From Globe to Local: Public-Private Partnerships in Harm Reduction Policies August 29, 2019 GLAD Yeouido Hotel Seoul, Korea

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Introducing Alcohol Harm Reduction Policy into Korea Prof. Aeree Sohn Professor, Health Management, Sahmyook University, Korea

Think Globally, Act Locally Alcohol Control essential for Sustainable Development Goals The United Nations declared Sustainable Development Goals(SDGs) on September 25,

2015. (The development goals the international community work together to achieve for the 15-year period.)

Alcohol Control for SDGs (Sustainable Development Goals)

17 Goals

SAFER: five high-impact strategies to promote health and development by reducing the harmful use of alcohol and related health, social and economic consequences.

1. Strengthen restrictions on alcohol availability

Environment conducive to drinking

One, except minors, can purchase alcohol anytime and anywhere. There are many bars, 24-hour convenience stores and restaurants where one

can purchase alcohol. High risk drinking rate is higher in areas where many bars are located. (Lee

Jaegyeong, 2014)

Environment conducive to drinking

High risk drinking rate of adults (%)

Male

Female

Alcohol related mortality (2017, unit: 100, 000)

No. of deaths: 4,809(2018)

13 pers. /day

Amount of alcohol consumed by adults over 15

(unit: liter/pers.)

Source: Ministry of Health & Welfare, WHO

Disability rate associated with alcohol use disorder(over 15, %)

Abuse

Dependence global

America Mediterrian Europe Southeast Asia

Korea

global

Int’l & local statistics on alcohol consumption

Korea

Environment conducive to drinking permissive drinking culture

1.5

4.2

7.1

10.3

31.1

33.6

36.2

70.1

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

Behaviors under the influence of alcohol are acceptable.

Drinking of high school students

Refusing a friendly offer of alcohol is impolite.

Public parks, mountains

Daytime drinking

Drinking in convenience stores(inside/outside) not frowned on.

Okay to get drunk.

Solitary drinking

Drinking permissiveness

• Only a permit, no license, is required for

manufacturing, distribution and sales of alcohol. (Liquor license is required in most countries.)

• No restraint on venue, hours and days of alcohol sale.

• One can buy and drink alcohol in grocery stores and convenience stores.

• No restraint on retail sale outlets. • Age limit on purchase and drinking of

alcohol, but almost no actual enforcement.

• Minimum age limits for alcohol

purchase(O) • Liquor licensing policy and monopolized

manufacturing and retailing (X) • Sales outlet density(Restricting venues) –

(X) • Public drinking ban(X) • Restrictions on date and time of liquor

sales(Restricting time) (X)

Examples of Restriction policies

1. Restricting alcohol availability

Local situation

Restaurant/Bar (On-premises) Outlet (Off-premises)

New York Mon-Sat: 8 a.m~4 a.m

Sun: noon~4 a.m

beer: 24 hours

wine/sprits Mon-Fri: 9 a.m~midnight

Sun: noon~9 p.m (different between state law,

and each county)

Massachusetts

8 a.m~ 2 a.m Mon- Sat: 8 a.m~ 11 p.m Sun: banned before noon

Texas

Mon-Fri: 7 a.m~midnight Sat: 7 a.m ~ 1 a.m Sun: noon~midnight

beer Mon-Fri: 7 a.m~midnight

Sat: 7 a.m~ 1 a.m Sun: noon~midnight

Wine/spirits Mon-Sat: 10 a.m~ 9 p.m

Restraint on hours of alcohol sale by state, U.S.

1. Strengthen restrictions on alcohol availability - USA

Early Morning Restriction Orders(EMROs) The policy to enforce 2011 Police Reform and Social Responsibility Act EMROs enable a licensing authority to prohibit the sale of alcohol for a

specified time period between the hours of 12 a.m and 6 a.m in the whole or part of its area.

Enforced with Late Night Levies (LNLs) - It allows licensing authorities to impose Late Night Levies (LNLs) on

alcohol selling premises which open from midnight till 6 a.m., considering the association between late night drinking and crime occurrence.

1. Strengthen restrictions on alcohol availability - England

(○ : total restraint ▵:partial x: no restraint ◻: voluntary restraint) G20 (Major 20 countries) Drinking in pubic places

Category

Gov’t and private facilities Public facilities Social cultural leisure

school Gov’t institutions hospital workplace Park and

street

Public transport-

tation

Religious places

Sports event

Leisure event

Asia

South Korea Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ China □ □ □ ○ Ⅹ Ⅹ △ △ △ Japan □ □ □ □ □ □ □ □ □ India ○ ○ ○ ○ ○ ○ ○ ○ △

Indonesia ○ ○ ○ ○ ○ ○ ○ ○ ○

Saudi Arabia ○ ○ ○ ○ ○ ○ ○ ○ ○

Turkey ○ ○ ○ △ Ⅹ △ ○ ○ ○

Europe

France △ △ △ △ △ ○ △ △ △ England Ⅹ Ⅹ Ⅹ □ △ △ Ⅹ △ Ⅹ Russia ○ ○ ○ △ ○ ○ ○ ○ ○

Germany □ □ □ □ □ □ □ □ □

Italy △ □ △ △ △ Ⅹ Ⅹ △ △

America

America* △ △ △ △ △ △ △ △ △- Canada □ □ □ □ ○ ○ □ △ △ Mexico ○ ○ ○ ○ ○ ○ □ △ △ Brazil ○ △ ○ □ Ⅹ △ △ △ △

Argentina ○ ○ ○ □ □ □ Ⅹ ○ △ Oceania Australia △ □ □ △ △ △ □ □ △ Africa South Africa Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ Ⅹ

* In case of U.S., it is illegal to possess and drink alcohol in public places except in several states.

1. Alcohol availability –Restraint on public places

Source: Global Information System on Alcohol and Health Alcohol Policy Report (2014)

% of Alcohol Drinking in Public Places

Source: A Study on Public Dry Areas(Entrusted by the Ministry of Health & Welfare, Sohn Aeree, 2018)

59.5

84.1

43.7

87.7

71.1

53.5

23.4

68.4 60.5

28.2 38.9

94.7

0 10 20 30 40 50 60 70 80 90

100

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% of people who saw others’ alcohol drinking in public places

16.8

34.7

10.7

40.1

14.6 10.9 6

29.1

18.4 9.1 7.2

43.9

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20

30

40

50

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% of drinking experience in public places

Serious hazards of public drinking due to no restriction policy

본인의 공공장소 음주경험(%) 타인의 공공장소 음주 목격경험 (%)

Source: A study on dry areas in public areas(entrusted by the Ministry of Health & Welfare, Sohn Aeree, 2018)

92.8

86.7

87.4

84.8

83.1

74.4

70.1

66.7

46.2

38.3

98.3

0.0 20.0 40.0 60.0 80.0 100.0 120.0

Trash, throw-up, etc

drunks sleeping in streets or waiting rooms

foul oder from drunks sitting next(bus, subways) to me.

Feeling unsafe in public places due to drinkers

Feeling fear when encoutered drunks in streets

reckless behavior(blocking or running to roads)

Feeling fear due to aggressive behavior(destroying things,…

harrassed or annoyed(cursing or quarrel)

physical touch or fell down by drunks

more than one damages described here

Damages caused by drinking in public places

“95% of people support public drinking ban.”

“A Study on Drinking Culture and Restriction of alcohol availability”” Sahmyook Univ. Prof. Sohn Aeree

“Public places where people drink most frequently are convenience stores, parks and beaches in order.”

3,015 adults surveyed.

26% experienced harm caused by ‘black out’

The majority support imposing a fine.

Public places people frequent most for drinking are convenience stores, parks and beaches.

No higher law over restriction on public drinking

Restriction on public drinking is not legislated in the highest health law at the

national level, National Health Promotion Act, weakening its actual

enforcement.

Restriction on public drinking is stipulated only in 61 ordinances at local

government level, making it hard to enforce due to absence of related higher

law.

Korea – Examples of local govt’s ordinance on alcohol free zone

Seoul 16 Incheon 2 Daejeon 2 Daegu 3 Busan 7 Kwangju 4 Sejong 1

「Seoul Metropolitan government Ordinance on the Promotion of Healthy Drinking Culture」(‘17.5.18, Ordinance No. 6508) A person who makes loud noises and foul odor and creates disgust to others by drinking in designated alcohol free zone shall be punished by a fine not exceeding 100,000 won. (Grounded on 「Act on Urban Parks and Green Space」 Article 49, Clause 1, No 3 and Article 56, Clause 2, No. 3) Only Seoul metropolitan govt. imposes a fine while other local governments just recommend.

10 more local governments enacted ordinances on alcohol free zone

compared to February 2017. (51 governments → 61)

Kyeonggi 12 Chungbuk 4 Chungnam 2 Gangwon 1 Keongbuk 2 Keongnam 1 Jeonnam 3 Jeonbuk 0 Jeju 1

61 cities, provinces, counties and districts enacted ordinances on alcohol free zone.(as of January, 2018)

Example of no alcohol zone designation and operation: Seoul

Opinions on restricting public drinking(%)

Total restriction Respondents: 3,015 pers.

Opposed to restri

ction Partial restriction

Restricting drinking in events held in schools (including playground)

Restricting drinking and sale of alcohol in parks

Tougher Govt’s restriction on public drinking

2. Advance & Inforce drink driving counter measures

Blood alcohol concentration(BAC) limit

Strengthening sobriety tests

Restricting driving license of drink drivers

Ignition interlock

19,517 drink driving accidents, 33,364 injuries and 439 deaths

in 2018 (Road Traffic Authority)

Yoon Changho’s Law Congressman, Lee Yongju

Lenient punishment imposed by authorities, regarding drink

driving as a mistake rather than an offence.

2. Advance & Enforce drink driving counter measures

Strengthening penality for drunk drivers – Enforced as of

June 25 2019

2. Advance & Inforce drink driving counter measures -Korea

Category

After revision

Penalties Driver License

Action

< 0.03% Released on warning Released on

warning

0.03 ~ <0.08% Imprisonment of less than one year Civil penalty of less than 5 million won

License suspension

0.08 ~ < 0.2% Imprisonment of one -two year Civil penalty of 5 -10 million won

License revocation

> 0.2 % Imprisonment of two-five year Civil penalty of 10 -20 million won

Refused to be tested Imprisonment of one - five year Civil penalty of 10 - 20 million won

More than two offences

Imprisonment of two - five year Civil penalty of 5 - 20 million won

1. Higher BAC standard for

drunk driving

0.05% 0.03%

2. Tougher penalties for

drunk driving

3. Facilitate access to screening brief interventions & treatment

3. Facilitate access to screening brief interventions & treatment

High morbidity rate associated with alcohol abuse - low mental health

service use rate

- Percentage of people who used community services among high risk

drinkers : 0.5% (2014)

- Proportion of high risk drinkers who received treatment services among

those seeking help : 4%

- Fragmented treatment services provided repeatedly

- Increased alcoholics’ voluntary admission to hospital Increased civil

complaints due to alcohol related accidents during hospital stay.

Screening and brief interventions at primary health care settings(intervention)

Treatment and prevention of alcohol related disorders and establishment of social welfare

service

Integrated services of prevention, treatment and care for alcohol related disorders(drug

addiction, depression, suicide, HIV/AIDs, TB, etc)

Strengthening response to harmful use of alcohol by conducting evaluation on status of

city/province alcohol hazards(health status, drinking rate)

Early identification, treatment, rehabilitation and return to society of addicts by expanding

addiction care centers and its workforce and linking its care with mental health centers.

3. Facilitate access to screening brief interventions & treatment

4. Enforce bans/comprehensive restrictions on alcohol advertising, sponsorship & promotion

4. Strengthening restriction on alcohol marketing -Korea

Restricting contents, frequency and channels of advertisement – advertising

through celebrities

Restricting sponsorship of alcohol companies – alcohol advertisement

strategy getting more active and multidimensional

Establishing monitoring system on alcohol marketing – Idolizing drinking

culture through media should be deterred.

4. Strengthening restriction on alcohol marketing - Korea

Inserting health warning labels on alcohol containers (O) – Hard to notice

Inserting alcohol advertising ( X)

Advertisement of spirits with alcohol content of over 17% is banned on

major TV channels. (O)

Regulations on alcohol advertising and education and campaign in TV, radio,

movie theaters, subways and transportations ( O)

Legal punishment on infringement of alcohol advertising regulations – weak

punishment, a fine of one million won

Alcohol warning labels, Korea

건강증진개발원 「주류용기 과음경고문구 표기 기준 안내서」

Compliance rate of alcohol warning labelling

Category Content Compliance

Percent

No. 1(labelling)

Marking in a rectangular box 8.7%

Marking as “warning:” 83.7%

Content of warning(choose one of three warnings set by MOHW 87.3%

No.2 (size of text) Size of text2)(more than one tenth of brand label) 10.6%

Minimum size of text3)(below 300ml over 7 point, over 300ml over 9 point) 58.4%

No.3 (color) Make warning text clear using complementary color to brand label 3.2%

No. 4 (text style) Gothic style 98.3%

No.5 (positioning of label) Below brand label 0.6%

Note:

1) Results of analysis on 471 containers with warning labels out of 474 displayed in major malls as of Sept. 2018.

2) The standard is a main brand label.

3) The standard of text size point is height.

4) The standard is a main brand label. Source: Korea Health Promotion Institute, Internal document (2018)

Compliance rate of alcohol warning labelling

5. Raise prices on alcohol through excise taxes & pricing policies

Best Buy of WHO to prevent NCD

Imposing taxes in proportion to alcohol contents(Progressive taxes)

England: differentiating taxes on beer with alcohol contents of over 7.5 and one with

below 2.8

Regular reviews of alcohol prices with regard to incomes and consumer price

The England government set alcohol tax by 2% more than inflation increase and applied it

in 2014 and 2015.

Prohibiting or restricting promotion of alcohol through pricing such as discount and cost

price sale.

Minimum alcohol pricing was introduced in England and Wales for the first time.

There should be no difference in unit price between when more than one bottle of alcohol

were purchased and one bottle of alcohol. (‘Buy one and get one free’ or ‘Buy six and get

one free’ sales promotion prohibited)

Price incentive for non alcoholic beverages

Reducing and removing government subsidies for alcohol industry.

5. Pricing policies – England

Actual alcohol prices are in a steady decline as they fails to reflect inflation rates.

Shifting from proportional tax for alcohol to progressive one is under way.

The price of beer is expected to decline if the tax for beer is changed into progressive one.

Spirits – It is suggested to set the tax for spirits considering both amount and alcohol

contents, which is expected to make no big difference in terms of tax burden.

5. Pricing policies – Korea

current

current

revised

beer

rice wine

(Unit:won)

Changes in the amount of tax if shifted to progressive tax Scenarios for alcohol tax revision Scenario 1 Only tax for beer shifted to progressive. Scenario 2 Taxes for beer and rice wine shifted to progressive. Scenario 3 Taxes for all kinds of alcohol shifted to progressive, but those for beer and rice wine first and the rest postponed for five years. Source: Korea Institute of Public Finance

An example of alcohol sale promotion event

Promotion in Korea!!!!! Every Friday in April Big discounts for 8 cans of beer!!

10,000 won four cans of beer, but 15,000 for eight. Source: GS Retail

April 5, 12, 19, 26 Only 15,000 won for 8 cans of beer

Percentage of Korean People supporting alcohol restriction policies

32.6 37.2

48

53

75.5 79.1

94.8 94.9

57.5 72.6

75.3 77.8 80.1

63.4 96.2

0 10 20 30 40 50 60 70 80 90 100

■ 가격정책 가격인상

주류가격 할인등과 같은 판촉활동 제한 세금 중 건강부담금을 올려야 함

■ 이용접근성 제한 정책

술파는 시간(예: 자정부터 새벽 5시)을 규제해야 함

집회나 행사 시 음주를 제한 공원에서는 술을 팔지 말아야 함

공공장소음주제한 주류판매점 종사자들이 청소년에게 술을 팔지 않도록 단속

■ 마켓팅 제한 정책 지역행사나 축제에서 주류회사에서 무료로 술을 주는 것은 제한

술도 담배처럼 경고그림을 부착

■ 광고 제한 정책

유명인등장주류광고제한 TV 프로그램에서 과도한 음주장면 노출을 제한

청소년이 주류광고에 노출되지 않도록 하기 위하여 인터넷을 통한 주류광고를 …

■ 기타 음주로 인해 발생하는 질병, 사고 비용을 국민건강보험에서 충당하는데, 이 …

주취감형하지 말아야 함

Alcohol use restriction policies

Pricing policies Raising prices

Restricting sales promotion like big discounts Raising health duty tax

Restricting alcohol availability

Restrictiong hours of alcohol sale(midnight - 5 a.m)

Restricting alcohol use in rallies and events

Banning alcohol sales in parks Restricting alcohol use in public places

Punishing those who sell alcohol to minors

Restricting alcohol marketing

Banning giving away of alcohol in community events Health warning labels on containers of alcohol

Restricting alcohol advertisement

Restricting alcohol advertising using celebrities Restricting scenes of excessive drinking on TVs

Restricting digital alcohol advertising for youths

Others

No national health insurance coverage for diseases and accidents caused by alcohol No lenient punishment for crimes committed while intoxicated

Alcohol Policies of MOHW, Korea, Action Plan to reduce harmful use of alcohol

Vision

Strategies

Goals

Healthy and safe society with no health hazards of alcohol

Reducing an average amount of alcohol consumed by adult over 19: ’15 9.0L ->’20 8.5L

Returning to society of alcoholics by supporting their rehabilitation

Shifting from alcohol friendly environment to health promoting environment

Changing individual and social norm on alcohol use

Designating alcohol free zone in public places –

Restricting access to alcohol

Adjusting restriction on alcohol advertising in

accordance with changing advertising environment

Development of a guideline for awareness raising on

moderate use of alcohol

Strengthening public campaigns to encourage

moderate use of alcohol

Distributing capacity building programs for each

target group to support moderate use of alcohol

Strengthening self-regulation of media on drinking

scenes

Improving service delivery system for alcoholics

Reinvigorating alcoholics’ (rehabilitated) self-

regulation activities

Introduction of treatment/rehabilitation program and

strengthening related medical services

Expanding metal rehabilitation facilities for alcoholics

Establishing government - private network to reduce

alcohol hazards

Strengthening researches for evidence-based policy

development

Alcohol Policies of MOHW, Korea, Action Plan to reduce harmful use of alcohol

Improvement of alcohol control policy

- Restricting marketing and advertisement of alcohol - Prevention of juvenile drinking - Establishing a system to protect heavily drunken people and prevent recurrence - Expanding access to early screening and short-term intervention - Expansion of support for civil societies’ activities. - Systematic implementation of education and campaign

Current policies to be strengthened

Future Tasks

Alcohol duties/health tax Restricting alcohol availability (Public drinking ban is in the process of being institutionalized by the govt. ) Reducing alcohol use at national level and establishing monitoring system National alcohol strategies considering input-action-output-impact based on logical model are required.

Current challenges

1. Monitoring and evaluation on alcohol policies

2. Raising awareness and commitment

3. Establishing new drinking norm to change drinking culture

Thank You August 29, 2019 GLAD Yeouido Hotel Seoul, Korea

@AHRFCommunity AsiaHarmReductionForum #AHRF #AHRF2019 #AHRFSeoul2019 #HarmReduction