Title: Alcohol in Development and in Health and Social Policy
1Alcohol in Development and in Health and Social
Policy
- David Jernigan PhD
- Center on Alcohol Marketing and Youth
- Georgetown University
- Washington, D.C.
- dhj_at_georgetown.edu
- Robin Room PhD
- Center for Social Research on Alcohol and Drugs
- University of Stockholm
- Stockholm, Sweden
- Jürgen T. Rehm PhD
- Addiction Research Institute
- Zurich, Switzerland
2Presentation Overview
- To what extent is alcohol harmful or beneficial
to health and social well-being? - Alcohols role in the global burden of disease
- Alcohol and social harms
- Relationship between alcohol production,
consumption, benefits and problems - Monitoring alcohol problems
- Preventing and reducing alcohol problems
3WHOs Comparative Risk Assessment Collaborating
Group
- 27 groups
- Core, metholodology, etc. group
- 26 risk factor groups
- Alcohol group
- J Rehm, R Room, M Monteiro, G Gmel, K Graham, N
Rehn, C T Sempos, U Frick, D Jernigan
4WHOs Comparative Risk Assessment (CRA)
- Childhood and maternal undernutrition
underweight, iron deficiency, vitamin A
deficiency, zinc deficiency - Other diet-related risks and physical inactivity
blood pressure, cholesterol, overweight, low
fruit and vegetable intake, physical inactivity - Sexual and reproductive health risks unsafe sex,
lack of contraception - Addictive substance use tobacco, alcohol,
illicit drugs - Environmental risks unsafe water, sanitation and
hygiene, urban air pollution, indoor smoke from
solid fuels, lead exposure, climate change - Occupational risks risk factors for injury,
carcinogens, airborne particulates, ergonomic
stressors, noise - Other selected risks to health unsafe health
care injections, childhood sexual abuse.
5The epidemiological model
6Prevalence data
- Adult per capita consumption estimates for
countries totaling 90 of worlds population - Survey data from 69 countries, covering 80 of
worlds population - Survey and adult per capita consumption data for
more than 50 of countries
7Adult per capita consumption inlitre pure
alcohol 2000 (based on CRA)
8Patterns of drinking
- Countries assigned hazardous drinking scores, a
numeric indicator of hazard per litre of alcohol
consumed - Information drawn from research literature
supplemented by key informant questionnaires - Applied to two areas injuries and CHD.
9Dimensions of patterns of drinking
- High usual quantity of alcohol per occasion
- Festive drinking common at fiestas or community
celebrations - Proportion of drinking occasions when drinkers
get drunk - Low proportion of drinkers who drink daily or
nearly daily - Less common to drink with meals
- Common to drink in public places
10Pattern of drinking 2000(based on CRA)
11Aspects of alcohol used in estimating alcohol
attributable fraction (AAF) for different
conditions
Volume of drinking
Drinking pattern hazard score (predominance
of intoxication)
Prior alcohol dependence
Physical diseases (except CHD)
Alcohol- attributable conditions
Injuries
Coronary heart disease
Depression
AAF 1 by definition
12Estimating AAFs
- Alcohol-specific categories
- Chronic health conditions
- CHD
- Depression
- Injuries
13Alcohol-related disorders
- Chronic disease
- Conditions arising during perinatal period low
birth weight - Cancer lip oropharyngeal cancer, esophageal
cancer, liver cancer, laryngeal cancer, female
breast cancer - Neuropsychiatric diseases alcohol use disorders,
unipolar major depression, epilepsy - Diabetes
- Cardiovascular diseases hypertension, coronary
heart disease, stroke - Gastrointestinal diseases liver cirrhosis
- Injury
- Unintentional injury motor vehicle accidents,
drownings, falls, poisonings, other unintentional
injuries - Intentional injury self-inflicted injuries,
homicide, other intentional injuries - AAF based on volume of drinking only
14Estimating AAFs 5. Alcohol-attributable
depression
- Started with estimated rates of alcohol
dependence in each region (derived from pooled
psychiatric epidemiological studies) - Used some of same studies to derive proportion of
cases with both depression and alcohol problems
where alcohol onset was prior to onset of
depression - Regressed these proportions on rates of alcohol
dependence to establish upper-limit estimates - To eliminate effect of co-occurrences due to
chance, rate of alcohol use disorders then
subtracted from these estimates - Finally, halved AAFs to account for lack of
control of confounders
15Alcohol-related global burden of disease
16Global mortality burden (deaths in 1000s)
attributable to alcohol by major disease
categories - 2000
17Global burden of disease (DALYs in 1000s)
attributable to alcohol by major disease
categories - 2000
18Disability-Adjusted life Years (DALYs)
attributable to ten leading risk factors, 2000
World World High mortality developing countries High mortality developing countries Low mortality developing countries Low mortality developing countries Developed countries Developed countries
DALYs (millions) total total total total total total total
Males Females Males Females Males Females
Underweight 138 9.5 14.9 15 3 3.3 0.4 0.4
Unsafe sex 92 6.3 9.4 11 1.2 1.6 0.5 1.1
Blood pressure 64 4.4 2.6 2.4 4.9 5.1 11.2 10.6
Tobacco 59 4.1 3.4 0.6 6.2 1.3 17.1 6.2
Alcohol 58 4 2.6 0.5 9.8 2 14 3.3
Unsafe water, sanitation, hygiene 54 3.7 5.5 5.6 1.7 1.8 0.4 0.4
Cholesterol 40 2.8 1.9 1.9 2.2 2 8 7
Indoor smoke from solid fuels 39 2.6 3.7 3.6 1.5 2.3 0.2 0.3
Iron deficiency 35 2.4 2.8 3.5 1.5 2.2 0.5 1
Overweight 33 2.3 0.6 1 2.3 3.2 6.9 8.1
19Leading risk factors for disease (WHR 2002) in
emerging and established economies ( total DALYS)
Developing countries Developing countries Developing countries Developing countries Developed countries Developed countries
High mortality Low mortality Developed countries Developed countries
Underweight 14.9 Alcohol 6.2 Tobacco 12.2
Unsafe sex 10.2 Blood pressure 5.0 Blood pressure 10.9
Unsafe water sanitation 5.5 Tobacco 4.0 Alcohol 9.2
Indoor smoke (solid fuels) 3.6 Underweight 3.1 Cholesterol 7.6
Zinc deficiency 3.2 Body mass index 2.7 Body mass index 7.4
Iron deficiency 3.1 Cholesterol 2.1 Low fruit vegetable intake 3.9
Vitamin A deficiency 3.0 Low fruit vegetable intake 1.9 Physical inactivity 3.3
Blood pressure 2.5 Indoor smoke from solid fuels 1.9 Illicit drugs 1.8
Tobacco 2.0 Iron deficiency 1.8 Unsafe sex 0.8
Cholesterol 1.9 Unsafe water sanitation 1.8 Iron deficiency 0.7
20Alcohol-related social harms
- Child abuse 8.6-63
- Domestic violence 26-76
- Family budget 1-11 overall
- Greater for families with frequent drinkers
- E.g. Delhi 24 of budgets of families with
frequent drinkers - Problems for youth
- Criminal behavior
- Failure to achieve educational qualifications
21Measuring social harms
- Cost of illness studies
- E.g. Scotland
- Health care costs 139 million
- Social work costs 125 million
- Criminal justice and fire costs 390 million
- Service system utilization by problem drinkers
- California urban/suburban/rural county
- 41 in criminal justice system
- 8 in social welfare system
- 42 in general health care system
- 3 in public mental health system
- 6 in public alcohol or drug treatment system
- Survey research
- Canada harms from someone elses drinking
- 7.2 pushed, hit or assaulted
- 6.2 friendships harmed
- 7.7 family or marriage difficulties
22Trends in alcohol consumption
23Relationship between alcohol production and
consumption
- Alcohol production and consumption
- Most alcohol consumed near point of production
- 8 of recorded alcohol production enters into
international trade - Consumption tends to be concentrated in minority
of population, e.g. - USA 10 drinks 61 of the alcohol
- New Zealand 5 drinks 1/3 of the alcohol
24Relationship between alcohol consumption and
alcohol problems
- Alcohol problems arise from
- Intoxication occasions
- Repeated episodes of intoxication
- Steady heavy drinking
- Protective effect from consistent moderate
drinking - This pattern rare in developed countries, even
less common in developing societies - Bottom line level of alcohol problems in a
society will tend to rise with level of alcohol
consumption
25Social and health benefits of drinking
- Social benefits of drinking largely
unquantifiable - Alcohols role as integrative, bonding or
socially lubricative substance - Health benefits of alcohol
- Protective effect for CHD evident at individual
level at as low as one drink every other day - Protection not found at the aggregate level
- Could be some drinkers shift to more
heart-healthy pattern, as others change to more
dangerous patterns - Leads to conclusion that there are no net
benefits at the population level from any policy
that seeks to increase alcohol consumption
26Alcohol and development
- Alcohol consumption tends to rise with economic
development, absent mitigating factors (e.g.
religion) - Four modes of production of alcohol
- Traditional/indigenous
- Industrialized traditional/indigenous
- Industrialized cosmopolitan
- Globalized cosmopolitan
- Trend is towards the latter, particularly in
distilled spirits and beer
27Alcohol and development benefits?
- Employment and income generation
- Direct employment declines with industrialization
- Indirect employment may increase in wholesaling
and distribution, but less likely in retail
sector - Government revenue justifiable for
- Economic efficiency correct for negative
externalities - Public health reduce consumption
- Revenue raising as high as 24 of some state
revenues
28Alcohol and development benefits?
- Quality improvement
- Industrialization leads to greater uniformity and
reliability of product - Sourcing of inputs and balance of payment issues
- Import substitution constrained by size of
domestic market also may require import of
inputs as opposed to finished product - Alcohol unlikely to make much contribution to
exports
29Alcohol and development benefits?
- MNCs and technology transfer
- Turnkey technologies increasing
- Design, RD and engineering expertise remains in
headquarters countries - Encouragement of packaging and distribution
networks - Early form of foreign direct investment
- If increased alcohol supply will not worsen
public health and safety situation regarding
alcohol
30Preventive interventions individual-based
- Education and persuasion
- Little evidence of effectiveness of school-based
programs beyond the short-term - Media campaigns unlikely to change behavior, but
may increase support for more effective policies - Deterrence
- Effective in reducing drinking-driving
- Speed and certainty of punishment crucial to
effectiveness
31Preventive interventions individual-based
- Encouraging alternatives
- Little evidence of effectiveness of lasting
effects - Too many alternatives go well with alcohol, e.g.
soft drinks - Do contribute to improving quality of life for
disadvantaged populations - Treatment and mutual help
- Part of a humane societal response
- Brief interventions, self-help effective and
result in net savings in social and health costs - Treatment alone is not a cost-effective means of
reducing alcohol-related problems
32Preventive interventions environmentally-based
- Insulating use from harm
- Server and manager training can reduce
drinking-driving, violence - Provision of public transport, relocation of
drinking places away from residences can also be
effective - General protections, e.g. airbags, sidewalks, are
effective - Designated driver programs lack evidence of
effectiveness
33Preventive interventions environmentally-based
- Regulating availability, conditions of use
- Prohibitions
- Difficult to enforce
- Minimum-age drinking laws (partial prohibition)
- Effective if enforced
- Taxation and other price increases
- Demand for alcohol generally inelastic
- Can be effective if market is under control
34Preventive interventions environmentally-based
- Regulating availability, conditions of use
- Limiting sales outlets, hours and conditions of
sale - Research literature shows effectiveness of
measures making alcohol purchase less convenient - Monopolies on production or sale
- Retail monopolies have greater public health
effects - Production monopolies assist in control of market
- Production restrictions
- Can be effective but difficult to enforce
- Limits on advertising and promotion
- Some evidence bans are effective
- Unmeasured activities increasing, and difficult
to regulate
35Other policy concerns
- Social and religious movements, civil society and
NGOs can be key - Alcohol policy needs to be societal, integrated
and consistent - International trade agreements need to make
exception for alcohol as no ordinary commodity
36Monitoring alcohol consumption
- Per capita alcohol consumption (age 15)
- Number of abstainers
- Pattern of drinking
- frequency of getting drunk or drinking gt60 grams
of ethanol (5 drinks), - usual quantity per drinking session,
- fiesta drinking,
- drinking in public places,
- not drinking with meals, and not drinking daily
- frequencies and percentages of all alcohol drunk
on gt40g. days for men and gt20g. days for women - Youth use
37Monitoring alcohol problems
- alcohol-involved traffic crashes/injuries
- alcohol-involved crimes
- hospitalizations and deaths from strongly
alcohol-involved causes - liver disease (if rates of hepatitis B and C are
low), - alcohol-specific causes such as alcoholic liver
disease, alcohol dependence, and alcoholic
psychosis - other alcohol-related problems
- problems with family, friendships, work, police,
financial, health, alcohol dependence - problems from others drinking
- family, friendships, work, injury, property loss,
public nuisance
38The Future
- Increase in alcohol-related burden for two
reasons - The disease categories related to alcohol are
relatively increasing chronic disease, accidents
and injuries - Alcohol consumption is increasing in the most
populous parts of the world - Patterns are stable if not getting worse
- If there are no interventions!!!