Public health advocates refuse to give up the notion that alcohol beverage marketing/advertising cause people to drink, especially young people. They reject the notion that marketing primarily aims to alter brand choice, regardless of the clear economic stakes, and ignore the fact that drinking rates, at least in the US, have remained virtually unchanged for many decades despite the industry’s marketing bombardment. Some studies do find an “association” between ads and drinking, though that association tends not to be very strong. Others don’t even find an association. If a causal link can be established, these advocates fervently believe, ad (and other marketing) restrictions can be justified and should be broadly adopted. Such a finding would render industry self-regulation, which they deem ineffective, unnecessary, and the alcohol industry can thus be treated like the tobacco industry, the true motivation for many in public health.
That’s clear from a special supplement to the March edition of the Journal of Studies on Alcohol and Drugs: “Alcohol Marketing and Youth Drinking: Is there a Causal Relationship?” Spoiler alert: Yes, there is. This determination “could have enormous implications for public health policy designed to prevent the onset of numerous non-communicable diseases [as] well as premature mortality.” So conclude a trio of authors in their introduction, including Thomas Babor, the Journal’s editor, and longtime tobacco/alcohol marketing researcher James Sargent. Along the way, numerous authors, including Babor, emphasize the alcohol-tobacco link, citing three Surgeon General Reports. One of those reports, published in 2012, decided: “The evidence is sufficient to conclude there is a causal relationship between advertising and promotional efforts of the tobacco companies and the initiation and progression of tobacco use among young people.” The rest is history: heavy regulation of tobacco marketing, at least “in most countries,” Babor notes.
How do Babor and Sargent determine a causal relationship between alcohol marketing and underage drinking? Basically, they move the goal posts and declare a “summary judgment” based on previous findings and new reviews of the data. First, they acknowledge that “the proposition that exposure to marketing affects drinking behavior is not easily tested using the ‘gold standard’ research tool – the randomized trial.” Too many obstacles in setting up large groups exposed to or not exposed to marketing over long periods of time, teasing out other influences and then determining accurate drinking behaviors. Still, there have been many experimental and observational studies, with different results and interpretations.
Citing a key set of criteria for determining causation of disease outcomes developed by epidemiologist Bradford Hill, Babor and Sargent point out: “From his perspective, causation was not something that could be proved by any one study or research design but was based on a summary judgment, typically by a panel of scientists, after reviewing all the evidence on a given association.” That’s what the JSA attempts: review the research and make the judgement. Babor and Sargent (a panel of two predisposed judges) apply nine criteria, including the strength, specificity and consistency of the association (between marketing and youth drinking), the “dose response relationship” (to the extent it can be determined), the biological “plausibility,” its “coherence,” the experimental evidence and by “analogy” (i.e. the similarities between alcohol and, of course, tobacco). Different criteria have different levels of support, Babor and Sargent allow. But it all adds up to a causal relationship in their summary judgment.
A Key Question: “Plausibility” To their credit, Babor and Sargent at least address the ginormous plausibility question regarding any potential causal link between marketing and especially youth consumption, specifically in the US. There has been a significant decades-long decline in youth alcohol consumption despite a massive increase in the amount and breadth of marketing they have been “exposed” to, intentionally or not. Not to mention the other “3 Ps” that have also expanded without apparent effect on stopping the decline of youth drinking: affordable prices, numerous new products that might appeal to younger drinkers (i.e. sweet, fruity, and in tempting, convenient packaging) and more and more places to purchase them. Babor and Sargent do note that “in the United States, youth drinking has been declining for three decades.”
“Given the extent of marketing that will be documented in this supplement, the decline in youth drinking is not coherent with a strong causal association,” the authors admit. “But” [still, in any case, we will maintain] “neither is it inconsistent with a modest association that is only one of many factors that influence youth drinking.” So, modesty can be a sufficient basis for restrictive policy, in this view. Ref 1
1 Rehm, J, et al, “Alcohol use in times of the COVID-19: Implications for monitoring and policy,” Drug and Alcohol Review, May 2, 2020; doi.org/10.1111/dar.13074