ABSTRACT

OBJECTIVE

To evaluate the support of the Brazilian population to the alcohol-policies proposed by the World Health Organization to decrease alcohol harm (specifically: to decrease alcohol availability and advertising, and to increase pricing). In addition, we evaluated the factors associated with being against those policies.

METHODS

Data from 16,273 Brazilians, aged 12–65 years, interviewed in the 3^rd Brazilian Household Survey on Substance Use (BHSU-3) were analyzed. The BHSU-3 is a nationwide, probability survey conducted in 2015. Individuals were asked if they would be against, neutral, or in favor of seven alcohol policies grouped as: 1) Strengthen restrictions on alcohol availability; 2) Enforce bans or restrictions on alcohol advertising, sponsorship, and promotion; and 3) Raise prices on alcohol through excise taxes and pricing. Generalized linear models were fitted to evaluate factors associated with being against each one of those policies and against all of policies.

RESULTS

Overall, 28% of the Brazilians supported all the above mentioned policies, whereas 16% were against them. The highest rate of approval refers to restricting advertising (53%), the lowest refers to increasing prices (40%). Factors associated with being against all policies were: being male (AOR = 1.1; 95%CI: 1.0–1.3), not having a religion (AOR = 1.4; 95%CI: 1.1–1.8), being catholic (AOR = 1.3; 95%CI: 1.1–1.5), and alcohol dependence (AOR = 1.6; 95%CI: 1.1–2.4).

CONCLUSIONS

The Brazilian government could count on the support of most of the population to restrict alcohol advertising. This information is essential to tackle the lobby of the alcohol industry and its clever marketing strategy.

Alcohol Drinking, prevention & control; Products Publicity Control; Public Policy; Public Opinion; Brazil

INTRODUCTION

Decreasing the harmful use of alcohol is a specific objective of the Sustainable Development Goals (SDGs) since it is a leading risk factor associated with an increased burden of disease worldwide, and the leading risk factor for mortality among people aged 15–49 years¹1. World Health Organization. Global status report on alcohol and health 2018. Geneva (CH); WHO; 2018 [cited 2021 Jul 23]. Available from: https://www.who.int/publications/i/item/9789241565639
https://www.who.int/publications/i/item/... . In Brazil, the prevalence of alcohol use in the last 12 months has been estimated at 43.1%, while the prevalence of binge drinking and alcohol dependence were estimated at 16.5% and 1.5%, respectively⁴4. De Boni RB, Vasconcellos MTL, Silva PN, Coutinho C, Mota J, Peixoto JNB, et al. Reproducibility on science: challenges and advances in Brazilian alcohol surveys. Int J Drug Policy. 2019;74:285-91. https://doi.org/10.1016/j.drugpo.2019.07.029
https://doi.org/10.1016/j.drugpo.2019.07... . Accordingly, alcohol use is estimated to be the 5^th most relevant risk factor for death and disability in the country⁵5. Institute for Health Metrics and Evaluation. Burden of Disease: country profiles-Brazil. Seattle, WA: IHME; 2017. .

Alcohol policies are effective to decrease alcohol-related problems⁶6. Room R, Babor T, Rehm J. Alcohol and public health. Lancet. 2005;365(9458):519-30. https://doi.org/10.1016/S0140-6736(05)17870-2
https://doi.org/10.1016/S0140-6736(05)17... . In 2010, the World Health Organization (WHO)’s Global Strategy to Reduce the Harmful Use of Alcohol⁷7. World Health Organization. Global strategy to reduce the harmful use of alcohol. Geneva (CH): WHO; 2010 [cited 2022 Jan 14]. Available from: https://www.who.int/publications/i/item/97892415999318.
https://www.who.int/publications/i/item/... recommended policies and interventions in ten target areas “(a) leadership, awareness and commitment, b) health services’ response, c) community action, d) drink-driving policies and countermeasures, e) availability of alcohol, f) marketing of alcoholic beverages, g) pricing policies, h) reducing the negative consequences of drinking and alcohol intoxication, i) reducing the public health impact of illicit alcohol and informally produced alcohol, and j) monitoring and surveillance.” In 2018, the WHO launched the SAFER initiative to help governments implement five of the most cost-effective policies⁸8. Monteiro MG. The World Health Organization’s SAFER initiative and the challenges in Brazil to reducing harmful consumption of alcoholic beverages. Epidemiol Serv Saude. 2020;29(1):e202000. https://doi.org/10.5123/S1679-49742020000100011
https://doi.org/10.5123/S1679-4974202000... . SAFER is the acronym for “Strengthen restrictions on alcohol availability”, “Advance and enforce drink driving counter measures”, “Facilitate access to screening, brief interventions and treatment”, “Enforce bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion”, and “Raise prices on alcohol through excise taxes and pricing policies”⁹9. Organização Pan-Americana da Saúde, Unidade de Saúde Mental e Abuso de Substâncias, Departamento de Doenças Crônicas Não Transmissíveis e Saúde Mental. Pacote Técnico SAFER: Um Mundo Livre dos Danos Relacionados ao Álcool: cinco áreas de intervenção em âmbito nacional e estadual. Washington, DC: PAHO: 2020 [cited 2022 Jan 14 ]. Available from: https://iris.paho.org/handle/10665.2/51903
https://iris.paho.org/handle/10665.2/519... . Three of those policies are also recommended as “best buys” to tackle non-communicable diseases (increase prices, restrict advertising, and restrict physical availability)¹⁰10. World Health Organization, Department for Management of NCDs, Disability, Violence and Injury Prevention. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva (CH): WHO; 2017. (Tackling NCDs best buys). [cited 2022 Jan 14 ]. Available from: https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf
https://apps.who.int/iris/bitstream/hand... .

Such policies are sound and feasible, but implementation demand the government’s commitment with public health and consistency in confronting the powerful industry lobby. Partnership with the civil society should be assessed and explored in detail. The putative coalition of government and the civil society is key to remove vetoes imposed by different lobbies, especially the one fostered by the alcohol industry¹¹11. Tsebelis G. Veto players: how political institutions work. Princeton, NJ: Princeton University Press; 2002. .

Alcohol policies have evolved in Brazil in the last 20 years, although many gaps persist¹²12. Oliveira CWL, Mendes CV, Kiepper A, Monteiro MG, Wagner GA, Sanchez ZM. Analysis of gaps in alcohol policies in Brazil using the Pan American Health Organization’s Alcohol Policy Scoring. Int J Drug Policy. 2021;97:103322. https://doi.org/10.1016/j.drugpo.2021.103322
https://doi.org/10.1016/j.drugpo.2021.10... , ¹³13. Pan American Health Organization. Alcohol Policy Scoring: assessing the level of implementation of the WHO Global strategy to reduce the harmful use of alcohol in the Region of the Americas. Washington, WA: PAHO; 2018 [cited 2022 Jan 14]. Available from https://iris.paho.org/bitstream/handle/10665.2/49679/9789275120453_eng.pdf?sequence=2&isAllowed=y
https://iris.paho.org/bitstream/handle/1... . For instance, in 2010, a new legislation on drinking and driving was approved, in which the legal amount of alcohol blood concentration allowed for driving was decreased to zero and the random breath tests to be performed were increased¹⁴14. De Boni RB, Pechansky F, Vasconcellos MT, Bastos FI. Have drivers at alcohol outlets changed their behavior after the new traffic law? Rev Bras Psiquiatr. 2014;36(1):11-5. https://doi.org/10.1590/1516-4446-2013-1131
https://doi.org/10.1590/1516-4446-2013-1... . Restrictions on alcohol sales were implemented for specific events and on petrol stations. There are no alcohol monopolies, and although a license is required to sell alcohol, almost every commercial establishment is able to get one. Additionally, alcohol is largely sold in the informal market and there is no regulation on in/out premise drinking or alcohol density outlets¹⁵15. De Boni R, Pechansky F, Silva PLN, Vasconcellos MTL, Bastos FI. Is the prevalence of driving after drinking higher in entertainment areas? Alcohol Alcohol. 2013;48(3):356-62 https://doi.org/10.1093/alcalc/ags126
https://doi.org/10.1093/alcalc/ags126... , ¹⁶16. De Boni R, Silva PLN, Bastos FI, Pechansky F, Vasconcellos MTL. Reaching the hard-to-reach: a probability sampling method for assessing prevalence of driving under the influence after drinking in alcohol outlets. PloS One. 2012;7(4):e34104. https://doi.org/10.1371/journal.pone.0034104
https://doi.org/10.1371/journal.pone.003... . Regarding advertising policies, there are no regulations on alcohol industry sponsorship, alcohol sales promotion, and beer advertising. Finally, regarding pricing, there are excise taxes for beer, wine, and spirits¹1. World Health Organization. Global status report on alcohol and health 2018. Geneva (CH); WHO; 2018 [cited 2021 Jul 23]. Available from: https://www.who.int/publications/i/item/9789241565639
https://www.who.int/publications/i/item/... – but they are modest compared to other countries and are not clear to the general population.

It is reasonable to believe that governments from democratic countries would be more prone to implement policies supported by the general population. International studies have found that targeted policies – such as legal age to purchase alcoholic beverages and drinking and driving control – are more likely to be supported than general policies (such as increasing tax and prices)¹⁷17. Dekker MR, Jones A, Maulik PK, Pettigrew S. Public support for alcohol control initiatives across seven countries. Int J Drug Policy. 2020;82:102807. https://doi.org/10.1016/j.drugpo.2020.102807
https://doi.org/10.1016/j.drugpo.2020.10... , ¹⁸18. Seo S, Chun S, Newell M, Yun M. Korean public opinion on alcohol control policy: a cross-sectional International Alcohol Control study. Health Policy. 2015;119(1):33-43. https://doi.org/10.1016/j.healthpol.2014.10.016
https://doi.org/10.1016/j.healthpol.2014... . Moreover, support levels varied by age, gender, income level, and pattern of alcohol use¹⁷17. Dekker MR, Jones A, Maulik PK, Pettigrew S. Public support for alcohol control initiatives across seven countries. Int J Drug Policy. 2020;82:102807. https://doi.org/10.1016/j.drugpo.2020.102807
https://doi.org/10.1016/j.drugpo.2020.10... .

We aim to evaluate the support of the Brazilian population regarding policies targeted toward decreasing alcohol availability and advertising, as well as toward increasing prices. Such policies have shown to be effective and cost-effective in different settings¹⁹19. Burton R, Henn C, Lavoie D, O’Connor R, Perkins C, Sweeney K, et al. A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective. Lancet. 2017;389(10078):1558-80. https://doi.org/10.1016/S0140-6736(16)32420-5
https://doi.org/10.1016/S0140-6736(16)32... . Additionally, we evaluated the factors associated with being against those policies.

METHODS

This is a secondary analysis of data collected in the 3^rdBrazilian Household Survey on Substance Use (BHSU-3). The full methodological report describing the sampling design, questionnaires, data collection, data entry, handling of non-response and estimation procedures is publicly available at https://www.arca.fiocruz.br/handle/icict/34614 (in Portuguese, English, and Spanish). Briefly, the BHSU-3 was a nationwide, probability sample survey conducted in 2015. The study population comprised 16,273 Brazilians, 12–65 years old. Native individuals living in indigenous villages, inmates, and individuals with physical or mental disabilities that may preclude answering the interviews were not eligible. Individuals were interviewed face-to-face by trained interviewers after signing the informed consent/assent form. The study was approved by the institutional review board of the Escola Politécnica Joaquim Venâncio -Fiocruz (CAAE # 35283814.4.0000.5241)⁴4. De Boni RB, Vasconcellos MTL, Silva PN, Coutinho C, Mota J, Peixoto JNB, et al. Reproducibility on science: challenges and advances in Brazilian alcohol surveys. Int J Drug Policy. 2019;74:285-91. https://doi.org/10.1016/j.drugpo.2019.07.029
https://doi.org/10.1016/j.drugpo.2019.07... , ²⁰20. De Boni RB, Vasconcellos MTL, Silva KML, Bertoni N, Coutinho CFS, Mota JC, et al. Substance use, self-rated health and HIV status in Brazil. AIDS Care. 2021;33(10):1358-62. https://doi.org/10.1080/09540121.2020.1799923
https://doi.org/10.1080/09540121.2020.17... .

Outcomes

Individuals were asked if they would be in favor, neutral, or against, in case the following policies were implemented to decrease alcohol-related harm: reducing alcohol outlets, restricting opening hours, implementing licenses to sell alcohol, controlling advertising, forbidding sponsoring sports events, increasing price, and increasing taxes. Seven dichotomic outcomes were created for the present analysis. Initially we defined the three major policies to be evaluated (following the WHO’s “best buys” included in the SAFER initiative):

1. Strengthen restrictions on alcohol availability: included the questions on Reduce alcohol outlets policy, Restrict opening hours policy , and Implement license to sell alcohol policy ;

2. Enforce bans or restrictions on alcohol advertising, sponsorship, and promotion: included Control advertising policy and Forbid sponsoring sports policy ;

3. Raise prices on alcohol through excise taxes and pricing: included Increase taxes policy and Increase price policy .

To evaluate the frequencies of being “In favor” of each one of the above, individuals had to answer they were in favor to all the policies related to the group. Those who were neutral or against them were defined, for the sake of our study, as “not in favor.” Likewise, to be considered “against” each policy, individuals had to answer they were against all the policies from the group.

Finally, the main outcome “Being against all policies” was created as follows: Strengthen restrictions on alcohol availability policies was equal to “against” AND Enforce bans or restrictions on alcohol advertising, sponsorship, and promotion policies was equal to “against” AND Raise prices on alcohol through excise taxes and pricing policies was equal to “against.” Thus, “Being against all policies” was “yes,” and everything else was “no”.

Independent Variables

Demographic variables: were collected using questions from the Brazilian Demographic Census²⁵25. Instituto Brasileiro de Geografia e Estatística, Sistema IBGE de Recuperação Automática – SIDRA. Censo Demográfico 2010. Rio de Janeiro: IBGE; ano? [cited year Month day]. Available from: http://www.sidra.ibge.gov.br/bda/orcfam/default.asp
http://www.sidra.ibge.gov.br/bda/orcfam/... , and included: sex at birth (male versus female), color/race (white, black, mixed, other), educational level (primary, high-school, or college/university), income, religion (Catholic, Christian, none, other), reporting a steady partner (yes, no), number of children (none, one or more), Brazil’s geographic macroregions (North/ Northeast, Southeast/ South, and Center-west), living in urban versus rural areas.

Self-rated health: was evaluated by the question “Overall, how is your health?” Possible answers were provided using a Likert scale ranging from “very bad” to “very good”, which were categorized as very good/good, regular/don’t know, and very bad/bad²⁶26. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav. 1997;38(1):21-37. .

Alcohol use in the last 12 months: it is reported as composite variable “no use in the last 12 months”, “use but no dependence”, and “alcohol dependence”. Alcohol dependence was evaluated using the Diagnostic and Statistical Manual of Mental Disorders criteria⁴4. De Boni RB, Vasconcellos MTL, Silva PN, Coutinho C, Mota J, Peixoto JNB, et al. Reproducibility on science: challenges and advances in Brazilian alcohol surveys. Int J Drug Policy. 2019;74:285-91. https://doi.org/10.1016/j.drugpo.2019.07.029
https://doi.org/10.1016/j.drugpo.2019.07... , ²⁷27. Associação Americana de Psiquiatria. Manual diagnóstico e estatístico de transtornos mentais DSM. 4. ed. rev. Porto Alegre, RS: Artes Médicas; 2002. .

Substance use in the last 12 months: cannabis and cocaine were included since they are the most frequent illicit substances used in the country²⁸28. Silva PLN, Vasconcellos MTL, Bastos FI, De Boni RB, Bertoni N, Coutinho C, Mota J. First reproducible nationwide survey on substance use in Brazil: survey design and weighting. In: Proceedings of the Joint Statistical Meetings 2018 Survey Research Methods Section; Jul 28-Aug 2; Vancouver, Canada [cited year Month day]. Available from: http://www.asasrms.org/Proceedings/y2018/files/867101.pdf
http://www.asasrms.org/Proceedings/y2018... .

Statistical Analysis

Point prevalence and respective standard errors of being in favor of each group of policies (i.e. “Strengthen restrictions on alcohol availability policies”, “Enforce bans or restrictions on alcohol advertising, sponsorship, and promotion”, and “Raise prices on alcohol through excise taxes and pricing policies”) were calculated for the whole sample, as well, as stratified by the independent variables.

Generalized linear regression models were fitted to evaluate factors independently associated with “being against all policies” and being against each subset of policies. Initially, bivariate analysis was conducted to evaluate the association of independent variables and each one of the outcomes. Variables presenting association at p-value < 0.20 at the bivariate analysis were considered for the multivariable regression models. Four backward logistic models were fitted, until reaching the most parsimonious models. All analyses considered sample weights, design effect, and weight calibration. Analyses were carried out using R v.3.5.0 using the ‘survey’ and ‘surveyer’ libraries²⁹29. Lumley T. Complex surveys: a guide to analysis using R. Hoboken, NJ: John Wiley & Sons; 2010. .

RESULTS

The 16,273 individuals interviewed represent an estimated population of 153 million Brazilians. Overall, 27.6% (SE 1.0) were in favor of all alcohol-related policies. 53% of the population were in favor of enforcing bans or restrictions on alcohol advertising, while 40% were in favor of raising prices. The higher rates of support for all policies were reported by females, Christian, those with a steady partner, with children, living in the North/Northeast, reported bad/very bad self-rated health, and who did not use alcohol, cannabis, or cocaine ( Table 1 ).

Overall, 15.8% (0.9) of the Brazilians were against all alcohol policies: 25.3% were against the strengthening of restrictions on alcohol availability; 28.5% were against the enforcement of bans or restrictions on alcohol advertising, sponsorship, and promotion; and 30.6% were against the raising of prices on alcohol by excise taxes and pricing policies. Figure 1 and Table 2 show the factors associated with being against all policies and specifically against each subset of policies. The only factors associated with being against all policies and all subsets of policies were being male, not having a religion, or being Catholic (compared to Christian). Age above 44 years was associated with being against restrictions on alcohol availability. To live in the South/Southeast (most urbanized and industrialized) regions (compared to North/Northeast) was associated with being against restrictions on alcohol availability and price increase. Having primary education ( versus college education or more) increased the chance of being against advertising control. Alcohol dependence increased the likelihood of being against all policies, while alcohol use in the last 12 months increased the likelihood of being against advertising and price increase. Finally, cannabis use in the last 12 months was associated with being against restrictions on availability and pricing.

Interestingly, after controlling for confounding factors, having children and having used cocaine in the last 12 months were not found to be associated to any of the outcomes. Figure 2 shows the factors associated with each one of the abovementioned policies.

DISCUSSION

The present study shows that 28% of the Brazilian population was in favor of implementing all alcohol-related policies evaluated. Policies related to reducing advertisement were endorsed by most of the population. On the other hand, 16% of the population was against implementing all policies. Factors associated with being against implementation were being male, not having a religion or being catholic, and presenting alcohol dependence.

Overall, the support for alcohol public policies in Brazil (40%–52%) was similar to the United States (33%–72%) and Canada (35%–68%), but lower than other middle-high income countries, such as India (80%–86%) and China (57%–85%)¹⁷17. Dekker MR, Jones A, Maulik PK, Pettigrew S. Public support for alcohol control initiatives across seven countries. Int J Drug Policy. 2020;82:102807. https://doi.org/10.1016/j.drugpo.2020.102807
https://doi.org/10.1016/j.drugpo.2020.10... . This level of putative endorsement should be further explored via triangulation with further assessments using in-depth interviews and focus groups, among other methods³⁰30. Creswell JW, Creswell JD. Research design: qualitative, quantitative, and mixed methods approaches. 5. ed. Los Angeles, CA: SAGE Publications; 2018. .

Notably, alcohol-related policies are less restrictive and loosely enforced in Brazil compared to the United States/Canada. Currently, there are no regulations on alcohol outlets availability, policies regarding prices are not transparent, and beer advertising is permitted. Such permissiveness is not compatible with the high rates of alcohol-related mortality in the country. In addition to the fact that alcohol drinking is the 5^th risk factor regarding the overall burden of disease⁵5. Institute for Health Metrics and Evaluation. Burden of Disease: country profiles-Brazil. Seattle, WA: IHME; 2017. , Brazil ranks second, in the Americas (after the United States), on the absolute number of deaths that were 100% attributable to alcohol use³¹31. Chrystoja BR, Monteiro MG, Owe G, Gawryszewski VP, Rehm J, Shield K. Mortality in the Americas from 2013 to 2015 resulting from diseases, conditions and injuries which are 100% alcohol-attributable. Addiction. 2021;116(10):2685-96. https://doi.org/10.1111/add.15475
https://doi.org/10.1111/add.15475... .

Changing this situation, unfortunately, seems to be a distant dream. Brazil is still considered a market in expansion by the alcohol industry, which, in 2011, was one of the main investors in marketing in the country. Such industry, as well as the tobacco and the ultraprocessed food industries (known as “unhealthy commodity industry”³²32. Raynes-Greenow C, Gaudino JA, Wilson RT, Advani S, Weiss SH, Al Delaimy W. Beyond simple disclosure: addressing concerns about industry influence on public health. BMJ Glob Health. 2021;6(2):e004824. https://doi.org/10.1136/bmjgh-2020-004824
https://doi.org/10.1136/bmjgh-2020-00482... ), has a wide range of common strategies to influence public policies and maintain their profits³³33. Bartlett A, McCambridge J. Doing violence to evidence on violence? How the alcohol industry created doubt in order to influence policy. Drug Alcohol Rev. 2022;41(1):144-52. https://doi.org/10.1111/dar.13354
https://doi.org/10.1111/dar.13354... . Those include both “coercion and appeasement” strategies³⁶36. Lacy-Nichols J, Marten R. Power and the commercial determinants of health: ideas for a research agenda. BMJ Glob Health. 2021;6(2):e003850. https://doi.org/10.1136/bmjgh-2020-003850
https://doi.org/10.1136/bmjgh-2020-00385... . In 2018, a systematic review showed that the two main strategies used by the alcohol industry were of excluding from the debate issues against their interest (like increasing prices) and building relationships with different agents who could influence policy making (including researchers)³⁷37. McCambridge J, Mialon M, Hawkins B. Alcohol industry involvement in policymaking: a systematic review. Addiction. 2018;113(9):1571-84. https://doi.org/10.1111/add.14216
https://doi.org/10.1111/add.14216... .

The characteristics of individuals who support the policies are similar to those from other countries¹⁸18. Seo S, Chun S, Newell M, Yun M. Korean public opinion on alcohol control policy: a cross-sectional International Alcohol Control study. Health Policy. 2015;119(1):33-43. https://doi.org/10.1016/j.healthpol.2014.10.016
https://doi.org/10.1016/j.healthpol.2014... , ³⁸38. Trangenstein PJ, Greenfield TK, Karriker-Jaffe KJ. Interested constituents: identifying groups to mobilize in community organizing efforts to strengthen alcohol control policies. Am J Drug Alcohol Abus. 2021;47(3):393-401. https://doi.org/10.1080/00952990.2020.1870690
https://doi.org/10.1080/00952990.2020.18... , ³⁹39. Giesbrecht N, Ialomiteanu A, Anglin L, Adlaf E. Alcohol marketing and retailing: public opinion and recent policy developments in Canada. J Subst Use. 2007;12(6):389-404. https://doi.org/10.1080/14659890701262189
https://doi.org/10.1080/1465989070126218... , including sex, religion (Christian), and pattern of alcohol use (abstainers). Other characteristics, such as being a parent and not using cannabis or cocaine, are less studied elsewhere. Individuals raising children may be more likely to be concerned about their futures, especially because traffic crashes and violence (which are both related to alcohol consumption) are the main causes of death among male young adults in the country⁵5. Institute for Health Metrics and Evaluation. Burden of Disease: country profiles-Brazil. Seattle, WA: IHME; 2017. .

Furthermore, marketing strategies are aggressive toward adolescents⁴⁰40. Pantani D, Sanchez ZM, Pinsky I. The urgent need to advance alcohol marketing regulation to protect children. alcoholism: clinical and experimental research. 2020;44(10):2141-2. https://doi.org/10.1111/acer.14442
https://doi.org/10.1111/acer.14442... − who are particularly vulnerable to propaganda⁴¹41. Boniface S, Critchlow N, Severi K, MacKintosh AM, Hooper L, Thomas C, et al. Underage Adolescents’ Reactions to Adverts for Beer and Spirit Brands and Associations with Higher Risk Drinking and Susceptibility to Drink: a cross-sectional study in the UK. Alcohol Alcohol. 2021:agab018. https://doi.org/10.1093/alcalc/agab018
https://doi.org/10.1093/alcalc/agab018... − which may increase parents’ concerns. Restricting alcohol advertising is an effective measure to prevent alcohol harms. For instance, since 1975 alcohol advertising was banned in Norway, and alcohol sales have decreased over time⁴²42. Rossow I. The alcohol advertising ban in Norway: effects on recorded alcohol sales. Drug Alcohol Rev. 2021;40(7):1392-5. https://doi.org/10.1111/dar.13289
https://doi.org/10.1111/dar.13289... . Identifying groups who would putatively support these policies may be important to find community allies seeking to reduce alcohol consumption and harms³⁸38. Trangenstein PJ, Greenfield TK, Karriker-Jaffe KJ. Interested constituents: identifying groups to mobilize in community organizing efforts to strengthen alcohol control policies. Am J Drug Alcohol Abus. 2021;47(3):393-401. https://doi.org/10.1080/00952990.2020.1870690
https://doi.org/10.1080/00952990.2020.18... .

The characteristics of individuals who were against alcohol policies (male, alcohol use, and alcohol dependence) were also similar to other studies¹⁷17. Dekker MR, Jones A, Maulik PK, Pettigrew S. Public support for alcohol control initiatives across seven countries. Int J Drug Policy. 2020;82:102807. https://doi.org/10.1016/j.drugpo.2020.102807
https://doi.org/10.1016/j.drugpo.2020.10... . Notably, men are less likely to support alcohol policies, despite alcohol-related mortality among males being higher than among their female counterparts³¹31. Chrystoja BR, Monteiro MG, Owe G, Gawryszewski VP, Rehm J, Shield K. Mortality in the Americas from 2013 to 2015 resulting from diseases, conditions and injuries which are 100% alcohol-attributable. Addiction. 2021;116(10):2685-96. https://doi.org/10.1111/add.15475
https://doi.org/10.1111/add.15475... . One possible explanation is their historical higher use of alcohol (compared to women). In this sense, they could consider alcohol drinking as less harmful. Alcohol policies, in fact, tend to strongly affect men, as recent studies from Lithuania and Poland have shown⁴³43. Štelemėkas M, Manthey J, Badaras R, Casswell S, Ferreira-Borges C, Kalėdienėet R, et al. Alcohol control policy measures and all-cause mortality in Lithuania: an interrupted time–series analysis. Addiction. 2021;116(10):2673-84. https://doi.org/10.1111/add.15470
https://doi.org/10.1111/add.15470... , ⁴⁴44. Zatoński WA, Zatonski M, Janik-Koncewicz K, Wojtyla A. Alcohol-related deaths in Poland during a period of weakening alcohol control measures. JAMA. 2021;325(11):1108-9. https://doi.org/10.1001/jama.2020.25879
https://doi.org/10.1001/jama.2020.25879... . Similarly, it is possible that alcohol users/people who are alcohol-dependent have a lower risk perception regarding alcohol drinking. Considering that these individuals could be benefited by policies regarding screening and treatment, they may be more prone to see such policies as needed³⁸38. Trangenstein PJ, Greenfield TK, Karriker-Jaffe KJ. Interested constituents: identifying groups to mobilize in community organizing efforts to strengthen alcohol control policies. Am J Drug Alcohol Abus. 2021;47(3):393-401. https://doi.org/10.1080/00952990.2020.1870690
https://doi.org/10.1080/00952990.2020.18... . Since we did not collect this information in our survey, further research is necessary in Brazil.

The policy group with lower rate of support was the one related to raising prices and taxes, as many other studies have also shown¹⁷17. Dekker MR, Jones A, Maulik PK, Pettigrew S. Public support for alcohol control initiatives across seven countries. Int J Drug Policy. 2020;82:102807. https://doi.org/10.1016/j.drugpo.2020.102807
https://doi.org/10.1016/j.drugpo.2020.10... , ³⁸38. Trangenstein PJ, Greenfield TK, Karriker-Jaffe KJ. Interested constituents: identifying groups to mobilize in community organizing efforts to strengthen alcohol control policies. Am J Drug Alcohol Abus. 2021;47(3):393-401. https://doi.org/10.1080/00952990.2020.1870690
https://doi.org/10.1080/00952990.2020.18... , ³⁹39. Giesbrecht N, Ialomiteanu A, Anglin L, Adlaf E. Alcohol marketing and retailing: public opinion and recent policy developments in Canada. J Subst Use. 2007;12(6):389-404. https://doi.org/10.1080/14659890701262189
https://doi.org/10.1080/1465989070126218... . To raise price is one of the most effective public health policies for decreasing consumption of harmful products. Two systematic reviews evaluated empirical studies regarding the effect of increasing taxes on goods that represent risk to the public health, i.e.: tobacco, alcohol, sugar-sweetened beverages showing the benefit of those policies⁴⁵45. Wright A, Smith KE, Hellowell M. Policy lessons from health taxes: a systematic review of empirical studies. BMC Public Health. 2017;17:583. https://doi.org/10.1186/s12889-017-4497-z
https://doi.org/10.1186/s12889-017-4497-... , ⁴⁶46. Miracolo A, Sophiea M, Mills M, Kanavos P. Sin taxes and their effect on consumption, revenue generation and health improvement: a systematic literature review in Latin America. Health Policy Plan. 2021;36(5):790-810. https://doi.org/10.1093/heapol/czaa168
https://doi.org/10.1093/heapol/czaa168... . Interestingly very few studies related to alcohol use were included and the reasons for this low number were not discussed. Additionally, WHO clearly recommends tax rates for tobacco (70%) and sugar-sweetened beverages (20%), but not for alcohol. As recently stated, alcohol remains the “blind spot in global health”⁴⁷47. Marten R, Amul GGH, Casswell S. Alcohol: global health’s blind spot. Lancet Glob Health. 2020;8(3):e329-30. https://doi.org/10.1016/S2214-109X(20)30008-5
https://doi.org/10.1016/S2214-109X(20)30... . The reasons for that include the powerful lobby of alcohol industry across governments and countries, as well as its sophisticated marketing strategy⁴⁷47. Marten R, Amul GGH, Casswell S. Alcohol: global health’s blind spot. Lancet Glob Health. 2020;8(3):e329-30. https://doi.org/10.1016/S2214-109X(20)30008-5
https://doi.org/10.1016/S2214-109X(20)30... . Restricting or banning alcohol advertising is one of the most cost-effective policies to decrease alcohol drinking and its positive results on decreasing sales have been documented for a long time⁴²42. Rossow I. The alcohol advertising ban in Norway: effects on recorded alcohol sales. Drug Alcohol Rev. 2021;40(7):1392-5. https://doi.org/10.1111/dar.13289
https://doi.org/10.1111/dar.13289... . However, controlling advertising is getting even harder due to social media. Findings from a study on browsing contents disseminated by Twitter® show that the most frequent arguments used by alcohol industry/supporters relate to the idea that liberal policies would increase revenue, individual liberties must be prioritized over government control, and education is the best solution for alcohol related problems⁵¹51. Sama TB, Konttinen I, Hiilamo H. Alcohol industry arguments for liberalizing alcohol policy in Finland: analysis of Twitter data. J Stud Alcohol Drugs. 2021;82(2):279-87. .

It is worrisome that there are researchers and opinion makers who still think this way. Among the huge challenges ahead remains the need to create population demand, instead of general agreement, of effective public policies⁴⁸48. Madden M, McCambridge J. Alcohol marketing versus public health: David and Goliath? Global Health. 2021;17(1):45. https://doi.org/10.1186/s12992-021-00696-2
https://doi.org/10.1186/s12992-021-00696... . Such task is possible, as can be seen by the demand created for HIV pre-exposure prophylaxis and HIV self-testing – which, in less than five years, became freely available in the Brazilian Public Health System.

This study is not free of limitations. It is impossible to exclude social desirability bias, which could have increased the prevalence of people in favor of alcohol policies. Causality may not be inferred from the observed associations due to the cross-sectional design. Brazil lacks historical series regarding population opinion on alcohol/substance use perceptions and policies which could be useful in case of their actual implementation. Moreover, questions regarding policies related to drinking and driving, and alcohol screening/treatment were not performed in the survey. Additional questions are thus necessary to evaluate public opinion on every aspect of the SAFER initiative.

In conclusion, Brazilian government would count with the support of most of the population to implement and enforce restrictions on alcohol advertising, sponsorship, and promotion. However, strong political will and transparency are essential to tackle the strong lobby of the alcohol industry within this endeavor. The permanent partnership between government, at the national & subnational levels, and the civil society is key. Representatives and policymakers are sensible to the pressures of the alcohol industry (some of them quite subtle and hard to discern)⁵²52. Petticrew M, Maani N, Pettigrew L, Rutter H, Van Schalkwyk MC. Dark nudges and sludge in big alcohol: behavioral economics, cognitive biases, and alcohol industry corporate social responsibility. Milbank Q. 2020;98(4):1290-328. https://doi.org/10.1111/1468-0009.12475
https://doi.org/10.1111/1468-0009.12475... , but they should be, and usually are, also sensible to the points of view of their constituents and future voters.

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