Pol

1
Políticas Públicas em AlcoholProf. Dr.
Ronaldo LaranjeiraUniversidade Federal de São
Paulo
2
Chosing effective strategies

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

3
(No Transcript)
4
Proportion of alcohol consumers in WHO sub-regions
5
(No Transcript)
6
Drinking Pattern Values for Selected WHO Regions
7
(No Transcript)
8
12 leading selected risk factors as causes of
disease burden measured in DALYs
Developed countries
Developing 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
deficiency Body mass index Body
mass index 6 Iron deficiency Cholesterol L
ow 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
9
World Deaths in 2000 attributable to selected
leading risk factors
Number of deaths (000s)
10
World Disease burden (DALYs) in 2000 attributable
to selected leading risk factors
Number of Disability-Adjusted Life Years (000s)
11
World Disease burden (DALYs) in 2000 attributable
to Addictive Substances related Risks
Number of Disability-Adjusted Life Years (000s)
12
World Deaths in 2000 attributable to Addictive
Substances related Risks
Number of deaths (000s)
13
World Deaths in 2000 attributable to Addictive
Substances related Risks
Number of deaths (000s)
14
WHO Regions Deaths in 2000 attributable to
selected leading risk factors
Number of deaths (000s)
15
WHO Regions Disease burden (DALYs) in 2000
attributable to selected leading risk factors
Number of Disability-Adjusted Life Years (000s)
16
Burden of disease attributable to addictive
substances related risks ALCOHOL ( DALYs in
each subregion)
Proportion of DALYs attributable to selected risk
factor
lt0.5
0.5-0.9
1-1.9
2-3.9
4-7.9
8-15.9
17
Burden of disease attributable to addictive
substances related risks TOBACCO ( DALYs in
each subregion)
Proportion of DALYs attributable to selected risk
factor
lt0.5
0.5-0.9
1-1.9
2-3.9
4-7.9
8-15.9
18
Burden of disease attributable to addictive
substances related risks ILLICIT DRUGS ( DALYs
in each subregion)
Proportion of DALYs attributable to selected risk
factor
lt0.5
0.5-0.9
1-1.9
2-3.9
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
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.

24
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

25
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.

26
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

27
Pattern of drinking 2000(based on CRA)
28
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
29
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

30
Estimating AAFs

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

31
Alcohol-related global burden of disease
32
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
33
Global mortality burden (deaths in 1000s)
attributable to alcohol by major disease
categories - 2000
34
Global burden of disease (DALYs in 1000s)
attributable to alcohol by major disease
categories - 2000
35
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!!!

36
Global Alcohol Policy

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
37

WORKING 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

38

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

• Structure of presentation
• Eurocare
• The problem of alcohol
• Some solutions for alcohol policy
• Expectations of the WHO
• What NGOs can bring

39
Brief Description of Eurocare

• 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

40
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 industrys social aspects
  organizations A public health warning, 2002
• Drinking and driving in Europe, 2003

41
Brief Description of Eurocare

• 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.

42

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
43

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
These are net costs, accounting for heart
disease They do not include social harms They do
not include financial costs
44
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

45

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
46

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
47

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

• At the community level
• Drinking and driving
• Intoxication

48

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
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
49

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

• Healthy Public Policy
• Taxation
• Bans on advertising and marketing

50

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

• Strengthening Community Action
• Drink driving
• Educational and prevention programmes
• Manage availability

51

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

• Helping individuals
• Brief interventions in primary care
• Treatment for dependence

52

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
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
53

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? There is a strong
team But, it seems divided and unclear at present
54

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Strong Regional
Offices Seems a posteriority rather than a
priority
55

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Need a simple
metric (like a billion deaths from
smoking) Globally, every drinker loses on average
11 days of healthy life per year.
56

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Do we need a FCAC?
Or some other mechanism to mobilize action?
57

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Make the science
clear
58

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Calculate the
economic burden
59

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Estimate the social
burden
60

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Get some powerful
partners (?World Bank)
61

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? In dealing with
the alcohol industry, ENSURE that WHO sticks to
its guidelines
62

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Disseminate and
implement these guidelines throughout The
organization The Regional Offices The
Collaborating centres The country offices
63

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? The industry argues
that they have a place at the policy table. They
dont.
64

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? The industry argues
that they are a public health body. They are
not.
65

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Dont be duped by
the alcohol industry and their social aspects
organizations.
66
Price and the availability of alcohol
Effective policy Ineffective policy Opposed by social aspects organizations Supported by social aspects organizations
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
X
X
?
67
Creating safer drinking environments
Effective policy Ineffective policy Opposed by social aspects organizations Supported by social aspects organizations
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 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
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
?
68
Prevention and education programmes
Effective policy Ineffective policy Opposed by social aspects organizations Supported by social aspects organizations
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
?
?
?
69
Drink driving programmes
Effective policy Ineffective policy Opposed by social aspects organizations Supported by social aspects organizations
Legal drinking age Increased drinking age in US reduced traffic accidents by 5-281 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
X
X
X
X
?
?
?
70

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? There cannot be
common ground on drinking and driving
71

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

• Eurocare recommendation
• 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.

72

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? There should be no
discussion on self-regulation
73
We should not waste any more time 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

74

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? The Smirnoff day
off speaks much louder to politicians than all
the research
75

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Encourage litigation
76

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

• What can WHO (and its MS) do?
• Policy
• Action Plans
• Globally
• Regionally
• Country wide
• Regional
• Local

77

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Community
Action Database of community programmes
78

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can WHO (and its MS) do? Health sector Be
clear and consistent on nomenclature (ICD
10) Promote brief interventions Reorient health
care
79

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can the NGO sector do? We are your
friends But also your watchdog
80

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can the NGO sector do? 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
81

WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM
What can the NGO sector do? And do we write
formally to the WHO after this consultation, or
what?
82
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL
RELATED HARM

• Thank you for your attention

83
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

84
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

85
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

86
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.

87
The epidemiological model
   
88
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

89
Adult per capita consumption inlitre pure
alcohol 2000 (based on CRA)
90
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.

91
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

92
Pattern of drinking 2000(based on CRA)
93
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
94
Estimating AAFs

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

95
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

96
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

97
Alcohol-related global burden of disease
98
Global mortality burden (deaths in 1000s)
attributable to alcohol by major disease
categories - 2000
99
Global burden of disease (DALYs in 1000s)
attributable to alcohol by major disease
categories - 2000
100
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
101
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
102
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

103
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

104
Trends in alcohol consumption
105
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

106
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

107
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

108
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

109
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

110
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

111
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

112
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

113
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

114
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

115
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

116
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

117
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

118
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

119
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

120
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!!!

121
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

122
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
123
Ratings of policy-relevant stategies and
interventions PHYSICAL AVAILABILITY
Strategy Effective-ness Breadth of research support Cross-cultural testing 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
124
Ratings of policy-relevant stategies and
interventions ALTERING DRINKING CONTEXT
Strategy Effective-ness Breadth of research support Cross-cultural testing 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
125
Ratings of policy-relevant stategies and
interventions DRINKING-DRIVING
Strategy Effective-ness Breadth of research support Cross-cultural testing 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
126
Ratings of policy-relevant stategies and
interventions TREATMENT AND EARLY INTERVENTION
Strategy Effective-ness Breadth of research support Cross-cultural testing Cost to implement Target group
Brief intervention Moderate HR
Alcohol Problems Treatment High HD
Self-help Low HD
Mandatory treatment of repeat drinking drivers Moderate HD
127
Ratings of policy-relevant stategies and
interventions EDUCATION AND PERSUATION
Strategy Effective-ness Breadth of research support Cross-cultural testing Cost to implement 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
128
Ratings of policy-relevant stategies and
interventions REGULATING ALCOHOL PROMOTION
Strategy Effective-ness Breadth of research support Cross-cultural testing Cost to implement Target group
Advertising Bans Low GP
Advertising content controls 0 0 0 Moderate GP
129
Ratings of policy-relevant stategies and
interventions TAXATION AND PRICING
Strategy Effective-ness Breadth of research support Cross-cultural testing Cost to implement Target group
ALCOHOL TAXES LOW GP
130
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

131
The strong strategies

• Availability restrictions
• Taxation
• Enforcement
• Good research support
• Applicable in most countries
• Relatively inexpensive to implement and sustain

132
Essential Elements of Effective Prevention of
Alcohol Problems
Policies and Laws
Enforcement
Prevention
Public Support
133
Implementing Alcohol Control Strategies in Brazil

• Strengthen alcohol surveillance systems
• Epidemiologic surveys household, school,
  roadside, emergency room, special events, alcohol
  sales and service practices, industry marketing,
  etc.
• Increase expertise in behavioral health research
  methods and analysis.
• Create and staff a Brazilian alcohol research
  center and develop an integrative and
  multi-disciplinary research strategy.

134
Alcohol is a drug which is

• Mind altering
• Tolerance producing
• Addictive
• These basic facts are not changed by alcohol
  industry advertising.

135
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 Survey
• Anthony, Warner, and Kessler

136
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
137
Global Market Alcohol Spirits Sales Exceed 2
Billion Cases Annually
138
Product Categories Alcohol Spirits
Product Category
Case Volume
Baijiu
725
million cases
Vodka
400
Whisky
205
Cachaca
200
Rum
115
Brandy
82
Shochu
70
Soju
70
Liqueurs
51
Source
Mark Brown, President
Sazerac Company, Inc.
March 4, 2003
139
U.S. Economic Costs of ATOD Use, 1995 Total Costs
415 Billion
Sources Harwood, Fountain, Livermore, NIDA
NIAAA, 1998 Rice (unpublished) Institute for
Health and Aging, UCSF, 1995
140
Most U.S. adults do not drink or drink
infrequently.
Frequency of Drinking Among U.S. Adults 21 and
Older, 2002 (past 30 days)
Number of Drinking Days
Source NSDUH, 2002
141
Most U.S. adults do not drink at a hazardous
level.
Drinking Patterns among U.S. Adults 21 and Older,
2002(past 30 days)
Source NSDUH, 2002
142
Binge drinkers are 23 of the population, but
consume 76 of the alcohol.
U.S. Binge Drinkers, 2002
Source NSDUH, 2002
143
Most young people do not drink.
Drinking Among Youth, 2002 (past 30 days)
15- to 17-year-olds
10
Drinking occasions
18
0
1 to 4
5 or more
72
Among the 28 of 15-17 year olds who drink, 65
drank heavily at least once in the past month.
Source NSDUH, 2002
144
Strategy Options

1. Personal change strategies change people
2. Alcohol control strategies control alcohol
   availability

145
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

146
Research Evidence of EffectivenessPersonal
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.

147
Alcohol Control Strategies Essential Components

• changes in social norms
• policy interventions
• deterrence and enforcement

148
Alcohol Control StrategiesThe 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.

149
Alcohol Control Strategies Effective Public
Health Education Strategiesfor 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.

150
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?

151
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

152
Percent of U.S. Population (18 years of age)
favoring alcohol policies designed to reduce
alcohol problems among youth
Proposed Policy Favor Strongly Favor Somewhat Oppose Somewhat Oppose 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
153
Percent of U.S. Population (18 years of age)
favoring restrictions on drinking in public
locations
Public location Ban drinking By permit only No 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
154
Impact of enforcement on alcohol-related traffic
fatalities
Percentage traffic fatalities related to
alcohol(1977-1999)
155
Essential Elements of Effective Prevention of
Alcohol Problems
Policies and Laws
Enforcement
Prevention
Public Support
156
Implementing Alcohol Control Strategies in Brazil

• Strengthen alcohol surveillance systems
• Epidemiologic surveys household, school,
  roadside, emergency room, special events, alcohol
  sales and service practices, industry marketing,
  etc.
• Increase expertise in behavioral health research
  methods and analysis.
• Create and staff a Brazilian alcohol research
  center and develop an integrative and
  multi-disciplinary research strategy.

157
Every Ounce of Alcohol Sold in the United States
Generates 2.25 in Public Sector Costs
Alcohol Problem
Cost per Ounce

• Alcohol Related Violence 1.00
• Drinking Driving Problems .85
• Other Costs .40
• 2.25

Total Societal Costs, including Public Sector
Costs 6.00/ounce
Source Ted Miller, Ph.D. PIRE
158
Societal Costs Alcohol Sales
Beer Six Pack 7.30 19.45 Wine Fifth
Bottle 7.50 20.00 Spirits Fifth
Bottle 23.00 61.45

• Source Ted Miller, Ph.D.
• PIRE

159
Challenges Confronting the Community Prevention
Coordinator

• Provide translation services between
• Researchers
• Public health professionals
• Community organizers
• Policy makers
• Alcohol industry
• Alcohol law enforcement
• Provide honest broker services for each of the
  above groups.
• Keep a low profile!

160
Implementing Alcohol Control Strategies

• Establish a Brazilian technical assistance center
  for implementation of alcohol control strategies
• Organize services by problems, not by control
  policies (violence, youth drinking, traffic
  safety, noise and neighborhood disruption, etc.).
• Local communities are the first priority for
  services.
• Develop and implement a public health education
  strategy to change social norms.
• Respond quickly to unscheduled opportunities.

161
Implementing Alcohol Control Strategies

• Increase enforcement of existing alcohol control
  policies.
• Public health and law enforcement are not
  traditional allies build relationships!
• Support creation of law enforcement units which
  specialize in enforcement of alcohol laws.
• Document, and then acknowledge publicly, the
  results of alcohol law enforcement.

162
Community Prevention Case Studies

• Paulinia alcohol price controls
• Price/Enforcement
• Salinas alcohol control at special events
• Place/Social Norms
• Salinas reducing alcohol outlet density
• Place
• Diadema limiting alcohol sales
• Place, Social Norms, Enforcement

163
Case StudiesAlcohol Prevention Research in
BrazilPresentation Outline

1. 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?

164
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

165
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

166
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

167
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