Comments on the Draft Updated Appendix 3 of the WHO Global NCD Action Plan 20132020
(WHO Discussion Paper version dated 25 July 2016)
Submitted by the International Alliance for Responsible Drinking (IARD)
Who we are
The International Alliance for Responsible Drinking (IARD), launched in January 2015, is
dedicated to addressing harmful use of alcohol and promoting responsible drinking through
research, national and global programs, and policy dialogue. As an NGO, IARD has consultative
status with UN ECOSOC and builds on the work of two organizations - the International Center
for Alcohol Policies (ICAP) and the Global Alcohol Producers Group (GAPG).
IARD is funded by leading beer, wine and spirits producers and takes a multi-sectoral approach
to tackling harmful drinking. It supports global efforts to achieve the target of a 10% relative
reduction in harmful use of alcohol as laid out in the WHO Global Monitoring Framework for the
prevention and control of NCDs.
Also central to IARD’s mission is supporting implementation of the Beer, Wine and Spirits
Producers’ Commitments to Reduce Harmful Drinking, launched in 2013
(www.producerscommitments.org). Building on longstanding efforts in this area, producers have
undertaken these Commitments in recognition of the role that harmful drinking can play as a risk
factor for NCDs.
General comments
IARD welcomes the effort by WHO to reassess the evidence base around interventions that can
be used to reduce NCDs by tackling the harmful use of alcohol. A periodic updating of
recommended interventions through Appendix 3 of the Global Action Plan for the Prevention
and Control of Noncommunicable Diseases 2013-2020 (NCD Action Plan) (1) is important in
assisting Member States to identify state-of-the-art good practice.
The purpose of Appendix 3, as laid out in the NCD Action Plan, is “to provide information and
guidance on effectiveness and cost-effectiveness of interventions based on current evidence,”
and to help in expanding the evidence base. Both aspects are important – effectiveness to
determine what is likely to work, and cost-effectiveness to assess the cost implications of
implementation.
However, the proposed update to Appendix 3, as drafted on 25 July 2016 (2), falls short of this
original purpose.
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While the draft includes an updated assessment of cost-effectiveness, it ignores new
evidence around the effectiveness of interventions.
Similarly, while the original text of Appendix 3 identifies “the need to implement a
combination of population-side policy interventions and individual interventions,” the
revised draft places primary emphasis on regulatory measures.
There is room to reevaluate and strengthen the recommendations offered in Appendix 3, and to
provide a balanced and comprehensive assessment of the evidence, that can allow
governments of Member States to choose those interventions that offer greatest promise for
success. Reduction of the harmful use of alcohol, and, by extension, reduction of the burden of
NCDs can only be achieved by balancing population-level regulation and more carefully
targeted interventions.
Specific comments
The original text of Appendix 3 sets out as a requirement for selecting interventions
consideration of “effectiveness, cost-effectiveness, affordability, implementation capacity,
feasibility, according to national circumstances.” However, as laid out, the July 2015 update of
Appendix 3 and the evidence used in arriving at the highlighted recommendations around
reducing the harmful use of alcohol suffer from a number of shortcomings.
Evidence base
The 25 July 2016 draft update of Appendix 3 (2) lays out specific criteria to be applied in
identifying interventions that are effective, including:
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Having a “demonstrated and quantifiable effect size, from at least one published study in
a peer reviewed journal” (p.17); and
A clear link to one of the global NCD targets.
However, when highlighting interventions to reduce the harmful use of alcohol, the assessment
offers justification of the selection of particular interventions over others, and appears not to
have considered the full range of available research.
Furthermore, the actions listed under the heading “Harmful Use of Alcohol” ignore interventions
that meet the stated criteria for inclusion and for which evidence exits.
Among these interventions are:
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Education, including school-based programs (3-5);
Social norms approaches (6, 7);
Family-based interventions (8-12);
Multi-component interventions (13);
Screening and brief interventions (14-18);
Drink-drive interventions including lowering BAC and random and selective breath
testing (19-21); and
Workplace interventions that combine different strategies (22-24).
In some cases, for example, for multi-component and screening and brief interventions, there is
also demonstrable evidence of cost-effectiveness.
In setting the stage for the update of Appendix 3, a group of experts consulted by WHO in June
2015 identified a number of interventions for which new evidence was available. However, not
all of these are featured in the update of Appendix 3. Omitted from the list are:
 Drink driving policies (at least 3 different interventions, including BAC limits); and
 Reducing unrecorded alcohol.
Not only does the update of Appendix 3 ignore these interventions, it discounts brief
interventions in health care settings despite new evidence released by the OECD in 2015 that
shows them to be cost-effective (18).
The exclusive reliance on cost-effectiveness also runs directly counter to the recommendation
that is offered in the WHO Discussion Paper that accompanies the draft update to Appendix 3
(2).
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According to that document, “emphasis should be given to both economic and noneconomic criteria, as both will affect the implementation and impact of interventions”
(p.5).
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Among the key non-economic considerations are acceptability, sustainability, scalability,
equity, ethics, multi-sectoral actions, and monitoring of interventions. All of these are
likely to vary among countries and are important to take into account, but this variation
and its implications have not been considered in the assessment.
Cost-effectiveness
The assessment of cost-effectiveness offered in the draft update to Appendix 3 (2) also raises
some concerns.
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According to the original document, the regulatory measures that are highlighted as
“very cost-effective and affordable for all countries (…) have not been assessed for
specific contexts of individual countries” (p. 65). Yet these are the measures that
continue to be touted in the updated draft.
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In fact, the report of the Expert Consultation held in June 2015 (25) explicitly points out
that, when it comes to reducing harmful drinking, “it is unclear if “very cost-effective”
recommendations will apply to all countries – eg [sic] Saudi Arabia and countries with
high abstainer levels” (p. 15).
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The determination of cost effectiveness is made based on the apparent assumption that
all costs are exclusively borne by government. In reality, interventions around health in
many countries, including prevention and treatment, are often supported, either in part or
in their entirety, by other stakeholders, including civil society and the private sector.
The menu of interventions included in both the original and updated versions of Appendix 3
emphasizes the cost-effectiveness of particular measures, although the robustness of some of
the evidence is questionable.
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For example, enforcement of “bans or comprehensive restrictions on alcohol advertising”
is touted as a highly cost-effective intervention. At the same time, the report of the
Expert Consultation (25) explicitly singles out these measures as ones for which
evidence of effectiveness is variable. According to the report, “this has implications for
cost-effectiveness calculations“(p. 15).
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A recent systematic review (26) has shown that impact of such bans on harmful drinking
cannot be demonstrated. This evidence is not considered.
More generally, some of the basic assumptions underlying cost calculations have been
challenged. For example:
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The classification of costs as internal or external has been questioned, as well as how to
account for intangibles, including benefits. Cost-effectiveness calculations must take
into consideration all of these variables (27, 28).
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Questions have also been raised regarding the applicability of cost assessments across
countries. The cost of interventions in one country cannot be directly extrapolated to
others, nor can the relative impact of policy measures (27).
“Non-financial considerations” are highlighted in the documents but without acknowledging that
they carry their own financial costs, which must be taken into account.
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For example, “capacity for implementing and enforcing regulations and legislation” is
associated with obvious financial considerations, particularly where infrastructure and
resources are lacking, that need to be included in the calculation of cost and costeffectiveness.
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The WHO discussion paper (2) also calls upon Member States to apply additional
assessments to “help individual countries cost specific interventions in their national
context” (p. 5). This additional step is reflected neither in Appendix 3 nor in its
recommended actions.
Regulatory measures
While the limitations and caveats outlined above are also in part reflected in the relevant WHO
documents relating to Appendix 3, the recommendation regarding interventions for reducing
harmful drinking continues to favor regulatory measures.
However, it is important to raise several key concerns about the evidence base underpinning
these measures.
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There is little empirical evidence for the effectiveness of regulation, notably from lowand middle-income countries; available data are generally derived from a small number
of highly developed countries and from modelling studies, making their generalizability
questionable.
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More recent empirical evidence, such as the EU-sponsored AMPHORA study, clearly
shows a lack of correlation between regulatory policy measures, consumption, and
indicators of harmful drinking (29).
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While WHO estimates that around 25% of all alcohol consumed worldwide is unrecorded
(30), the figures are often significantly higher at the country level, where consumption
may be overwhelmingly of unrecorded products.
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As a result, even if they cost relatively little to apply, regulatory measures are likely to be
ineffective and inappropriate for reaching this segment of the alcohol market.
Unrecorded alcohol likely cannot be reached through government regulation, and is not
likely to be affected by population-level policies.
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In fact, severe regulation of the recorded alcohol market has been shown to be a major
driver of production and consumption of unrecorded alcohol.
There is also an important consideration regarding the effect of regulatory measures on harmful
drinking and, ultimately, NCDs.
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While regulatory and population-level measures already exist around alcohol in most
countries around the world, they are often poorly enforced.
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Based on evidence from systematic reviews and meta-analyses, regulatory measures,
such as increases in pricing of beverage alcohol, are also poor policy levers when it
comes to addressing heavy drinking and other harmful patterns.
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Furthermore, there is evidence that where the application of regulation is excessively
stringent and inappropriate for local circumstances, it may result in the growth of the
unrecorded alcohol market and have adverse implications for harmful drinking and
NCDs.
Final remarks
On balance, while the periodic revision of Appendix 3 is to be welcomed, in principle,
consideration should be given to the following in order to strengthen the process and output:
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A comprehensive review of all relevant evidence around interventions and regulatory
measures, taking into account all available and varying perspectives;
Transparency around the process employed and the evidence considered;
Emphasis on effectiveness, rather than cost-effectiveness in driving the selection of
interventions;
Consideration of the costs of potential unintended outcomes of regulatory measures, as
well as other relevant costs, such as enforcement;
Acknowledgment that costs need not be borne by government alone, but can be shared
among various relevant stakeholders, as appropriate at the national level;
Weighing of both financial and non-financial considerations in determining the most
appropriate course of action, depending on national context and circumstances.
A more comprehensive approach to addressing the harmful use of alcohol that reflects the
above considerations would serve to better implement actions that work, not only those that are
cost-effective for governments. Such an approach is also in keeping with other areas
addressed in the NCD Action Plan, such unhealthy diet and physical activity, where featured
(and cost-effective) interventions include educational approaches, such as public awareness
programs.
Broader assessment of costs related to effective interventions, and consideration of the
implications of involving a range of stakeholders to shoulder their burden of would not only be a
more realistic approach, but offer greater flexibility in implementation to Member States and
reduce the burden on national governments.
Such an approach is also consistent with the spirit of the NCD Action Plan, which lists multisectoral action as one of its Overarching Principles. It is also in keeping with the other relevant
initiatives, including the Global Strategy to Reduce the Harmful Use of Alcohol (31).
August 2016
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