global trends in alcohol consumption, related harm and policy responses v. poznyak management of...

Global Trends in Alcohol Consumption, Related Harm

and Policy Responses

V. Poznyak Management of Substance Abuse

Department of Mental Health and Substance Abuse

The First National Conference on Alcohol Consumption and Related Problems in ThailandBangkok, 13 July 2005

Total alcohol adult (15+) per capita consumption in the world

(2000)

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

© WHO 2004. All rights reserved

World Health OrganizationDepartment of Mental Health and Substance Abuse

Adult per cap ita consum ption 2000

0.21 to 2 .85

2.85 to 4 .45

4.45 to 6 .41

6.41 to 9 .47

9.47 to 13.08

13.08 to 19.30

Global trends in alcohol consumption in 1961-1999 (unweighted

means)

0

1

2

3

4

5

6

1961 1967 1973 1979 1985 1991 1997

Years

Beer

Wine

Spirits

Total

Figure 1. Adult (15+) Per Capita Alcohol Consumption by Development Status

0

1

2

3

4

5

6

7

1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997

Year

Litr

es

Developed Developing Former Soviet

Alcohol consumption by developmental status in 1961-

1999

Recorded alcohol consumption in WHO regions in 1961-1999 (population

weighted means)

0

2

4

6

8

10

12

14

16

18

1961

1963

1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Year

litr

es o

f p

ure

alc

oh

ol

SEARO

WPRO

EURO

EMRO

AMRO

AFRO

Adult per capita consumption in WHO South-East Asian and Western Pacific

Regions

1960 1970 1980 1990 2000YEAR

0

2

4

6

8

adult p

er

capita c

onsum

pt ion in l p

ure

al c

ohol

WPR_BWPR_ASEAR_DSEAR_B

Patterns of alcohol consumption in the world (2000)

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

© WHO 2004. All rights reserved

World Health OrganizationDepartment of Mental Health and Substance Abuse

Patterns o f drinking

1.00 to 2 .00

2.00 to 2 .50

2.50 to 3 .00

3.00 to 4 .00

Mechanisms relating alcohol use to health and social problems (adapted from Babor et al.,

2003)

Chronic disease

Accidents/injuries

(acute disease)

Acutesocial

problems

Chronicsocial

problems

IntoxicationToxic and other

biochemicaleffects

Dependence

Pattern of alcohol use

Amount of alcohol use

World Health Organization

Disability-Adjusted Life Year (DALY)

Definition: DALY is an integrated indicator that shows the number of life years that are lost due to premature deaths or cases of disability occurring in a particular year

0 20000 40000 60000 80000 100000 120000 140000 160000

Illicit drugs

Lead exposure

Occupational risk factors for injury

Physical inactivity

Vitamin A deficiency

Fruit and vegetable intake

Zinc deficiency

High Body Mass Index

Iron deficiency

Indoor smoke from solid fuels

Cholesterol

Unsafe water, sanitation, and hygiene

Alcohol

Tobacco

Blood pressure

Unsafe sex

Underweight

Disease burden (DALYs) in 2000 attributable to selected leading risk

factors

Number of Disability-Adjusted Life Years (000s)

0 20000 40000 60000 80000 100000 120000 140000 160000

Urban air pollution

Childhood sexual abuse

Unsafe health care injections

Illicit drugs

Lead exposure

Risk factors for injury

Physical inactivity

Vitamin A deficiency

Low fruit and vegetable intake

Zinc deficiency

High Body Mass Index

Iron deficiency

Indoor smoke from solid fuels

Cholesterol

Unsafe water, sanitation and hygiene

Alcohol

Tobacco

Blood pressure

Unsafe sex

Underweight

High Mortality Developing Countries

Low Mortality Developing Countries

Developed Countries

Disease burden (DALYs) in 2000 attributable to selected leading risk factors (world)

Number of Disability-Adjusted Life Years (000s)

Source: WHR, 2002


High MortalityDeveloping Countries

Low MortalityDeveloping Countries

= Major NCD risk factors

1 Underweight Alcohol Tobacco 2 Unsafe sex Blood pressure Blood pressure

3 Unsafe water Tobacco Alcohol 4 Indoor smoke Underweight Cholesterol 5 Zinc deficiencyBody mass index Body mass index 6 Iron deficiency Cholesterol Low fruit & veg. intake 7 Vitamin A deficiency Low fruit & veg intake Physical inactivity 8 Blood pressure Indoor smoke - solid fuels Illicit drugs 9 Tobacco Iron deficiency Unsafe sex 10 Cholesterol Unsafe water Iron deficiency 11 Alcohol Unsafe sex Lead exposure 12 Low fruit & veg intake Lead exposure Childhood sexual abuse

DevelopedCountries

Leading 12 selected risk factors as causes of disease burden


Burden of Disease Attributable to Alcohol

0.5-0.9%

1-1.9%

2-3.9%

4-7.9%

<0.5%

8-15.9%

Proportion of DALYsattributable to

selected risk factor


Alcohol-related mortality and disease burden in different WHO regions

WHO region Percent of total mortality Percent of total disease burden

Men Women Men Women

Europe AEurope B Europe C

S-E Asia BS-E Asia D

W-Pacific AW-Pacific B…World

3.2 9.7 18.0

4.1 2.3

3.7 8.5 … 5.6

-4.1 2.7 5.1

0.9 2.8

-5.4 1.3 … 0.6

11.1 10.2 21.5 5.3 2.8

8.1 9.1 … 6.5

1.6 2.5 6.5

1.0 0.4

0.6 1.8 … 1.3

Percentage of total global mortality and DALYs attributable to psychoactive

substances Risk factor

High mortality developing countries

Low mortality developing countries

Developed countries

World

Men Women Men Women Men Women

MortalityTobaccoAlcoholIllicit drugsDALYsTobaccoAlcoholIllicit drugs

7.52.60.5

3.42.60.8

1.50.60.1

0.60.50.2

12.2 8.5 0.6 6.29.81.2

2.91.60.1

1.32.00.3

26.3 8.0 0.6

17.114.02.3

9.3-0.30.3

6.23.31.2

8.83.20.4

4.14.00.8

Global burden of disease (DALYs in 000) attributable to alcohol in 2000 (Rehm et al,

2003)Diseases and accidents

…CancerNeuropsychiatric disordersCardio-vascular diseasesOther non-commdiseases Unintentional injuriesIntentional injuries

Women

1021

3814

-428

860

24871117

Men

3180

18090

4411

3695

140085945

Total

4201

21904

3983

4555

164957062

% of alcohol-related disease burden

7

38

7

8

28 12

Percentage of global DALYs attributable to different neuropsychiatric conditions (WHO,

2002)Neuropsychiatric conditions

Total DALYs193,278,495

Percentage100%

Unipolar depressive disorder

67,294,858 35%

Alcohol use disordersSchizophreniaBipolar disorderAlzheimer disease and other dementiasMental retardationMigraineDrug use disordersEpilepsyPanic disorder…

20,330,90916,149,01013,952,00610,396,902

9,956,313 7,666,232 7,387,679 7,327,500 6,757,894…

11%8%7%5%

5%4%4%4%3%…

Prevalence of alcohol use disorders in 2000

(Global Burden of Disease Study)76.4 million people worldwide with alcohol use disorders (ICD-10 F10.1 and F10.2 - harmful use of alcohol and alcohol dependence)– 63.7 million men

– 12.7 million women (F:M=1:5)

Source: Colin D. Mathers, Claudia Stein, Doris Ma Fat et al (2001). Global Burden of Disease 2000: Version 2 methods and results. GPE Discussion paper 50; Geneva, WHO.


Approaches to Reduce the Burden Associated with Alcohol Use

• Reduction of exposure to alcohol and its harmful metabolites (shifting population distributions of exposure)– Frequency– Quantity– Period of substance use (delayed onset of

substance use) – Pattern of use

• Reduction of high risk exposure to alcoholWorld Health Organization

a: Burden at To attributable to prior exposure

b: Burden caused by other factors only

A conceptual model of attributable and avoidable risk (Murray et al., 2004)

Types of alcohol policy measures• Population-based policies

– Aimed at altering levels of alcohol consumption among the population e.g. through taxation, advertising, availability restrictions, regulation of density of outlets, hours and days of sale.

• Problem-directed policies– Aimed at specific alcohol-related problems such as

drinking driving (e.g. promoting widespread random breath testing). These policies are more focused and thus, are less likely to affect the non-problem drinker.

• Direct interventions– Policies aimed at individual drinkers, such as brief

interventions or rehabilitation programmes.Basis: Godfrey & Maynard (1995)

Reductions in male death rates if alcohol consumption per capita reduced by 1

litre

Reductions in male death rates if alcohol consumption per capita reduced by 1

litre

-12

-10

-8

-6

-4

-2

0

AccidentsCirrhosisHomicideHeartSuicideAll causes

Source: Norström & Skog 2001


Alcohol: No Ordinary CommodityResearch and Public Policy (OUP/WHO, 2003)

• Thomas Babor• Raul Caetano• Sally Casswell• Griffith Edwards• Norman Giesbrecht• Kathryn Graham• Joel Grube• Paul Gruenewald

• Linda Hill• Harold Hodler• Ross Homel

• Esa österberg

• Jürgen Rehm• Robin Room• Ingeborg Rossow


Alcohol policy-relevant strategies and interventions (Babor et al, 2003)

• Regulating physical availability

• Taxation and pricing

• Altering the drinking context

• Education and persuasion

• Regulating alcohol promotion

• Drinking-driving countermeasures

• Treatment and early interventions


Choosing the right intervention (Babor et al, 2003)

• Effectiveness + ++ +++– Quality of scientific information

• Breadth of research support + ++ +++– Quantity and consistency of the evidence available

• Cross-cultural testing + ++ +++– Applicability to different countries, regions and

subgroups• Cost to implement and sustain Low Moderate High


Regulating physical availability

• Total ban on sales

• Minimum legal purchase age

• Rationing

• Government monopoly on retail sales

• Hours and days of sale restrictions

• Restrictions on density of outlets

• Server liability

• Different availability by alcohol strength


Implementation of restrictions on availability of alcoholic beverages

• Minimum age requirements – No age limit in 15% of countries for drinking beer on the premises and

no minimum age for purchasing takeaway beer in 12% of countries.

• State monopolies and licensing systems– 15% of countries have state monopoly on off-premise sale of beer, wine

or spirits. – 73% have licensing systems for at least one beverage and 12% had no

restrictions on takeaway alcohol sales.

• Restrictions on off-premise retail sale– only 25% of countries that reported sales restrictions stated that the

restrictions were fully enforced.

Global Status Report: Alcohol Policy. WHO, 2004

Taxation and pricing

• Taxes on alcohol beverages– General sales tax (VAT) (average

worldwide 16.6%)

– Alcohol-specific taxes• Excise tax (average percentage of retail price) • Excise or tax stamps on beverage containers or

bottles


Definition of alcoholic beverage• An integral part of alcohol legislation as that

definition sets the limit for when the laws apply and to what beverages they apply.

• Definitions ranged from 0.1 – 12.0% alcohol by volume, with the mean being 1.95% (median 1.2%, SD = 1.93).

• Legal limit can be exploited in advertising. Global Status Report: Alcohol Policy. WHO, 2004

Frequency of low, middle and high alcohol-specific tax on alcohol

Alcohol-specific tax Beer (n=65) Wine (n=60)

Low (<10%) 23.1 28.3

Middle (10-29%) 52.3 43.3

High (>30%) 24.6 28.3

Alcohol- specific tax Spirits (n=60)

Low (<30%) 36.7

Middle (30-49%) 33.3

High (>50%) 30.0

Price and taxation

In 16 countries, a beer is cheaper than a soft drink. In most countries, between one and three soft drinks can be bought for the price of one beer. The rationale for looking at the price of beer and soft drinks (beer-cola ratio) is that one aspect of pricing policy of alcoholic beverages by governments can be to encourage the consumption of non-alcoholic drinks.


Altering the drinking context• Outlet policy not to serve intoxicated

• Training bar staff and managers to prevent and better manage aggression

• Voluntary codes of bar practice

• Enforcement of on-premise regulations and legal requirements

• Promoting alcohol-free activities and events

• Community mobilization


Education and persuasion• Alcohol education in schools

• College student education

• Public service messages

• Warning labels


Regulating alcohol promotion• Advertising bans and restrictions

– Total bans– Partial restrictions– Voluntary agreements

• Advertising content controls• Restrictions on sponsorships

– Youth events– Sport events

• Enforcement of advertising and sponsorship restrictions


Drinking-driving countermeasures• Sobriety check points

• Random breath testing (RBT)

• Lowering BAC limits

• Administrative licence suspension

• Low BAC for young drivers ("zero tolerance")

• Graduated licensing for novice drivers

• Designated drivers and ride services


Drink driving legislation

• Earlier general laws against drink driving have been replaced in most countries by more effective laws forbidding driving while above a specified blood alcohol concentration (BAC) level.

• In almost 40% of countries, the legal limit is around 0.5 per mille (50 mg of ethanol in each litre of blood). The limit was lower in nearly 30% of countries and higher in over 25%.

• Close to one-third of countries that have a BAC limit do not perform Random Breath Testing (RBT) as a measure of enforcing the drink driving legislation. Countries with a higher legal BAC perform RBT checks less frequently.


Treatment and early interventions

• Brief interventions with at-risk drinkers

• Treatment of alcohol use disorders

• Mutual help/self-help attendance

• Mandatory treatment of repeat drinking-

drivers


Comparison of different alcohol policy related measures (Babor et al, 2003)

Strategy or intervention…

Minimum legal

purchase age

Gvt. monopoly of

retail sales

Restrictions on

hours/days of sale

Outlet density

restrictions

Alcohol taxes

Effect.

+++

+++

++

++

+++

Res. Supp.

+++

+++

++

+++

+++

Cross-cult.

+++

++

++

++

+++

Cost

Low

Low

Low

Low

Low

Comparison of different alcohol policy related measures (continued)

Strategy or intervention…Sobriety checkpoints

Lowered BAC limits

License suspension

for driving under

influence

Graduated licensing

Brief interventions

for hazardous

drinkers

Effect.

++

+++

++

++

++

Res. Supp.

+++

+++

++

++

+++

Cross-cult.

+++

++

++

++

+++

Cost

Moderate

Low

Moderate

Low

Moderate

A mix of alcohol policies needed

• Definition of alcoholic beverage (low enough to include most alcoholic beverages consumed)

• Government control over retail sale • Sales restrictions• Culturally appropriate age limit• Blood alcohol concentration level limit• Comparative promotion of lower or non-alcoholic

beverage consumption• Taxation• Advertising and sponsorship controls• Restricting drinking in public places

P Pa O

Distal Socio-Economic Causes

Proximal CausesPhysiological and

PathophysiologicalCauses

Outcomes

P Pa O

P Pa

1

2

3

1

2

3

1

2

D

D

D

1

2

3

Simplified causal web linking exposures and outcomes

Monitoring Alcohol Consumption and Related Harm (WHO, 2000)

• Chronic harms (liver disease, alcohol dependence, alcohol psychoses, some cancers etc.)

• Acute harms (fatal road crashes, suicides, alcohol poisonings, assaults etc)

• Volume of alcohol consumption• High risk alcohol consumption (patterns of drinking)

Alcohol: no ordinary commodity

• Alcohol use associated with substantial mortality and morbidity

• Availability and markets of alcohol beverages should be differentially controlled

• The public health interests should supersede commercial and national interests

• Public health should be taken into account in trade negotiations involving psychoactive substances

• International coordination, cooperation and support necessary• To be effective public health policies should target also mode,

patterns and context of alcohol and other substance use • Societies have obligation to provide treatment and care for

those with alcohol use disorders


Evidence-based Policy Responses

"… Many gaps remain to be filled in our understanding of the issues related to substance use and dependence but… we already know a great deal about the nature of these problems that can be used to shape policy responses".

LEE Jong-wook, WHO Director

General


WHA resolution "Public health problems caused by harmful use of

alcohol" (2005)

REQUESTS Member States:

to develop, implement and evaluate effective strategies and programmes for reducing the negative health and social consequences of harmful use of alcohol


Thank you for your attention

www.who.int/substance_abuse/Management of Substance Abuse

WHO Department of Mental Health and Substance Abuse


http://www.who.int/substance_abuse/

global trends in alcohol consumption, related harm and policy responses v. poznyak management of...

Documents

total alcohol adult

substance abusethe

substance abuseglobal

related harm

related problems

legal status

developmental status

dotted lines