Alcohol Policy Document

PO OP L TO T IC BI R IO Y DR NG E NS IN IN E DU AF S K C E RI OU IN CA TH G

contents 2

Introduction

4

South Africa has a binge drinking problem

6

What is driving the high prevalence of binge drinking in South Africa?

14

What happened during the 2020/2021 lockdowns and alcohol bans?

16

Where DID the ‘culture ’ of heavy drinking in South Africa start?

18

Weighing up the benefits and costs of the alcohol industry Economic benefits vs economic costs Alcohol excesses and societal harm in South Africa

22 24 26 30 40 48

56 62

How can we adjust policy to address the problem?

Place a comprehensive ban on the advertising of alcohol Implementation considerations Increase the price of alcohol Implementation considerations Reduce the legal limit for drinking and driving to a blood alcohol content of 0.02% or below Implementation considerations Reduce the availability of alcohol Implementation considerations Intensify the availability of counselling and medically-assisted treatment for persons struggling with dependence Implementation considerations

70

References

76

Contributors

introduction The national ban on the sale of alcohol, applied at various times during the Covid-19 lockdown in South Africa, gave us glimpses of a better society: fewer trauma cases in hospital casualties, less domestic violence and less public money needed to offset the negative effects of alcohol abuse. After years of denial and obfuscation by the liquor industry, it would be only too easy for those advocating for greater control of the industry to say, “I told you so”.

After all, the international evidence of better liquor control has been staring us in the face for a long time. The World Health Organisation (WHO) has advocated for a number of policy measures based on the experience of countries that have reduced the social and economic damage of excessive alcohol consumption. These policy ‘best buys’ have been shown to be highly effective, feasible and implementable at low cost.1 Even a heavy-drinking country like Russia has shown that targeted interventions can work. There, after a number of these measures were introduced, the annual per-person consumption of total pure ethanol dropped from 20.4 litres in 2004 to 11.7 litres in 2016.2 Finance ministers have swallowed the industry’s line that the sale of alcohol contributes substantially to the national economy; it does, if you ignore the economic costs of its harms. If the harm associated with binge drinking were reduced through the ‘best buy’ interventions that have been shown to work, there would be more money in the fiscus – not less. It is now time for proper accounting of both the revenue and costs of the liquor industry in the income statement of SA Inc.

2

The economic benefit of alcohol harms reduction is only one part of the story. The other part concerns us as people, as communities, as families. The alcohol ban has shown that there can be fewer road deaths, fewer children born damaged in utero by excessive drinking, fewer homicides and less sexual violence. In other words, a healthier society.

But it won’t help to just say, “I told you so”. It will simply entrench the partisan nature of the debate about alcohol. The ban was instructive, but it can’t continue forever, whether we like it or not.

Our fight is not against alcohol consumption, but against industry and societal practices that promote excessive drinking.

There are ways to reduce the excesses without impinging on people’s right to drink in moderation. Implementing them now will vastly improve the rights to safety and well-being, for children and women in particular. Some of these ways are already legislated for and just need to be properly enforced. But even effective enforcement of the current set of measures won’t be enough to reduce the harms of binge drinking. This document provides background and policy recommendations for sensible reforms that are cost-effective and feasible - with compounding benefits.

3

South Africa has a binge drinking problem.

Relatively few South Africans drink alcohol compared to people in other countries. Yet, those South Africans who do drink tend to drink far more and heavier than their global counterparts.

Men are far heavier drinkers, and these patterns of drinking are set in late adolescence and early adulthood, while the brain is still particularly susceptible to toxins.

World average

drink alcohol

Engage in binge drinking Grams pure alcohol Consumed per day

4

south africa

43% 31% 50%

59%

32.8g

64.6g

38%

70%

80%

15-34-yearold males

5

6 7

6

W dr ha th iv t pr e in is bi e h g in ng va ig Af S e l h ri ou dr en ca th in ce ? ki o ng f

It’s a culture, sustained through advertising.

The country’s drinking culture is partly rooted in the past, a legacy of factors such as the migrant labour system, the ‘dop’ system practised on wine farms, and the pre-democratic government’s use of revenue from alcohol sales in townships to build the apartheid infrastructure.

See page 16 for more on this.

Advertising is only (and barely) regulated by the liquor and communications industries themselves,7 and there is widespread exposure to alcohol messaging by underage youth through sports sponsorships, billboards and external marketing on the outside of liquor outlets near schools and elsewhere in communities.

Alcohol is promoted as a lifestyle choice and is associated with success, glamour and social acceptance. For young people eager to break out of poverty and make their way in life, alcohol consumption is seen as a status symbol.8 8

9

Alcohol entertains and numbs.

Half of all people living in South Africa live below the poverty line of R1 268 per month,9 with little opportunity to work themselves out of it – the unemployment rate was more than 30% in the third quarter of 2020.10 What is more, South African households also have high levels of debt, with on average 9.4% of their disposable income spent on servicing debt.11 Poverty, depression and hopelessness coupled with a lack of social and recreational opportunities in many communities drives binge drinking among many South Africans. Shebeens and taverns provide venues for socialising.

10

11

Alcohol is easily accessible and cheap.

We have a weak regulatory environment with inadequate legislation and regulations, poor enforcement thereof, or both, especially in areas such as the enforcement of drink driving regulations, underage drinking, illegal brewing and selling of alcohol without a licence.

Much of the alcohol sold in South Africa comes from unregulated outlets, many of which operate out of peoples’ homes, where hours are very flexible and where there is substantial exposure of liquor to underage youth.

Alcohol is also very cheap in South Africa, with much sold for between R4 and R6 per standard drink of 12g (or 15ml) of pure alcohol. It is often sold in oversized containers in restaurants or from liquor outlets, where a volume-based discount reduces the price per unit of pure alcohol (e.g. 750ml and 1-litre beers and 2 to 5-litre wine containers).

This brings down the price per unit and increases the risk of heavy drinking. Often surplus wine is also dumped in poorer communities at ultra-low prices.

12

13

Unlike what happened in other countries, the number of domestic violence cases in South Africa decreased by 69.9% between March and April 2020.

Fake news and claims of a massive rise in Covid-19 cases may have deterred women from seeking help. It is also possible, however, that the ban on alcohol sales reduced the severity of domestic violence cases and the lockdown reduced the opportunity for rape outside of the home.12

23 April

Level 4 lockdown More freedom of movement, but alcohol ban is still in place

Reports of murder, rape and common assault plunged by 40% between April and June 2020, while non-contact crimes such as arson and malicious damage to property dropped by 30%.13

26 March

17 June

Level 5 lockdown Alcohol ban commences

What happened during the 2020/2021 lockdowns and alcohol bans?

Covid-19 is a worldwide crisis, but no other country had to implement a total ban of alcohol sales to curb the spread of the virus.20 This begs the question, would such a drastic measure have been necessary if sensible policies to manage the sale and consumption of alcohol were effectively implemented during normal times?

14

12 july

Level 3 lockdown Alcohol ban reinstated

Over the course of a few weeks, 21 women and children were murdered, shocking the nation.

President Ramaphosa stated that, especially in the light of the unbridled violence against women and children, “we will also need to look at further, more drastic measures to curb the abuse of alcohol.”14

When the second alcohol ban was instituted for a month, murders still rose by 6% compared to the same period in 2019. Possibly traders and tavern-owners stockpiled liquor as rumours swirled ahead of the second sales ban; but it also shows that firearm-related violence is endemic in many areas of our country.15

By January 2021 South African Breweries (SAB) cancelled investments in South Africa totalling R5 billion since the first alcohol bans were introduced in March 2020,19 illustrating another economic consequence of the total ban.

18 august

During the second alcohol ban, the Western Cape saw a 48% weekend and 32% daily drop in alcoholrelated traumas.16

Level 2 lockdown Alcohol sales resume

It is estimated that the wine and wine tourism industry lost more than R8 billion in direct sales revenue in the 17 weeks following the ban in March 2020,18 and that at least 165 000 people have lost their jobs due to the successive alcohol bans.19

Level 3 lockdown Alcohol sales resume for home consumption The number of cases in the Baragwanath Hospital trauma unit almost doubled within 24 hours of the introduction of Level 3 with alcohol-related cases.14

28 DECEMBER

Soon after the reinstatement of the alcohol ban, trauma admissions to casualties linked to alcohol dropped again by 47% on weekends and by 58% in the Western Cape. On New Year’s Eve and New Year’s Day, there was a 65% drop in trauma cases linked to liquor abuse – compared to the same period in 2019.16

Level 3 lockdown Alcohol ban reinstated

For the first time in the history of the Chris Hani Baragwanath Hospital in Soweto, the hospital trauma rescue area had no patients on the first day of the new year, while some of the busiest hospitals in KwaZulu-Natal were also virtually empty on this day.17 Together with the alcohol sales ban, South Africans were subject to a curfew of 9pm to 6am.

While the total ban on alcohol sales has had a positive effect on managing the Covid-19 virus, it has had a severe impact on the alcohol industry and the livelihoods depending on it.

15

16 17

W th he of e r dr h ‘c e So in e u DID st u k av lt ar th in y ur g t? Af in e’ ri ca

1960

1833 The origins of our drinking problem go back to 1833, when the British Slavery Abolition Act abolished slavery in most British colonies, freeing more than 800 000 people within a year, mainly in the Caribbean and South Africa.

Wine farmers in the Cape Colony created a new form of slavery, retaining cheap, pliant labour by supplementing meagre wages with tots of wine, administered up to five times a day.21

1928 Lesser known is the story of collusion between the apartheid government and the liquor industry in building the bantustans while grinding down their people.

It started with the state’s cooption of beer production and distribution as instruments of control and compliance, through the Liquor Act of 1928.

Until then, the sorghum beer industry had been the remit of black women entrepreneurs.

But the Pact government of the National and Labour Parties, under General Barry Hertzog, declared a monopoly on its production, robbing the women of their livelihoods and encouraging public drinking by establishing municipal beerhalls for working men.

By 1960, things were decidedly uncomfortable for then Prime Minister Hendrik Verwoerd.

His decision to leave the Commonwealth and declare a republic had lost South Africa its preferential trade status.

At the same time, Verwoerd faced internal opposition to repressive legislation both from the liberation movements and from his own Afrikaner constituency, who did not want to fund the massive infrastructure required for separate development. Not that they didn’t want apartheid; they just didn’t want their taxes going to black people.

2020 Today Carling Black Label (known as ‘Zamalek’) is the country’s best-selling beer.

Its alcohol content is 5.5% – higher than most other massproduced commercial beers.

The actions described here shaped racial and class patterns of drinking that continue to this day.

One consequence of the ‘dop system’ is the high prevalence of foetal alcohol spectrum disorder (FASD), which still affects up to a quarter of children in some communities of the Western Cape.22

In terms of the Act, African people were forbidden from drinking ‘European liquor’ – wine and spirits – except for “educated male natives” who could apply for a permit to do so.

It took a couple of decades for the financial stupidity of this decision to sink in, during which time illicit sales boomed and unregulated taverns (‘shebeens’) sprang up across the townships – serviced via the back door by the forerunner to South African Breweries.

As a result, the Liquor Act was amended in 1962 to allow Africans to buy ‘European liquor’ at beerhall outlets and ‘Non-European off-sales’.

Most significantly, it required that 80% of the municipalities’ net profits from these sales should go to Bantu Areas Administration Boards (BAABs) to fund township upgrades.

However, as the homeland policy took root and bantustan leaders required more money for their fiefdoms, revenue was increasingly diverted away from the townships.

Government’s monopoly in the sorghum beer industry did not extend to the ‘homelands’. It wasn’t given back to black women entrepreneurs, but handed to the South African Breweries, by now firmly in the hands of Afrikaner Nationalists.23

In the racial terms of apartheid, a quarter of Indian men and two-fifths of white men who drink, say they binge drink. The comparable figures for African and Coloured men is three out of every five.

Similar differences are found between salaried and casual workers. Almost half (47.2%) of salaried drinkers report binge drinking, compared to 60.6% of casual workers. Not surprisingly, the proportion of unemployed men who drink heavily is inbetween (52.2%).24 These figures reflect the reality that social and economic marginalisation drives heavy drinking, and heavy drinking perpetuates socio-economic marginalisation. It’s a vicious cycle that continues to generate inequality in South Africa.

18 19

W th ei an e gh th d b in in e c en g du a os e u l st c ts fit p ry oh o s ol f

THAT MAY BE TRUE. BUT THIS DOES NOT ACCOUNT FOR ITS COSTS TO SOCIETY AND THE ECONOMY. *

“As an industry, we create employment for over one million people across the value chain, contribute 3% to the GDP of South Africa’s economy, and make an indirect tax contribution — VAT, customs and excise revenue — of R51bn.”25 - Liquor Industry

20

21 * How employment estimates are calculated is not disclosed by the industry.

Economic Benefits R68 Billion

Economic costs R277 Billion

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27

Contribution to GDP = +3%

Employment, tourism and other spinoffs

R26

BILLION

Cost to GDP = -10-12%

Tax revenue

R42

BILLION

Value of loss of life and health Productivity losses from absenteeism

Individual loss of earnings and related welfare costs

R14

BILLION

R25

BILLION

Direct cost to fiscus

R38

BILLION

R200

BILLION

How would you weigh the social costs versus the social benefits of the alcohol industry?

Socialisation, camaraderie

Personal enjoyment

Family misery through bereavement and domestic violence

22

Community stress

Life potential Gender-based diminished by foetal violence alcohol syndrome 23

(2009 prices)

40%

0 0 0 40 ed ar are caus e y r e p s h t dea nder the by people u ohol.28 f alc influence o

of men ad mit to rap ing a women w hile unde r th influence of alcoho 29e l.

Alcohol excesses and societal harm in South Africa

61%

of femicid es in Cape are the Western assoc te d with alco ia hol. 30

24

18-26%

% 54

of children in some highrisk rural communities have foetal alcohol spectrum disorder.32

ce violen th d n a es wi micid ssociated o h f o are a 6% of cases ohol and 5 .31 s alc death road 25

26 27

Ho ad w to j c th a u a s e dd t n w pr r po e ob es li c s le y m ?

We need to act now, but ‘drastic action’ that could be hugely polarising and destabilising to the economy is not the solution. We can implement sensible policies that are highly cost-effective, feasible and implementable at low cost, with compounding benefits.

The World Health Organisation’s 5 best measures to curb the abuse of alcohol:

1.

2.

3.

4.

Place a comprehensive ban on the advertising of alcohol (except at the site of sale, where it should not be visible to those under 18 years).

Increase the price of alcohol, both through excise taxes and by introducing a minimum price per unit of pure alcohol in liquor products.

Reduce the legal limit for drinking and driving to a blood alcohol content of 0.02% or below.

Reduce the availability of alcohol, especially in residential areas (by limiting the density of liquor outlets, shorter trading hours, and ending the sale of alcohol in larger containers like 1-litre bottles of beer).

5.

Intensify the availability of counselling and medically-assisted treatment for persons struggling with dependence.

5 Increase access to counselling and treatment

1

2

Comprehensive ban on alcohol advertising

Increase price of alcohol

A virtuous cycle for social development Mutually reinforcing strategies to reduce heavy drinking

3 Reduce legal limit for drinking and driving to BAC 0.02% or lower

4 Reduce availability of alcohol

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South Africa’s heavy drinking culture is linked to how alcohol is marketed and

1

1.

Place a comprehensive ban on the advertising of alcohol

sold to consumers. While cheap pricing is the key strategy to drive sales, the demand for alcohol is boosted by advertising and promotion. The industry maintains that it advertises to differentiate products and ensure brand loyalty.

The reality is that the industry is dominated by a handful of major producers, and the main reason for advertising is to sustain and protect the market and to grow it wherever possible. Hence advertising tries to normalise drinking,

Place a comprehensive ban on the advertising of alcohol.

portraying it as part of a regular healthy lifestyle, rather than something that causes harm. Advertising tries to convince people who don’t drink to begin drinking and to encourage current drinkers to drink even more.

Strictly regulating the marketing and advertising of alcohol is a key evidencebased strategy to reduce consumption in the long term. The WHO includes banning and/or restricting exposure to alcohol advertisements, across all media, among its best buys to reduce alcohol harm. The WHO’s recommended strategies to restrict alcohol marketing include: Regulating content and volume of marketing Regulating direct/indirect marketing in certain or all media Regulating sponsorship activities Restricting promotions that target youth Regulating new forms of alcohol marketing techniques (such as social media) Surveillance systems to monitor marketing of alcohol products run by independent bodies Administrative and deterrence systems for infringements on marketing restrictions.

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Where in the world has this worked?

cinemas is banned. It also prohibits alcohol sponsorship and the sale of alcohol

Most countries have some type of restriction for advertising alcohol, with

etc.), making it less attractive to young people. All advertisements must carry

total bans most common for national television and national radio. Regulation

a message that alcohol is dangerous to one’s health.

1 Place a comprehensive ban on the advertising of alcohol

in gyms and other sports facilities. Advertising content is restricted to product characteristics, such as quality (not lifestyle, fun, success, attractiveness,

lags behind for online content with only about half the countries in the world restricting alcohol advertising on the internet and social media.

ASIA: China, Mongolia and Vietnam only allow advertising for low-content alcoholic beverages. China totally bans alcohol advertising on TV, and in the Republic of Korea alcohol advertisements may only be shown after 10pm.

Mongolia prohibits all alcohol sponsorship and promotions (like alcohol prizes or competitions and alcohol-branded merchandise).

Why IS advertising in South Africa so important to the industry?

Like with smoking, governments in most high-income countries recognise alcohol harms far outweigh any benefits. Regulations are becoming stricter

AUSTRALASIA: In both Australia and New Zealand advertisements for alcohol

and stricter. As a result, the alcohol industry has identified low- and middle-

can only be aired on TV and radio after 8.30pm.

income countries with weak regulations, particularly in Africa, as potentially

EUROPE: In Norway, Iceland and the Faroe Islands alcohol advertising is completely banned, including internet-based advertising. France, Italy, Denmark and Belgium have set partial bans on alcohol advertising, which allow advertising on print media but not on broadcast media. In Russia alcohol advertising was restricted as part of its comprehensive strategy to reduce alcohol harm. Advertising was banned on all types of public transportation

attractive new markets. With large populations, low rates of drinking in some groups, and binge drinking among those who do drink, there is lots of opportunity to increase sales. SA Breweries (SAB) previously indicated that it intended to raise annual beer consumption from 8 litres to 30 litres per person per year. There are also more countries in Africa than anywhere else in the world with no marketing regulations whatsoever.

infrastructure in 2012, and alcohol advertising was banned on the internet and electronic media too. In recent years some restrictions have been relaxed, but very carefully.

France is considered to have some of the most comprehensive regulations limiting both exposure and content. Alcohol advertising is permitted in print media, on radio and billboards, while alcohol advertising on television and in

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SOUTH AFRICA IS SEEN AS A GATEWAY TO AFRICA South Africa has considerable production capacity and comprises a wide range of socio-economic groups: a cosmopolitan urban elite, the urban poor, as well as more traditional rural populations, and everything in between.

There is also a well-developed civil society and academic/research advocacy

33

Since democracy, the alcohol industry has used advertising to change this

If the industry succeeds in South Africa, it sets a precedent for the rest of the

historical narrative. Beer advertisements, in particular, have taken on a

continent.

‘nation-building’ tone. Bold, brave and strong men of all race groups join

1 Place a comprehensive ban on the advertising of alcohol

network challenging industry expansion plans. It is the perfect testing ground.

together at the end of a hard day’s work to enjoy a beer. They also zero in on young people aged 18-25 years whose brains are wired for risk-taking and peer

What are the key advertising strategies for Africa?

pressure, many of whom have little to lose from excessive drinking. Of course,

Internationally, advertising focuses not only on the quality and attributes

largely ignored. Instead – a feature mirrored in other parts of the continent –

of the alcohol product, but also discounted prices and specials for large

alcohol is portrayed as part of a sophisticated and successful lifestyle.

these advertisements ignore the reality of low-paid workers spending a large portion of their meagre weekly wages on alcohol binges that have damaging consequences to themselves and their families. Women and children are

purchases, which tends to boost consumption and is particularly appealing to heavy drinkers. There are some additional features prevalent in South Africa that are also relevant to the rest of Africa.

YOUNG DRINKERS Advertising is often aimed specifically at young drinkers, making it seem

LIFESTYLE AND WELL-BEING

drinkers is very important to the industry because they constitute one of the

It is well-known that the development of the industry is historically intertwined

largest market segments. Maintaining a large cohort of young heavy drinkers,

with apartheid. The long associations between political and social oppression

and refreshing this group every year, ensures reliable sales for the industry

and excessive liquor supplies have been described on page 16. A more toxic

for many years to come.

mix would be hard to find: heavy drinking promoted by the state to sponsor the Verwoerdian project, and heavy drinking in shebeens instilling a false sense of freedom, all to the benefit of South African Breweries and other distillers of that time. Inevitably, these factors created a vicious cycle of socio-economic marginalisation and excessive alcohol consumption that persists to this day.

No wonder the youth of 1976 criticised the complicity of inebriation and burnt the beerhalls down!

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normal and appealing, ensuring success and popularity. Reeling in young

There is strong evidence that young people exposed to alcohol advertising are more likely to begin drinking at an earlier age, consume more than normal and will engage in binge drinking. Ads are often placed where the youth are more likely to see them. These ads encourage young people to create identities as drinkers. Even the standard messaging: ‘Not for sale to persons under the age of 18’ may appeal to underage youth. Drinking is portrayed as something that is ‘grown up’ and only for adults.

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WOMEN

in South Africa it is estimated that only 20% of women drink. Men who drink already drink very large quantities and so there is limited opportunity for the industry to expand that market. For this reason, increasing the number of women drinkers offers a much better opportunity for the industry to grow.

1 Place a comprehensive ban on the advertising of alcohol

Currently, women generally have low drinking rates in Africa. For example,

Implementation considerations for South Africa

Women are being targeted in very specific ways. New flavoured products are regularly developed to appeal to women, such as alcopops. Packaging has instead of six-packs. Some alcohol companies have recruited successful

APPROVE THE PROPOSED 2013 LEGISLATION

and influential young women – like the singer Lira – to represent brands and

There is already legislation in the pipeline – it just needs to be approved. The

convey the message that alcohol enhances women’s independence.

Control of Marketing of Alcoholic Beverages Bill placed before Cabinet in 2013

been changed to make products lighter and easier to carry, such as five packs

restricts the advertising/marketing of alcoholic beverages except at the point of sale, sponsorship and promotion of alcoholic beverages. The Bill was placed before Cabinet in 2013 but the industry lobbied hard to stall it. The industry denied evidence of a link between alcohol advertising and consumption, argued that an advertising ban was anti-competitive, that it would impact the economy, promote trade in illicit liquor, erode personal freedoms, and that the loss of sponsorships would damage the development of arts and sports. The Bill has had two regulatory-impact assessments and one socio-economic assessment, none of which have been made public and it has still not been passed.

The ban on tobacco advertising serves as a good point of reference. Both alcohol and tobacco have associative harms – and both appeal to the youth through advertising. The tobacco advertising ban coincided with other policy interventions, like tax increase and public restrictions on smoking in public. As a result, smoking has declined most notably with a 26% reduction in 15- to 16-yearolds. The advertising industry and sports sponsorships survived the ban.

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RESTRICT BRANDED COPORATE SOCIAL RESPONSIBILITY FUNDING

As well as interfering with policy and legislation, the alcohol industry advocates

One mechanism the industry uses to bypass advertising restrictions is to

self-regulation and has devised a code through its Industry Association for

fund public interest campaigns and organisations directly through their

Responsible Alcohol Use. This code has restrictions appearing to protect the

corporate social responsibility initiatives. This is already increasing in South

vulnerable and prevent harmful use, but the reality is that this code is not

Africa, particularly where the industry is responsible for increasing risk such

strictly enforced, and breaches have negligible consequences. International

as with gender-based violence and road safety. This type of sponsorship

research has found that self-regulatory systems do not meet the intended

should be restricted similarly to tobacco sponsorships as set out in the WHO

goals of protecting vulnerable populations from alcohol marketing. In African

Framework Convention on Tobacco Control.

1 Place a comprehensive ban on the advertising of alcohol

STOP THE INDUSTRY’S INTERFERENCE

countries more than 25% of alcohol advertisements were in violation of the industry’s own standards. The most typical violation was the suggestion that alcohol could enhance attractiveness and remove social and sexual inhibitions.

REGULATE PACKAGING Product packaging is a key strategy employed by the industry to promote

RESTRICT SOCIAL MEDIA

heavy drinking. Local research has shown that people who drink from larger

Social media is particularly appealing to the alcohol industry. It provides

campaign to promote its 750ml bottles of Black Label beer is one of the best-

access to a wide community with less regulation. Finland has banned

known examples. The advertisement shows a regular 340ml bottle beside

interactive ads on social media and Russia has banned all alcohol ads on the

SAB’s larger 750ml bottle and suggests that a big man (adult) drinks a larger

internet. Strict restrictions for social media advertising should also be put in

bottle while the smaller one is for youngsters. This ad specifically targeted

place in South Africa, as its access to young internet users is vast.

young drinkers encouraging them to drink more. SAB withdrew the ad after

containers are nearly eight times more likely to engage in heavy drinking than people drinking from average-sized containers. SAB’s ‘Bigger is better’

widespread complaints, but there were no consequences.

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South Africans are renowned to be heavy binge drinkers. Even though the

2

2.

Increase the price of alcohol.

Increase the price of alcohol

majority of South Africans do not drink at all, those who do drink consume large volumes of alcohol, which is particularly cheap in South Africa.

Excise taxes Increasing the retail price of alcohol is one of the most effective ways to reduce alcohol consumption. Governments typically use excise taxes to do this. Also known as ‘sin taxes’, these tax increases are passed on to consumers almost immediately in the form of higher prices. The current levels of excise taxes are less than they were 60 years ago, in real terms. However, the democratic government must be commended as year-on-year increases in excise taxes since 1994 have been consistently and significantly higher than inflation. This was not the case, pre-democracy when increases in excise taxes for liquor were below inflation.

Volume-based discounts Manufacturers respond to the price increases from taxes by discounting alcohol bought in larger volumes. For example, it is cheaper to buy a six-pack of beer than to buy six beers individually. It is also cheaper to buy beer in larger containers. For example, beer in a 750ml bottle works out cheaper than a beer in a 340ml bottle. In this way, manufacturers use the pricing mechanism to encourage higher consumption. After all, alcohol is addictive and the more you can get people to drink excessively, the more dependent they become.

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MUP reduces harms, specifically binge drinking

Minimum Unit Pricing (MUP) is another way to increase prices. The government

In relation to household income, alcohol is more affordable in low- and middle-

passes legislation regulating the minimum price that alcohol can be sold for

class communities in South Africa than in any other country: the cheapest

at a retail outlet. It takes into account the percentage of alcohol in different

alcohol in SA is currently available at just less than R5 per standard drink.

types of beverage, as well as the size of the container.

Increasing prices through MUP reduces drinking among binge drinkers by

For example, if we use a simple standard of a 375ml beer representing 1 unit of alcohol, then a 750ml bottle of beer would be equal to 2 units. In comparison, if our beer is 5% alcohol and a bottle of wine is 12.5% alcohol, then a 750ml bottle of wine would be equivalent to 5 units. Similarly, if a bottle of spirits is 40% alcohol then it is equivalent to 8 times as much alcohol as a 750ml bottle of beer – so 16 units. If we set a per unit price at R10 then the minimum unit prices in this example would be as follows:

2 Increase the price of alcohol

Minimum Unit pricing (MUP)

specifically targeting the cheapest products that are most easily abused, such as sugar-fermented alcohol. MUP makes cheap alcohol substantially more costly. One local study showed that setting a minimum price for a standard drink at R6 (expressed in 2019 prices) could decrease alcohol consumption by 6.2% among binge drinkers, by 15.5% among other heavy drinkers, and by 4.6% among moderate drinkers. Setting prices at a higher level would reduce alcohol consumption by even more. MUP also prevents manufacturers from selling alcohol for less than cost or giving away alcohol in promotions.

375ml beer (@5% alcohol) – 1 unit = R10 750ml beer (@5% alcohol) – 2 units = R20 750ml wine (@12.5% alcohol) – 5 units = R50 750ml brandy (@40% alcohol) – 16 units = R160

Tax increases vs MUP Excise taxes on alcohol are not only a good way for governments to curb

MUP is an effective way to increase prices and to discourage manufacturers

consumption, but also to increase their revenue generally. However, they are

from applying volume-based discounts.

vulnerable to manipulation: increased taxes can be absorbed by the supplier or distribution chain. Retailers also tend to increase prices on cheaper products by much less than expensive products. They know that binge drinkers buy a disproportionate amount of alcohol and cheaper prices are attractive to them.

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On the other hand, while MUP does not increase revenue for the Treasury directly – it potentially does this for retailers, who get bigger margins on every item sold – government increases tax revenue indirectly through the increase in VAT from higher prices. In addition, the government benefits from the savings incurred from lower alcohol consumption – i.e. a reduction in health-, welfare-, labour- and crime-related costs. MUP also does not rule out excise tax increases, which can be implemented alongside MUP.

International successes The experience from other countries around the world is that taxing alcohol at a rate closer to its total cost to society makes for a safer, healthier and more prosperous nation. Scotland, Wales, Australia and Russia have all introduced MUP. Scotland experienced a drop of 4-5% in alcohol consumption among the heaviest of drinkers. Since Russia introduced MUP for vodka – the most commonly abused alcohol in that country – there has been a reduction in overall mortality rates.

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South Africans are renowned to be heavy binge drinkers.

Even though the majority of South Africans do not drink at all, those who do drink consume large volumes of alcohol, which is particularly cheap in South Africa.

45

The introduction of the legislation would mean that the prices of some

2

alcoholic products would increase compared to other provinces.

Increase the price of alcohol

Implementation considerations for South Africa

Enforcement reduces this risk as does the cost of transport between provinces.

Introducing MUP will be easier with the support of national government.

Ales, beers and all sugar-fermented beverages all fall within the Liquor Products Act. It would be helpful if definitions and regulations for content

MUP can be introduced either nationally or provincially. For example, in the

and labelling could be revised to ensure that MUP can be applied easily

United Kingdom, Scotland and Wales applied MUP, whereas England did not.

across all alcohol categories.

Certainly in South Africa, alcohol abuse and binge drinking is not limited to just one province, and so a national MUP framework is preferable. However, if only introduced provincially it would operate as follows:

Legal counsel opinion obtained by DGMT indicates that legislation enabling MUP would fall within an exclusive provincial legislative competence in terms of Schedule 5 of the Constitution, provided that

The Minimum Unit Price for alcohol would be determined by the Provincial

such legislation was structured to impose minimum unit pricing as a

Minister.

condition of licences issued by provincial liquor licensing authorities.

The liquor licensing authority would be required by the legislation to impose a condition when it grants new liquor licences, to the effect that a licensee may not price its products below the minimum unit price for that product. Existing licences will be “transitioned” so as to impose a similar obligation.

Provincial legislation structured in this way could only be superseded by national legislation in circumstances contemplated in section 44(2) of the Constitution, that is if the national legislation was necessary to: maintain national security; maintain economic unity; maintain essential national standards; establish minimum standards required for the rendering of services; or prevent unreasonable action taken by a province which is

The effect of the legislation is that the holder of a liquor licence in the

prejudicial to the interests of another province or to the country as a

province would be required by the conditions of its licence not to sell

whole.

liquor below the Minimum Unit Price. The licensee would remain at liberty to sell liquor at the minimum unit price or at any higher price.

Cost increases may lead to more home brewers, but the extent tends to

Finally, it is important to note that neither excise tax nor MUP alone will stop alcohol abuse, but it is a strong foundation that can target heavy drinkers without penalising occasional drinkers.

be overstated by industry lobbyists. Proper enforcement of liquor sales minimises this risk.

46

47

Consuming alcohol increases the risk of being involved in a crash because

3

it impairs vision, delays reaction time, lowers vigilance and increases poor

Reduce the legal limit for drinking and driving

3.

judgement. Physiologically, alcohol can also lower blood pressure and depress

Reduce the legal limit for drinking and driving to a blood alcohol content of 0.02% or below.

48

consciousness and respiration and increase drowsiness. This is due to the depressing or stimulating effects of alcohol on the brain, depending on how much is consumed. It also lowers inhibition and increases risky behaviour, such as speeding, not wearing a seatbelt or crash helmet, and taking other drugs that can also impair driving ability. The crash risk from drinking and driving increases exponentially as blood alcohol concentration increases – in other words, the effects become progressively worse with each additional drink.

In South Africa approximately 14 000 - 15 000 people are killed on the country’s roads every year. About half of the motor vehicle drivers killed on our roads are under the influence of alcohol. Among pedestrians, alcoholrelatedness is even higher – about 60% of the deaths.

For this reason, the WHO includes drink-driving policies and countermeasures among its 10 recommended target areas for alcohol policy and intervention, and the enforcement of blood alcohol concentration limits among its key road safety interventions. In South Africa it has been estimated that if we were to eliminate drunk driving entirely, we would reduce our road traffic fatalities by a quarter.

49

What are the strategies?

3 Reduce the legal limit for drinking and driving

Relative crash risk by blood alcohol concentration

There are several strategies to curb drunk driving, such as:

ODDS RATIO (relative Crash Risk)

Increasing random breath testing and sobriety check points at high-risk 140.00

times and high-risk locations and publicising the intervention.

120.00

Implementing graduated alcohol limits for drivers. Non-criminal sanctions for lower levels of intoxication can enable more widespread

100.00

testing without over-burdening the criminal justice systems.

80.00

Imposing stricter restrictions on younger drivers. Young, inexperienced drivers have nearly twice the risk of older, more experienced drivers at

60.00

similar levels of intoxication.

40.00

Introducing alcohol interlocks in diversion programmes to prevent drivers convicted of drunk driving to use their vehicles when they are

20.00

drunk. An alcohol interlock is a device that requires the driver to provide 0.000 0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0.18

blood alcohol concentration

0.20

0.22

0.24

a breath sample to start the vehicle.

Introducing mandatory collection of blood samples for all crashes involving a death or injury.

Imposing restrictions on the sale of alcohol on premises that are on

Source: WHO: Drinking and driving: a road safety manual for decision-makers and practitioners

national or provincial roads (e.g. at petrol stations).

Funding public education to change attitudes to drinking and driving.

This is an important additional activity, but it cannot work in isolation and needs to be accompanied by strict enforcement.

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A synthesis of international research across multiple countries has shown that random breath testing can reduce fatal traffic crashes by 20%. It is one of the most effective interventions to prevent drunk driving, but it must be

Implementation considerations for South Africa

3 Reduce the legal limit for drinking and driving

Where in the world have these strategies worked?

implemented at scale.

AUSTRALIA: Australia halved its alcohol-related crashed through a accompanied by wide-scale police enforcement, public announcements,

Lowering the limit

community programmes and mandatory blood tests for drivers involved in

The legal blood alcohol concentration limit for drunk driving in South Africa

crashes. This changed attitudes so that the behaviour is no longer socially

currently stands at 0.05g/100ml, which is in line with most other countries.

acceptable. Random breath testing substantially lowered the number of

Lowering the blood alcohol limit even further to 0.02g/100ml or even to zero

alcohol-related crashes.

is a popular rallying point for politicians and activists wanting to address drunk

combination of strategies, including lowering the limit to 0.05g/100ml

EUROPE: Like Brazil, both Germany and Portugal have non-criminal offences for driving under the influence alongside criminal offences for serious transgressions. In Germany this can include heavy fines and driver’s licence suspensions, but with no criminal record.

SOUTH AMERICA: Brazil’s banning of alcohol sales on state highways has had some impact in reducing traffic injuries. The country has also implemented a graded BAC limit. Drivers are screened with a breathalyser and those with breath alcohol concentration equivalent to 0.06g/100ml are detained (i.e. they cannot continue driving) and have to pay a spot fine. Criminal prosecution is reserved for drivers with higher levels.

driving. However, the increase in crash risk is much more noticeable above 0.05g/100ml. At the moment the current laws are not being properly enforced, so it can be argued that better enforcement of these laws is a more important priority.

The existing National Road Traffic Act provides for the limits of 0.05g and 0.02g/100ml for drivers and professional drivers respectively. The National Road Traffic Amendment Bill currently provides for a zero limit for both. Whether or not a stricter limit is adopted for everyone, it should definitely be considered for new drivers that have held their licence for less than three years to 0.01g or 0.02g per 100 ml. For young drivers, in particular, this separates two important processes: learning to drive and learning to drink.

Reducing the limit to 0 is ill-advised. People with insufficient alcohol to substantially impair their driving would test positive e.g. with trace elements

52

53

from cough medicines or hand sanitisers. This would overburden the criminal justice system whereas it is more important to apprehend people who are very intoxicated.

Increasing mass screening A high probability of being caught is a greater deterrent for drunk driving than the severity of the sentence. Every effort should be made to increase screening for drunk driving either at sobriety checkpoints at high-risk times (e.g. late at night or early in the morning, particularly on weekends, as well as on holidays and close to paydays) or through regular random breath testing.

Decriminalising minor offences In South Africa, blood alcohol content legislation is most commonly used to prosecute offenders. It is worthwhile considering a more nuanced approach

A synthesis of international research across multiple countries has shown that random breath testing can reduce fatal traffic crashes by 20%.

with non-criminal alcohol limits in addition to the criminal limits for more severe transgressions. This is a key strategy to reduce the burden on the courts and to increase the capacity for mass screening. Licence suspensions, community service and alcohol interlocks are preferable to fines because they are less susceptible to corruption and are also more equitable in that they do not favour the rich.

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Controlling the supply of alcohol to consumers effectively is crucial if we

4

4.

Reduce the availability of alcohol

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

Reduce the availability of alcohol.

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

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57

Regulating the number and location of alcohol outlets

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

4

by introducing operating hours and a levy of up to 55% on alcohol. In 2019,

Reduce the availability of alcohol

Regulating the times and days that alcohol can be sold to members of

Botswana’s previous president, Ian Khama, reduced consumption of alcohol 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.

Developing policies for the production of illicit and informal alcohol.

Raising the drinking age

International success stories

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.

There are numerous examples from around the world, but some are particularly relevant to South Africa.

Reduce availability In Russia, the last decade has seen a number of control measures being put in

Trading times Brazil showed ground-breaking success when the Mayor of Diadema

include:

introduced closing-time restrictions in 2002. A resounding 44% decline in

Minimum price of vodka

homicides resulted from the on- and off-consumption restrictions. For this

Where alcohol can be sold and consumed

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

No trade between 11pm and 8am

Brazilian Bar-Closure Act of 2002 is still in place, it is not being enforced and

Most importantly, monitoring wholesale and retail sales (outlets were

has led to an increase of 18.8% in the number of homicides.

58

place, which has led to a 43% reduction in consumption of liquor. Measures

equipped with cash registers dedicated to alcohol products).

59

Trading times

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.

starting point for all OTTs. These need to be made binding through inclusion in

Tracking and tracing

National and Provincial Liquor Acts. Provinces and municipalities can consider

A tracking system needs to be put in place: knowing where the liquor is from

setting stricter limits than the national limit, but they should never allow

production to consumption will reveal where the legal product becomes illegal

trading beyond the national Norms and Standards. Currently, three provinces

and who the guilty party is. This will help to address the sale of alcohol to and

(KwaZulu-Natal, Gauteng and North West) have trading hours that exceed

from unlicenced outlets and distributors.

The national Norms and Standards provide clear guidelines that can form the

4 Reduce the availability of alcohol

Implementation considerations for South Africa

national guidelines, with most municipalities in Mpumalanga and the Eastern Cape and a few in the Western Cape non-compliant.

The road to success

Minimum drinking age

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.

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.

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5.

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5

Advertising, availability and pricing are important to address the demand and

Intensify the availability of counselling and medically-assisted treatment

Intensify the availability of counselling and medicallyassisted treatment for persons struggling with dependence.

Addressing alcohol harm reduction requires a whole-of-society approach. 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.

63

Imposing earmarked fines for noncompliance with alcohol regulations

5

Taxation and excise duties on casinos and other forms of gambling.

Intensify the availability of counselling and medically-assisted treatment

Implementation considerations for South Africa

Treatment facilities are divided into: • Prevention

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.

• Early intervention • Treatment • After-care • Reintegration

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

These facilities need to be equitably distributed across the country, becoming

health promotion initiatives, including treatment of alcohol and substance

accessible for rural and semi-urban communities specifically; and emergency

use disorders.

medical services, including detoxification services, are needed to ensure

The onus is on government to implement innovative funding and preventative strategies and interventions; and to provide treatment for substances that are legally traded.

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.

Examples of funding could be generated from: State-owned retail monopolies Profit levy across alcohol beverage value chains Taxing alcohol advertising

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Measures include:

5

Educate women at child-bearing age about the risks of alcohol

Intensify the availability of counselling and medically-assisted treatment

Brief interventions

consumption to foetal development Healthcare settings In these settings, educational interventions based on alcohol consumption

Encourage early antenatal services for both expecting parents; screening/monitoring alcohol use of mothers-to-be

patterns (resulting from screening) is highly effective. WHO recommends

Case management of mothers who are at high risk of alcohol exposure

healthcare providers offer simple advice about alcohol-related risks to

during pregnancy.

light-to-moderate drinkers, including limits and goals to moderate-to-heavy drinkers.

Well distributed healthcare and health facilities provide the perfect

Schools/learning institutions

opportunity for screening alcohol use and provide early referrals to treatment

Youth who drink before turning 15 are five times more likely to develop an

and rehabilitation services. This is where standardised screening protocols

alcohol disorder than those who wait. If they start before 14, they will probably

need to be in place, so that these opportunities are not missed – and returning

encounter an alcohol-related injury, such as a traffic accident or being in a fight.

patients will be well considered.

It has been found that children who drink are likely to have mental health

Limitations include: only a small percentage of emergency centres are able

disorders and binge drink. It is vital to focus on this demographic to address

to offer these services, and managing alcohol-use disorders and perceived

alcohol-related harms.

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.

Referral system For long-term treatment, prevention and diversion activities treatment centres must be available (in South Africa, treatment facilities and referrals

Antenatal clinics Interventions in these settings will help reduce alcohol-exposed pregnancies.

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.

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Outpatient care

communities must be made a priority; active involvement of families, faithbased organisations and NPOs will help significantly.

5

lasts for at least three years. The patient is only removed from the state

Intensify the availability of counselling and medically-assisted treatment

To improve treatment and rehabilitation service outcomes, outreach into

inpatient institutions, by a psychiatrist-narcologist. Narcological monitoring 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

Integrated surveillance system

institutions.

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

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Contributors This document draws on the contributions of many of the individuals and organisations that have undertaken substantial research into the potential impact and viability of implementation of the measures described in this document, for example, the South African Medical Research Council (SAMRC) and the Chronic Disease Initiative for Africa at the University of Cape Town (CDIA).

The document was produced by the DG Murray Trust. The articles on the five measures were written by Dr Richard Matzopoulos.

Published March 2021 by DG Murray Trust (DGMT) Douglas Murray House 1 Wodin Rd +27 (0)21 670 9840 www.dgmt.co.za

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DGMT is a South African foundation built on endowments from Douglas George Murray and his wife, Eleanor. DGMT is committed to developing South Africa’s potential through public innovation and strategic investment. Our goal for South Africa is a flourishing people, economy and society. Towards this end DGMT currently distributes about R160-million per year and leverages and manages a similar amount of funding through joint ventures with other investors.