Alcohol in Development and in Health and Social Policy

1
Alcohol 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

2
Presentation 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

3
WHOs 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

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WHOs 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.

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The epidemiological model
   
6
Prevalence 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

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Adult per capita consumption inlitre pure
alcohol 2000 (based on CRA)
8
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.

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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

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Pattern of drinking 2000(based on CRA)
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Aspects 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
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Estimating AAFs

1. Alcohol-specific categories
2. Chronic health conditions
3. CHD
4. Depression
5. Injuries

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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

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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

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Alcohol-related global burden of disease
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Global mortality burden (deaths in 1000s)
attributable to alcohol by major disease
categories - 2000
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Global burden of disease (DALYs in 1000s)
attributable to alcohol by major disease
categories - 2000
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Disability-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
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Leading 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
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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

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Measuring 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

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Trends in alcohol consumption
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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

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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

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Social 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

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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

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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

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Alcohol 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

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Alcohol 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

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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

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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

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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

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Preventive 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

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Preventive 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

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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

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Monitoring 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

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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

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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!!!