When faced with the need to respond to pressing public health challenges, it is often said solutions must involve a “whole of society approach”, in which as many stakeholders as possible are involved, reflecting the urgency and scale of the problem. While conceptually appealing, this approach can be influenced and co-opted in damaging and self-defeating ways. If you are in desperate need of protecting your hen house, should a whole of society approach mean you need to involve foxes? If society is faced with the urgent challenge of reducing emissions, is the best way forward to include a large delegation of fossil fuel lobbyists, since they too are part of the “whole of society”? Put simply, does a whole of society approach mean that even those actors that represent major drivers of a problem, and obstacles to its resolution, be unquestioningly involved in trying to solve it?
Alcohol industry representatives certainly argue this is the case. In a submission to the World Health Organisation’s consultation on an action plan to reduce global alcohol harms in 2020, the Portman Group wrote:
We believe that the UK market stands as an international example of industry best practice and the substantial progress that has been made to tackle the harmful use of alcohol in the country… The success of industry initiatives also demonstrates that the sector has a serious commitment to tackling harm in the UK and across the world and should continue to be seen as an active and willing partner as part of a ‘whole-of-society’ approach to tackling harmful alcohol use.
However, such claims of “substantial progress” contrast with the evidence, as in 2022, the last year for which data is available, there were 10,048 deaths from alcohol-specific causes in the UK, the highest number on record, and the UK remains one of the heaviest drinking countries in the world. It is worth noting that this “active and willing partner” derives a disproportionate amount of its revenue from those most harmed by its products – the heaviest drinkers – and sued the Scottish Government to prevent the implementation of Minimum Unit Pricing.
Indeed, there is now substantial evidence that not all actors and sectors are helpful parts of a “whole of society” approach, particularly when goals such as reducing alcohol consumption or increasing public awareness of alcohol harms pose a direct risk to future revenue. The recent governance guidance published by the Institute of Alcohol Studies (IAS) makes it clear that for critical social and health problems, there is a need to, on the one hand, involve as many relevant stakeholders and voices as possible, so all expertise, experience and marginalised groups are heard, but on the other, manage and where possible avoid the presence of stakeholders who have a fundamental conflict of interest, which in the case of alcohol harm, is the alcohol industry. This reflects wider acknowledgement by academics, NGOs and the World Health Organisation that there is an “inherent contradiction between the interests of alcohol producers and public health”.
What this means in practice is that partnerships with alcohol industry bodies, including those in receipt of its funding, should be rejected, as these pose risks to the integrity, credibility, trustworthiness and independence of policy development around alcohol harms. Furthermore, engagement of any sort by government organisations, such as health departments or similar bodies, with such alcohol industry actors should be clearly and transparently documented and organised on civil servants’ terms and premises, in accordance with objectives set in advance by the respective agency, rather than industry stakeholders. These types of limited interactions demark “engagement” within clearly defined parameters based on areas of relevant expertise, from wider, less well-defined and more exploitable notions of partnership.
The governance guidance from IAS reflects both the available evidence on how best to manage conflicts of interest, but also the growing evidence of the dangers of failing to manage conflicts of interest in alcohol policy in transparent and accountable ways. What is more, as well as clear guidance on what will help ensure the best possible, effective alcohol policies, we also have evidence of the various ways in which commercial operators can undermine such policies, making it even more important to safeguard credibility and independence. In other words, we increasingly understand how we might best manage conflicts of interest, and we increasingly understand how things can go wrong when we fail to do so.
The Drink Free Days campaign and commercial influence
Our recent paper illustrates the dangers to both integrity and credibility on the one hand, and the challenges of a lack of transparency on the other. We analysed documents revealed by freedom of information (FoI) requests regarding communications between Drinkaware, Public Health England (PHE), and the Portman Group before and during the Drink Free Days campaign, one of the most prominent examples of partnership between an alcohol industry body and a public body. The analysis revealed a range of less visible effects of the partnership that served commercial, rather than public health interests.
The emails show that the Portman Group (which it is worth remembering, is currently the alcohol marketing self-regulator in the UK) was actively seeking to influence PHE’s work in non-transparent ways, including the focus of an upcoming evidence review on alcohol policy, claiming new drinking guidelines would:
…only undermine efforts to convince drinkers low risk drinking is sensible and achievable”, and complaining about the composition of PHE’s expert advisory group, including the request that “…members of the group do not have track records in publicly campaigning for or against any of the alcohol policy evaluations your evidence review will be evaluating, as this would make it impossible for them to be objective or independent in their advice.”
Such criteria would remove almost all potential alcohol charity partners (other than industry-funded ones, which have been found to avoid mentioning evidence-based policies in their public-facing communications).
The correspondence also revealed that after the campaign was launched and faced widespread opposition including from members of PHE’s own alcohol advisory board, independent charities, the Alcohol Leadership Board, and the Association of Directors of Public Health, there was internal coordination between PHE and Drinkaware leadership about how best to avoid and manage criticism of “ivory tower professors”, rather than to publicly engage with the concerns of such organisations. This reflects a sense of how mutual dependency is created once a partnership has been begun, and that termination becomes difficult irrespective of how unpopular it becomes, or how evidence emerges to challenge it. The emails highlight this tension internally, as they show PHE sharing internal concerns with the language around alcohol and cancer on the Drinkaware website, and noting the lack of information about policy best buys; both concerns consistent with past thematic analyses of the misleading content of such organisations. This led to an internal review of Drinkaware website content, which Drinkaware requested control over:
…we will need to consider very carefully the scale, nature and terms of reference for such a review and who is commissioned to carry it out… it must be for Drinkaware to put forward proposals on these issues in the first instance….
This case study demonstrates the strategic functions of such partnerships, as it complemented ongoing efforts by the Portman group to define who is and isn’t seen as a legitimate actor in this space (including its questioning of who is on PHE’s advisory board, and its framing of certain charities as “anti-alcohol”), and its efforts to promote education and personal responsibility-focused initiatives rather than policies addressing marketing, price and promotion (which were largely absent from the campaign and the Drinkaware website).
The partnership also served to create division within public health, pitting the leadership of PHE against a wide range of health stakeholders who held legitimate concerns, and creating a tension between what PHE could say publicly, and the concerns it was expressing internally, which mirrored some of the external criticisms and past evidence.
These findings offer further evidence of the need for strong governance principles that are consistent with international recommendations by avoiding partnership with the alcohol industry and being proactively transparent about any interactions. Not to do so comes with high reputational costs as well as indirect negative consequences for policymaking and trusting relationships with civil society, researchers, and the wider public. Our analysis shows that more needs to be done by public health policymakers and agencies to implement robust mechanisms that can ensure that all their activities and (often limited) resources serve the interests of promoting the public’s health and are not blunted, distracted or undermined by the influence of commercial operators with a conflict of interest.
Written by Dr Nason Maani, University of Edinburgh, and Professor Mark Petticrew and Dr May van Schalkwyk, London School of Hygiene and Tropical Medicine.
All IAS Blogposts are published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Institute of Alcohol Studies.