políticas públicas em alcohol prof. dr. ronaldo laranjeira universidade federal de são paulo

Políticas Públicas em Alcohol

Prof. Dr. Ronaldo LaranjeiraUniversidade Federal de São Paulo

Chosing effective strategies

• Need for a systematic procedure to evaluate the evidence, compare alternativa interventions and assess the fbenefits to society of different approaches

Global Supply of Pure Beverage Alcohol

0

10

20

30

40

50

60

70

80

90

100

1961 1965 1969 1973 1977 1981 1985 1989 1993 1997

Year

Mill

ion

s o

f h

ect

olit

res

Barley Beer Spirits Wine Other

Proportion of alcohol consumers in WHO sub-regions

Region % alcohol consumption

AFR-DAFR-EAMR-AAMR-BAMR-DEMR-BEMR-DEUR-AEUR-BEUR-CSEAR-BSEAR-DWPR-AWPR-B

384467666210 587628621148457

Adult (15+) Per Capita Alcohol Consumption in Selected Latin American Countries

0

2

4

6

8

10

12

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

Lit

res

Brazil Mexico Venezuela

Drinking Pattern Values for Selected WHO Regions

Region Pattern value

Afr DAfr EAmr AAmr BAmr DEur ASear BSear D

2.483.092.003.143.101.342.502.95

Prevalence (%) of problematic illicit drug use in the past12 months among persons 15 years and above accordingto 14 WHO regions

Opioids Cocaine AmphetamineEurope A 0.11 0.18 0.24Europe B 0.09 0.01 0.10Europe C 0.19 0.01 0.04America A 0.13 0.78 0.20America B 0.03 0.24 0.20America D 0.07 0.43 0.11Emirates B 0.55 - 0.02Emirates D 0.41 - 0.14SE Asia B 0.04 - 0.10SE Asia D 0.15 - -W. Pacific A 0.04 0.28 0.22W Pacific B 0.02 - 0.34Africa D 0.09 0.26 0.31Africa E 0.01 0.05 0.12Note: UNDCP-derived estimates

12 leading selected risk factors as causes of disease burden measured in DALYs

Developed countriesDeveloping countries High Mortality Low Mortality

1 Underweight Alcohol (6.2%) Tobacco (12.2%)2 Unsafe sex Blood pressure Blood pressure

3 Unsafe water Tobacco (4.0%) Alcohol (9.2%) 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 (1.8%) 9 Tobacco (2.0%) Iron deficiency Unsafe sex 10 Cholesterol Unsafe water Iron deficiency 11 Alcohol Unsafe sex Lead exposure 12 Low fruit & veg intake Lead exposure Child sexual abuse

0 1000 2000 3000 4000 5000 6000 7000 8000

Occupational risk factors for injury

Unsafe health care injections

Vitamin A deficiency

Zinc deficiency

Urban air pollution

Iron deficiency

Indoor smoke from solid fuels

Unsafe water, sanitation, and hygiene

Alcohol

Physical inactivity

High Body Mass Index

Fruit and vegetable intake

Unsafe sex

Underweight

Cholesterol

Tobacco

Blood pressure

WorldDeaths in 2000 attributable to selected leading risk factors

Number of deaths (000s)

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


Cholesterol

Unsafe water, sanitation, and hygiene

Alcohol

Tobacco

Blood pressure

Unsafe sex

Underweight

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

factors

Number of Disability-Adjusted Life Years (000s)

0 10000 20000 30000 40000 50000 60000 70000

Illicit drugs

Alcohol

Tobacco

High Mortality DevelopingCountries

Low Mortality DevelopingCountries

Developed Countries

WorldDisease burden (DALYs) in 2000 attributable to

Addictive Substances related Risks

Number of Disability-Adjusted Life Years (000s)

0 1000 2000 3000 4000 5000

Illicit drugs

Alcohol

Tobacco

High Mortality Developing Countries

Low Mortality Developing Countries

Developed Countries

WorldDeaths in 2000 attributable to

Addictive Substances related Risks

Number of deaths (000s)

0

200

400

600

800

1000

1200

1400

1600

1800

AFR AMR EMR EUR SEAR WPR

Tobacco

Alcohol

Illicit drugs

WHO RegionsDeaths in 2000 attributable to selected leading risk factors

Num

ber o

f dea

ths

(000

s)

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

AFRO AMRO EMRO EURO SEARO WPRO

Tobacco

Alcohol

Illicit drugs

WHO RegionsDisease burden (DALYs) in 2000 attributable to selected leading risk

factors

Num

ber o

f Dis

abili

ty-A

djus

ted

Life

Yea

rs (0

00s)

Burden of disease attributable to addictive substances related risks:

ALCOHOL(% DALYs in each subregion)

0.5-0.9%

1-1.9%

2-3.9%

4-7.9%

<0.5%

8-15.9%

Proportion of DALYs attributableto selected risk factor


TOBACCO(% DALYs in each subregion)


0.5-0.9%

1-1.9%

2-3.9%

4-7.9%

<0.5%

8-15.9%


<0.5%

0.5-0.9%

1-1.9%

2-3.9%


ILLICIT DRUGS(% DALYs in each subregion)

Percentage of total global mortality and DALYs attributable to tobacco,alcohol and illicit drugs

High mortalitydevelopingcountries

Low mortalitydevelopingcountries

Developedcountries

Risk factor

Males Females Males Females Males Females

Global

MortalityTobaccoAlcoholIllicit drugs

DALYsTobaccoAlcoholIllicit drugs

7.52.60.5

3.42.60.8

1.50.60.1

0.60.50.2

12.28.50.6

6.29.81.2

2.91.60.1

1.32.00.3

26.38.00.6

17.114.02.3

9.3-0.30.3

6.23.31.2

8.83.20.4

4.14.00.8

Attributable mortality by risk factor, sex and mortality stratum (‘000) in the Americas

Very low child, verylow adult

Low child, lowadult

High child, highadultAddictive

substancesMales Females Males Females Males Females

Tobacco

Alcohol

Illicitdrugs

352

27

10

294

-22

7

163

207

7

58

39

4

5

22

1

1

6

0

Source: WHO (2002). World health report 2002.

Attributable DALYs by risk factor, sex and mortality stratum (‘000) in the Americas

Very low child, verylow adult

Low child, low adult High child, high adultAddictivesubstances


Tobacco

Alcohol

Illicit drugs

3,567

2,925

797

2,606

702

410

2,190

7,854

758

813

1,443

323

51

789

199

14

170

71

Source: WHO (2002). World health report 2002.

Estimates of mortality attributed to illicit drug use in 14WHO regions

AIDSOpioid

overdoseSuicide via

opioids TraumaEurope A 6,236 5,527 2,355 3,387Europe B 733 1,281 1,465 651Europe C 773 6,895 4,156 830America A 10,698 6,397 2,034 4,057America B 5,349 1,845 922 2,342America D 1,035 498 78 716Emirates B 962 3,881 673 813Emirates D 4,273 12,852 2,015 2,954SE Asia B 1,586 955 576 797SE Asia D 57,011 22,989 14,982 3,128W Pacific A 1,310 825 1,251 1,028W Pacific B 10,122 2,909 456 9,295Africa D 4,003 1,891 1,191 2,768Africa E 1,334 407 64 922Total 105,425 69,152 32,216 33,689

Conclusions

• The burden of licit and illicit drug problems is increasingly evident.

• From a public health perspective tobacco and alcohol use carry much higher burdens that illicit drug use.

• Alcohol and drug polices need to address the relative harms of these substances.

• In the management of psychoactive substance problems (prevention and treatment) more attention should be paid to epidemiologic evidence and developments in neuroscience.

WHO’s 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

Patterns 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.

Dimensions 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

Pattern of drinking 2000(based on CRA)


1.00 to 2.00

2.00 to 2.50

2.50 to 3.00

3.00 to 4.00

Volume of drinking

Drinking patternhazard score

(predominance ofintoxication)

Prior alcohol dependence

DepressionInjuriesCoronary

heartdisease

Physicaldiseases

(except CHD)

Alcohol-attributableconditions*

Aspects of alcohol used in estimating alcohol attributable fraction (AAF) for different

conditions

*AAF = 1 by definition

Alcohol-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

Estimating AAFs

1. Alcohol-specific categories

2. Chronic health conditions

3. CHD

4. Depression

5. Injuries

Alcohol-related global burden of disease

Alcohol-attributable mortality

0.35 to 1.00

1.00 to 4.00

4.00 to 6.00

6.00 to 8.00

8.00 to 20.00

Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS)

Developing countriesDeveloped countries

High mortality Low mortality

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 %

Disease conditions Males Females Total% of all alcohol-

attributable deaths

Conditions arising during the perinatal period

2 1 3 0%

Malignant neoplasm 269 86 355 20%

Neuro-psychiatric conditions 91 19 111 6%

Cardiovascular diseases 392 -124 268 15%

Other non-communicable diseases (diabetes, liver cirrhosis)

193 49 242 13%

Unintentional injuries 484 92 577 32%

Intentional injuries 206 42 248 14%

Alcohol-related mortality burden all causes

1,638 166 1,804 100.0%

All deaths 29,232 26,629 55,861 In comparison: estimate for 1990: 1.5%

% of all deaths which are alcohol-attributable 5.6% 0.6% 3.2%

Global mortality burden (deaths in 1000s) attributable to alcohol by major disease categories - 2000


attributable DALYs


68 55 123 0%

Malignant neoplasm 3,180 1,021 4,201 7%

Neuro-psychiatric conditions 18,090 3,814 21,904 38%

Cardiovascular diseases 4,411 -428 3,983 7%


3,695 860 4,555 8%

Unintentional injuries 14,008 2,487 16,495 28%

Intentional injuries 5,945 1,117 7,062 12%

Alcohol-related disease burden all causes (DALYs)

49,397 8,926 58,323 100%

All DALYs 755,176 689,993 1,445,169 In comparison: estimate for 1990: 3.5%% of all DALYs which are

alcohol-attributable 6.5% 1.3% 4.0%

Global burden of disease (DALYs in 1000s) attributable to alcohol by major disease categories - 2000

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!!!

Global Alcohol Policy

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM


Declarations of interest

Used to be Regional Advisor for both alcohol and tobacco policy, WHO Regional Office for Europe

Scientist and policy advisor for Eurocare


Structure of presentation

1. Eurocare

2. The problem of alcohol

3. Some solutions for alcohol policy

4. Expectations of the WHO

5. What NGOs can bring

Eurocare was formed in 1990 as an alliance of non-governmental organisations concerned with the impact of the European Union on alcohol policy in Member States

Starting with 9 member organisations in 1990, it now has 46 members from 12 EU States, 5 non EU States and 3 International Organisations with members in 26 European countries

Brief Description of Eurocare: Brief Description of Eurocare:

Eurocare promotes the implementation of evidence based alcohol policy and provides support to its member organizations

Key publications include: Alcohol problems and the family, 1998 The beverage alcohol industry’s social

aspects organizations: A public health warning, 2002

Drinking and driving in Europe, 2003


Eurocare will be implementing a 3 year European Commission funded project (Alcohol Policy Network in the Context of a larger Europe: Bridging the Gap): Creating an alcohol policy network in 27 European

Member States and applicant countries, Norway and Switzerland

Preparing a report on alcohol in Europe Preparing an advocacy training manual Convening a European conference, Bridging the Gap,

Warsaw, Poland, 16-19 June 2004 Convening two summer advocacy schools, Slovenia

2005 and Catalonia 2006.



These are net costs, accounting for heart disease

They do not include social harms

They do not include financial costs


At the community level:

Drinking and driving

Intoxication


WHO Region % dependent on alcohol

North and Central Africa 0.7

Southern Africa 1.6

North America 5.1

Latin America 3.5

South America 3.2

Middle East 0.0

Western Asia 0.0

Western Europe 3.4

Central Europe 0.8

Caucasus and Central Asia 0.2

Former Soviet Union 4.8

South-East Asia 0.4

Indian sub-continent 0.8

Australasia and Japan 2.1

Western Pacific, including China 0.9


Healthy Public Policy:

Taxation

Bans on advertising and marketing


Strengthening Community Action:

Drink driving

Educational and prevention programmes

Manage availability


Helping individuals:

Brief interventions in primary care

Treatment for dependence


What can WHO (and its MS) do?

Match resources to the size of the problem

The purpose of alcohol policy is to reduce the harm done by alcohol. The greater the harm, the greater the need for policy.

4% of GBD; 5th in list of risk factors



There is a strong team

But, it seems divided and unclear at present



Strong Regional Offices

Seems a posteriority rather than a priority



Need a simple metric (like a billion deaths from smoking)

Globally, every drinker loses on average 11 days of healthy life per year.



Do we need a FCAC?

Or some other mechanism to mobilize action?



Make the science clear



Calculate the economic burden



Estimate the social burden



Get some powerful partners

(?World Bank)



In dealing with the alcohol industry, ENSURE that WHO sticks to its guidelines



Disseminate and implement these guidelines throughout:

The organization

The Regional Offices

The Collaborating centres

The country offices



The industry argues that they have a place at the policy table.

They don’t.



The industry argues that they are a public health body.

They are not.



Don’t be duped by the alcohol industry and their social aspects organizations.

Effective Effective

policypolicy

Ineffective Ineffective

policypolicy

OpposedOpposed by by social aspects social aspects organizationsorganizations

SupportedSupported by by social aspects social aspects organizationsorganizations

Taxation Negative elasticities between price of alcohol and cirrhosis, fatal and non-fatal traffic accidents and intentional injuries (as price goes up, harm goes down)1

Takes the view that taxation has no impact on alcohol-related harm; takes the view that the solution to the problem of misuse does not lie in restrictions which penalize everyone for the mistakes of a minority3

Legal drinking age Increased drinking ages reduce traffic fatalities; reduced drinking ages lead to increases in assaults2

Suggests that there is no consensus as to whether or not minimal drinking ages are desirable4 ; opposed to increasing legal drinking ages believing that it does not address those who abuse the product3

Outlet density Increased outlet density associated with traffic accidents, assaults and liver cirrhosis2

Opposed to limiting outlet density believing that it does not address those who abuse the product3

Days and Hours of sale Closure of stores associated with reduced alcohol related violence; extended trading hours associated with increases in road traffic accidents and alcohol-related violence2

Believes that programmes that restrict days and hours of sale are ineffective and do not go to the heart of the problem of alcohol-related violence; opposed to restricting days and hours of sale believing that they do not address those who abuse the product3

Proof of age schemes Evidence for the impact of policy measures such as proof of age schemes is not available

Supports campaigns against underage access, such as proof of age schemes5

X

X

XX

Price and the availability of alcoholPrice and the availability of alcohol

Effective Effective

policypolicy


policypolicy



Physical environment Changing the physical environment of drinking places reduces alcohol related violence1

Takes the position that the vast majority of drinking episodes do not involve violence, and most violence does not involve drinking, but recognizes that in some individuals and groups, a pattern of behaviour may include both abusive drinking and violence; offers no concrete proposals2

Social environment Decreasing the permissiveness of the environment (better staff control; less discount drinks) reduces alcohol-related violence1

Server training with legal sanctions Responsible server programs supported by legal sanctions reduce harms from intoxication1

Opposed to legal sanctions; accepts that server training leads to a reduction in licensee liability for damages resulting from illegal service by trained servers3

.

Server training without legal sanctions Responsible server programs not supported by legal sanctions do not reduce harms from intoxication1

Trains servers not to sell to underage drinkers, but without legal sanctions4

X

X

Creating safer drinking environmentsCreating safer drinking environments

Effective Effective

policypolicy


policypolicy



Community action based on both environmental and educational approaches Comprehensive locally based community prevention programs have led to 10% reductions in alcohol involved car crashes, 25% reductions in fatal crashes and 43% reductions in alcohol related violence1

Opposed to environmental approaches, believing that they do not address those who abuse the product.

Locally based community prevention programs based only on educational approaches Have limited or no effect1

Describes school based alcohol education, and drink driving education programmes as community based programmes6

Legal restrictions Although difficult to evaluate, there is evidence for a link between advertising and consumption at individual and aggregate level; econometric analysis suggest that advertising restrictions reduce motor vehicle fatalities2

Takes the view that there is insufficient evidence to support an association between advertising and levels or patterns of drinking; opposed to legislative marketing restrictions

Alcohol education in schools In general no, or very limited impact on use of alcohol; no evidence for an impact on harm3

Promotes and funds school based educational programme, in which “the pleasure of drinking responsibly is part of a balanced lifestyle” 7

Public education campaigns In general no, or very limited impact on use of alcohol; no evidence for an impact on harm4

Stresses the importance of educational programmes as the key policy choice to reduce alcohol-related harm6

Self-regulation Considerable evidence that self regulatory codes are not adhered to5;

The production and dissemination of self-regulatory codes a core area of work,8,9

X

X

Prevention and education programmesPrevention and education programmes

Effective Effective

policypolicy


policypolicy



Legal drinking age Increased drinking age in US reduced traffic accidents by 5%-28%1

Suggests that there is no consensus as to whether or not minimal drinking ages are desirable2; opposed to increasing legal drinking ages believing that it does not address those who abuse the product (i.e. drink driving) 3

Regulating the conditions of sale Extending trading hours increases traffic accidents; targeted programmes at high risk premises reduce accidents1

Believes that programmes that restrict days and hours of sale are ineffective and do not go to the heart of the problem of alcohol-related accidents; opposed to restricting days and hours of sale believing that they do not address those who abuse the product (i.e. drink driving)3

Random breath testing High visibility can reduce deaths by between one third and one half1

Generally opposed to high visibility random breath testing4

Reducing legal BAC limit Reduces drink driving and fatalities across all levels of BAC1

Opposed to any reductions in legal BAC limits5

Public education campaigns No evidence for a beneficial effect on alcohol-related crashes1

Believes that educational programmes are the core component of drink driving programmes6

Interventions by servers, hosts and peers Ineffective, although increased protection of drinking peers1

Works with the hotel, restaurant, cafe and bar sectors to develop anti-drink driving initiatives3

Alternative transportation programmes Limited evidence suggests ineffective1

Alternative transportation programmes (designated river campaigns) are priority projects6

XX

X

X

Drink driving programmesDrink driving programmes



There cannot be common ground on drinking and driving


Eurocare recommendation:

6. Because of limited evidence for their effectiveness in reducing drinking and driving, public education efforts to persuade drinkers not to drive after drinking, programmes to encourage servers to prevent intoxicated individuals from driving, and organized efforts to make provisions for alternative transportation should not be the main cornerstones of drinking and driving policy.



There should be no discussion on self-regulation

It serves the needs of the industry

The reality is based on complaints rather than compliance

The advertisements still go ahead anyway

There is no enforcement

It is not independent, and reflects the ‘intentions’ of the advertisers

Does not reflect the marketing to young people

We should not waste any more time on self-regulationWe should not waste any more time on self-regulation



The Smirnoff day off speaks much louder to politicians than all the research



Encourage litigation


What can WHO (and its MS) do?Policy

Action Plans: Globally

Regionally

Country wide

Regional

Local


What can WHO (and its MS) do?Community Action

Database of community programmes


What can WHO (and its MS) do?Health sector

Be clear and consistent on nomenclature (ICD 10)

Promote brief interventions

Reorient health care


What can the NGO sector do?

We are your friends;

But also your watchdog



Support you in any or all of the above

Promote and disseminate the science that empowers alcohol policy

Develop advocacy and promote advocacy skills

Monitor the alcohol industry



And do we write formally to the WHO after this consultation, or what?

Thank you for your attention

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM

Alcohol in Development and in Health and Social Policy

David Jernigan PhDCenter on Alcohol Marketing and Youth

Georgetown UniversityWashington, D.C.

[email protected]

Robin Room PhDCenter for Social Research on Alcohol and Drugs

University of StockholmStockholm, Sweden

Jürgen T. Rehm PhDAddiction Research Institute

Zurich, Switzerland

mailto:[email protected]

Presentation Overview

• To what extent is alcohol harmful or beneficial to health and social well-being?

• Alcohol’s 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

WHO’s 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

WHO’s 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.

The epidemiological model

Attributable fractions

= f(prevalence, pattern weight, relative risk)

Defined as: With a given outcome exposure factor, and population, the attributable fraction is the proportion by which the incidence rate of the outcome would be reduced if the distribution of exposure would change to an alternative distribution:““When an exposure is When an exposure is believed to be a cause of believed to be a cause of a given disease, the a given disease, the attributable fraction is attributable fraction is the proportion of the the proportion of the disease in the specific disease in the specific population that would be population that would be eliminated in the absence eliminated in the absence of the exposure.”of the exposure.”

Four drinking categories (old English et al. terminology: abstainer, moderate, hazardous, harmful) are distinguished. Prevalence for all four categories are taken from surveys

Steps to derive at pattern weight:1. Determine pattern value from survey of key informants, and/or survey data where available.2. Conduct hierarchical linear analyses on mortality using per capita consumption gross-national product, year (level 1 variables) and pattern values (level 2 variable) as determining factors (separate by age and sex).3. Construct pattern weight based on intercept and regression weight for patterns.

Relative Risk estimates for each drinking category are either taken directly from meta-analyses (chronic diseases) or indirectly from meta-analyses of attributable fractions (injuries)

Prevalence data

• Adult per capita consumption estimates for countries totaling 90% of world’s population

• Survey data from 69 countries, covering 80% of world’s population

• Survey and adult per capita consumption data for more than 50% of countries

Adult per capita consumption inlitre pure alcohol 2000 (based on CRA)

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


• 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.

Dimensions 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

Pattern of drinking 2000(based on CRA)


1.00 to 2.00

2.00 to 2.50

2.50 to 3.00

3.00 to 4.00

Volume of drinking

Drinking patternhazard score

(predominance ofintoxication)

Prior alcohol dependence

DepressionInjuriesCoronary

heartdisease

Physicaldiseases

(except CHD)

Alcohol-attributableconditions*

Aspects of alcohol used in estimating alcohol attributable fraction (AAF) for different

conditions

*AAF = 1 by definition

Estimating AAFs

1. Alcohol-specific categories

2. Chronic health conditions

3. CHD

4. Depression

5. Injuries

Alcohol-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

Estimating 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

Alcohol-related global burden of disease

Alcohol-attributable mortality

0.35 to 1.00

1.00 to 4.00

4.00 to 6.00

6.00 to 8.00

8.00 to 20.00


attributable deaths


2 1 3 0%

Malignant neoplasm 269 86 355 20%

Neuro-psychiatric conditions 91 19 111 6%

Cardiovascular diseases 392 -124 268 15%


193 49 242 13%

Unintentional injuries 484 92 577 32%

Intentional injuries 206 42 248 14%

Alcohol-related mortality burden all causes

1,638 166 1,804 100.0%

All deaths 29,232 26,629 55,861 In comparison: estimate for 1990: 1.5%

% of all deaths which are alcohol-attributable 5.6% 0.6% 3.2%

Global mortality burden (deaths in 1000s) attributable to alcohol by major disease categories - 2000


attributable DALYs


68 55 123 0%

Malignant neoplasm 3,180 1,021 4,201 7%

Neuro-psychiatric conditions 18,090 3,814 21,904 38%

Cardiovascular diseases 4,411 -428 3,983 7%


3,695 860 4,555 8%

Unintentional injuries 14,008 2,487 16,495 28%

Intentional injuries 5,945 1,117 7,062 12%

Alcohol-related disease burden all causes (DALYs)

49,397 8,926 58,323 100%

All DALYs 755,176 689,993 1,445,169 In comparison: estimate for 1990: 3.5%% of all DALYs which are

alcohol-attributable 6.5% 1.3% 4.0%

Global burden of disease (DALYs in 1000s) attributable to alcohol by major disease categories - 2000

Disability-Adjusted life Years (DALYs) attributable to ten leading risk factors, 2000

World High mortality developing countries

Low mortality developing countries

Developed countries

DALYs(millions)

% total % total % total % total


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


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

Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS)

Developing countriesDeveloped countries

High mortality Low mortality

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 %

Alcohol-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

Measuring social harms

1. Cost of illness studies• E.g. Scotland:

» Health care costs $139 million» Social work costs $125 million» Criminal justice and fire costs $390 million

2. 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

3. Survey research• Canada – harms from someone else’s drinking

» 7.2% pushed, hit or assaulted» 6.2% friendships harmed» 7.7% family or marriage difficulties

Trends in alcohol consumptionFigure 2: Adult (15+) Per Capita Alcohol Consumption

by Macro-Region

0

1

2

3

4

5

6

7

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

Year

Lit

res

Asia Central and South America Sub-Saharan Africa Developed Former Soviet

Relationship 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

Relationship 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

Social and health benefits of drinking

• Social benefits of drinking largely unquantifiable– Alcohol’s 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

Alcohol 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

Alcohol 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


• 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


• MNCs and technology transfer– “Turnkey” technologies increasing– Design, R&D 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

Preventive 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

Preventive 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

Preventive 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


• 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


• 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

Other 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”

Monitoring alcohol consumption

• Per capita alcohol consumption (age 15+)• Number of abstainers: • Pattern of drinking:

– frequency of getting drunk or drinking >60 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 >40g. days

for men and >20g. days for women

• Youth use

Monitoring 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

The 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!!!

Target groups (cont.)

• Of the 32 interventions and strategies evaluated, 16 are targeted at the GP, 12 at HR, and 4 at HD.

• Interventions directed at the general population have higher effectiveness ratings thatn those targeted at other groups.

• Interventions directed at the general population and high-risk groups tend to be less costly to implement and maintain than interventions with harmful drinkers

Table 16.1. Ratings of policy-relevant stategies and interventions

Strategy Effective-ness

Breadth of research support

Cross-cultural testing

Cost to implement

Target

group

Total ban on sales +++ +++ ++ High GP

Alcohol taxes +++ +++ +++ Low GP

Training bar staff against aggression

+ +++ ++ Moderate HR

Alcohol education in schools

0 +++ ++ High HR

Random breath tests +++ ++ + Moderate GP

Mandatory treatment of drinking-drivers

+ ++ + Moderate HD

Ratings of policy-relevant stategies and interventions – PHYSICAL AVAILABILITY




Cost to implement

Target

group

Total ban on sales +++ +++ ++ High GP

Minimum legal purchase age

+++ +++ ++ Low HR

Government Monopoly

+++ +++ ++ Low GP

Hours and days of sale restrictions

++ ++ ++ Low GP

Restrictions on density of outlets

++ +++ ++ Low GP

Server Liability +++ + + Low TG

Ratings of policy-relevant stategies and interventions – ALTERING DRINKING CONTEXT




Cost to implement

Target

group

Outlet policy to not serve intoxicated

patrons

+ +++ ++ Moderate HR

Training bar staff + + + Moderate HR

Voluntary codes of bar practice

0 + + Low HR

Enforcement of on-premise regulations

and legal requirements

++ + ++ High HR

Promoting alcohol free activities and

events

0 ++ + High GP

Community mobilization

++ ++ + High GP

Ratings of policy-relevant stategies and interventions – DRINKING-DRIVING




Cost to implement

Target

group

Sobriety check points

++ +++ +++ Moderate GP

Random breath test +++ ++ + Moderate GP

Lowered BAC level +++ +++ ++ Low GP

License Suspension ++ ++ ++ Moderate HR

Low BAC for young +++ ++ + Low HR

Designated drivers and ride services

0 + + Moderate HR

Ratings of policy-relevant stategies and interventions – TREATMENT AND EARLY

INTERVENTIONStrategy Effectiv

e-nessBreadth

of research support


Cost to implem

ent

Target

group

Brief intervention

++ +++ +++ Moderate

HR

Alcohol Problems

Treatment

+ +++ +++ High HD

Self-help + + ++ Low HD

Mandatory treatment of

repeat drinking drivers

+ ++ + Moderate

HD

Ratings of policy-relevant stategies and interventions – EDUCATION AND PERSUATION


Breadth of

research support


Cost to implem

ent

Target

group

Alcohol education in

schools

0 +++ ++ High HR

College student

education

0 + + High HR

Public service messages

0 +++ ++ Moderate

GP

Warning labels 0 + ++ Low GP

Ratings of policy-relevant stategies and interventions – REGULATING ALCOHOL

PROMOTIONStrategy Effecti

ve-ness

Breadth of

research

support


Cost to

implement

Target

group

Advertising Bans

+ ++ ++ Low GP

Advertising content controls

0 0 0 Moderate

GP

Ratings of policy-relevant stategies and interventions – TAXATION AND PRICING

Strategy Effective-

ness

Breadth of

research

support


Cost to

implement

Target

group

ALCOHOL TAXES

+++ +++ +++ LOW GP

Integrated alcohol policies

Our ratings suggest that a combination of pjysical availability limits at the general population level, certain drinking-driving countermeasures directed at all three target groups, and brief interventions directed at high-risk drinkers will offer the best value as the foundation for a comprehensive alcohol policy approach

The strong strategies

• Availability restrictions

• Taxation

• Enforcement

Good research support

Applicable in most countries

Relatively inexpensive to implement and sustain

Essential Elements of Effective Prevention of Alcohol Problems

Public Support

EnforcementPolicies and Laws

Prevention

Implementing Alcohol Control Strategies in Brazil

A. Strengthen alcohol surveillance systems

1. Epidemiologic surveys: household, school, roadside, emergency room, special events, alcohol sales and service practices, industry marketing, etc.

2. Increase expertise in behavioral health research methods and analysis.

3. Create and staff a Brazilian alcohol research center and develop an integrative and multi-disciplinary research strategy.

Alcohol is a drug which is:

1. Mind altering

2. Tolerance producing

3. Addictive

These basic facts are not changed by alcohol industry advertising.

Drug “Capture” Rate

Percent of Users Who Become Clinically Dependent

Tobacco 31.9%Heroin 23.1%Cocaine 16.7%Alcohol 15.4%Stimulants 11.2%Marijuana 9.1%

Source: National Comorbidity SurveyAnthony, Warner, and Kessler

Global Burden of Disease(Disability-Adjusted Life Years)

Attribution

Tobacco Alcohol Illicit Drugs

Worldwide 4.1% 4.0% 0.8%

North America 8 - 15.9% 4 - 7.9% 2 - 3.9%

South America 2 - 3.9% 8 - 15.9% 1 - 1.9%

Source: World Health Report 2002

World Health Organization

Global Market – Alcohol Spirits Sales Exceed 2 Billion Cases Annually

Country Case Volume

China 725 million casesRussia 350India 249Brazil 195Japan 176United States 135Korea 79Thailand 76Germany 60France 37

Source: Mark Brown, President

Sazerac Company, Inc.

March 4, 2003

Product Categories – Alcohol Spirits

Product Category Case Volume

Baijiu 725 million casesVodka 400Whisky 205Cachaca 200Rum 115Brandy 82Shochu 70Soju 70Liqueurs 51

Source: Mark Brown, President

Sazerac Company, Inc.

March 4, 2003

U.S. Economic Costs of ATOD Use, 1995

Total Costs = $415 Billion

40%

33%

27%Alcohol-$167 Billion

Tobacco-$138 Billion

Illicit Drugs-$110 Billion

Sources: Harwood, Fountain, & Livermore, NIDA & NIAAA, 1998Rice (unpublished) Institute for Health and Aging, UCSF, 1995

Most U.S. adults do not drink or drink infrequently.

46%

26%

13%9%

6%

0%

20%

40%

60%

0 1 to 4 5 to 10 11 to 21 21+

Frequency of Drinking Among U.S. Adults 21 and Older, 2002 (past 30 days)

Source: NSDUH, 2002

Number of Drinking Days

Most U.S. adults do not drink at a hazardous level.

46%

31%

16%

7%Nondrinker

Nonbingers

Infrequent Bingers

Frequent Bingers

Drinking Patterns among U.S. Adults 21 and Older, 2002(past 30 days)

Source: NSDUH, 2002

Binge drinkers are 23% of the population, but consume 76% of the alcohol.

23%

76%

0%

20%

40%

60%

80%

100%

Population Alcohol

U.S. Binge Drinkers, 2002

Source: NSDUH, 2002

Most young people do not drink.

15- to 17-year-olds

Drinking occasions

0 1 to 4 5 or more

Drinking Among Youth, 2002 (past 30 days)

18%

72%

10%

Among the 28% of 15-17 year olds who drink, 65% drank heavily at least once in the past month.

Source: NSDUH, 2002

Strategy Options:

1. Personal change strategies – change people

2. Alcohol control strategies – control alcohol availability

Personal Change Strategies

The U.S. has spent a fortune trying to “change people” through programs for adults, youth and children to:

1.Provide alcohol education

2.Change attitudes about drinking

3.Provide early intervention and treatment services for individuals with alcohol problems, and for their families

Research Evidence of Effectiveness:Personal Change Strategies

1. With few exceptions, these programs have not been effective in preventing societal alcohol problems.

2. As for the exceptions, these programs are too expensive to be implemented across society.

3. Despite this evidence, programs implementing personal change strategies are the most popular, most prevalent, and best funded prevention efforts in the U.S.

Alcohol Control Strategies:Essential Components

• changes in social norms

• policy interventions

• deterrence and enforcement

Alcohol Control Strategies:The Role of Public Health Education

in Changing Social Norms

1. Raise societal awareness and concern about alcohol problems.

2. Educate the society that these problems can be prevented.

3. Inform the society about specific policy controls and deterrence strategies that are effective.

4. Publicize successes.

Alcohol Control Strategies: Effective Public Health Education Strategies

for Changing Social Norms

1. Rely on research epidemiology.

2. Develop a strategic plan to educate society incrementally and sequentially.

3. Stay on message.

4. Utilize mass media.

Sequence of U.S. Public Awareness of Alcohol Problems

Pre 1960

1960-1970

1970-1980

1980-1990

1990-2000

2000-

Duh – what problems?

Addiction, public drunkenness, social disorder

Youth drinking

Drinking and driving, fetal alcohol effects

Alcohol industry behavior

Violence and crime?

Alcohol Control StrategiesPolicy Interventions

• To prevent alcohol problems, policy interventions must focus on the Availability of alcohol.

• Effective policies address the–Price–Place–Product–Promotion…

…of alcohol products

Percent of U.S. Population (18+ years of age) favoring alcohol policies designed to

reduce alcohol problems among youthProposed Policy Favor

StronglyFavor

SomewhatOppose

SomewhatOppose Strongly

Increase alcohol tax by 5 cents to fund prevention programs

65.0 16.8 5.7 12.6

Restrict alcohol ads to make drinking less appealing to youth

52.6 26.0 10.5 10.8

Conduct compliance checks to reduce illegal sales to minors

46.5 19.0 9.5 25.0

Require registration of beer kegs

39.9 21.3 15.3 23.5

Source: Harwood, et al, 1998

Percent of U.S. Population (18+ years of age) favoring restrictions on drinking in

public locationsPublic location Ban

drinkingBy permit

onlyNo restrictions

Parks 63.0 27.3 9.8

Concerts 51.2 34.1 14.6

Beaches 53.1 28.7 18.2

Stadiums/arenas 47.8 29.6 22.6

Source: Harwood, et al, 1998

Impact of enforcement on alcohol-related traffic

fatalities

25

30

35

40

45

Percent alcohol-related

Percentage traffic fatalities related to alcohol(1977-1999)

Essential Elements of Effective Prevention of Alcohol Problems

Public Support

EnforcementPolicies and Laws

Prevention

Implementing Alcohol Control Strategies in Brazil

A. Strengthen alcohol surveillance systems

1. Epidemiologic surveys: household, school, roadside, emergency room, special events, alcohol sales and service practices, industry marketing, etc.

2. Increase expertise in behavioral health research methods and analysis.

3. Create and staff a Brazilian alcohol research center and develop an integrative and multi-disciplinary research strategy.

Every Ounce of Alcohol Sold in the United States Generates $2.25 in Public

Sector Costs

Alcohol – Related Violence $1.00

Drinking Driving Problems .85

Other Costs .40

$2.25

Alcohol Problem Cost per Ounce

Total Societal Costs, including Public Sector Costs: $6.00/ounce

Source: Ted Miller, Ph.D.

PIRE

Societal Costs – Alcohol Sales

Source: Ted Miller, Ph.D.PIRE

Sales Unit Public Sector Costs

Total Societal Costs

Beer – Six Pack $7.30 $19.45

Wine – Fifth Bottle $7.50 $20.00

Spirits – Fifth Bottle $23.00 $61.45

Challenges Confronting the Community Prevention Coordinator

A. Provide “translation” services between:1. Researchers2. Public health professionals3. Community organizers4. Policy makers5. Alcohol industry6. Alcohol law enforcement

B. Provide “honest broker” services for each of the above groups.

C. Keep a low profile!

Implementing Alcohol Control Strategies

B. Establish a Brazilian technical assistance center for implementation of alcohol control strategies

1. Organize services by problems, not by control policies (violence, youth drinking, traffic safety, noise and neighborhood disruption, etc.).

2. Local communities are the first priority for services.3. Develop and implement a public health education

strategy to change social norms.4. Respond quickly to “unscheduled opportunities”.

Implementing Alcohol Control Strategies

C. Increase enforcement of existing alcohol control policies.

1. Public health and law enforcement are not traditional allies – build relationships!

2. Support creation of law enforcement units which specialize in enforcement of alcohol laws.

3. Document, and then acknowledge publicly, the results of alcohol law enforcement.

Community Prevention Case Studies

1. Paulinia: alcohol price controls

Price/Enforcement

2. Salinas: alcohol control at special events

Place/Social Norms

3. Salinas: reducing alcohol outlet density

Place

4. Diadema: limiting alcohol sales

Place, Social Norms, Enforcement

Case Studies:Alcohol Prevention Research in Brazil

Presentation Outline1. What was your research interest?2. What were your fears and concerns beginning

your research?3. What was the major difficulty you faced in

conducting your research?4. What was the biggest assistance you received

in conducting your research?5. What was the biggest unexpected “surprise”

you encountered?6. What is your advice to those who come along

next in conducting research in your area?

Alcohol Prevention Research in Brazil

Research Topic• Bar surveys and underage buyer

surveys• Municipal school surveys• Collaboration with municipal

officials• Utilizing municipal records for

evaluation, and roadside driver surveys

• Local and national household surveys, and emergency room surveys

• Alcohol industry structure and marketing practices

Researcher• Marcos

Romano• Denise Vieira• Nino Meloni

• Sergio Duailibi

• Ronaldo Laranjeira

• Illana Pinsky

Science more accessible to policy-makers

• Policy changes should be made with caution and with a sense of experimentation to determine whether they have their intended effects

• Interdisciplinary research is capable of playing a critical role in the progress of public health by applying the methodologies of the medical, behavioural, social and population sciences

The precautionary principleA general public health concept

• “To take preventive action even in the face of uncertainty”

• To shift the burden of proof to the proponents of a potentially harmful actitivy

• To offer alternatives to harmful actions• To increase public involvement in decision-

making• Decision-making must be guided by the

likelihood of risk, rather than the potential for profit

Extraordinary oportunities

• Multiple • Changes can be made rationally• Combine rationally selected strategies into an

integrated overall policy• The research base is strong• Policies can be implemented at multiple levels• Public awareness and support can be

strengthened• International collaboration can be enhanced

políticas públicas em alcohol prof. dr. ronaldo laranjeira universidade federal de são paulo

Documents

systematic procedure

alternativa interventions