The alcohol industry—A commercial determinant of poor health for Rainbow communities
Handling editor: Cassandra Wright
Abstract
Background
Alcohol use is an area of challenge for health promotion internationally. The alcohol industry operates as a key commercial determinant of health in that its actions contribute to alcohol misuse, resulting in a range of health and social harms to individuals, families and communities. Rainbow people (including those who identify as lesbian, gay, bisexual, transgender or gender diverse) are one group experiencing considerable harm from alcohol use.
Methods
Data from 24 focus groups involving 131 people held in six cities in New Zealand during 2018, were used to explore local understandings of the ways in which the alcohol industry operates as a commercial determinant of health for Rainbow communities. The focus group discussions were analysed thematically.
Results
Three key themes were identified. First, the alcohol industry was identified as present in the ‘everyday’, through targeted alcohol promotion to Rainbow people, and due to the centrality of bars to their social and cultural landscapes. Second, participants recognised the benefits of alcohol industry support for Rainbow communities. Last, an opposing view was articulated, with the alcohol industry and its commercial activities viewed negatively.
Conclusions
These findings highlight that alcohol as a commodity and the alcohol industry are successfully and firmly embedded within Rainbow communities. Overall, given alcohol is widely regarded in a positive way, this is likely to create difficulties for health promotion efforts to reduce alcohol related harm in these communities.
1 INTRODUCTION
Alcohol use is a key area of concern for health promotion worldwide, contributing negatively to health and social outcomes at a population level.1 Specific groups within populations have also been identified as being at more risk of harm due to drinking alcohol. One such group is Rainbow people—an umbrella term that includes people who identify as lesbian (L), gay (G), bisexual (B), transgender (T) or gender diverse. Rainbow was the preferred descriptor among those who took part in the community consultation for this research.
The international evidence clearly shows that people who identify as LGB have higher rates of alcohol consumption and experience more alcohol-related harm than non-LGB identifying people.2-5 While this claim usefully highlights disparity experienced by LGB people, it obscures some of the differences within this group. A recent review of studies identified that while high levels of alcohol use are relatively similar among men irrespective of sexuality, problematic alcohol use are much more common among sexual minority women than among heterosexual women.6 The evidence regarding transgender people and alcohol use is not as strong. Nevertheless, high levels of alcohol use among transgender people have been reported.7
The evidence in New Zealand is less robust—but is broadly consistent with international evidence. A national survey of 13,000 adults (15 years+) identified LGB people as 2.2 times more likely than non-LGB people to drink hazardously (AUDIT score of 8 or above).8 Surveys of young people (13-17 years old) identified binge drinking (consumption of five or more alcoholic drinks within 4 hours at least once in the last 4 weeks) as more likely among same-sex/both-sex attracted students (40.8%), compared with opposite-sex attracted students (23.1%). Additionally, transgender-identified students were found two times more likely to drink alcohol at least weekly than nontransgender students.9
Problematic alcohol use does not happen in a vacuum. Among Rainbow people, alcohol use is typically accounted for as a way to cope with experiences of discrimination and marginalisation due to having a ‘minority’ identity,10 and as a way to explore and feel comfortable with having a Rainbow identity.11, 12 Heavy alcohol use in such contexts is framed positively as an appropriate way to counter ‘challenges in life’.13 Additionally, it is argued that drinking is normalised for Rainbow people, with bars being safe meeting places and widely frequented,14 providing readily accessible opportunities for risky and heavy drinking.15
Increasingly, health promotion has moved away from a focus on individual factors and health behaviours to understanding the crucial role of nonbiological and nongenetic factors in the health of individuals and populations. While health promotion has had a long-standing interest in the impact of the social determinants of health (including economic systems and policies), an emergent interest is understanding how commercial determinants impact the health of individuals and populations. These commercial determinants include industries producing and distributing health harming products,16 often on a global scale. Transnational corporations are considered major drivers of the global epidemic of noncommunicable diseases.17 Commonly identified harmful products include alcohol, tobacco and ultra-processed foods and beverages.18
To date the alcohol industry has been comparatively successful in rebuffing the stigma associated with the use of its products. One successful tactic has been its efforts to maintain a health agenda that focuses on the individual drinker, rather than the industry itself as suppliers and marketers of alcohol products.19 The global health community has simultaneously demonstrated a reluctance to make alcohol control a policy priority,19, 20 especially when compared with the policy attention and health promoting actions directed against the tobacco industry and its products.
A current area of concern with the alcohol industry is its global or cross-border marketing, advertising and promotion practices.21 Rainbow people, particularly gay men, have long been a market targeted by the alcohol industry. Since at least the 1950s in the USA, alcohol has been explicitly promoted to gay men through a range of advertisements.22 The rationale for this attention is that the market is of sufficient size in itself, and also that gay men act as opinion leaders or ‘influencers’, allowing brands to gain an entrée into mainstream markets. Alongside this has been other promotion to the wider Rainbow communities in the form of sponsorship of festivals such as Pride Events.23 Similar (historical) advertising and promotion has been noted in New Zealand, however, there have not been any recent local investigations.22
Our article draws on data collected in a study that explored the social and cultural influences on drinking among Rainbow New Zealanders.24 Specially, our aim is to identify local understandings of the ways in which alcohol operates as a commercial determinant of health for Rainbow communities.
2 METHODS
2.1 Design and recruitment
The study used a qualitative design with focus groups. Focus groups are an excellent method for studying collective meaning-making and obtaining shared cultural information and understandings.25
The recruitment process was designed to attract a range of Rainbow people living in New Zealand. Inclusion criteria for participation in the study were being aged 16 years and over, an alcohol drinker or nondrinker and self-identifying as a Rainbow person. The research team approached community-based organisers to recruit participants for the study and potentially host a focus group. These organisers were typically leaders of existing Rainbow community groups or people with strong professional or social networks within these communities. Both the organisers and participants received a small monetary gift for organising a group or taking part in a group.
2.2 Participants and data collection
A total of 24 focus groups involving 131 participants were held in six cities across New Zealand (Auckland, Hamilton, Palmerston North, Christchurch, Dunedin, during February-May 2018). The focus groups consisted mainly of people who could be considered drinkers (Table 1). The groups were of varying sizes (ranging from two to nine participants; mean size five participants). Many of the groups had a specific focus on a particular Rainbow or age grouping (Table 2).
| n | % | |
| Age | ||
| 16-19 | 7 | 5 |
| 20-29 | 49 | 37 |
| 30-39 | 24 | 18 |
| 40-49 | 19 | 15 |
| 50-59 | 12 | 9 |
| 60-69 | 16 | 12 |
| 70+ | 4 | 3 |
| Ethnicity | ||
| NZ European | 76 | 58 |
| Māori | 28 | 21 |
| Pacific | 15 | 11 |
| Asian | 9 | 7 |
| Another ethnicity | 3 | 2 |
| Work status | ||
| Employed | 78 | 60 |
| Student | 27 | 21 |
| Unemployed | 9 | 7 |
| Retired | 7 | 5 |
| Other/not provided | 10 | 8 |
| Gender | ||
| Female/Cis-female | 40 | 31 |
| Male/Cis-male | 70 | 53 |
| Transgendera | 13 | 10 |
| Nonbinary | 4 | 3 |
| Another gender | 4 | 3 |
| Sexuality | ||
| Gay | 59 | 45 |
| Lesbian | 16 | 12 |
| Queer | 13 | 10 |
| Pansexual | 8 | 6 |
| Bisexual male | 7 | 5 |
| Takatāpuib | 7 | 5 |
| Bisexual female | 3 | 2 |
| Fa'afafinec | 2 | 2 |
| Another sexuality | 12 | 9 |
| Alcohol use | ||
| Drink in last year | 120 | 92 |
| Drink in last 4 weeks | 100 | 77 |
| 7+ drinks on one occasion last 4 weeks | 55 | 42 |
| Purchased alcohol in bar/club last 4 weeks | 58 | 44 |
- a All participants who identified a transgender identity (eg, trans man) are included in this category.
- b An umbrella term that describes Māori (indigenous New Zealanders) of diverse gender, sexuality and sex characteristics.48
- c A Samoan word which translates as ‘in the manner or like a woman. Fa'afafine are biological males whose gendered behaviours are, to varying degrees, feminine.49
| n | |
|---|---|
| Māori/Takatāpui | 4 |
| Asian | 2 |
| Samoan/Fa'afafine | 1 |
| University students | 2 |
| School students/youth focused | 3 |
| Mid-age/older gay men | 3 |
| Gender diverse | 1 |
| Mixeda/social | 7 |
| Deaf | 1 |
| Former drinkers in recovery | 1 |
- a Included participants with a range of gender and sexual identities, ages and ethnicities.
Nearly all the groups were moderated by one of the authors (who identify as sexually diverse). A few groups were moderated by research colleague who were typically chosen because their ethnic identity matched that of focus group members. Moderators therefore had some affiliation with participants due to ‘insider’ status because of a shared sexual and/or ethnic identity but were also ‘outsiders’ as they were academics in a research role. Moderators took care to avoid making assumptions based on their own knowledge during the focus groups and acted as much as possible as naïve questioners guiding the discussion.
The focus groups ranged in length from 35 minutes to 2 hours (median 1 hour 14 minutes). Moderators followed an interview guide to ensure a similar range of topics was covered in the groups. The group discussions were digitally recorded and transcribed.
2.3 Data analysis
Thematic analysis was used to identify patterns of shared meaning across the focus groups.26 The approach to analysis was inductive and data-driven, focusing initially on the semantic content, and then the latent constructs underpinning this content. The analysis was led by the first two authors and involved reading the entire transcripts and then coding them within NVivo. These two authors then identified and agreed on provisional themes. All authors then reviewed and discussed these themes before further refinement and development of themes was undertaken by the first author. The authors brought their ‘Rainbow affiliation’ to the research and analysis process, as well as extensive experience of research within Rainbow communities. The authors are also employed in academic roles (public health or nursing) and have interests in community health and wellbeing.
In addition, the initial results of the study were reported back to Rainbow community members at two meetings (Auckland, Wellington). This process allowed for guided discussions about the research results and was an opportunity for Rainbow community members to question and critique the researcher's interpretation of results and to provide further ideas and insights. A feedback meeting was also held with the funding agency and this allowed alcohol health promoters views about the results to be provided. These discussions helped the research team refine their understandings and analysis. Following these meetings all authors subsequently reviewed and agreed upon the final themes reported and the illustrative quotes selected.
In line with Massey University guidelines this research was assessed by peer review to be low risk. Consequently, it was not reviewed by one of the university's human ethics committees, and the research team were responsible for the ethical conduct of the research. Information sheets about the study (including contact details for support services) were provided to all participants. A written consent form was completed before participation.
3 RESULTS
Across the groups there was considerable debate about the role of the alcohol industry as a commercial determinant of health. Three key themes were identified. First, the alcohol industry was identified as present in the ‘everyday’. Second, there was recognition of alcohol industry support for Rainbow communities as largely positive. Last, an opposing view was articulated, where the alcohol industry and its commercial activities were viewed negatively.
3.1 Alcohol industry is present in the everyday
Participant 1 (P1): I'm surprised there's no vodka in your cups actually, to be honest, because the only times that I see you guys is when we are drinking.
P2: This is true … when you think about, the only time we always catch up is if we are drinking.
If we turn the clock back and look at queer [Rainbow people] history and venues and stuff, pre-law reform there was a lot of bars … so historically queers always hung out in bars, it was a dark sort of place and the place to be sort of anonymous …
Although attitudes towards Rainbow people were noted to have improved over the years, the important social and community-building role played by modern ‘gay’ bars was affirmed. This was viewed as inevitable as few other suitable non-bar venues were available for these purposes.
I bought a Rainbow bottle of vodka because the bottle had a rainbow on it.
Traditional forms of promotion were more commonly reported than digital marketing. Some presence of alcohol companies and products was noted on social media (eg, Facebook) and in online publications. Some exposure to the advertisements and promotions of alcohol brands based in overseas jurisdictions was also identified.
3.2 Alcohol industry focus and support is valuable
So I do not know, if I'd say that, that's necessarily a bad thing, because we sort of want ad campaigns demonstrating approval from, not just drink companies, but everyone. So, I think there's a fine line where it's like, it's sort of good, that any company is targeting the LGBT community in terms of saying, hey, we accept you, we support you …
Yeah, they are still a business. They do care about the community, and they do …
You know they set up for a party, they have got a PA, they have got a stage, and they are able to support sometimes with the DJ and stuff, so it makes a whole lot easier for serving other people.
P1: I do not blame alcohol companies for …
P2: … for heavy drinking …
P1: … focusing on, our, or communities that have historically always met in drinking establishments. I do not think that's necessarily exploitative.
3.3 Alcohol industry exploits and harms us
Interviewer: Do you think, these companies out there are wanting to hook you into their networks?
P1: Yes, that is exactly what I think.
P2: I think it's possibly more prevalent now than it has been just because in a lot of the media it's giving more popular and advantages to like prove that you are accepting of the queer community like this good.
P3: This is sort of saying like having the best like gay best friend, stuff like that.
P1: We're a commodity. I do not want to be a commodity.
Well, it's just like pink washing is not it, it's just like using people's identity to sell a product and get you to buy into both capitalism and harmful behaviours.
I guess, with the advertising specifically to all the queer, rainbow community and stuff … its not cool because it's already like, we know we drink a lot, we do not need to be encouraged. We encourage ourselves enough.
4 DISCUSSION
The research clearly identifies the alcohol industry and its products and practices are firmly embedded in the lives of participants and within their Rainbow communities, thereby acting as a commercial determinant of health. Participants noted global and national brands advertised and promoted products to Rainbow people, while locally, bars provided a range of support to community groups and were valued as important meeting places. As noted elsewhere the alcohol industry has been successful through targeted marketing in linking its products to the social and cultural milieu of Rainbow people.12 While links between this marketing and consumption cannot be established,27 it is apparent that permissive views about alcohol use exist within Rainbow communities have been informed by alcohol industry actions. It also remains unclear to what extent alcohol marketing is driving or responding to these views.
The participants also reported contrasting views on the impacts for Rainbow communities of the alcohol industry's promotion of its products. The support expressed for the alcohol industry is consistent with earlier studies, which have reported tobacco industry support for Rainbow communities signifies legitimacy and provided visibility for these communities and provides valuable economic support community groups.28, 29 Conversely, other participants point to Rainbow communities being used for the benefit of the alcohol industry, at the expense of poorer health outcomes for these communities. In such instances, intervening to achieve equity in health outcomes for Rainbow people is supported.23
The implications for health promotion from these research findings are substantial. From a global perspective, it is clear the alcohol industry, unlike the tobacco industry, is still able to influence health policymaking to advance its commercial interests.30 The alcohol industry has been successful in keeping the health promotion focus on individual drinkers. In this scenario, attention is paid to the individual factors that promote drinking, as if this exists within a void where advertising, promotion and other means of encouraging alcohol consumption do not feature. The alcohol industry has adopted various corporate social responsibility strategies that enable it ‘to deflect and shift the blame from those who manufacture and promote alcoholic products to those who consume them.’31 Such actions are about protecting markets and maintaining the industry's reputation rather than concern for the health and wellbeing of populations.32 Industry and health promotion agencies have, for example, promoted responsible drinking.33 This is often done through the provision of relatively passive responsible drinking messages. The alcohol industry provides these types of messages on products and in advertisements, while health promotion agencies may specify low risk drinking guidelines to encourage people to make better decisions about alcohol.34, 35
While the effectiveness of these messages and this approach is not established,36 from a health promotion perspective ensuring people have access to accurate information has inherent validity. Nevertheless, it is increasingly recognised that health promotion alone is not sufficient to influence behaviour change and healthy choices. As a consequence there has been a shift away from a focus on influencing individual drinkers, to the role played by the alcohol industry in encouraging the use of its products.23 For health promotion this is likely to involve increased policy actions to address the wider environment in which alcohol use is encouraged.37
The concerns raised above suggest implementing successful health promotion will be a challenge, but nonetheless a number of ‘best buy’ policies exist to focus responses to alcohol harm.38 Because the alcohol industry uses sophisticated strategies to protect, maintain and enhance its commercial interests, health promotion needs to respond in kind and to ‘develop, refine and modernise their own set of strategies, to create a public health playbook.’39
Given a recent observation of ‘gender blindness’ in alcohol policy responses,40 we suggest the concerns of Rainbow people as another area of blindness in alcohol policy. Rainbow communities have a role to play in efforts to ‘push-back’ against the alcohol industry as even within stronger alcohol policy environments, reduced harm for these groups is not guaranteed.23 Rainbow community organisations should also re-evaluate the appropriateness of accepting alcohol industry support.27 It will be easier to action this if there are more alcohol-free venues available,41 and more direct financial support so these organisations are not reliant on support from the alcohol industry.22 Existing non-alcohol socialising opportunities could also be promoted more effectively.42
4.1 Limitations
The grouping of Rainbow populations is broad. To ensure a wide range of participants, a variety of people were approached to organise focus groups. Despite this, there was some gaps in the sample with lesbian, bisexual and gender diverse people, as well as rural dwelling participants less well represented in the sample. Participants were also likely to have been connected with an existing community or social group, meaning those not connected were unlikely to have taken part.
5 CONCLUSION
Government policy interest in health and wellbeing issues, including alcohol issues, for Rainbow people in New Zealand has been minimal for some time.43, 44 Given the threats to public health from the alcohol industry,45, 46 health promotion agencies should continue to focus on general population actions to address the actions of the alcohol industry, while Rainbow people and organisations have a role to play to ensure their social realities social realities are addressed in these responses.47 Heath promotion agencies need to work alongside Rainbow communities to counteract the negative impact of the alcohol industry.
ACKNOWLEDGEMENT
The authors thank participants who took part in this research and offer special thanks to those who organised the focus groups. We acknowledge colleagues (Dr Teah Carlson, Dr Belinda Borell, Jitesh Prasad, Rommel Coquilla) who assisted with focus group moderation. Dr Lanuola Asiasiga contributed this project while employed at Massey University; she is now an independent researcher. Open access publishing facilitated by Massey University, as part of the Wiley - Massey University agreement via the Council of Australian University Librarians.
FUNDING INFORMATION
This article reports on research funded by the Health Promotion Agency. The views expressed in the article are those of the authors.
CONFLICT OF INTEREST
No potential competing interest was reported by the authors.
ETHICS STATEMENT
This study was undertaken in accord with Massey University processes for ethical conduct of research. The project was assessed by peer review to be low risk (notification number: 4000018320). Consequently, it was not reviewed by one of the University's Human Ethics Committees, and the researchers (authors of this article) were responsible for the ethical conduct of the research.
Open Research
DATA AVAILABILITY STATEMENT
Research data are not shared.
