The alcohol in alcoholic beverages is toxic to many bodily systems ^{[1][2][3][4][5]}[1,2,3,4,5], is genotoxic and is a carcinogen ^[6][7][6,7], being a cause of cancers of the oral cavity, pharynx, larynx, oesophagus, colorectum, liver (hepatocellular carcinoma) and female breast ^[8][9][10][8,9,10]. Within the European Union (EU), a population 447 million people as of 2020, alcohol is responsible for a little under 300,000 deaths a year, with cancer the top cause of alcohol-related deaths (29% of all deaths due to alcohol), followed by liver cirrhosis (20% of all deaths due to alcohol), and cardiovascular diseases (19% of all deaths due to alcohol) (data for 2016) [11]. Alcohol is also detrimental to societal well being, with societal costs ranging from 0.12% to 3.47% of GDP across EU countries ^[12][13][12,13].

Better health and well being are at the heart of the United Nations Agenda 2030, which has an overall aim to drive transformative change to shift the world onto a sustainable and resilient path through cross-sectoral and cross-cutting actions [14]. Target 3.5 of Agenda 2030 is to “strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol” [14], operationalized as a non-communicable disease (NCD) target by the World Health Organization (WHO) to reduce the harmful use of alcohol in relative terms by 10% between 2010 and 2025 [15].

Promoting sustainable health, the key to reducing the harm done by alcohol, is to drink less alcohol [16]. The WHO SAFER initiative calls on governments to encourage people to drink less alcohol by making alcohol more expensive, decreasing its availability, banning or strictly regulating its advertising, putting in place strict drink-driving laws, and providing advice, support and treatment to reduce consumption [17]. Alcohol policies in general, including setting a minimum price per gram of alcohol sold, and regulating or banning advertising generate savings in heath expenditure, and improve employment and productivity, with high returns on investment [18].

In its action plan (2022–2030) to effectively implement the global strategy to reduce the harmful use of alcohol as a public health priority, in addition to the “continued enforcement of high-impact cost-effective policy options included in the WHO SAFER initiative” [17], WHO calls on economic operators to “substitute, whenever possible, higher-alcohol products with no-alcohol and lower-alcohol products in their overall product portfolios, with the goal of decreasing the overall levels of alcohol consumption in populations and consumer groups, while avoiding the circumvention of existing regulations for alcoholic beverages and the targeting of new consumer groups with alcohol marketing, advertising and promotional activities” [19].

2.1.1. The Extent of the Production of Lower Strength Products

Grey Literature: The report forecasted that no- and low-alcohol volume would grow by +8% compound annual growth rate (CAGR) between 2021 and 2025, compared to regular alcohol volume growth of +0.7% CAGR during that same period. No-alcohol beer was projected to grow at +11% CAGR between 2021–2025, and no-alcohol ready-to-drinks (RTDs) and no-alcohol spirits at +14% CAGR. Wine was expected to differ, with low-alcohol wine expected to grow at +20%, and no-alcohol wine at +9% CAGR.

Academic Publications: Routinely published Eurostat Data is only available for no-alcohol beers, and not for other products; further, data is not available for all EU countries. An analysis of Eurostat Data from 18 out of 27 EU countries found that sold production of beer with an ABV ≤ 0.5% represented 3.8% of the volume of sold production of all beer in 2019, having increased from 1.8% in 2013 ^[20][28]. Five countries accounted for 81% of sold production volume: Germany, the Netherlands, Spain, Poland and Czechia.

2.1.2. To What Extent Are Consumers Buying and Drinking Lower Strength Alcohol Products?

Grey Literature:  (i) in 2018, 13% of Dutch adults reported drinking no-alcohol beer on a monthly basis ^[21][44]; (ii) in 2021, 20.3% of German adults reported having drunk no-alcohol beer, with 8.9% of respondents doing so at least monthly ^[22][45]; and, (iii) in 2021, 21% of British adults reported consuming a no-alcohol product during the past 12 months and 17% a low-alcohol product during the last 12 months ^[23][46].

Academic Publications: Based on PRODCOM data, the top four countries with the highest apparent consumption of no-alcohol beer as a percentage of total beer consumption are Czechia, the Netherlands, Spain and Luxembourg ^[20][28], with three of these countries having relatively high beer consumption (Czechia, the Netherlands, and Luxembourg) ^[24][141], which could explain the higher proportion of non-alcoholic beer as percentage of all beer in these countries. Consumption of no-alcohol beer does not seem to be related to changes in per-capita alcohol consumption; between 2010 and 2019, there was no change in per-capita alcohol consumption in Czechia (1% increase), a decrease in the Netherlands (6%), a large increase in Spain (25%), and no change in Luxembourg (1% decrease) ^[24][141].

2.1.3. What Are the Currently Implemented Policies Relevant for Lower Strength Alcohol Products?

Grey Literature: On the whole, it seems that little policy is set that might favour substitution. Four grey-literature publications found or stated: (i) in 2020, the voluntary Dutch Advertising Code for Alcohol Free and Low Alcohol Beer came into effect, stipulating that advertising for alcohol-free and low-alcohol beer may not be aimed at young people under the age of 18, and that advertising for low-alcohol beer may not be aimed at pregnant women and drivers ^[25][32]. The realist paprevierw found no evaluation of the code. Based on previous experiences of evaluation of voluntary advertising codes ^[26][33], it is unlikely to have any favourable impact; (ii) in its consultation document, “Advancing our health: prevention in the 2020s”, whilst not without its critics ^[27][34], the UK Government made a commitment to work with the drinks industry to “deliver a significant increase in the availability of alcohol-free and low-alcohol products by 2025” ^[28][35]. On the other hand, it seems that much policy is set that disfavours substitution of higher strength products with lower strength products. Four grey-literature publications found or stated: (i) market research data from the United Kingdom, undertaken during 2020, found that 89% of respondents could not accurately define a low-alcohol drink (ABV ≤ 1.2%) and 80% could not accurately define an alcohol-free (ABV ≤ 0.05%) drink ^[23][46]. Of respondents, 62% agreed that the definitions of low-alcohol, de-alcoholised and no-alcohol drinks were confusing; (ii) Regulation (EU) 1169/2011 specifies that alcoholic products with an ABV ≤ 1.2% are not required to specify the ABV on the label ^[29][41]; (iii) Regulation (EC) No 1924/2006 states that “beverages containing more than 1.2% by volume of alcohol shall not bear: (a) health claims; (b) nutrition claims, other than those which refer to a reduction in the alcohol or energy content. In the absence of specific Community rules regarding nutrition claims referring to the reduction or absence of alcohol or energy in beverages which normally contain alcohol, relevant national rules may apply in compliance with the provisions of the Treaty” ^[30][42].

Academic Publications: None.

2.2. Context

2.2.1. Who Buys and Drinks Lower Strength Alcohol Products and Why?

Grey Literature:  In terms of who buys and drinks lower strength products: (i) in 2018 in the Netherlands, drinking non-alcoholic beer was more common amongst men, younger adults and those with higher levels of education ^[21][44]; (ii) in 2021, in Germany, men, the middle-aged and individuals with higher incomes were more likely to consume non-alcoholic beer ^[22][45]; (iii) in 2021, in the United Kingdom, drinking no- and low- alcohol products was more common amongst men, young adults, existing drinkers and those with higher incomes ^[23][46]; and, (iv) based on an the 2022 IWSR No- and Low-Alcohol Strategic Study (Australia, Brazil, Canada, France, Germany, Japan, South Africa, Spain, the United Kingdom, and the United States), young adults and higher income consumers were more likely to report the use of no- and low-alcohol products ^[31][27]. In terms of why consumers buy and drink lower strength products: (i) in a 2021 survey of Dutch adults that consume beer at least monthly, undertaken by the Dutch Brewers, the highest rated reasons for drinking no- or low-alcohol beer reported were: liking it (56%, increased from 37% in 2018); having to drive (47%, similar to 51% in 2018); and, wanting to drink less alcohol (44%, increased from 32% in 2018) ^[32][47]; (ii) data from the United Kingdom, collected during 2021, found that two fifths of respondents who had drunk no- and low- alcohol products within the previous 12 months did so because they were trying to drink less alcohol, with 7% doing so because they were recovering from “alcohol dependency” ^[23][46]; and, (iii) based on the IWSR market research report ^[31][27], among adults who had purchased no- and low-alcohol products, 37% of people reported that the reason for doing so was to avoid the effects of drinking alcohol, with 17% reporting that they were drinking no/low to avoid alcohol completely; a third of drinkers reported that they bought no/low alcohol because they enjoyed the taste ^[31][27].

Academic Publications: In terms of who buys and drinks lower strength products, household purchase data from Great Britain for the years 2015 to 2020 and market-research-based consumer surveys from Great Britain for the years 2015 to 2018 found that alcohol-free beer was more likely to be bought and drunk by those who generally bought and drank the most alcohol, those who bought and drank beer with an ABV > 3.5%, men, those with younger ages, and those with higher incomes and higher social grades ^[33][48], with gaps in buying alcohol-free beer between households in higher and lower social grades widening between 2015 and 2020 ^[33][48]. In terms of why consumers buy and drink lower strength products, qualitative research suggests that buying and consuming no- and low-alcohol beers are driven by health and wellbeing issues, price differentials, brand familiarity, improved product taste, and overall decreases in the social stigma associated with drinking alcohol-free beverages ^[34][35][49,50].

2.2.2. What Factors Influence the Production of Lower Strength Products?

Grey Literature: capital investments required for machinery to de-alcoholise beers, wines and spirits may be beyond the resources of smaller enterprises, requiring them to outsource de-alcoholization at costs per volume treated [18]. The same report found that increased production costs of de-alcoholization are offset by increased revenue streams that result from lower-alcohol strength products for both producers and vendors [18].

Academic Publications: Within the European Union, complimentary to working towards a stronger Health Union is a commitment to implementing the UN 2030 Agenda for Sustainable Development, in particular, its goals that address good health and wellbeing, clean water and sanitation, responsible consumption, and climate action, all of which are impacted by, and impact on, alcohol production ^[36][142]. For example, the water footprint is estimated to be 300 litres per one litre of beer and 870 litres per one litre of wine ^[37][51], and, for whiskey, for example, measured as a water scarcity footprint ^[38][52], of 790 litres per litre of 100% alcohol ^[39][53]. The carbon-dioxide equivalent (CO_2-eq) emissions are approximately 0.575 to 0.842 kg per litre of beer (dependent on the packaging) ^[40][54], 0.85 kg per 70 cl bottle of wine ^[41][55] and, for whiskey, 4.4 kg per litre of pure alcohol ^[39][53].

23.2.3. Policies That Promote Lower Strength Products

Grey Literature: A modelling study in the United Kingdom estimated that, with a fixed duty per gram of alcohol that doubled with an ABV of between 2.0% and 5.0% and then doubled again between >5.0% and 40%, there would be an additional reduction in overall alcohol consumption of 5.4% compared to the present tax regime, with reductions in alcohol consumption due to off-trade (from shops, supermarkets etc.) beer of 0.2%, of off-trade wine of 4.7% and of off-trade spirits of 9.9% ^[42][76]. Taxes on the dose of alcohol rather than on the volume of the beverage may incentivize producers to reduce the volume of alcohol in beverages, ^[43][77] as seems to have been the case ^[44][78].

Academic Publications: The main policies that favour substitution of higher strength alcohol products with lower strength products relate to price, availability and improved labelling. Household purchase data from Great Britain for the years 2015 to 2018 and for the first half of 2020 found that price promotions and lower prices increased household purchases of no- and low-alcohol beers ^[45][79]. Household purchase data from Great Britain for the years 2015 to 2018 and for the first half of 2020 found that, in relative terms, the ABV of purchased beer decreased by 2% following the introductions of a minimum unit price in both Scotland and Wales ^[45][79]. Household purchase data from Great Britain for the years 2015 to 2020 found that the proportion of all beers purchased with an ABV ≤ 3.5% increased in relative terms by 11% following the introductions of a minimum unit price in Scotland ^[46][80]. When looking at purchases, the introduction of minimum unit prices (MUPs) in Scotland and Wales, which promote substitution from higher to lower strength products ^[45][46][79,80], were associated with reductions in overall purchases of alcohol that were largely restricted to households that bought the most alcohol; the introduction of MUPs was not associated with an increased expenditure on alcohol by lower purchasing households, and, in particular, those with lower incomes ^[47][48][81,82].

2.3. Mechanisms of Impact

2.3.1. Do Current Consumers Substitute Higher Strength with Lower Strength Products?

Grey Literature: two fifths of respondents who bought and drunk no- and low-alcohol reported doing so to substitute higher strength products with lower strength products, often as a desire to drink less alcohol; whereas, one third reported that they had been using these products on top of, rather than instead of, existing levels of alcohol consumption ^[23][31][27,46].

Academic Publications: One publication analysing British household purchases of alcohol over the years 2015 to 2019 indicated substitution. Households that had previously bought same-branded regular-strength beers and who went on to buy newly introduced same-branded no- and low-alcohol beers subsequently reduced purchases of the regular-strength beers by 48.5 mL per adult per household per day for days in which a purchase was made, a 22.5% reduction, matched by new purchases of 34.6 mL of the new no- and low- alcohol beers, with such changes stable over at least two years follow-up (the length of time available for analyses) ^[49][89].

2.3.2. Does Buying and Drinking Lower Strength Products Act as a Gateway to Buying and Drinking Higher Strength Products?

The gateway hypothesis is predicated on a sequence of drug-use initiation with drug use itself viewed as the cause of drug-use development, with a progressive and hierarchical sequence of stages of drug use that begins with tobacco or alcohol, proceeds to marijuana, and from marijuana to other drugs, such as cocaine, methamphetamines and heroin ^[50][90]. An explanation for the development of involvement with psychoactive substances, however, seems better explained by a common liability to the use of psychoactive substances, which is grounded in genetic theory and supported by data identifying common sources of variation in the use of psychoactive substances, with identifiable neurobiological substrate and plausible evolutionary explanations ^[51][91].

Grey Literature: Among Dutch school pupils aged 12 to 16 years, 9% reported drinking an alcohol-free drink at least once a week (12% of boys and 7% of girls), mainly non-alcoholic beer; those pupils who had drunk alcohol in the past month consumed non-alcoholic alternatives more often (16%) than those who had not drunk alcohol in the past month (7%) ^[52][143].

Academic Publications: For adults, household purchase data from Great Britain for the years 2015 to 2018 found that households that had never previously bought a same-branded higher strength beer but bought a new same-branded no- or low-alcohol beer were less than one third as likely to go on and newly buy the same-branded higher strength product as households that had never bought a new same-branded no- or low-alcohol beer, suggesting that no- or low-alcohol beverages did not act as triggers for higher strength products ^[49][89]. Household purchase data for both Great Britain and Spain indicate that, since the time of new purchases of no-alcohol products, substitution remained stable with no drift back to higher strength products for the length of time that it was studied (up to two years in Great Britain ^[49][89] and up to four years in Spain ^[53][31]).

2.3.3. Is There Additional and Alibi Marketing Due to the Introduction of Lower Strength Alcohol Products?

Grey Literature: Marketing strategies by producer companies to promote no- and low- alcohol products include opening up new contexts and times to drink (addition marketing), selling lifestyles and identities, and sports marketing/sponsorship ^[34][49].

Academic Publications: With respect to marketing, household purchase data from Great Britain for the years 2015 to 2018 found that households were more than twice as likely to buy a newly introduced no- or low-alcohol beer if they had previously bought the same-branded higher strength beer ^[49][89].

23.3.4. Is There Policy Interference Following the Introduction of Lower Strength Products?

Grey Literature: Concern has been expressed that no- and low- alcohol products may broaden the normalization of drinking cultures, including in environments where drinking does not normally take place, such as in the workplace ^[27][34], or may counter the de-normalization of drinking that is currently occurring, at least amongst European youth ^[54][144].

Academic Publications: Substitution of higher strength products with lower strength products are an addition to, and not a replacement of, the mainstay of reducing the harm done by alcohol, which is the strengthened enforcement of the high-impact cost-effective policies included in WHO’s SAFER technical package ^[17][19][17,19]. Governments need to ensure that, as alcohol producers take responsibilities for their products by substituting higher- with lower strength products, alcohol producers take responsibility for not further encroaching the policy environment as they ^{[55][56][57][58][59]}[111,112,113,114,115], like the food industry ^[60][116], do. WHO calls on economic operators in alcohol production and trade “to abstain from interfering with alcohol policy development and refrain from activities that might prevent, delay or stop the development, enactment, implementation and enforcement of high-impact strategies and interventions to reduce the harmful use of alcohol.” [19].

2.4. Outcomes

2.4.1. Does Substitution Recue Alcohol Consumption?

Academic Publications: In Great Britain during 2015–2019, based on 4 million separate alcohol purchases by 69,803 households, the ABV of beer decreased over time; time-series analysis found that, for every drop in the absolute value of ABV of 0.1% over time (from a baseline of 4.34), the associated drop in purchases of grams of all alcohol contained within beer was 6.9% ^[61][30]. In Spain, at the beginning of 2021, two new same-branded 20% ABV variants of whiskey and gin were launched. Households that purchased the 20% variants did not switch purchases from the same-branded regular-strength products, but did switch purchases from other spirits products to the 20% variants, with reductions in purchases of 26.7 g of alcohol in all spirits products (95% CI = 23.6 to 29.8) per adult per household per purchase day, a 17% drop, with the mean % ABV of purchased spirits decreasing by 6.1 (95% CI = 5.8 to 6.4), a 15% drop ^[53][31].

2.4.2. Does Substitution Improve Health?

Academic Publications: In the Northern Territory of Australia, one study reported time-series analyses that found that a tax levy on beverages with an ABV >3.0%, combined with community-based programmes, was associated with reductions in alcohol-attributable deaths ^[62][117]. It was not possible, though, to fully separate the independent effects of the tax levy (which was used to finance the community-based programmes) and the community-based programmes themselves.

3. Conclusions

WHO’s call on economic operators, to “substitute, whenever possible, higher-alcohol products with no-alcohol and lower-alcohol products in their overall product portfolios, with the goal of decreasing the overall levels of alcohol consumption in populations and consumer groups,” [19] appears, at least from the perspective of consumers, to be evidence-based. Although limited, the existing evidence demonstrates that substitution results in fewer grams of alcohol purchased. Alcohol policy that favours substitution is one that facilitates increased availability of lower strength products, provides such products with clearer labelling, and sets alcohol taxes that increase based on the (mathematical) product of the ABV. A disproportionate uptake of substitution by more affluent consumers needs to be balanced by social-norm campaigns ^[63][169] that extend the reach of lower strength products to all of society, and implementation of evidence-based alcohol policy measures that lessen health inequalities ^[64][170]. In Europe, at least, the full potential of alcohol policy is held back by a range of administrative regulations that hamper increased availability and improved labelling and by tax requirements that, if anything, favour higher strength products ^[65][66][171,172]. WHO has set out clear guidance to manage problems that might occur with substitution: (i) whilst, within individual brands, substitution occurs from higher to lower strength products rather than the other way around, a backdrop of effective marketing regulation ^[34][49] needs to avoid the use of alcohol-free and no-alcohol products circumventing existing marketing regulations for same-branded higher strength alcoholic beverages (alibi marketing ^[67][68][98,99]), and the targeted marketing of new consumer groups or new drinking occasions, as emphasized by WHO [19]. A backdrop of effective marketing regulation can be integrated within element ‘E’ of WHO’s SAFER initiative, “Enforce bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion” [17], irrespective of the ABV of the product down to 0.0%, as implemented in some countries ^[69][100]; (ii) greater responsibility in the policy environment, as called for by WHO, requires producer companies to abstain from “interfer(ing) with alcohol policy development and refrain(ing) from activities that might prevent, delay or stop the development, enactment, implementation and enforcement of high-impact strategies and interventions to reduce the harmful use of alcohol.” [19]. Governments, themselves, need to increase their responsibilities through strengthened implementation and enforcement of the high-impact cost-effective policy options itemised in WHO’s SAFER technical package [17], and amend the administrative restrictions to effective alcohol policy that they, themselves, have made, and which lead to avoidable lost lives.