The new project of public health

In July 2020, the World Health Organization hosted the webinar “Alcohol marketing in the WHO European region: Results from the update report on the evidence and recommended policy actions”. The event had a three-fold scope: (1) to launch the report on “Alcohol marketing in the WHO European region: Update report on the evidence and recommended policy actions” (WHO, 2020); (2) to discuss the main conclusions and policy considerations of this report, including how the conclusions and considerations can be translated into concrete actions at a country level; and (3) to learn from member states that have successfully implemented alcohol marketing restrictions and to discuss ways forward as well as challenges faced by the member states.

The report is authored by myself and my colleague Mikaela Lindeman, but many others have contributed with additions, input and suggestions, for which we are grateful. It is published in the WHO’s “Focus on Best Buys” series, in which evidence and knowledge are gathered and presented in an easily grasped comprehensive overview for understanding and dealing with different kinds of public health questions. The main message of these reports can be boiled down to “This is the evidence, and this is what has worked elsewhere; this action can be recommended on the basis of that experience”. The target audience and users are member states’ civil servants and politicians and other stakeholders in the matters at hand.

A great challenge in authoring this particular report was to stick to the scope, i.e., alcohol marketing and its evidence. As a phenomenon it ties into massive contemporary trends and principle questions regarding how to understand health behaviour, citizens and consumers in view of governance principles and commercial interests. Without such a contextual framing, the evidence on alcohol marketing makes little sense in today’s world. This is true for other global health questions as well.

What’s new?

The altered reality of the contemporary political project of public health becomes obvious when one starts to contemplate concrete action of controlling the internet space for marketing unhealthy products. Public health officials all over the world have become painfully aware of the insufficiency of old evidence-producing tools and governance models that are based on strict understandings of limited spaces of jurisdictions and consumers’ rationalities. They are simply not on their own sufficient enough for grasping the logic of peoples’ health-related behaviour in its many materialisations.

Lessons from alcohol marketing regulation point out two elements that need to be combined in order for public health strategies to be successful: In order to tackle or prevent ill health – whether the problems are communicable, such as pandemic viruses, or non-communicable such as drinking alcohol – we need insight into a new reality (or ‘ontology’), on the one hand, combined with a strict focus on traditional principles of governance in democracies with accountable societal contracts, on the other. This approach can be described as the combination of the new and the old.

In the case of alcohol consumption, the new reality is this: what is being consumed is no longer only ethanol molecules, i.e., alcohol, but “that what people drink is the marketing”, to cite the WHO programme manager Carina Ferreira-Borges. The brand, the experience, our social lives and self-apprehension images are part of a digitalised global normalisation of alcohol. The image and the marketing are inseparable parts of the product that is being consumed. The old reality backdrop consists of the fundamental task of governments to inform about and protect citizens against unhealthy behaviour and to remain accountable in such a societal contract. Sticking to this task is the main responsibility in view of the populations health and wellbeing.

A successful example

An example of a strategy that was able to incorporate a combination of new global and digital realities, and a strict focus on the traditional democratic task division between state and citizens in view of public health, is the 2015 amendment to the Finnish alcohol law (Hellman et al., 2018; Kauppila et al., 2019).

The amendment stated that all marketing of alcoholic beverages is prohibited if the advertising commercial operator in an information network service (such as social media platforms) uses the kind of textual or visual content produced by consumers or places into the services’ textual or visual content material that is intended to be shared by consumers (see Alcohol Act 28.12.2017/1102 § 50). In other words, brands operating in social media are not allowed to use citizens as marketers of their products through messages of encouragements such as “likes”, “shares” and “post a picture”-type of messages. User-generated content includes pictures that social media users have shared online; reviews and appraisals they may have written about products; or funny videos they may upload when (for example) enjoying a specific alcoholic beverage. Brands are not allowed to use and share this kind of content and by doing so produce networks of consumers that serve their brands as free marketers.

An evaluation of the act, in which we inquired into the particular dimensions of prevalence of the forbidden elements, showed almost no legal trespassing among Finnish alcohol beverage companies, or among their Swedish counterparts either (Katainen et al., 2018; Katainen et al., 2020; Lindeman et al., 2019). It is good to remember that both of these countries have histories of strict alcohol policies including high taxes and retail monopolies.

As to the principles underpinning the authoring of the act – the principle of protecting citizens from becoming marketers of unhealthy products – our comparisons found that the amendment had worked well in at least two concrete respects:

The law had seemed to have improved awareness and imposed more thorough control over messages published on social media brand platforms operated by alcoholic beverage producers.

Finnish social media regulations seemed to have combatted the otherwise globally increasing trend of publishing user-generated content, competitions and lotteries. No similar curbing trend was witnessed in Sweden.

The overall conclusion of the study was that banning user-generated content had laid down an important marker of preventing citizens from being employed as free marketers on behalf of commercial enterprises.

Re-focus on principles

Just as marketers have become more focused on the symbolic as an ingredient in their products (the product IS the message), so must the law-making of the new public health project. The new reality requires a reminder of the fundamental responsibilities that citizens are to expect by democratically elected law-makers and executive powers.

The main take-home message from the experiences of the 2015 amendment of the Finnish alcohol legislation is the importance of focusing on basic governance principles and role divisions in order not to lose sight of the structural frameworks that need to be protected in a completely new media reality.

The new reality is complex and difficult to grasp. Confos & Davis (2016) have listed six features of marketing within digital networks that make content attractive to children and maximise its impact on young people: ubiquitous connectivity, personalisation, peer-to-peer networking, engagement, immersion, and content creation. When massive economic resources and global information gathering and citizen-monitoring internet platform companies are put to work for creating these new ways of “drinking the marketing”, public health policies can re-orient towards the normative standards of societal conduct. A critical inspection of the nature, quality and accountability of the contract between the legal controlling unit and the population is the ultimate guarantee of good governance in public health policies now and in the future.