Alcohol and women VIRGINIA SLIMS IN A BOTTLE: GIRLS, WOMEN AND ALCOHOL MARKETING. Young women and alcohol 9/6/2013

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1 Alcohol and women VIRGINIA SLIMS IN A BOTTLE: GIRLS, WOMEN AND ALCOHOL MARKETING David H. Jernigan PhD Associate Professor Johns Hopkins Bloomberg School of Public Health and Director, Center on Alcohol Marketing and Youth U.S. data: Excessive alcohol use causes 23,000 deaths and 633,000 YPLLs among women and girls per year Binge drinking accounts for more than half of these One in eight adult women, one in five high school girls report binge drinking (27% of high school seniors) Average for adult women binge drinkers is 5.7 drinks per occasion 52% of female current high school drinkers are binge drinkers (60% of 12 th grade current drinkers) (CDC YRBS 2011) Source: CDC Vital Signs, Jan 2013 Source: d/fasd/data.html Source: CDC Vital Signs, Jan 2013 Young women and alcohol Young women start drinking earlier than young men: 30.3% of 8 th grade females have ever drank alcohol compared to 28.4% of 8 th grade males (Johnston et al., 2012) 30.3% of 9 th grade females had alcohol in the past month compared to 29.3% of 9 th grade males (YRBSS 2011) Female college students are more likely to exceed weekly limits for alcohol than males: Women exceeded weekly limits more frequently (15% of weeks [14 to 17%]) than men (12% [10 to 14%])) (Hoeppner et al., 2013) Source: CDC Vital Signs, Jan

2 Percent of female binge (5+ in past two weeks) drinkers Percent drinking 5+ in past 30 days 9/6/2013 Alcohol and women: why we care Women generally drink less and less often than men. However, women drinkers are at higher risk for certain medical problems, including liver, brain, and heart damage, than are men who drink comparable amounts. Women metabolize alcohol differently than men. When women and men of the same body weight drink the same amount of alcohol, women reach higher peak blood alcohol levels. Women are vulnerable to interpersonal and sexual violence these are much more likely when alcohol is in the picture. Several meta-analyses have found that any consumption of alcohol increases the risk of breast cancer, and that the degree of risk rises as the level of consumption increases. Adolescent girls are two times more likely to be depressed as adolescent boys. There is also a stronger relationship between depression and substance use in young girls than young boys. Binge drinking can lead to unintended pregnancies. It is not safe to drink at any time during pregnancy. Risk of FASD is highest in the 2 nd half of the first trimester. Trends in young women s drinking US data: girls catching up with boys (ages 12-20) Males Year Females Source: NSDUH Factors in young women s drinking (CDC) WHY DO YOUNG WOMEN DRINK? At the state level, highly correlated with adult women s drinking Price and availability of alcohol Religious and cultural factors Exposure to alcohol marketing Women and alcohol Beverage preference of 12 th grade binge drinking females Although young women are catching up to young men in terms of drinking prevalence All over the world, women drink less than men, and in most age groups (except the youngest), girls drink less than boys For alcohol marketers, this is an opportunity Year Liquor Beer Wine Source: MTF 2

3 How did this happen? The Beginning Developing Brand Loyalty at an Early Age Diageo rolled out Smirnoff Ice in the US market...it suddenly put the once-stodgy Smirnoff name on the tips of millions of echo boomers tongues (Impact, May 15, 2003) Echo Boomers: Americans born from years old in 2003 The beauty of this category is that it brings in new drinkers, people who really don t like the taste of beer. Marlene Coulis Director of New Products Anheuser-Busch Co. Advertising Age April 22, 2002 Who are New Drinkers? Average Age of First Use of Alcoholic Beverages among year olds, 2004: 14.4 years old. Every day, 4,500 young people under 16 years old start drinking. How popular are alcopops among kids? Most popular with the youngest drinkers. 78% of current 8 th grade drinkers (past 30 days) drank alcopops in the past 30 days. 71% of current 10 th grade drinkers (past 30 days) drank alcopops in the past 30 days. 65% of current 12 th grade drinkers (past 30 days) drank alcopops in the past 30 days. 42% of current drinkers, age 19 to 30, drank alcopops in the past 30 days. Source: MTF

4 Percent of current drinkers 9/6/2013 Alcopops most popular with females in every age group Alcopop marketing today 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Male Female 8th graders 10th graders 12th graders year-olds An offshoot Back to our main story Marketing alcohol to women and girls: The right product Promoted in the right way and at the right time At the right price In the right place Focus on product and promotion here The right product The right product 4

5 The right product The right product Alcohol Marketing and Young People 15 longitudinal studies Followed groups of young people over time, monitoring alcohol marketing exposure and drinking behavior Link increased exposure to alcohol advertising and marketing with drinking initiation, increased consumption, and greater likelihood of negative consequences, even after controlling for other variables Alcohol Marketing A Major Risk Factor for Underage Drinking Forms of alcohol advertising and marketing that predict drinking onset among youth Alcohol advertisements in magazines Beer advertisements on television Alcohol advertisements on radio Alcohol advertisements on billboards In-store beer displays and sports concessions Alcohol use in movies Ownership of alcohol promotional items Anderson et al., Alcohol Alcohol 2009:44: Collins et al., Journal of Adolesc Health 2007:40:527-34; Snyder et al.,arch Pediatr Adolesc Med 2006:160:18-24; Stacy et al., Am J Health Behav 2004:38: Pasch et al. J Stud Alcohol Drugs 2007:68: ; McClure et al., Am J Prev Med 2006:30:277-83; Stoolmiller et al., BMJ Open 2012:Feb 20;2:e000543; Sargent et al, J Stud Alcohol. 2006:67:54-65; Henriksen et al., J Adolesc Health 2008:42:

6 The Problem: Alcohol Marketing Is Self-Regulated Alcohol industry has established its own voluntary codes to guide alcohol advertising Content: What is in the ads Placement: What age audiences will see, hear or read them Content violations: Frequent and often unenforceable Difficult to regulate in the U.S.: First amendment Enforcement is subjective Content changes and/or disappears quickly, especially in digital media Placement Can be measured Industry is committed to a voluntary proportional standard based on percent of population under 21 (formerly 30%, as of %) NRC/IOM, 24 attorneys general argue standard too lax advocate 15% standard based on population ages 12-20, the group most at risk Alcohol industry self-regulation Beer Institute code: Beer advertising and marketing materials should not claim or represent that individuals cannot obtain social, professional, educational, athletic, or financial success or status without beer consumption. Beer Institute Advertising and Marketing Code Models and actors employed to appear in beer advertising and marketing materials should be a minimum of 25 years old, substantiated by proper identification, and should reasonably appear to be over 21 years of age. Alcohol industry self-regulation Distilled Spirits Council of the United States (DISCUS) Code: Beverage alcohol advertising and marketing materials should not contain any lewd or indecent images or language Brand Photos from Miller Lite Facebook Page DISCUS Code of Responsible Practices Beverage alcohol advertising and marketing materials should not contain any lewd or indecent images or language. Beverage alcohol advertising and marketing materials should not contain the name of or depict Santa Claus. Brand photos on Captain Morgan Facebook Page 6

7 Alcohol industry self-regulation User-generated content? DISCUS code Beverage alcohol advertising and marketing materials should not depict situations where beverage alcohol is being consumed excessively or in an irresponsible manner. Limit is five times the U.S. dietary guideline for women. Center on Alcohol Marketing & Youth Founded in 2002, our philosophy is that reducing underage drinking requires a twopronged public health approach: 1) Reduce young people s access to alcohol. 2) Reduce the appeal of alcohol to young people, by: - Providing public health messages about alcohol and underage drinking - Limiting impact of alcohol advertising on youth by reducing youth exposure to it What CAMY does Answers the question: how much alcohol advertising do kids see? Tracks alcohol advertising on TV and radio and in magazines Uses standard industry sources Neilsen, Arbitron, etc. to measure the audiences for that advertising. Shows that over and over again, kids are exposed to more alcohol advertising per person than adults. Youth exposure to alcohol advertising: magazines In 2008, youth years old, compared to adults 21 years old, saw per capita 10% more beer ads 16% more ads for alcopops 73% fewer wine ads The overwhelming majority of youth exposure (79%) came from ads placed in magazines with disproportionate youth audiences Youth Are Overexposed to Alcohol Advertising on Television In 2009, 315,581 alcohol product commercials appeared on U.S. television Youth were more likely (per capita) than adults to have seen 21% of alcohol ads (>67,000 ads) The average TV-watching youth saw 366 alcohol ads: 1/day 23,718 ads (7.5%) played to audiences greater than the industry s 30% threshold Trends Youth exposure to alcohol advertising on television grew at a rate faster than that for 21 years old ( ) Center on Alcohol Marketing and Youth. Youth Exposure to Alcohol Advertising in National Magazines, Baltimore: Center on Alcohol Marketing and Youth;2010 Center on Alcohol Marketing and Youth. Youth Exposure to Alcohol Advertising on Television, Baltimore: Center on Alcohol Marketing and Youth;2010 7

8 Percent of Ads Overexposing 9/6/2013 Youth Are Overexposed to Alcohol Advertising on Radio In 2009, 1 in 11 (9%) of radio placements violated the industry's 30% standard Nearly a third (32%) of advertising placements played to disproportionately youthful audiences More than half of youth exposure came from ads placed on programs that youth were more likely to hear per capita than adults Girls overexposure compared to women greater than boys overexposure compared to men Translation: women s advertising skews younger than men s Most advertising in magazines is for distilled spirits. Alcohol advertising in magazines greatly overexposes underage girls Radio, 2009: In five of 11 markets measured Washington, Philadelphia, Houston, San Francisco, and Detroit underage girls were more exposed to alcohol advertising than adult women, age 21 and above. 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Female Male 43 Center on Alcohol Marketing and Youth. Youth Exposure to Alcohol Product Advertising on Local Radio in 75 U.S. Markets, Baltimore: Center on Alcohol Marketing and Youth;2011. Television overexposure of underage girls by brand Alcohol industry responsibility advertising no one can match the alcohol industry s long-term commitment to public-service advertising that discourages underage drinking Jeff Perlman, American Advertising Federation a: exposure > 21+ b: exposure > Alcohol industry responsibility advertising A mixed message. From 2001 to 2009, youth were 22 times more likely to see a product ad for alcohol than an alcohol industry responsibility ad. What are underage youth drinking? First-ever survey by brand Rank Male (%) Female (%) 1 Bud Light (28.1) Bud Light (27.7) 2 Budweiser (17.0) Smirnoff Malt Beverages (22.7) 3 Jack Daniels Whiskeys (14.2) Mikes (14.4) 4 Coors Light (13.7) Smirnoff Vodkas (13.3) 5 Heineken (13.2) Bud (12.2) 6 Captain Morgan Rums (13.1) Coors Light (11.7) 7 Smirnoff Vodkas (12.2) Absolut Vodkas (11.3) 8 Smirnoff Malt Beverages (11.6) Corona Extra (11.2) 9 Corona Extra (11.3) Bacardi Malt Beverages (10.3) 10 Blue Moon (10.2) Jose Cuervo Tequilas (9.5) 8

9 Trends in alcohol marketing Like other products, selling alcohol as a health food All natural, organic etc. Functional food fitness friendly Diet drink Particularly targeted at women ALL NATURAL AND ORGANIC Food & Natural Claims Natural vodka Natural junk foods Calories in one serving: 150 (90 fat) 10 grams of fat, 150 mgs sodium Beer * Natural beer Vodka from soy gluten-free! 9

10 Organic tequila Natural tequila Natural binge in a can Binge in a can with natural Brazilian healing powers A personal trainer from Holland FITNESS FRIENDLY 10

11 Antioxidant beer Beer plus a smart choice Full speed beer A DIET DRINK A smart choice beer only 95 calories 11

12 Low calorie is here! Even the can is slim No carbs even better 12

13 No carbs no question Women and alcohol marketing Women s exposure has increased, especially on television Men s exposure has increased even more, and much of the advertising is not targeted at women Women in alcohol ads are the beverage itself they are the goal, and the alcohol Who is getting whipped? Effects of images of women in alcohol ads Researchers in San Jose, CA looked at density of alcohol ads featuring Latinas in their city Controlled for: Ethnic composition of the block group where victimization occurred Socioeconomic characteristics of the area Population and residential stability Race- and gender-specific measures of poverty and unemployment Alcohol availability (density of outlets) After controlling for all these other variables, found that density of ads featuring Latina models had significant effect on levels of sexual violence among Latinas and non-latina females Researchers conclusion: In general the results of these analyses are supportive of the notion that advertising content plays a detectable role in sexual violence. Where are the advertising protections? WHAT CAN BE DONE? Little regulatory effort being expended towards alcohol Loose approval of new products No apparent enforcement of provisions about content (which are loose in the first place) 13

14 Percent 9/6/2013 Alcohol advertising reform: national Institute of Medicine recommendations (2003): Industry self-regulation needs to get better companies should move towards a 15% maximum youth audience composition for their advertising Why 15%? Any alcohol use Age Binge alcohol use NSDUH, 2003 According to the National Household Survey, there is very little current use of alcohol among those below 12. Thus, is the population at highest risk. Young people in the population Youth are 15.0% of total population 12 and above. (Population Estimates Program, Population Division, U.S. Census Bureau, 5/17/2007) Magazines, radio only measure 12+ population. Youth are 13.0% of the total population 2 and above. (Population Estimates Program, Population Division, U.S. Census Bureau, 5/17/2007) Television measures 2+ population. A 30% youth audience threshold means youth are twice as likely to be in the viewing/reading/listening audience. Principal Policy Goals 1) Get the industry to adopt tighter standards for alcohol ad placement - After examining the issue, concluded that 15% based on year-olds was the right standard 2) Institutionalize monitoring of alcohol advertising to youth - After examining range of options in federal government, settled on CDC as right place for this activity Year CAMY and Public Policy CAMY Reports on Youth Overexposure 2002 Magazines, television 2003 Radio, television, African- American and Hispanic youth 2004 Radio, internet, magazines, TV 2005 Magazines, TV, Hispanic youth 2006 Radio, television, magazines, African American youth Policy Developments FTC presses beer and spirits to move from 50% to 30% NRC/IOM recommends 25%, with eventual movement to 15% State attorneys general get industry to remove ads from magazines going to schools and libraries 20 state attorneys general ask FTC to explore with industry move to 15% 2007 Magazines, radio, television Beam Global Spirits moves to 25%, 15% annual aggregate average by brand 2008 Television One sitting FTC Commissioner dissents, calls for industry to move to 25% 2010 Magazines, television FTC Bureau of Consumer Protection asks industry to drop to 25%, industry refuses 2011 Radio, African American youth, local television 24 state attorneys general call for industry to move to 15% standard based on population State Level Policy Options CAMY report: Review of existing laws regarding alcohol advertising in the 50 states Identification of best practices from among those laws Content Placement Other measures States ranked BP I or 14

15 Measured media: content regulation Prohibit false and misleading alcohol advertising Best practices 11 states: Idaho, Illinois, Maine, Massachusetts, Montana, New Hampshire, Ohio, Texas, Utah, Vermont, West Virginia 17 States and DC had at least one, but not all of the best practices elements. The remaining 22 States received a -- designation. Measured media: content regulation Prohibit alcohol advertising that targets minors Best practices 9 states: Alabama, Delaware, Maine, New Hampshire, North Carolina, Oregon, Utah, Vermont, and Virginia. There is no incomplete category. 41 States and DC received a designation. Problems with content regulation Measured media: Claiming state jurisdiction over electronic media Best practice 19 states: Delaware, DC, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Mississippi, Missouri, Nebraska, New Hampshire, North Carolina, Ohio, Oregon, Pennsylvania, Tennessee, Utah, Virginia, and West Virginia. Two States received an I rating Texas and Washington. The remaining 29 States received a -- designation. Measured media: placement Restrict outdoor alcohol advertising in locations where children are likely to be present Can be done through general restriction of outdoor advertising, without reference to alcohol Needs to be tailored so that youth viewing is restricted but adult viewing is still possible, e.g. by using youth presence criteria Bans on outdoor advertising in public-owned venues (e.g. beaches, parks, buses, public buildings, stadiums, etc.) raise no constitutional issues Best practices: Ban or severely restrict outdoor advertising generally: 4 states Alaska, Hawaii, Maine, Vermont New Mexico has ban on alcohol ads only on school buses Other states New York, Pennsylvania, Massachusetts considering bans on alcohol ads on all publicly-funded transportation Incomplete: 8 states (Alabama, Indiana, Kentucky, Mississippi, Ohio, Pennsylvania, Tennessee, and Washington) Measured media: placement Restrict alcohol advertising on alcohol retail outlet windows and outside areas Should significantly limit amount of advertising on outside and in immediate vicinity of the retail establishment Should significantly limit amount of advertising placed on both inside and outside of windows Should not pre-empt stronger local actions One state has best practice (Virginia); four states rated incomplete California, Kansas, Missouri, Texas Measured media: placement Prohibit alcohol advertising on college campuses Should prohibit advertising in college newspapers and other publications Should prohibit advertising on campus, including handbills, posters, etc. Should include all campuses within the state. Best practices (3 states) New Hampshire, Pennsylvania, Utah Incomplete - Virginia 15

16 Unmeasured media: promotions Restrict sponsorship of civic events Should ban alcohol industry sponsorship of college/school events Should ban sponsorships of events in public venues (e.g. parks, street fairs, government buildings) Should significantly limit sponsorship in private venues other than alcohol retail outlets Best practices Four states incomplete : Florida, Minnesota, Utah, Virginia Unmeasured media: promotions Limit giveaways (contests, raffles, etc.) Should prohibit any giveaways as reward for purchasing the producer s or distributor s products Should prohibit distribution of promotional materials at commercial or civic events at least to those under the legal drinking age No Best practices 17 states rated incomplete : Alabama, Arkansas, California, Connecticut, Georgia, Indiana, Mississippi, Montana, New Jersey, North Carolina, Ohio, Oregon, Pennsylvania, South Dakota, Texas, Utah, and Virginia. Summary for California Eight areas of possible state action reviewed: Content: False or misleading -- Targeting minors -- Placement: Electronic media -- Outdoor ads -- Retail windows I College campuses -- Sponsoring civic events -- Promoting giveaways I California Retail windows: 33% limit (BP is 15%) Giveaways: prohibits any giveaways as rewards for purchasing the producer s or distributor s products, but does NOT prohibit the distribution of promotional materials at commercial or civic events at least to those under the legal drinking age. Much potential Evidence Base for Effects of Reducing Youth Exposure to Alcohol Advertising An econometric study published in Health Economics in 2006 predicted that 28% decrease in alcohol advertising would lead to a 4% to 16% drop in monthly youth drinking, and an 8 to 33% drop in youth binge drinking. (Saffer and Dave 2006) A demography-based test of likely effects of several alcohol policies on youth drinking behavior in the U.S. concluded that a complete ban on alcohol advertising would be the most effective for reducing premature mortality. Complete ban: 7,609 fewer deaths from harmful drinking and a 16.4% drop in alcohol-related life-years lost. Partial ban: 4% drop in alcohol-related life years lost. (Journal of Studies on Alcohol 2006) An analysis of the impact of evidence-based interventions on disabilityadjusted life-years (DALYs) in 12 regions of the world found that in regions where heavy drinking is less prevalent, targeted strategies such as brief physician advice, roadside breath testing, and advertising bans would be most effective. (Journal of Studies on Alcohol 2004) Counter-ads Successful in tobacco, little used in alcohol Continuum, ranging from PSA s to true counter-advertising IOM calls for many experiments in youthoriented media campaign none ever funded One example Dover Y2Y Alcohol advertising reform: global France has one of the strongest anti-alcohol advertising laws in the world No advertising is allowed on television or in cinemas; No sponsorship of cultural or sport events is permitted; The law has been upheld by the European Court of Justice Thailand passed a new Alcoholic Beverage Control Act in 2008: Prohibits sales of alcoholic beverages to anyone under 20 Bans consumption or sale of alcohol on government premises, schools, hospitals, petrol stations, parks Bans alcohol advertising that in any way includes pictures of a product or encourages drinking leaves only corporate advertisement and advertising originating outside of Thailand Finland, Ireland, South Africa considering bans of various kinds 16

17 Community Guide Recommendation The Community Preventive Services Task Force recommends increasing the unit price of alcohol by raising taxes based on strong evidence of effectiveness for reducing excessive alcohol consumption and related harms. Public health effects are expected to be proportional to the size of the tax increase. State-level actions: examples In 2004, CAMY produced report on state policy options regarding regulation alcohol advertising and youth CAMY s most requested report updated last fall CAMY partners in various states took steps to reduce youth exposure to alcohol marketing: Connecticut Philadelphia Ohio Oregon State/City Somerville, MA Greater Boston, MA Action Ban on all alcohol signage except at point of purchase at Renschler Field Ban on alcohol advertising on bus shelters 500 foot limit on billboard placements adopted into OLCC administrative rules Local department stores convinced to remove prodrinking clothing and paraphernalia Ban on alcohol billboards within 500 feet of schools etc, combined with grassroots enforcement Ban on alcohol ads on public transit WHO s Global Strategy (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 alcohol1 (j) monitoring and surveillance. WHO s Global Strategy (a) setting up regulatory or co-regulatory frameworks, preferably with a legislative basis, and supported when appropriate by self-regulatory measures, for alcohol marketing by: (i) regulating the content and the volume of marketing; (ii) regulating direct or indirect marketing in certain or all media; (iii) regulating sponsorship activities that promote alcoholic beverages; (iv) restricting or banning promotions in connection with activities targeting young people; (v) regulating new forms of alcohol marketing techniques, for instance social media; (b) development by public agencies or independent bodies of effective systems of surveillance of marketing of alcohol products; (c) setting up effective administrative and deterrence systems for infringements on marketing restrictions. Alcohol advertising reform: global France has one of the strongest anti-alcohol advertising laws in the world No advertising is allowed on television or in cinemas; No sponsorship of cultural or sport events is permitted; The law has been upheld by the European Court of Justice Thailand passed a new Alcoholic Beverage Control Act in 2008: Prohibits sales of alcoholic beverages to anyone under 20 Bans consumption or sale of alcohol on government premises, schools, hospitals, petrol stations, parks Bans alcohol advertising that in any way includes pictures of a product or encourages drinking leaves only corporate advertisement and advertising originating outside of Thailand Dutch researchers emulating CAMY approach in monitoring youth exposure in EU countries Advertising restrictions being implemented now in Russia; under serious consideration in South Africa, Ireland JHSPH developing technical tool for WHO on how countries can regulate/restrict alcohol marketing Evidence Base for Effects of Reducing Youth Exposure to Alcohol Advertising An econometric study published in Health Economics in 2006 predicted that 28% decrease in alcohol advertising would lead to a 4% to 16% drop in monthly youth drinking, and an 8 to 33% drop in youth binge drinking. (Saffer and Dave 2006) A demography-based test of likely effects of several alcohol policies on youth drinking behavior in the U.S. concluded that a complete ban on alcohol advertising would be the most effective for reducing premature mortality. Complete ban: 7,609 fewer deaths from harmful drinking and a 16.4% drop in alcohol-related life-years lost. Partial ban: 4% drop in alcohol-related life years lost. (Journal of Studies on Alcohol 2006) An analysis of the impact of evidence-based interventions on disabilityadjusted life-years (DALYs) in 12 regions of the world found that in regions where heavy drinking is less prevalent, targeted strategies such as brief physician advice, roadside breath testing, and advertising bans would be most effective. (Journal of Studies on Alcohol 2004) 17

18 TOGETHER, we can make a difference!