Substitution of higher-strength beers with zero-alcohol beers:Interrupted time series analyses of Spanish household purchase data, 2017-2022

In its action plan (2022-2030) to reduce the harmful use of alcohol, WHO calls on economic operators to "substitute, whenever possible, higher-alcohol products with no-alcohol and lower-alcohol products in their overall product portfolios, with the goal of decreasing the overall levels of alcohol consumption in populations and consumer groups". This paper investigates substitution within beer brands at the level of the consumer, based on Spanish household purchase data using interrupted time series analysis. For households (n = 1791, 9.1% of all households) that newly bought at least one of eleven branded zero-alcohol beers (responsible for over three-quarters of all zero-alcohol beer purchased), the associated purchases of all grams of alcohol after the first purchase of zero-alcohol beer were reduced by 5.5%, largely due to substituting every one litre of higher strength beer (ABV > 3.5%) with 0.75 litres of same-branded zero-alcohol beer (ABV = 0.0%). For households (n = 337, 1.8% of all households) that had never previously purchased a same-branded higher-strength beer, but newly purchasing a same-branded zero-alcohol beer, the associated purchases of all grams of alcohol after the first purchase of zero-alcohol beer were reduced by 14%; this reduction was largely due to such households' decreasing their associated purchases of wines and spirits. Thus, at the level of the consumer, based on Spanish household purchase data of branded zero-alcohol beers, the evidence behind WHO's call for substitution appears to be substantiated

Effects of Substitution of Higher-Alcohol Products with Lower-Alcohol Products on Population-Level Alcohol Purchases:ARIMA Analyses of Spanish Household Data

In its action plan (2022-2030) to reduce the harmful use of alcohol, the WHO calls on economic operators to "substitute, whenever possible, higher-alcohol products with no-alcohol and lower-alcohol products in their overall product portfolios, with the goal of decreasing the overall levels of alcohol consumption in populations and consumer groups". This paper investigates substitution at the level of the consumer, based on Spanish household purchase data. ARIMA modelling of market research data of 1.29 million alcohol purchases from 18,954 Spanish households is used to study the potential impact of lower-strength alcohol products and the impact of beer prices in reducing household purchases of grams of alcohol between the 2nd quarter of 2017 and 1st quarter of 2022. Reducing the alcohol strength of existing higher-strength beers and wines had a much greater associated impact on reducing the purchases of all grams of alcohol than the relatively small increases in purchases of no-alcohol beers (ABV ≤ 1.0%) and zero-alcohol wines (ABV = 0.0%). For beers, the relative price per gram of alcohol decreased with the increasing ABV of the beer. Increasing the price per gram of alcohol in beers with an ABV > 3.5%, adjusted for the ABV of the beer, was associated with much greater increases in purchases of no-alcohol beers (ABV ≤ 1.0%) and much greater decreases in purchases of all grams of alcohol than decreases in the price of no-alcohol beers or increases in the price of beers with an ABV > 3.5% unadjusted for ABV. Thus, a key to reducing purchases of grams of alcohol, which also results in increased purchases of no-alcohol beers, is to increase the price of higher strength beers (ABV > 3.5%) with the price per gram of alcohol increasing as the ABV of the product increases

The Impact of Lower-Strength Alcohol Products on Alcohol Purchases by Spanish Households

In its action plan (2022-2030) to reduce the harmful use of alcohol, the WHO calls on economic operators to "substitute, whenever possible, higher-alcohol products with no-alcohol and lower-alcohol products in their overall product portfolios, with the goal of decreasing the overall levels of alcohol consumption in populations and consumer groups". In this paper, we investigate substitution at the level of the consumer based on Spanish household purchase data. ARIMA modelling of market research data of 1.29 million alcohol purchases from 18,954 Spanish households is used to study the potential impact of lower-strength alcohol products on reducing household purchases of grams of alcohol between the second quarter of 2017 and the first quarter of 2022. For households that recently bought either no-alcohol beer or wine (ABV ≤ 0.5%), the subsequent associated purchases of higher-strength beers and wines, respectively, and total grams of alcohol were reduced, the more so the higher the volume of initial purchases of beers and wines. The introduction of 20% ABV variants of same-branded 40% ABV whisky and gin during early 2021 was associated with reduced purchases of grams of alcohol within all spirits and of total grams of alcohol as a result of switching from other spirits products to the 20% variants, although not associated with reduced purchases of grams of alcohol within all variants of the studied same-branded whisky and gin; instead, an increase was observed in this category. With respect to Spanish household purchase data, the evidence behind the WHO's call for substitution is substantiated. Further research across different jurisdictions is needed to provide ongoing monitoring of the impact of potential substitution on consumer behavior and public health, including unintended consequences, with findings from research informing future alcohol policies at all levels

Production, consumption, and potential public health impact of low- and no-alcohol products: results of a scoping review.

Switching from higher strength to low- and no-alcohol products could result in consumers buying and drinking fewer grams of ethanol. We undertook a scoping review with systematic searches of English language publications between 1 January 2010 and 17 January 2021 using PubMed and Web of Science, covering production, consumption, and policy drivers related to low- and no-alcohol products. Seventy publications were included in our review. We found no publications comparing a life cycle assessment of health and environmental impacts between alcohol-free and regular-strength products. Three publications of low- and no-alcohol beers found only limited penetration of sales compared with higher strength beers. Two publications from only one jurisdiction (Great Britain) suggested that sales of no- and low-alcohol beers replaced rather than added to sales of higher strength beers. Eight publications indicated that taste, prior experiences, brand, health and wellbeing issues, price differentials, and overall decreases in the social stigma associated with drinking alcohol-free beverages were drivers of the purchase and consumption of low- and no-alcohol beers and wines. Three papers indicated confusion amongst consumers with respect to the labelling of low- and no-alcohol products. One paper indicated that the introduction of a minimum unit price in both Scotland and Wales favoured shifts in purchases from higher- to lower-strength beers. The evidence base for the potential beneficial health impact of low- and no-alcohol products is very limited and needs considerable expansion. At present, the evidence base could be considered inadequate to inform policy

Lower Strength Alcohol Products-A Realist Review-Based Road Map for European Policy Making

This paper reports the result of a realist review based on a theory of change that substitution of higher strength alcohol products with lower strength alcohol products leads to decreases in overall levels of alcohol consumption in populations and consumer groups. The paper summarizes the results of 128 publications across twelve different themes. European consumers are increasingly buying and drinking lower strength alcohol products over time, with some two fifths doing so to drink less alcohol. It tends to be younger more socially advantaged men, and existing heavier buyers and drinkers of alcohol, who take up lower strength alcohol products. Substitution leads to a lower number of grams of alcohol bought and drunk. Although based on limited studies, buying and drinking lower strength products do not appear to act as gateways to buying and drinking higher strength products. Producer companies are increasing the availability of lower strength alcohol products, particularly for beer, with extra costs of production offset by income from sales. Lower strength alcohol products tend to be marketed as compliments to, rather than substitutes of, existing alcohol consumption, with, to date, the impact of such marketing not evaluated. Production of lower strength alcohol products could impair the impact of existing alcohol policy through alibi marketing (using the brand of lower strength products to promote higher strength products), broadened normalization of drinking cultures, and pressure to weaken policies. In addition to increasing the availability of lower strength products and improved labelling, the key policy that favours substitution of higher strength alcohol products with lower strength products is an alcohol tax based on the dose of alcohol across all products

Additional file 1 of How much do Europeans know about the link between alcohol use and cancer? Results from an online survey in 14 countries

Supplementary Material

Protocol for a process evaluation of SCALA study: Intervention targeting scaling up of primary health care-based prevention and management of heavy drinking and comorbid depression in Latin America

This paper describes the plan for a process evaluation of a quasi-experimental study testing the municipal level scale-up of primary health care-based measurement and brief advice programmes to reduce heavy drinking and comorbid depression in Colombia, Mexico, and Peru. The main aims of the evaluation are to assess the implementation of intervention components; mechanisms of impact that influenced the outcomes; and characteristics of the context that influenced implementation and outcomes. Based on this information, common drivers of successful outcomes will be identified. A range of data collection methods will be used: questionnaires; interviews; observations; logbooks; and document analysis. All participating providers will complete a pen-and-paper questionnaire at recruitment and two time points during the implementation period. Providers attending training will complete post-training questionnaires. Additionally, 1080 patients will be invited to self-complete a patient questionnaire. One-in-ten participating providers and fifteen other key stakeholders will participate in semi-structured interviews. Training sessions and community advisory board meetings will be observed by a neutral observer. Logbooks will be kept by local research teams to document events affecting the implementation. Project related documentation and other relevant reports describing the context will be examined

Effect of community support on the implementation of primary health care-based measurement of alcohol consumption.

Alcohol measurement delivered by health care providers in primary health care settings is an efficacious and cost-effective intervention to reduce alcohol consumption among patients. However, this intervention is not yet routinely implemented in practice. Community support has been recommended as a strategy to stimulate the delivery of alcohol measurement by health care providers, yet evidence on the effectiveness of community support in this regard is scarce. The current study used a pre-post quasi-experimental design in order to investigate the effect of community support in three Latin American municipalities in Colombia, Mexico, and Peru on health care providers' rates of measuring alcohol consumption in their patients. The analysis is based on the first 5 months of implementation. Moreover, the study explored possible mechanisms underlying the effects of community support, through health care providers' awareness of support, as well as their attitudes, subjective norms, self-efficacy, and subsequent intention toward delivering the intervention. An ANOVA test indicated that community support had a significant effect on health care providers' rates of measuring alcohol consumption in their patients. Moreover, a path analysis showed that community support had a significant indirect positive effect on providers' self-efficacy to deliver the intervention, which was mediated through awareness of support. Specifically, provision of community support resulted in a higher awareness of support among health care providers, which then led to higher self-efficacy to deliver brief alcohol advice. Results indicate that adoption of an alcohol measurement intervention by health care providers may be aided by community support, by directly impacting the rates of alcohol measurement sessions, and by increasing providers' self-efficacy to deliver this intervention, through increased awareness of support