Reducing alcoholrelated harm

1
Reducing alcohol-related harm
Ian Gilmore, Royal College of Physicians of London

2
WHO 2004 (from Rehm et al 2003)
3
Alcohol damage main systems affected

• Heart and blood vessels
• Liver
• Pancreas
• Gut
• Brain and peripheral nerves
• Muscle and bone
• Endocrine and reproductive
• Blood

4
Alcohol and the cardiovascular system

• Atherosclerosis
• Arrhythmias
• Hypertension
• Cardiac muscle
• Coronary artery tone
• Sudden death

5
Alcohol and the holiday heart

• Moderate consumption raises pulse rate by 5-10
  bpm
• Atrial fibrillation 2-3x commoner in heavy
  drinkers
• Direct effect or related to early cardiomyopathy?

6
(No Transcript)
7
Alcohol and hypertension

• Reduction of intake reduces BP
• gt30 g/d -4/-2 mm Hg
• 10 g/d -1/-0.5 mm Hg
• (MONICA)
• Randomised cross-over studies impressive
• 80 g/d -gt 0 g/d -20/-5 mmHg
• (Potter et al 1984)
• Works in normals and hypertensive
• Alcohol-attributable fraction about 15

8
Alcohol and stroke

• Ischaemic stroke
• Mild-mod consumption ? reduced risk
• Heavy consumption ? increased risk (but
  cigarettes and blood pressure confound)
• Haemorrhagic stroke
• More frequent for regular (gt40g/d) and binge
  drinkers

9
Liver cirrhosis
10
Alcohol and the liver

• A spectrum of damage
• normal liver
• fatty change (hepatic steatosis)
• alcoholic hepatitis (steatohepatitis)
• cirrhosis
• hepatocellular carcinoma

11
Why dont all heavy drinkers get liver damage?

• Genetic influences are likely to be most
  important variable
• Gender
• Dehydrogenase polymorphisms
• Cyp 2E1 polymorphisms
• Cytokine polymorphisms

12
Trends in cirrhosis deaths between England and
EU, 1970 1998 CMOs report, 2001
13
Leon and McCambridge, Lancet 2006
14
Leon and McCambridge, Lancet 2006
15
Differences in standardised mortality rates over
the last decade all ages ()
Leon and McCambridge, Lancet 2006
16
Differences in standardised mortality rates over
the last decade ages 15-44 ()
Leon and McCambridge, Lancet 2006
17
change in mortality for a one litre of per
capita alcohol consumption
Norström, 2001
18
Alcohol and musculoskeletal system

• Most important effect is through violence and
  falls
• Chronic alcohol misuse leads to
• Osteoporosis
• Reduced calcium and magnesium
• Depressed 25-hydroxyvitamin D
• myopathy

19
Alcohol and accidental injury

• Factor in 20-30 of all accidents
• Honkanen, 1993
• Associated with 15 of drownings
• RSPA, 1998
• Associated with 39 of deaths in fires
• Tether, 1986
• 550 deaths per year from drink driving
• DETR, 1999
• 2940 serious casualties per year
• DETR, 1999
• 37 of pedestrians killed on the road had drunk
  over the legal limit for driving
• DETR, 1999

20
Alcohol and the endocrine system

• Effects on sexual function and reproduction
• Effects on glucose metabolism
• Pseudocushings syndrome.

21
Effects on pregnancy and the fetus
22
Alcohol and cancer

• Ethanol is not directly carcinogenic
• Probably acts through modulation of chemical
  carcinogenesis
• Effects strongest in upper GI tract
• Oropharynx and larynx
• Oesophagus and stomach
• Also effect in breast, colon

23
Why is the spotlight on crime and disorder?

• Crime and social disorder is easy it is caused
  by someone else
• We are all on the same side bad for industry,
  bad for Government, bad for Police
• We are uncomfortable to be among the 30-40 of
  the population drinking at potentially hazardous
  levels for our health

24
Why should the spotlight be on health?

• Alcohol together with tobacco and hypertension is
  main cause of premature and preventable death
• Main cause of AE attendances
• Three to five million dependent drinkers in the
  UK
• Cirrhosis rates risen tenfold in younger adults

25
Current harm-reducing strategies currently used
by UK Government

• Voluntary partnerships with drinks industry
• Education and public information
• Cross-working between agencies

26
International, evidence-based harm-reducing
strategies not currently used by UK Government

• Price
• Advertising
• Access
• Outlets (supermarkets, garages)
• Availability (licensing hours)
• EU imports

27
Are we drinking more? And why?
28
(No Transcript)
29
Social responsibility and the Industry

• Stop serving under-age drinkers and those who are
  drunk
• Stop irresponsible promotions and advertising
• Commit to an independent body to enforce highest
  standards
• Co-ordinate across the industry, invest and share
  best practice

Raising the Bar on Responsible Practice Alcohol
Concern, November 2005
30
Effect of availability of alcoholic beverages

• New Mexico Sunday sales led to 40 increase in
  fatal car crashes that day (McMillan and Lapham
  2006)
• Swedish extending of sales to Saturdays led to
  increase in consumption but no measurable
  short-term increase in harm (Norstrom and Scogg
  2005)

31
Patterns of drinking and harm

• Both pattern and amount important
• Pattern more important in acute harm (violence,
  accidents)
• Amount more important in chronic damage
  (cirrhosis)

32
Patterns of drinking and harm
Pattern of drinking (adjusted for total
consumption) and mortality risk Kauhanen et al,
BMJ, 1997
33
reducing alcohol-related harm requires a range of
methods-
But must include a fall in per capita consumption
through price and access