A Drink Best Not Served: Conflicts of Interests When the Alcohol Industry Seeks To Inform Public Health Practice and Policy

The inherent contrast between the priorities of public health and the goals of for-profit companies becomes overwhelmingly obvious when examining the “public health” efforts/policies for-profit industries support and oppose. The purpose of this commentary is to highlight the divergent goals of public health and for-profit industry, as well as the risks associated with collaboration between public health and for-profit entities. Ongoing alcohol industry-supported endeavors, such as wait-staff training, alcohol education programs, and promotional advertising, are presented as heuristic examples. By collaborating with the alcohol industry, public health officials and organizations become more willing to compromise standards and adopt values of the industry, and less likely to oppose values, operations, and products of the industry. The heuristic examples provided make overwhelmingly clear, advertising, partnerships, and program involvement by the alcohol industry are only intended to sell more alcohol. J Clin Res Bioeth, an open access journal ISSN:2155-9627 Journal of Clinical Research & Bioethics J o u r n a l o f C lin ical Resrch& Bioe t h i c s ISSN: 2155-9627 Citation: Piazza-Gardner A, Barry AE (2011) A Drink Best Not Served: Conflicts of Interests When the Alcohol Industry Seeks To Inform Public Health Practice and Policy. J Clin Res Bioeth S4:001. doi:10.4172/2155-9627.S4-001


Background
The overall goal of public health is to promote societal health and well-being by enacting organized efforts aimed at preventing disease and prolonging life [1,2]. Conversely, the overarching goal of forprofit business is growth and monetary gain. This inherent contrast becomes overwhelmingly obvious when examining the "public health" efforts/policies for-profit industries support and oppose. For instance, in-person semi-structured interviews with alcohol-industry representatives characterize the industry's vehement opposition [3] to proven, effective strategies such as increasing the monetary price of alcohol (i.e., higher taxes) [4]. Additionally, the alcohol industry has long supported designated driver campaigns/programs [5], despite the lack of systematic evidence indicating their effectiveness at reducing alcohol-impaired driving or alcohol-related consequences [6]. As Miller, de Groot, McKenzie & Droste [7] contend, "the [alcohol] industry has invested massive resources in a global effort to produce a light-touch self-regulatory environment that favours its commercial interests while allowing industry members to represent themselves as 'responsible' corporate citizens" (p1560).
The purpose of this commentary is to highlight the divergent goals of public health and for-profit industry, as well as the risks associated with collaboration between public health and for-profit entities. In order to accomplish these objectives, several recent and ongoing alcohol industry-supported endeavors, both educational and promotional, will be presented as heuristic examples. Current scientific knowledge will be used to provide context to all presented examples. Furthermore, we will conclude with a summative commentary highlighting how industry-backed promotions/initiatives/activities can be detrimental to the overall goals of public health.

Educational and Training Programs Wait staff training
Throughout both the United States and Canada, companies such as ProServe (Canada) and TIPS (Training for Intervention Procedures; U.S.) [8] offer liquor staff training/certifications for bartenders, servers, and owners of licensed liquor establishments. In general, this training is designed to aid in the prevention of underage drinking, overconsumption of alcohol, impaired driving, and alcohol-related violence by teaching wait and bartending staff responsible service strategies and how to visually identify intoxicated patrons [9,10].
Currently, alcohol industry entities such as Wine & Spirits Wholesalers of America, Inc. (WSWA) are partnered with the national overseer of TIPS (Health Communications, Inc.; HCI)) to train and certify WSWA employees so they can, in turn, train retail staff on TIPS techniques for serving alcohol safely. Ignoring the conflict of interest present between such partnerships, it is no surprise alcohol entities would support such programs. After all, no group of trained (physicians, bartenders) or untrained (laypersons, college students) persons can consistently and accurately determine alcohol-related impairment without access to specialized instruments (i.e. breathalyzer) and prescribed testing (i.e., standardized field sobriety tests) [11]. Research documents mixed results regarding wait-staff training effectiveness for identifying intoxication and using intervention strategies [12]. Moreover, previous studies suggest that wait-staff denying service to intoxicated patrons is rare [13][14][15][16].

Alcohol 101
Alcohol 101 Plus is funded by The Century Council, comprised of America's leading distillers, who, as of 1991, report investing nearly $175 million into the program [17]. In general, this "virtual" CD-ROM-based initiative is designed to help college students make "safe and responsible decisions about alcohol" and reduce deleterious consequences of alcohol misuse and abuse [18]. At face value, these efforts appear efficacious however, formal reviews reveal no significant differences between Alcohol 101 and traditional educational programs [19]. Reviews of similar programs have also documented general ineffectiveness at reducing alcohol-related harm [20]. While the evidence-base for any internet-based alcohol prevention program (e.g., AlcoholEdu, e-CHUG, myStudentBody) is still in its infancy, the overwhelming majority suggest only a short-term positive impact from these efforts [21-23].

Norms restructuring campaigns
Industry-funded "social norms" alcohol awareness programs are designed to decrease campus alcohol consumption through advertisements (e.g., posters, public service announcements, flyers) suggesting evidence-based average alcohol consumption levels [24][25][26]. For example, a social norms message may be something along the following lines: "Most people only drink an average of two-three drinks in a week". Most typically implemented on college campuses, social norms campaigns are built on the assumption that college students overestimate the drinking levels (frequency and quantity) of their peers [27,28]. Since the perceived drinking level of peers positively correlates to personal alcohol consumption [29,30], it is believed students drink to what they perceive to be normal. Wechseler et al. [31] contend social norms campaigns are appealing to the alcohol industry because they a) fail to emphasize the negative consequences of heavy drinking, and b) downplay the level of drinking on campuses. In a longitudinal comparison of 37 schools utilizing social norms campaigns and 61 schools without social norms programs, there was no significant difference in drinking behaviors across frequency, quantity, drunkenness or heavy episodic drinking [31]. Some quasiexperimental evaluations have actually documented increased drinking associated with social norm programs [32].

Promotional and Advertising Campaigns "Safe" levels of drinking
As early as the 1980s, health official coined the term "safe" level of drinking, following endorsements by National Health and Medical Research Council [33]. Eventually, support for these recommendations lessened as experts became reluctant to recommend any level of drinking as inherently "safe", recognizing the message could be misinterpreted as suggesting individuals should drink up to those levels [34]. Furthermore, guidelines for "safe" or "sensible" drinking often fail to recognize that many people (e.g., pregnant women, recovering alcoholics, prior to operating a motor vehicle) should refrain from drinking completely [35]. Nevertheless, the alcohol industry continues to support and contribute to the development of "low-risk" drinking levels [36].

Responsible drinking
Currently, the alcohol industry has entrenched their marketing efforts within a "responsible drinking" context. As a whole, these efforts typically center upon encouraging drinkers to refrain from drinking and driving [37]. Since 1982, Anheuser-Busch reports investing more than $675 million in responsibility campaigns, alcohol awareness, and education programs -an average of 27 million per year. For 2006 alone, however, Anheuser -Busch spent $22.5 million on Super Bowl advertising airtime, not including advertisement production costs [38]. Between the years of 2001 -2007, alcohol companies spent 43 times as much on product advertisements than responsibility messages [39]. Critical examination reveals alcohol industry-sponsored responsible drinking advertisements a) project pro-drinking themes [5], b) are strategically ambiguous in nature [40], c) lack unity between the visuals and verbal message [5], while at the same time convincing viewers that sensible advice is being provided [41]. In fact, Barry [42] contends responsible drinking promotions may actually provide dissonant individuals (i.e., those feeling anxiety about one's drinking behaviors) alleviation through consistent exposure to visual imagery employed in these advertisements. Overall, researchers characterize responsible drinking campaigns/promotions as amalgams of "commercial, public relations, and public service persuasion strategies" [43]. Smith, Atkin & Roznowski [40] contend more accurate labels for responsible drinking campaigns would be "private service messages" (p1).

The health benefits of drinking
Recently, the alcohol industry has begun to market alcoholic beverages as "healthy" or "diet-friendly". With the rise in popularity of carb-conscious diets, such as Atkins, the alcohol industry has responded with an increase in low-carb beer offerings [44]. Through the use of health buzzwords like "fortified", "antioxidant", "light", "low-carb", and "all-natural", company advertisements are keying in on health-and weight-conscious consumers [45]. Unfortunately, little scientific evidence is available to support the applicability of such claims. For instance, the Marin Institute (2011) contends such claims represent false-advertising in that "only the company's descriptions of the products seem to have changed" (page 6). In other words, "allnatural" and "low-carb" beers contain the same composition and ingredients as other, presumably less healthy, alcoholic offerings.
In the past, alcohol producers and distributors swooned over research suggesting potential health benefits of daily alcohol consumption [46], employing slogans such as "Drink to your health" to suggest consumption as both socially acceptable and beneficial to health [47]. While prior research has identified decreased risk of cardiovascular disease with low-level alcohol use (2 drinks per day or fewer), these findings have been reconciled when considering the "quality" of the investigations [48]. Thus, the relative quality of investigations supporting health benefits of drinking were found to strongly influence the dose-effect relationship, leading researchers to conclude "the degree of any protective effect due to moderate doses of alcohol should be reconsidered" [48].

Fan cans
In conjunction with the 2009 United States' National College Athletics Association's college football season, Anheuser-Busch unveiled the "fan can" promotion [49]. In general, this marketing promotion consisted of decorating Bud Light cans with the colors of several college football teams. In addition to the Federal Trade Commission, many colleges immediately protested, requesting omission from the "fan can" promotion [50,51]. Detractors were primarily concerned that the promotion was unduly aimed at underage drinkers, who account for approximately 11% of alcohol consumed in the U.S. [52]. In response, Anheuser-Busch claimed it would abort promotion of the product in the community if a college complains; however, when Boston College submitted a letter objecting to the use of its school colors, Anheuser-Busch asserted that it had the right to market its product using the colors [53]. To avoid further dispute, the beer company agreed to discontinue production and promotion of products using such color combinations. Unfortunately, many colleges still allow the "fan can" to invade their communities and boost company sales.

Promotion of underage drinking
In 2002, an Australian-based public health group [Alcohol and Drug Foundation -Queensland (ADFQ)] formed a partnership with the liquor industry to promote responsible, moderate alcohol consumption [54]. Not long after forming the organization, the partnered liquor industry submitted an application for a new alcoholic beverage, Moo Joose to Liquor Licensing Victoria (LLV), the state licensing authority. Moo Joose was a 5% alcohol by volume product intended to mimic flavored milk and would be sold in flavors of chocolate, banana, strawberry, and coffee. In their decision to ultimately reject the product application, LLV asserted that Moo Joose posed risks to underage drinking by appearing overly attractive to children [55]. Looking to the ADFQ for advice, the product manufacturer (Wicked Holdings Pty Ltd) was instructed to adjust the product appearance and marketing strategy, while changing the name to Alcoholic Moo Joose [56]. By ultimately supporting the product, the decision ADFQ ran counter to previous policies prohibiting Candy Shots, a vodka drink marketed in flavors of chocolate, banana, caramel, and marshmallow [57].
As is clear in both instances (Moo Joose & Candy Shots), the targets of such a product are underage drinkers. This is concerning considering the growing body of scholarly literature indicating a positive association between youth drinking behaviors and exposure to alcohol advertising [58][59][60]. In 2003, the Center on Alcohol Marketing and Youth reported that for every ad referring to the legal drinking age, there were 179 product ads aimed at underage drinking. This should come as no surprise, as "today's underage drinkers are tomorrow's legitimate customers" [61]. Of the total annual consumer expenditures on alcohol, economic estimates attribute $22.5 billion (17.5% of all expenditures) to underage drinkers [62].

Conclusion
As the heuristic examples outlined above clearly demonstrate, the goals of the alcohol industry run counter to that of public health. The organized efforts (educational and promotional) enacted by the alcohol industry are not grounded in, or supported by, current scientific literature documenting effective/best practice. Moreover, the advertising activities, partnerships, and program development/ involvement in which the alcohol industry engage are only intended to sell more alcohol. Consequently, these efforts fail to contribute to the overall goals of public health to either prevent disease and/or prolonging life [1,2]. As a result, public health officials researchers and practitioners should consider the alcohol industry a wolf in sheep's clothing. The evidence presented herein demonstrates how the role they are playing (attempting to positively impact the health and welfare of the public), is contradictory to their basic character/nature (dedicated to profit and monetary gain). By collaborating with the alcohol industry, public health official and organizations become more willing to compromise standards and adopt values of the industry, and less likely to oppose values, operations, and products of the industry [63,64]. When organizations become dependent on corporate funds, the industry continually gains further power over that organization. As one public health activist participating in Kaskutas' (2004) qualitative investigation incisively articulated, partnership with the alcohol industry is "not an issue of collaboration, it's an issue of negotiation… because we are at odds in terms of the underlying purposes" (p660).