Background
Alcohol use is a leading risk factor for a global burden of disease and causes substantial damage to health [
1‐
3]. 4·0% of the global burden of disease is attributable to alcohol [
4]. Excessive alcohol consumption induces 3.3 million deaths each year, 5.9% of all deaths [
5].
Alcohol Use disorders (AUDs), defined by the DSM 5 [
6], are characterised by an impaired control over alcohol consumption and a chronic,escalating pattern of alcohol use despite significant damage concerning global health, alsoto the lives of family members and friends, and to society in general [
7]. AUDs are among the most prevalent mental disorders, more particularly in high and upper middle-income countries [
8,
9]. They are the leading risk factor for premature mortality and disability among 15–49 year-olds around the world [
1]. In Europe, in 2010, the number of people affected by AUD was 23 million [
10,
11]. It is one of the most important risk factors for morbidity, along with high blood pressure, tobacco use and excess weight [
12]. In France it is the second most important cause of preventable mortality after smoking [
13]. 47 million French people (aged 11–75) have already consumed alcohol at some point in their lifetime, 43 million in the last 12 months [
14]. 10% consume alcohol daily, and 8% have a severe AUD [
14].
AUDs are complex chronic disorders and risk factors are individual, environmental, and associated with alcohol [
7]. Factors associated with alcohol include alcohol availability, the social role of alcohol and alcohol marketing. In terms of the public health perspective, it is particularly useful to evaluate and monitor these factors because they are modifiable. To combat alcohol misuse, health actors recommend several measures. The SAFER initiatives of the WHO recommend Strenghteningrestrictions on alcohol availability, Advancingand enforcing drinking countermeasures, Facilitating access to screening, providing brief interventions and treatment, Enforcing bans or comprehensive restrictions on alcohol advertising, sponsorship and promotion and Raising prices on alcohol through excise taxes and pricing policies [
8]. Alcohol availability, prices and advertising can be included in the larger concept of alcohol marketing. This is defined as a management process from concept to customers, and it includes the four elements called the 4Psof marketing: (1) identification, selection and development of a Product, (2) determination of its Price, (3) selection of a distribution channel to reach the customer’s Place and (4) development and implementation of a Promotional strategy.
The impact of alcohol marketing in a young population, identified as vulnerable [
15], is well described. In this subgroup, exposure to alcohol marketing is associated with an earlier initiation, increases drinking intentions and increases consumption and binge drinking [
16‐
19]. It also leads to a normalisation of alcohol consumption and an underestimation of the risks linked to consumption [
20].
Drinkers with an AUD are also a vulnerable group, according to Babor et coll [
15].. They are vulnerable to health damage [
21,
22]; the relative risk of severe liver disease is very high in adulthood among men between 18 and 20 years of age who consume 3 standard units per day [
23]; in fact, 90% of the deaths attributable to alcohol concern people with a daily consumption of 5 standard unitsper day or more [
1].
Drinkers with AUD are potentially vulnerable to alcohol marketing, but very little work has been done on the links between exposure to alcohol marketing and alcohol consumption in people with an AUD. In literature, some studies focused onheavy users of alcohol, meaning those who were consuming more than the prescribed limits. They react strongly to alcohol cues, and increased alcohol consumption is associated with increased attentional biases towards alcohol cues, which may increase subjective alcohol craving [
24,
25]. The young, heavy users of alcohol sawhigher than average alcohol consumption in alcohol ads, but perceived this consumption to be responsible, unless it was excessive [
26].
Experimental studies were also conducted, using functional magnetic resonance imaging, on small groups of adolescents (
n = 15) responding to DSM IV AUD criteria [
27], or students(
N = 46) regularly consuming alcohol with moderate or heavy drinking [
28], or on heavy users of alcohol (
n = 20). They all exposed participants to alcohol images or advertising or films, and concluded that adolescents and students with AUD criteria or higher alcohol consumption had higher brain responsiveness when exposed to alcohol stimuli [
27,
28], and higher psychophysiological responsiveness [
28]. De Sousa Fernandes Perna et al. showed that, in heavy users of alcohol, public advertising of alcohol elicits striatal activation in the brain’s reward circuit [
29].
Only two studies focused on drinkers with an AUD who were seeking treatment [
30,
31], but they were both conducted under experimental conditions. Sobell et al. in 1993 exposed 96 drinkers seeking treatment to television programs which included alcohol advertising. They showed that the more severe the AUD, the less confident the patients felt in their ability to control alcohol craving and their desire to drink after the viewing [
30]. Witteman developed a mixed methodology in a population of 80 drinkers with an AUD who were seeking treatment and combined an experimental exposure to experimental alcohol promotional films, and a prospective follow-up over 5 weeks, where drinkers self-reported alcohol marketing exposure. They showed a high psychophysiological responsiveness to alcohol cues, and a higher craving after exposure to alcohol cues, proportional to the severity level of their AUD. The drinkers reported being exposed to five alcohol marketing cues per day [
31].
Consequently, there is no large-scale study on the impact of alcohol marketing in the population of drinkers with an AUD. Previous studies focused on a young population or on heavy drinkers [
24‐
26,
32], but only two focused on drinkers with an AUDwho were seeking treatment [
30,
31]. They were all conducted on a small number of participants and,in the majority of cases,under experimental conditions [
26‐
28,
30,
31]. They all limited their exposure to a single alcohol marketing tool, either posters or promotional films, which does not reflect the broad scope of marketing [
26‐
28,
30‐
32]. Furthermore, none of them used a qualitative study to explore the drinkers’ perception of the marketing and to understand the links between marketing and drinkers’ behaviour. Finally, none of these studies wasconducted in France, however the French setting is specific where alcohol marketing is concerned. In 1991, the Evin law imposed alcohol marketing regulations [
33], but this law has been debated many times and it has been progressively deconstructed so that, nowadays, there is broad exposure to alcohol marketing [
20].
Drawing on thesefindings, this study was designed in collaboration with researchers specialising in addictive disorders, in social marketing and in primary care. It is funded by the French National Cancer Institute (INCA). This study will evaluate the impact of alcohol marketing on drinkers with an AUD who are seeking treatment, using a mixed methodology in four steps. The hypotheses are that 1/ patients with an AUD are sensitive to alcohol marketing strategies because of their AUD and in proportion to the severity of their disorder, 2/ the impact of marketing tools differs according to the type of technique used (ads in public places, product placement in films and series, prices, promotions, etc.), 3/ the marketing of alcohol products influences different factors that contribute to the consumption of drinkers with an AUD who are seeking treatment (affective reactions, social norms, etc.), 4/ exposure to marketing of alcohol brands may be a triggering factor, sustaining or aggravating a higher craving among this particular category of consumers, and that, 5/ the development of interventions that focus on the manipulation of consumers and the effect of the marketing of alcohol products (i.e. demarketing strategies). This could have relevance for drinkers with AUD who are seeking treatment in order to increase their resistance skills and prevent them from relapse.
This article presents the protocol; it follows the Standard Protocol items: recommendations for Interventional Trials (SPIRIT) 2013 guidelines [
34].
Discussion
This protocol is original because it applies marketing strategies to evaluate the impact of alcohol marketing on groups of drinkers with an AUD who are seeking treatment. There is no large body of data in literature which explores the influence of several types of marketing tools on drinkers with an AUD and uses a mixed methodology. However, this population of drinkers with an AUD does present a target for alcohol marketing strategies. Indeed drinkers presenting an AUD, represent 8% of the French population, but they represent 50% of alcohol purchases in France [
49]. The ultimate objective is to be able to propose individual and collective prevention measures to help reduce the risk from alcohol toa vulnerable population of persons with an AUD. The expected impact of this project is multi-faceted. At a preventive level, this study will help to analyse the influence of alcohol marketing, and the modalities of this influence, on drinkers with an AUD who are seeking treatment. It will be one of the first large studies, using a mixed methodology, that will underline the probable impact of alcohol marketing on vulnerable drinkers with an AUD. These results will help to put pressure on public authorities to put in place preventive measures which could reduce the impact of marketing on patients with an AUD. Measures to be considered are: realistic and effective limits on advertising, in terms of the media used as well as the content, but which also take into consideration pricing and brand strategies.
These results would make it possible to discuss current collective prevention measures in France, including the regulation of alcohol marketing. The Evin law was introduced in 1991 [
33], to limit exposure to advertisements for alcohol brands among the youngest members of society, with restrictions concerning certain marketing media (posters on the street, television, etc.) and the content of authorised advertising (informative and objective presentation of products...). However, it was gradually deconstructed, with the posting of advertisements being authorised in 1993; advertising on the Internet in 2009 [
50]; and, more recently, (2015) an extension of the authorised media and advertising content, as long as the message referred to the gastronomic and cultural heritage and the geographical origin of the product [
51]. The result of these developments is that exposure to advertising and marketing of alcohol brands has been growing in France in a significant way and we note their omnipresence in the daily environment of the citizens: posters in the street, promotions, competitions in shops, in the press, on the internet (official sites and social networks), radio and also in films and series etc. [
20,
51]. Until now, public health actors failed to take a stand in favour of limiting these developments. Consumer protection is, however, a public duty and there are many public health issues at stake. Given the high social cost of alcohol use disorders, the results of this work seem particularly promising in reducing the societal financial impact of this disorder. With regard to the impact on public health, recommendations will be made to regulatory authorities to improve the supervision of advertising and, more broadly, alcohol marketing practices.
On atherapeutic level, this study will be innovative, with the development of counter-marketing messagesamong drinkers on an AUD program. This study will help to build the content of the educational intervention, including alcohol counter-marketing strategies. In addition, it will make it possible to identify whether this type of focusis useful in treating patients’craving and their perception of their ability to stop consuming alcohol. If this study shows that this kind of intervention improves outcomes for drinkers with an AUD, it will be necessary to develop strategies of this type for drinkers receiving AUD care. Alcohol use disorders are complex diseases:vulnerability factors are a combination of individual factors (gender, psychiatric disorders, familial history of addictive disorders..); environmental factors (social integration, social entertainment, professional and familial status..) and factors linked to alcohol (type of alcohol, social status, damage ..) Alcohol marketing interferes with the environmental factors, because it induces unconscious, daily exposure on multiple occasions, to alcohol marketing cues. It also interferes in factors linked to alcohol, because it maintains the status of alcohol, and positive social attitudes towards it, and it plays down the risks considerably. So in order to reduce the impact of marketing high-risk products,to these vulnerable patients, it would be invaluable to be able to show individuals how they are being affected by marketing without their knowledge, and to provide them with tools to resist such marketing. The hypothesis is that this intervention on demarketing, combined with a therapeutic educational program which targets strategies to control alcohol consumption, will help to give patients a better perception of control. It would help patients with an AUD to better resist alcohol advertising stimuli [
40]. Such work has never been carried out in the field of alcohol use, nor on populations with problematic alcohol consumption.
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