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to address the problem? place a comprehensive ban on the advertising of alcohol
4. reduce the availability of alcohol.
controlling the supply of alcohol to consumers effectively is crucial if we want to manage alcohol and minimise its harm. this means supervising or setting prices – and regulating the distribution and retail of alcohol to limit/ guide/curb its availability.
In south africa alcohol is widely available and the sale of alcohol is poorly regulated. It was estimated in 2009 that more than 70% of alcohol sold by sab reached consumers through the informal sector. this makes it difficult to control who drinks, when they drink and how much they drink.
curb availability
reducing the availability of alcohol limits opportunities to drink and limits the amount a person can drink on each drinking occasion.
south africa’s alcohol sales ban during the covid-19 lockdown serves as an extreme example of limiting alcohol availability. the alcohol sales ban coincided with a notable decline in road traffic injuries and interpersonal violence as reflected in hospital and crime statistics. however, a complete sales ban can only ever be considered as a temporary measure. to achieve a sustained reduction of alcohol availability requires a coordinated approach: multiple interventions that all have a positive effect in reducing harm.
reducing alcohol availability reduces alcohol harm. the following key strategies are based on evidence collected around the world from a range of settings:
controlling who can buy and sell alcohol through a carefully regulated licensing system
regulating the number and location of alcohol outlets
regulating the times and days that alcohol can be sold to members of the public
regulating retail sales in certain places and during special events
setting an appropriate minimum drinking age
penalising those who sell alcohol to intoxicated or under-age people
developing policies controlling drinking in public and at public functions
developing policies for the production of illicit and informal alcohol.
international success stories
there are numerous examples from around the world, but some are particularly relevant to south africa.
trading times
brazil showed ground-breaking success when the mayor of diadema introduced closing-time restrictions in 2002. a resounding 44% decline in homicides resulted from the on- and off-consumption restrictions. for this kind of success to happen – and for it to be maintained – political leadership, community buy-in and policing need to be stringent. unfortunately, while the brazilian bar-closure act of 2002 is still in place, it is not being enforced and has led to an increase of 18.8% in the number of homicides. botswana’s previous president, Ian khama, reduced consumption of alcohol by introducing operating hours and a levy of up to 55% on alcohol. In 2019, new relaxed restrictions have been reported.
locally, in a village in the eastern cape, libode, the community through leadership temporarily closed all shebeens after the death of two young men. the shebeen owners were forced to pay for the funeral and all liquor outlets in the area had to pay “taxes”. In nearby nqileni, the community imposed a 7pm curfew on liquor sales. this has coincided with a considerable reduction in alcohol-fuelled interpersonal violence, which is now extremely rare in the area.
raIsIng the drInkIng age
the usa is one of many counties to implement a minimum drinking age, over the past few decades. this has effectively reduced the quantity of alcohol consumption and traffic casualties.
reduce avaIlabIlIty
In russia, the last decade has seen a number of control measures being put in place, which has led to a 43% reduction in consumption of liquor. measures include:
minimum price of vodka
Where alcohol can be sold and consumed
no trade between 11pm and 8am
most importantly, monitoring wholesale and retail sales (outlets were equipped with cash registers dedicated to alcohol products).
implementation considerations for south africa
trading times
the national norms and standards provide clear guidelines that can form the starting point for all otts. these need to be made binding through inclusion in national and provincial liquor acts. provinces and municipalities can consider setting stricter limits than the national limit, but they should never allow trading beyond the national norms and standards. currently, three provinces (kwaZulu-natal, gauteng and north West) have trading hours that exceed national guidelines, with most municipalities in mpumalanga and the eastern cape and a few in the Western cape non-compliant.
minimum drinking age
the draft liquor amendment bill (2016) already proposes increasing the minimum drinking age to 21 years. this important policy needs to be enacted; however, if the increase from 18 to 21 years is considered too drastic then it would be beneficial to increase the minimum drinking age incrementally, for example: increase the age to 19 in 2021, 20 years in 2023 and 21 years in 2025.
outlet density
south africa does not have national restrictions on the density of alcohol outlets. the first step would be to introduce a limit of one outlet per 1 200 people in any particular area or suburb. this is the least restrictive outlet density limit internationally, but already considerably more restrictive than many places in south africa.
tracking and tracing
a tracking system needs to be put in place: knowing where the liquor is from production to consumption will reveal where the legal product becomes illegal and who the guilty party is. this will help to address the sale of alcohol to and from unlicenced outlets and distributors.
the road to success
Interventions need to be consistently applied and enforced to ensure their effectiveness. a valid liquor licence needs to be highly valued. this will ensure that licence holders follow their licence conditions very carefully.
5. intensify the availability of counselling and medicallyassisted treatment for persons struggling With dependence.
addressing alcohol harm reduction requires a whole-of-society approach. advertising, availability and pricing are important to address the demand and supply for alcohol, to limit uptake and consumption, but for some people, it’s already too late and these measures have negligible effect.
It is important to note that south africa has a high prevalence of alcohol dependence and alcohol use disorders (7%), particularly among males (12.4%). International experience shows that brief interventions with atrisk drinkers and treatment of individuals with alcohol use disorders are among the strongest and most cost-effective strategies to reduce alcoholattributable harm.
this is where health and social services can play a key role.
some of the considerations include:
ensuring the availability of early intervention programmes
detoxification
treatment and aftercare evidence-based interventions
providing programmes for screening
provision of information
brief motivational interventions
providing interventions at antenatal clinics
ensuring emergency medical services for alcohol-related conditions are equitably distributed.
implementation considerations for south africa
although treatment is a key strategy to reduce alcohol harm, the international experience is that only 14% of countries (mainly high- or upper-middle income countries) show high treatment coverage (treating 40% of individuals needing treatment), while twice as many, 28%, report limited to no treatment coverage, all these being low- or lower-middle-income countries.
the lack of resources to finance these programmes and interventions is one of the main barriers. there is a need for innovative funding mechanisms. some countries use revenues from taxes on alcoholic beverages to fund health promotion initiatives, including treatment of alcohol and substance use disorders.
the onus is on government to implement innovative funding and preventative strategies and interventions; and to provide treatment for substances that are legally traded.
examples of funding could be generated from:
state-owned retail monopolies
profit levy across alcohol beverage value chains
taxing alcohol advertising imposing earmarked fines for noncompliance with alcohol regulations
taxation and excise duties on casinos and other forms of gambling.
treatment facilities are divided into:
• preventIon
• early InterventIon
• treatment
• after-care
• reIntegratIon
these facilities need to be equitably distributed across the country, becoming accessible for rural and semi-urban communities specifically; and emergency medical services, including detoxification services, are needed to ensure advanced harms reduction, as well as a post-emergency programme, which supports individuals and their families. minimum norms and standards should be set for in-patient community-based organisations and halfway houses to adhere to.
brief interventions
healthcare settings
In these settings, educational interventions based on alcohol consumption patterns (resulting from screening) is highly effective. Who recommends healthcare providers offer simple advice about alcohol-related risks to light-to-moderate drinkers, including limits and goals to moderate-to-heavy drinkers.
Well distributed healthcare and health facilities provide the perfect opportunity for screening alcohol use and provide early referrals to treatment and rehabilitation services. this is where standardised screening protocols need to be in place, so that these opportunities are not missed – and returning patients will be well considered.
limitations include: only a small percentage of emergency centres are able to offer these services, and managing alcohol-use disorders and perceived time constraints are frustrating for staff. for interventions to be successful, financial and managerial support and training needs to be implemented. the moderate cost for this is far outweighed by the potential benefits to the population.
antenatal clinics
Interventions in these settings will help reduce alcohol-exposed pregnancies. measures include:
educate women at child-bearing age about the risks of alcohol consumption to foetal development
encourage early antenatal services for both expecting parents; screening/monitoring alcohol use of mothers-to-be
case management of mothers who are at high risk of alcohol exposure during pregnancy.
schools/learning institutions
youth who drink before turning 15 are five times more likely to develop an alcohol disorder than those who wait. If they start before 14, they will probably encounter an alcohol-related injury, such as a traffic accident or being in a fight.
It has been found that children who drink are likely to have mental health disorders and binge drink. It is vital to focus on this demographic to address alcohol-related harms.
referral system
for long-term treatment, prevention and diversion activities treatment centres must be available (in south africa, treatment facilities and referrals are low). a place for detoxification and community-based treatment for inpatients, and effective risk stratification and referral systems are necessary. compulsory enrolment in a rehabilitation programme is also a recommended countermeasure for drunk driving offenders.
outpatient care
to improve treatment and rehabilitation service outcomes, outreach into communities must be made a priority; active involvement of families, faithbased organisations and npos will help significantly.
integrated surveillance system
While improving access to services is a key strategy, a monitoring system (for alcohol abuse disorders) to assess ongoing needs and treatment, as well as associated morbidity and mortality of patients, is a salient challenge.
In russia there are two types of monitoring procedures for officially registered individuals with substance use disorders:
Preventive monitoring
this is for individuals who reach out independently, or who are referred by a public organisation or medical institution or internal affairs body, such as the police. generally, these individuals use alcohol in a harmful way but are not necessarily dependant on alcohol. they are considered to be a group at risk and can be monitored for up to a year. When these individuals are admitted to the narcological service for the first time, they are put under preventive monitoring and are required to visit the psychiatrist-narcologist at their local outpatient clinic regularly, during their monitoring period.
Narcological monitoring
this is imposed on individuals who are repeatedly admitted to the narcology service or who meet the diagnostic criteria of alcohol dependence and/or other drug dependence. this diagnosis is established in both outpatient and inpatient institutions, by a psychiatrist-narcologist. narcological monitoring lasts for at least three years. the patient is only removed from the state register when remission is reached and a number of conditions are met: no use of psychoactive substances during the entire monitoring period without interruption; regular visits to the local psychiatrist-narcologist; and absence of traces of drugs in the urine following routine checks in the narcology institutions.
references
pages 2 - 25
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4. national department of health (ndoh), statistics south africa (stats sa), south african medical research council (samrc) & Icf. 2017. south african demographic and health survey 2016: key indicators report. pretoria, south africa, and rockville, maryland, usa.
5. World health organisation. 2018. global status report on alcohol and health. available at: https://apps.who.int/iris/bitstream/hand le/10665/274603/9789241565639-eng.pdf?ua=1
6. unless otherwise indicated, all facts quoted in this section are from: parry, c., gray, g., maker, a. & smithers, m. 2020. charting a healthier way forward for alcohol in sa, now and into the future. south africa medical research council online. access at: https://www. samrc.ac.za/news/charting-healthier-way-forward-alcohol-sa-now-and-future
7. early in 2020 the south african alcohol industry announced it was restricting its advertising times on tv and radio, and prohibited billboard advertising within immediate proximity of schools. alcohol advertising on radio and tv is now limited to between 19:00 to 06:00 during weekdays. on saturdays and sundays, alcohol adverts can only be broadcast between 12:00 and 06:00. advertising of alcohol will only be placed on media channels and programmes where at least 70% of the audience is expected to be of legal drinking age. the commitment binds all alcohol manufacturers, suppliers and retailers, is contained in the marketing code will be enforced by the advertising regulatory board.
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page 16 images
braIn scan: http://newscenter.sdsu.edu/sdsu_newscenter/news_story.aspx?sid=74454
old south afrIcan flag: https://www.theflagshop.co.uk/south-africa-1928-1994-flag.html
Woman makIng beer: masixole feni (courtesy of groundup)
beer hall: https://www.timeslive.co.za/sunday-times/opinion-and-analysis/2017-02-05-first-draft-of-history-meet-our-hero-mr sorghum-mqombothi/
hendrIk verWoerd: https://www.britannica.com/biography/hendrik-frensch-verwoerd
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1. place a ban on the advertising of alcohol
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