use in Africa is characterized by a pattern of high rates of abstention, which is influenced by religious beliefs, particularly among Muslims where Islam prohibits alcohol use (6), and among regular religious service attendees, both Muslim and Christian (7). Consequently, only one-third of the African population drinks alcohol; however, the volumes consumed per alcohol user is high (5) as shown in Table 1 (8). Therefore, although alcohol consumption in Africa, per person, was intermediate compared to other world regions, total alcohol per capita among alcohol consumers was the second highest at 19.5 liters (8). This is important because the overall volume of alcohol consumption is the primary factor in the harmful use of alcohol (9). Furthermore, greater relative harm associated with a given amount of alcohol consumed has been shown in Africa and other developing regions probably because of the harmful patterns of consumption (10); 19% of men in Sub-Saharan Africa could be classified as binge drinkers (11).

Table 1. Alcohol use in ≥15-year olds in 2010 (8) in the 15 most populous countries in the WHO Africa Region (1).

	Alcohol per capita consumption (APC)				Among drinkers only
Country	Total^1	Men^1	Women^1	Unrecorded	Total Consumption^1	Heavy episodic drinking, %^2
Nigeria	10.1	14.9	5.1	1.0	23.1	15.3
Ethiopia	4.2	6.2	2.2	3.5	26.5	3.2
Democratic Republic of Congo	3.6	5.8	1.5	1.3	12.9	10.7
South Africa	11.0	18.4	4.2	2.9	27.1	25.6
Tanzania	7.7	11.4	4.0	2.0	18.4	34.0
Kenya	4.3	7.4	1.3	2.5	18.9	5.2
Algeria	1.0	1.6	0.4	0.3	10.9	4.7
Uganda	9.8	14.4	5.2	1.5	23.7	8.3
Mozambique	2.3	3.5	1.1	1.0	12.6	4.4
Ghana	4.8	7.8	1.9	3.0	20.6	9.2
Angola	7.5	12.0	3.0	1.6	20.9	11.8
Madagascar	1.8	2.9	0.7	1.0	12.5	64.8
Cameroon	8.4	13.3	3.5	2.6	19.3	27.9
Cote d’Ivoire	6.0	9.8	1.9	2.0	25.6	10.4
Niger	0.3	0.5	0.1	0.2	5.6	2.9

¹Recorded and unrecorded APC in liters of pure alcohol; ²Consuming ≥60 g of pure alcohol on at least one occasion in the past 30 days.

Notably, poor populations, like those in Africa, have a higher relative alcohol-related burden compared to high-income populations and developed countries (4,12). For example, in South Africa in 2000, 7.1% of mortality was attributable to alcohol misuse, which was more than double the global mortality average of 3.2% (4,13). Injuries and cardiovascular incidents were the main attributable causes of death. Alcohol-attributable burden was 7.0% with interpersonal violence, neuropsychiatric conditions, and road traffic accidents the most frequent (13). In addition to high healthcare costs, the mostly unmeasured social costs of alcohol misuse, such as domestic violence, family disruption, and workplace problems, are also substantial (12,14,15). Any cardio-protective benefits of light-to-moderate alcohol use are likely to be negligible in Africa because the most frequent pattern of alcohol use is one of excessive drinking, which negates any beneficial effects (16,17).

Alcohol control strategies

Decreasing the alcohol-related health burden has the potential to be one of the most cost-effective population-based health programs in developing regions such as Africa (18). Therefore, the harmful use of alcohol was included as one of the nine voluntary targets in the World Health Organization’s (WHO) Global action plan for prevention and control of NCDs 2013–2020 (19). The WHO has advocated at least a 10% relative reduction in the harmful use of alcohol by 2025 compared with the 2010 baseline level (19).

Evidence shows that the most cost-effective ways to reduce alcohol-related harm is to make alcohol less available, less acceptable, more expensive, and to prohibit alcohol advertising (20,21), similar to the proven and effective strategies used for tobacco control (22). These measures are supported in WHO policy documents such as the Global Strategy to Reduce the Harmful Use of Alcohol, which recommends 10 target areas for national action (14), and the Global Status Report on NCDs, 2010 (20). Such strategies have the potential to reduce alcohol-related burden by up to 25% (18).

Given that effective regulatory control, including cost-effective and affordable interventions to restrict alcohol harm, exists (23), the need now is to move beyond strategy development and encourage African nations to approve and implement alcohol policies (24). As demonstrated in North America, Europe, and Australia, this is a considerably more difficult process (24). Factors hampering progress include a lack of political will, alcohol industry obstruction in the policy process, and globalization with its free-trade environments that prevents an adequate response at a national level (2,23). Other obstacles include local economic interests where alcohol production and sales generate tax revenues for governments, are a major income source for the travel and hospitality industries, and create employment (15). The alcohol industry is complicit in preventing the formulation and implementation of comprehensive alcohol control policies, and in promoting ineffective strategies. For example, SAB Miller and the International Center for Alcohol Policies, an organization established and funded by the alcohol industry, assisted the governments of Lesotho, Malawi, Uganda, and Botswana to formulate their national alcohol control policies (25). These drafts were found to serve the alcohol conglomerates’ interests rather than those of public health. Therefore, civil society, religious leaders, NGOs, and healthcare professionals have a major role to play in holding governments accountable for responsible stewardship. Their influence and importance should not be underestimated, as demonstrated in the battle against tobacco use in Africa (26).

Current alcohol control measures in Africa and the way forward

There is a paucity of relevant research on the effectiveness of existing alcohol control policies in Africa and their impact on regulating alcohol misuse on the continent. Ferreira-Borges and colleagues did, however, examine the national alcohol policies of 46 African countries as of 2012 (27). Their findings revealed wide variations in the strength of alcohol control policies with regards to price, physical availability, marketing, and drink-driving measures.

Regarding alcohol excise taxes, these were present in 84% of the 46 African countries assessed (27). However, few of these countries adjusted the tax rates for inflation meaning that the effectiveness of these taxes will likely decrease with time. Alcohol will become more affordable and the ability to purchase alcohol will rise following the increases in disposable income that accompany expected economic development in the region (27).

It is well established that the price of alcohol is a key factor that influences the amount consumed and the subsequent alcohol-related harm (28). Notably, two vulnerable groups, i.e., young people and heavy drinkers, are especially sensitive to the price of alcohol (28). Considering that a strong connection prevails between purchasing power and per capita alcohol intake (23), it is imperative to reduce the affordability of alcohol in Africa with appropriate and effective excise taxes.

Additionally, the consumption of illicit or informally produced alcohol, i.e., unrecorded consumption, is high in Africa (31%) (29). Regulating this sector is necessary but remains a challenge; further research is needed to enable the state to gain effective control over informal alcohol production and distribution. Such control is important to avoid contaminated, low-quality alcohol, and for effective taxation to prevent legal alcohol being undercut by illegal products. Legally binding regulations for alcohol marketing were absent in the majority (70%) of the African countries studied by Ferreira-Borges and colleagues, despite such restrictions being low-cost interventions which have consistently proven to be cost-effective in reducing alcohol-related harm (30). Restrictions on alcohol sponsorship and retail sales promotion were present in only 15% and 13% of the countries, respectively (27). The GENACIS study, conducted in eight developing countries, including Nigeria and Uganda, reported that Uganda, together with Brazil and Mexico, had the least restrictions on the sale of alcohol (31). This is likely a reflection of the political unpopularity of such policies, influenced by aggressive lobbying from the alcohol industry (27).

Currently, social norms and taboos in many African countries discourage women from alcohol use but strong marketing initiatives are able to overcome these cultural prohibitions and increase the social acceptability of alcohol consumption in women and the youth. In Nigeria, for example, the alcohol industry uses innovative promotion and sponsorship strategies to target these vulnerable groups by sponsoring essay competitions, fashion shows, sports events, and musical segments, among other events. In this way, the alcohol industry infiltrates people’s daily lives, normalizes drinking and promotes it as a fun, modern, and enlightening activity associated with success and prestige. Additionally, although policies regulating alcohol production, distribution, and consumption exist in Nigeria, the government does not strictly enforce such laws (31).

Seeing that the alcohol conglomerates are a key driving force behind the uptake and spread of alcohol use and misuse, restrictions on alcohol marketing is vital to effectively reducing misuse among adults and the youth (27). This is particularly important in high-abstinence populations; otherwise, traditionally low alcohol-consuming groups such as youth and women in Africa may be transformed into high alcohol-consuming populations (23,32). This has transpired in Thailand, despite a strong faith in Buddhism which discourages alcohol use because of permissive, industry-friendly, governmental policies on production, marketing, and availability of alcohol (23,32,33). Similarly, well-organized and effectively lobbied industry-friendly global, regional, and national policies are supporting the expansion of alcohol corporations in developing regions including in Africa (23,34). Therefore, the only evidence-based mechanisms to prevent alcohol-related harm is public regulation and market intervention (35).

Additionally, measures to counter driving while under the influence of alcohol by setting legal blood alcohol concentration (BAC) limits for drivers are vital (10,12,18,20,28). Alarmingly, using a legal maximum BAC limit of ≤0.05 g/dl for drivers was not common practice in Africa. In 45% of the African countries the legal BAC limit was >0.05 g/dl while a further 15% did not have a policy based on BAC limits (27). The GENACIS study showed that Nigeria had among the most stringent restrictions on the BAC legal limit for drivers while Uganda had the least of the countries assessed (31). However, both African countries reported the least level of enforcement compared with their peers (31).

Optimal enforcement of drink-driving countermeasures requires access to breathalyzers and other alcohol testing equipment, but these were found lacking in Nigeria (36), and for officials to be adequately trained to enforce the law and effect punishment when necessary. Implementing a low maximum legal BAC limit together with strong, consistent enforcement has been proven to reduce traffic injuries and fatalities. This is an important policy measure, particularly in Africa where a large proportion of the alcohol-related disease burden is due to unintentional injuries, including road traffic accidents (27).

Given the irrefutable evidence of the harm imposed by alcohol misuse and that effective regulatory control, including cost-effective and affordable interventions to restrict alcohol harm, exist (23), the minimal focus on alcohol control in African countries with a piecemeal approach is disconcerting. Therefore, despite the increasing international recognition of alcohol as a health and developmental risk, it is unlikely that African countries will meet the global targets advocated for the reduction of harmful alcohol use.

In only a single African nation, i.e., South Africa, has there been a renewed interest in addressing the problem of alcohol misuse, which is rising in the country (37). As a means of reducing the alcohol-related burden, the Minister of Health has suggested a total ban on alcohol advertising and sponsorship, and to increase the age of legal alcohol consumption from the current 18 to 21 years, but this has not yet been formalized (20,38). There are also currently deliberations to introduce a 0.00 g/dl BAC limit for drivers (27). The Minister’s stance is based on the decrease in smoking that followed the ban on tobacco advertising. The extent to which this will translate into meaningful policies is unclear (37).

Of the 10 WHO recommend target areas to reduce alcohol-related harm, African countries should prioritize restricting and regulating alcohol availability and advertising, taxing alcohol, enforcing drink-driving countermeasures, and providing prevention and treatment interventions (14,15). Importantly, sustainable action requires strong political will with leadership awareness and commitment. Explicit comprehensive national alcohol control policies will, hopefully, enable the necessary resources to be allocated to reduce the barriers for effective implementation, enforcement and monitoring of these strategies. To develop and implement effective alcohol control policies, African nations need to increase training and build capacity. Furthermore, research should be conducted to assess the strengths of such polices over time as well as their levels of enforcement because strong enforcement of alcohol control legislation is vital to ensure compliance (27).

Conclusion

Despite the high rates of alcohol misuse in Africa, particularly in men, and the substantial health, economic, and social costs attributable to harmful alcohol use, the focus on alcohol control in the region is disturbingly inadequate. The fact that harmful alcohol consumption is not being addressed at a time when available strategies can efficiently and cost-effectively control alcohol-related harm is unacceptable. There needs to be substantial large scale responses from all stakeholders such as policymakers, public health organizations, and civil society, particularly to counter the aggressive tactics of the alcohol industry in preserving and expanding their consumer base (35). Moreover, African governments need to be held accountable to provide responsible leadership; they need to promote the public health and development agenda by actively implementing comprehensive policies to effectively reduce the harm associated with alcohol misuse. Otherwise, it is likely that economic development and rising incomes may lead to greater alcohol use and a subsequent worsening of the alcohol-related burden (3).

Declaration of interest

The author declares that she has no competing interests/financial disclosures.

Acknowledgments

None.

Funding

None for the study.

Additional information

Funding

None for the study.