It is time to shift South Africa’s heavy drinking culture and reduce the burden on public health. (Photo: iStock) 
South Africa’s relationship with alcohol is not only problematic – it is lethal. We drink too much, with the act of drinking until intoxication normalised and the consequences rippling across hospitals, streets, homes and workplaces.
The measures in place to reduce harmful drinking are either ineffective or are not being applied with any rigour. We need to understand why South Africans drink harmfully, to change behaviour from within, and reduce alcohol-related health harm.
South Africa has the fifth-highest alcohol consumption rate in the world, with the average drinker consuming nearly 30 litres of alcohol per year. On the surface, these rates don’t look catastrophic, but the devil is in the detail.
Seven out of 10 South Africans do not drink alcohol at all. However, the three out of 10 people who do drink alcohol, drink too much and drink in ways that put both themselves and society at risk.
This means that the risk is highly concentrated: a small portion of the population is drinking enormous amounts, often in hazardous ways.
The patterns are clear – binge-drinking (about five or more drinks in one sitting), typically on weekends and after paydays, and daily dependent-drinking (where daily alcohol is consumed to manage psychological and physical dependence).
The consequences of harmful drinking are devastating. Trauma units see their busiest nights over weekends and at month’s end, when paycheques are cashed.
Our road traffic fatality rate is nearly double the global average, with alcohol implicated in roughly half of those deaths. Violent assaults, sexual risk-taking and reduced workplace productivity pile further damage on to an already strained society.
Why South Africans drink the way we do
Why do we drink too much? A better understanding of the causes through all its layers will be key to managing alcohol intake, from harmful to responsible. To understand the scale of this problem, we must go beyond blaming individuals. Our patterns of consumption emerge from a multilayered system of drivers that shape behaviour at every level.
- Individual factors: some people carry genetic predispositions to alcohol dependence. Others drink heavily to self-medicate untreated mental illnesses such as anxiety or depression. Alcohol becomes both a coping mechanism and a trap;
- Interpersonal and family factors: fragmented families, absent parents and intergenerational cycles of trauma create environments where alcohol fills the gap of care and connection;
- Structural and societal factors: South Africa’s reality of deep poverty, staggering inequality and high unemployment feeds into harmful drinking. Many communities lack recreational spaces – no safe parks, libraries or cultural centres. In this vacuum, taverns, bars and shebeens become the default venues for social life;
- Cultural norms and social acceptance: perhaps the most potent factor is how drinking is embedded in our culture. Alcohol is expected at funerals, weddings, sports games and concerts. To “vibe” or generate “gees” often means to drink until drunk. This normalisation blurs the line between social drinking and harmful drinking. If everyone around you is drinking to excess, your own risky consumption seems unremarkable; and
- Hedonism and human nature: we must also be honest that the desire to indulge is part of being human. Across cultures and centuries, people have turned to intoxicants to enhance celebration, connection and pleasure.
The goal is not zero consumption – prohibition is neither realistic nor desirable – but balance. The challenge is how to protect communities from the devastation caused when this natural drive toward pleasure is hijacked by structural inequality, aggressive marketing and a culture that normalises drinking to the point of harm.
The bottom line: South Africa’s drinking culture is not simply about weak willpower or poor personal choices. It is a systemic product of individual vulnerabilities, family breakdown, economic hardship and a society that celebrates drinking as central to social life.
The cost of doing nothing
The consequences of inaction are staggering. Beyond health and mortality, harmful alcohol use drains productivity from the economy. Absenteeism, workplace accidents and long-term healthcare costs all add up.
Alcohol fuels interpersonal violence and crime, burdening the police and justice system. Families are fractured by addiction and children grow up in households marked by instability and neglect.
Excessive alcohol consumption is also a driver of chronic disease. From cancers to cardiovascular disease to dementia, the long-term toll undermines our already fragile health system. Every bottle of cheap liquor sold without restraint adds hidden costs that society as a whole is forced to pay.
In an attempt to combat harmful alcohol use, the World Health Organization (WHO) offers a blueprint for change through the Safer initiative:
S: Strengthen restrictions on the availability of alcohol;
A: Advance and enforce drinking-and-driving countermeasures;
F: Facilitate increased access to treatment;
E: Enforce restrictions on alcohol advertising, sponsorship and promotion; and
R: Raise prices on alcohol through taxes and pricing policies.
These measures target the systemic levers of harmful drinking. For example, reducing trading hours for alcohol outlets has been shown to cut consumption, crime and alcohol-related deaths.
Raising prices reduces binge consumption, particularly of large, cheap containers favoured by heavy drinkers. Strict advertising bans cut down youth exposure to alcohol marketing, delaying initiation and reducing long-term risks.
Yet, in South Africa, meaningful reforms have been repeatedly stalled. Bills to tighten liquor laws have been delayed for years, bogged down in consultations and blocked by political and economic lobbying.
Moreover, none of these measures targets direct intervention through individual-level factors.
Using behavioural science, individual interventions to reduce alcohol consumption from harmful to responsible levels will hinge on a triad of linked approaches: alcohol literacy and knowledge; harm-reduction behaviours; and the theory of motivational interviewing.
These methods are independent of dealing with active mental disorders that may uniquely drive alcohol use, such as anxiety disorders. Improved alcohol literacy is a key point of departure to inform decision-making to reduce harmful drinking behaviour.
Similarly, improving awareness of guidelines for low-risk consumption, such as those recommended by the National Institute of Alcohol Abuse and Alcoholism, may aid in people adopting lower-risk patterns of alcohol consumption. We need to know our individual limits to unblur the line between safe and harmful consumption.
Once we know our limits, how do we get there? Harm reduction strategies for individuals include several techniques that can be learnt and/or taught.
Our research suggests that peers – people around us with lived experience of addiction and recovery – are best placed to guide us here. Using peers in these instances allows us to connect with people who use alcohol heavily. This is most probably because of the guilt and shame associated with admitting that we drink too much.
We have successfully employed the idea of “waiting out the crave” for alcohol, comparing it to the image of waiting for a bus, or riding a wave.
One of the strategies in our research includes Behavioural Activation (BA), which is designed to promote behaviour change by increasing the frequency of positive reinforcement derived from value-based, alcohol-free activities. Also, finding ways to alleviate boredom, or to tolerate boredom.
Additionally, one might consider “slowing the flow” through substituting alcohol with alternatives, learning to say “no” (and tolerating the feedback), and setting physical limits (such as using measures or decanters).
Towards a new deal on alcohol
South Africa is drowning in its own thirst. The evidence is clear: our drinking culture is shaped by systemic forces, our health burden is catastrophic, and our policy progress has been stymied by powerful vested interests.
To address harmful drinking in South Africa, the alcohol industry needs to be part of the solution, not the cause of the problem. Reducing harmful consumption is in direct conflict with business incentives, and we need to move to a solution beyond self-regulation initiatives, voluntary marketing codes and glossy social responsibility campaigns.
Instead, pan-sectoral collaboration should be driven by the peer-reviewed evidence demonstrating real impact on harm reduction. We need an approach that combines stronger legislation aligned with the Safer initiative, community-level interventions that address cultural normalisation of intoxication, individual-level support to effect behaviour change, and crucially, industry accountability for its role in shaping behaviour and perpetuating harm.
We should not be calling for zero consumption – however, reducing harmful drinking by even a fraction would save thousands of lives, ease the burden on hospitals, cut violent crime and improve productivity. DM
Associate Professor Stephan Rabie is a chief research officer in the HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, University of Cape Town.
Pat Govender is the founder and managing director of The Behaviour Change Agency. He is an expert in behavioural interventions that shape how we think, feel, act and make decisions.
Dr Lwandile Tokwe is a professional nurse and senior research officer in the HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, University of Cape Town.
Prof John Joska is a psychiatrist and the director of the HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, University of Cape Town.