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Under the Influence Illustration by Mateusz Napieralski.

Under the Influence

When Big Alcohol claims to want to reduce harmful drinking, can you trust them?

A few days before Victoria Day 2016, Ted Fleming stood outside Toronto’s Union Station sipping free samples of a non-alcoholic “near-beer,” Budweiser Prohibition Brew, as the brand’s beloved Clydesdales clomped by. Forced to give up alcohol after a series of hospitalizations for Crohn’s Disease, Fleming is a professional connoisseur of near-beer who reviews, procures and ships non-alcoholic brews to consumers looking to stay dry. Surprised that the behemoth brewer had made a non-alcoholic product part of its flagship brand, backed by the full force of its marketing machine, Fleming blogged that Bud’s parent company, Anheuser-Busch InBev (AB InBev), was “reversing course on non-alcoholic beer.” One year later, Heineken followed suit with Heineken 0.0. To Fleming, both brews signal the category’s growing legitimacy, a response to an expanding market for near-beer.

But Anheuser-Busch claimed Budweiser Prohibition’s unveiling that spring was more than a sales scheme: it was part of a company project committing $1 billion USD to strategies for reforming how people drink, including making non-alcoholic or low-alcohol beer 20 percent of its production line by 2025. With Budweiser, Stella Artois, Corona, Labatt and Beck’s in its portfolio, the company makes nearly one-third of the beer volume consumed worldwide—so a fifth of its production translates into a whole lot of near-beer. Under the banner “Global Smart Drinking Goals,” Anheuser-Busch is also running experimental programs in nine cities around the world, aimed at reducing harmful drinking by 10 percent. In Zacatecas, Mexico, the program is sending teenage “mystery shoppers” into stores, who attempt to purchase alcohol and report their results, as part of an effort to encourage ID checks and reduce sales to buyers under eighteen. In Brasília, the capital of Brazil, an alcohol expert is helping family health teams intervene with individuals who have drinking problems. The program in Columbus, Ohio, planned to cut down on drunk driving by offering free rides on weekends via the ride-sharing service Lyft.

The idea that industries and individual companies can be socially progressive—and make even more money doing it—has recently exploded in business circles. Since 2011, Harvard Business School professor Michael Porter and management consultant Mark Kramer have written and presented extensively on this concept, driving a growing movement for companies to identify areas where they can “create shared value,” increasing earnings while addressing societal needs. Porter and Kramer’s cited examples include Anglo-American, a multi-billion dollar mining corporation in South Africa that developed the country’s first major HIV/AIDS treatment program as a way to keep workers on the job, and Yara, a Norwegian fertilizer manufacturer that partnered with the Tanzanian government and NGOs such as the World Food Programme to train subsistence farmers and boost agricultural production in Tanzania. In business schools and business magazines, the catch phrase is “doing well by doing good.”

But trusting wealthy multinationals to drive positive social change is a tall order when they necessarily have to prioritize their own interests and bottom line. In particular, when the world’s largest beer company plans to reduce consumption of what makes their core product so popular and so harmful, the response from scientists and health professionals is justifiably skeptical. They have spent decades trying to diminish the harms of drinking, using state-of-the-art tools to measure their success—and they’ve had to fight the alcohol industry every step of the way.

In 2017, the Canadian Institute for Health Information reported that more Canadians are now hospitalized for alcohol-related diseases than for heart attacks. In 2016, the United States Centers for Disease Control and Prevention found that drinking is a factor in one-third of deaths due to traffic crashes in Canada, placing Canada first among the world’s wealthy countries for alcohol-related traffic deaths. As Tim Stockwell, Director of the Centre for Addictions Research of British Columbia, puts it, alcohol “causes more harm than all the drugs put together, even fentanyl and all the opioids.” He can list “about sixty different ways” that drinking claims lives, including alcohol-related injuries, alcohol poisoning, chronic liver disease and cancers of the breast and liver.

In 2010, the World Health Organization (WHO) called for a worldwide coordinated effort to reduce harmful alcohol use. Endorsed unanimously by the WHO’s 193 member countries, the global alcohol strategy recommends approaches, such as limiting the number of places where alcohol is sold, that are strongly supported by scientific evidence. (Studies have shown that with a greater number of sales outlets, levels of alcohol consumption rise, along with rates of assault, homicide, self-inflicted injury and child abuse and neglect.) The WHO does not recommend, by contrast, alcohol-education programs, because the evidence shows that most of these programs have little impact.

In 2012, representatives from eleven of the largest alcoholic beverage corporations as well as two Japanese trade organizations publicly committed themselves to actions they claim support the WHO strategy. One such measure is strengthening the industry’s self-regulation of advertising by extending existing standards (like banning ads with underage drinkers) to online marketing. But the public health establishment, hardened by decades of Big Alcohol lobbying against policies to limit dangerous drinking—according to the Center for Responsive Politics, Anheuser-Busch has spent over $3.6 million USD on lobbying in 2017 alone—responded with disbelief.

In the UK, then-Prime Minister David Cameron pledged in March 2012 to pass a policy the WHO strongly recommends: setting minimum prices for alcohol. After Cameron’s government refused to follow through on this pledge, a British Medical Journal  investigation found that government staff and ministers had met with industry advocates arguing against minimum pricing and in favour of banning “below-cost” sales—alcohol priced at less than the tax and duties on the product—instead.  Health researchers had found such a ban would be ineffective, since fewer than 1 percent of alcoholic beverages in England are sold at below-cost prices, but it’s the policy Cameron’s government enacted. That same year, Scotland passed a law requiring minimum prices for alcohol. It has yet to take effect; a legal challenge by the Scotch Whiskey Association with support from other industry groups tied it up in court for five years.

Also in March 2012, pressure from FIFA (in anticipation of the 2014 FIFA World Cup) convinced Brazil to overturn its law barring alcohol sales at soccer stadiums, a policy intended to prevent game-related violence. Newspaper headlines referred to the new rules as the “Budweiser Bill,” because Anheuser-Busch is a major sponsor of FIFA. Industry pressure also led the country to delay a planned increase in alcohol taxes, another WHO-recommended strategy, until a few months after the games. In Britain, similar lobbying saw pub hours extended for World Cup games, despite the government’s stated position that the games did not warrant keeping pubs open longer—and despite research by UK physicians after the 2006 World Cup showing that alcohol-related emergencies, including assaults and traffic accidents, kept ambulances much busier on World Cup game days than on a normal day.

Just earlier this year in Canada, lobby groups for the restaurant and hospitality industry were among those arguing strongly against the Trudeau government’s plan to lower the legal alcohol limit for drivers from 0.08 to 0.05, the level used in most of Europe and in Scotland, Ireland, Australia and New Zealand.

So it should come as no surprise that some scholars were skeptical when the thirteen representatives endorsed the WHO strategy. In the journal Addiction, one group wrote that they suspected that the representatives’ commitments were mainly intended “to impede the development of effective alcohol control policies advocated by the public health community that would run counter to their commercial interests.” More than five hundred academics and health professionals and twenty-seven organizations signed on to a “Statement of Concern” to the WHO that said the companies’ proposed actions were unlikely to reduce problem drinking. In response, the Director General of the WHO, Margaret Chan, confirmed that in the WHO’s view, only national authorities should determine alcohol policies, and the alcohol industry should have no role in policy development.

Today, some academics are equally cynical about Anheuser-Busch’s latest billion-dollar commitment to near-beer, low-alcohol beer, and other strategies, such as tacking health labels on beer products. Tim Stockwell thinks it’s “a political ploy” to offset the possibility of higher alcohol taxes, one of the best studied and most successful strategies for reducing drinking’s harms. Michael Siegel of Boston University, who researches how alcohol advertising is tied to teenage drinking, calls it “a ruse” and “an attempt by the industry to make it look like they’re really committed to reducing the harmful use of alcohol when in fact they’re trying to promote alcohol.”

But two of the field’s biggest skeptics think the Anheuser-Busch project stands a chance. European alcohol expert Peter Anderson, of Newcastle University in England and Maastrich University in the Netherlands, and Jürgen Rehm, a German-Canadian scholar at Toronto's Centre for Addiction and Mental Health (CAMH), were intrigued enough to plan an evaluation to see if any of the project’s components actually work to decrease harmful drinking. Many of the industry’s prior efforts were so weak, “they were just marketing,” Rehm said. If this was different, the pair wanted to assess its effects.

Anderson began his career as a general practitioner and public health advisor in his hometown of Oxford City, England, where he designed the town’s alcohol strategy. Twenty years later, he’s tackling harmful drinking around the world for the WHO and is highly critical of the alcohol industry. He helped draft the “Statement of Concern” in 2013. But despite “a huge barrage of mistrust to get over,” he’s cautiously optimistic about the Global Smart Drinking Goals project. For one, it can be judged against clear targets, such as a 10 percent decrease in harmful drinking in the selected cities; for another, he respects the man who developed its rationale and architecture: Scott Ratzan, a physician and health communications expert with deep roots in global health.

With faculty appointments at universities—currently, Columbia University—and the editorship of a scholarly journal, Scott Ratzan is among a growing number of academics who straddle two worlds: he’s also a corporate executive, taking a pro-industry view. Before he worked at Anheuser-Busch, Ratzan was at pharmaceuticals giant Johnson & Johnson through the 2000s, when health scholars were making the case that so-called “direct to consumer” advertising—those TV commercials, still illegal in Canada, that encourage viewers to “ask their doctor about” specific drugs, promising wellness and erections—had dramatically increased prescription drug spending in the US, and led to people taking unnecessary drugs and suffering unnecessary side effects. Ratzan described these advertisements as an “opportunity to deliver quality health information to patients” and headed an industry task force pushing to overturn ad restrictions in Europe and the United Kingdom. In 2007, as the industry rep on a European Union working group, he lobbied for a pharma-funded digital channel to provide on-demand drug information, telling the Guardian that the idea was “to enable patients and citizens to make better decisions.”

The very next year, Ratzan became Johnson & Johnson’s Vice President of Global Health, and began co-chairing a United Nations Working Group aimed at bringing new innovations—and the companies behind them—into the UN’s program for improving maternal and child health. He became a go-to expert on public-private partnerships, testifying in the US Congress about the major role the private sector was playing in meeting the UN’s goals, and joining the corporate elite who descend upon the ski town of Davos, Switzerland, every few years to discuss ideas at the World Economic Forum. (Ratzan is quick to note, “I've never been, nor am I now, engaged in marketing or advertising.”)

Derek Yach, a former WHO executive director who was instrumental in pushing through its international tobacco treaty and advertising ban in the early 2000s, has known Ratzan for decades. Before Ratzan jumped from pharma to alcohol, Yach asked him, “Is this really going to be a good move?” Yach’s experience with tobacco had left him thinking an alcohol firm would focus more on public relations than dangerous drinking. Ratzan convinced him Anheuser-Busch was serious about trying to reduce drinking-related harms. Yach later became an advisor to the company, leaving in June of 2017.

Anheuser-Busch plans to spend even more on social responsibility platforms than the $1 billion Ratzan has at his disposal. In 2017, the company promised to use only renewable sources for its electricity by 2025, another costly aim. “Cutting back on fossil fuels is good for the environment and good for business,” CEO Carlos Brito said in a press release, echoing Porter and Kramer’s call to “create shared value.”

For Anheuser-Busch, Ratzan is a way into global health after the industry’s cool reception by the WHO. Alcohol producers have worried that they could face something like the WHO tobacco treaty, which took effect in 2005 and commits signers, including the European Union and 181 other countries, to raising taxes on tobacco, warning about tobacco’s dangers, enforcing bans on tobacco advertising and sponsorships, and helping people quit smoking, among other measures. When the WHO reiterated its call for a reduction in harmful drinking in 2013, Anheuser-Busch cited the agency’s dictum as an example of risks to the company in a statement filed with the US Securities and Exchange Commission. By combining Ratzan’s expertise and deep Rolodex with the company’s cash reserves, the company might push discussions away from an international agreement to control alcohol corporations. Preventing a WHO-led treaty is not on the Anheuser-Busch website as an official aim of the smart drinking goals project, but many—including Jürgen Rehm of the CAMH—believe it is logically a desired outcome.

Ratzan arrived at the company with a strategy he’d shared with public health students at the University of Maryland in the fall of 2013. People need “smarter choices” to choose from, he said, and he planned to use that idea to address the harmful use of alcohol. In December 2015, he blogged on a financial services site that the Global Smart Drinking Goals project was a way for the company to “do right” while “doing well.”

Before launching the project, Ratzan brought in some of the world’s top alcohol researchers to address an advisory council that included former Prime Minister Jean Chrétien and Cherie Blair, the spouse of former British Prime Minister Tony Blair. Though the US National Institutes of Health (NIH) has strict rules separating its scientists from vested interests, Peggy Murray, the director of the Global Alcohol Research Program at the NIH’s National Institute on Alcohol Abuse and Alcoholism (NIAAA), got permission from the US Department of Health and Human Services to speak to Anheuser-Busch about the project. Murray later told me that she was informing the company about scientific evidence, adding that NIAAA scientists have also discussed evidence-based prevention strategies with Mothers Against Drunk Driving.

As the NIH leaders offered comments, staff asked if they could videotape them. When Anheuser-Busch announced the project, clips of Murray, along with her institute’s director, Dr. George Koob, showed up on the company website in a film Ratzan calls a “quasi-testimonial.” The company, he said, was able to “capture it, fortunately, so we were able to share their hope and promise for this kind of intervention and what we can actually do for public health and medical research.” Murray is filmed saying the targeted cities project will provide “a wonderful lab to test individual ideas for how to reduce harmful use of alcohol.”

For several alcohol researchers, the NIH leaders’ star turn on an alcohol industry website came as a shock. The video gave the company “a very visible public relations coup to demonstrate that they are dealing with alcohol problems, when actually they’re doing it in a very superficial way,” said Thomas Babor of the University of Connecticut Health Center in Farmington, Connecticut.

Murray said that if they had it to do over again, they probably wouldn’t allow the footage to appear on Anheuser-Busch’s website and social media, as many viewers didn’t understand the context in which it was filmed. Anheuser-Busch is among several companies supporting the NIAAA’s research via the Foundation of the NIH. The Foundation is sponsoring an NIAAA study of the health effects of alcohol on the heart. (Disclosure: I covered that study for Wired.) But Murray remains impressed by the company’s program and rates at least one part of it very highly: its push for doctors and health professionals in the target cities to screen individuals for problem drinking and offer a “brief intervention”—essentially a talking-to that strongly encourages the person to cut back. This low-tech strategy has proven effective in several studies and it’s the method family health teams in the Brasília test site are now using.

Anderson, the former public health advisor, at first declined a similar invitation from Ratzan, but Ratzan pressed. “There’s no harm in you at least coming to give a presentation on the science of alcohol and public health,” Anderson recalls him saying, and in July 2015, Anderson attended a company meeting in London. He left “a bit surprised” to find himself viewing the project in positive terms. If the company could persuade heavy drinkers to switch to beers with lower alcohol content, he thought, that would be a public health success story. In studies, Anderson and other researchers have found that drinkers cannot tell the difference between a beer with an alcohol content of 3.8 percent and one of 5.3 percent, meaning a person drinking their usual number of bottles would consume less alcohol overall without noticing a difference.

Anderson now lives in Spain’s Catalonia region, where his wife is from. While chatting with Rehm in Barcelona, shortly after Anderson’s London presentation, the two agreed it was worthwhile to evaluate Anheuser-Busch’s project. They quickly identified their research question: “By the year 2025, have AB InBev’s goals positively or negatively impacted on reducing the harmful use of alcohol and subsequent public health?”

They wrote a paper describing how they would answer that question and submitted it to an academic journal, asking the editors to publish it quickly, since the project was about to launch. Anheuser-Busch announced its Global Smart Drinking Goals in December 2015, and, one month later, “Evaluating alcohol industry action to reduce the harmful use of alcohol,” a commentary by Anderson and Rehm, was out in Alcohol and Alcoholism.

The key, in Rehm’s view, was to design an independent evaluation: to assess the city projects, for example, they would choose a control city in the same country as each experimental city, recruit samples of adults in both, and survey them about their drinking over several years, to determine if people actually change their behaviour. The evaluation could not go forward without comparison communities, Anderson explained, because people could drink less for reasons other than the Anheuser-Busch intervention, like a change in the country’s financial situation or policies.

Furthermore, Rehm finds one aspect of the cities project problematic: the selected cities that have been announced so far are all places where the company has ties. For example, Anheuser-Busch has had a brewery in Columbus, Ohio, for decades, and Zacatecas, Mexico is home to the company’s largest brewery, producing twenty million bottles daily. The company could be perceived as using the city projects to build goodwill in places where it has local assets, and such a situation can bias research. To prevent the company from having further impact, Anderson and Rehm said they would need to independently select the control cities.

Ratzan invited Rehm, among others, to submit a research proposal. Once he had, it was a few weeks before the company responded. For his part, Ratzan was busy with another file. That fall, the company had announced it was spending more than $100 billion USD to take over SABMiller, the company that had combined South African Breweries with Miller Brewing. If it went through, the merger would be the biggest consumer products deal in history, but the plans first had to clear antitrust hurdles in markets around the world, and concerns about layoffs and local economies in South Africa. As Ratzan prepared to travel to South Africa, his contacts tried to line up meetings with key people who knew the local alcohol issues. On Ratzan and Anheuser-Busch’s behalf, multiple industry players reached out to Charles Parry, who runs alcohol and drug research for South Africa’s Medical Research Council. By the numbers, South Africans drink more than in many corners of the world, and Parry’s own province of the Western Cape has one of the world’s highest rates of children born with fetal alcohol syndrome. Parry notes that alcohol also adds to the country’s devastating HIV/AIDS epidemic because heavy drinking increases the risk of people acquiring HIV. As part of the country’s public health lobby, Parry felt it was inappropriate to talk to alcohol industry representatives, and declined the requests to meet with Ratzan and Anheuser-Busch. He also said no to several consulting firms that contacted him seeking information on behalf of anonymous clients, which he suspected were related. The deal was nevertheless inked on July 1, 2016, around the same time Torontonians like Ted Fleming were taking their first sips of Budweiser Prohibition Brew.

In August of that year, Rehm submitted the budget for an evaluation of the Anheuser-Busch initiative, along with a few PowerPoint slides listing what he labelled “dealbreakers”—he was willing to conduct the research using company dollars only if the company accepted his conditions: assurance that he would have operational independence from Anheuser-Busch and its advisors, ownership of the study data, and exclusive rights to make decisions about study publications.

Rehm and Anderson had written in their article that evaluating a program generally costs between 5 percent and 20 percent of the cost to mount the program, but the budget came in at less—he asked for $21.4 million USD (2.14 percent of the $1 billion program cost), with “severe penalties in case A-BI/foundation decides to cancel without cause or breach the contract.”

“These are very huge numbers,” Rehm acknowledges, “but how can I find out if they change behaviour in Bolivia or Mexico without going there and looking in those cities?” The penalties would protect against the sort of situations that arose in university-corporate partnerships during the 1990s, including in Toronto, where a company in a dispute over a study at the Hospital for Sick Children suddenly cancelled it.

Several weeks after Rehm sent in his conditions, Rehm says Anheuser-Busch thanked him for his “candor” but turned down the proposal, citing the study’s projected costs. After months of negotiations, the deal was off.

In the months that followed, the SABMiller megamerger became a reality and the new, bigger Anheuser-Busch InBev formed a foundation with Scott Ratzan as its inaugural president. The foundation then signed an organization affiliated with the California- and Maryland-based Pacific Institute for Research and Evaluation to evaluate the Smart Drinking Goals results. Health economist Ted R. Miller, the project’s lead scientist, says it makes a difference that his client is a foundation instead of a corporation. “When there’s a foundation in the middle, the company lawyer can’t say to me, ‘Oh, I don’t want you to do this,’ and I can’t do it,” he said. Miller has spent two decades working for the institute, and is considered an expert at calculating in lives and dollars the breadth of harm that results from underage drinking and drunk driving. He intends to study possible consequences of the smart drinking project by asking parents in the nine cities whether zero-alcohol drinks “open the gate” by introducing youth to a beer-like product.

His institute’s agreement guarantees it independence in conducting the evaluation and publishing the findings. Even so, Miller’s colleagues debated whether it was ethical to do the research, with some senior researchers who Miller describes as “very powerful and experienced” arguing against it. He recalls them asking, “What if this is just providing cover for the alcohol industry as they do some window-dressing on the harms that they’re not addressing?” Because of the project’s industry backing, alcohol researchers at several institutions have declined to speak to the academics providing technical assistance to the cities. But others have signed on as investigators and advisors, and two professors at Tufts University School of Medicine in Boston are planning a 2018 conference for the health labelling effort. Conference arrangements, they note, will be “according to Tufts University and AB InBev Foundation Policies.”

Anderson remains involved. In 2017, he helped to tweak the screening and brief intervention program in Brasília to improve its chances of effectiveness. Some of the test cities may see a decline in problem drinking, he says, but it will take about five years, and that’s difficult for the company to understand. “They say, ‘We want results next month,’” he adds.

The company contacted Rehm in early 2017 to ask if he was interested in analyzing data they’d hired the Gallup polling organization to gather in six of the cities. He sent a curt but polite—“Canadian,” he said, wryly—response, writing that his principles hadn’t changed, and it was “pretty clear” that he and Anheuser-Busch were far apart in this regard.

On the other hand, Derek Yach, the former WHO tobacco expert who became an Anheuser-Busch advisor, liked what he saw, and is now adapting the company’s model for an even more embattled industry. In September, the tobacco company Philip Morris International (PMI) announced it is dedicating itself to researching ways to decrease smoking worldwide through a new foundation. Founded and led by Yach, the Foundation for a Smoke-Free World will receive about $1 billion USD from Philip Morris over the twelve-year period from 2018 to 2030, to push new solutions for cutting down deaths and disease due to smoking. Despite criticism from smoking researchers and advocates who point out that Philip Morris still markets cigarettes (according to the Globe and Mail, the company sold 813 billion cigarettes in 2016), Yach argues that his foundation will research so-called “harm reduction” strategies for smokers unable to quit, and he blogged on his foundation’s site that “stringent safeguards” will ensure “the tobacco industry has zero influence over the Foundation’s agenda or research.” A few weeks before launching it, he told me he hoped his new initiative would be “very much aligned with how you move a major global health issue ahead.” In his view, working with the corporations behind some of the planet’s most lethal substances is essential to that process.

WHO scientists, however, are not persuaded. On September 28, 2017, the WHO issued a statement declaring that the agency will not partner with the PMI-funded foundation, discouraging governments from partnering with it, and suggesting that “the public health community should follow [their] lead.” The reasons for the WHO’s stance are well-founded: the tobacco industry has continually misled the public about the dangers of tobacco, and Philip Morris has invested millions of US dollars lobbying and litigating against countries that try to enact the policies WHO recommends in its tobacco treaty.

But Ted Fleming believes that consumer demand for healthier, less harmful options is only growing, with or without the involvement of huge multinational corporations. He’s betting his own livelihood on this potential market—he recently raised funds through Kickstarter to brew his own zero-alcohol beer, Partake, and hopes to begin distribution in Canada later this year. While Big Tobacco and Big Alcohol have earned their reputations as wealthy foes of the public health community and masters of spin, and there’s reason to doubt the motives of the AB InBev Foundation and the Foundation for a Smoke-Free World, the two industries will have to make changes if the buying public demands it—if only to save themselves.