53650 Alcohol at a glance on alcohol, compared to 2% in other families. Surveys among the Why is reducing alcohol-related urban poor in Sri Lanka found that 30% of families used alcohol problems a priority? and spent more than 30% of their income on it. Alcohol abuse is one of the leading causes of death and disability Alcohol and youth. Alcohol is of particular risk to adolescents and worldwide. Alcohol abuse is responsible for 4 percent of global young adults: in Latin America and Eastern Europe respectively, deaths and disability, nearly as much as tobacco and five times 36% and 41% of deaths among 15-29 year olds were due to the burden of illicit drugs (WHO). In developing countries with low alcohol use. Effective policies and prevention for youth have mortality, alcohol is the leading risk factor for males, causing immediate payoffs, in addition to longer-term effects from 9.8% of years lost to death and disability. Alcohol abuse forestalling development of alcohol dependence or alcohol-related contributes to a wide range of social and health problems, chronic diseases. including depression, injuries, cancer, cirrhosis, dependence, family disruption and loss of work productivity. Health and social Approaches to reducing alcohol abuse problems from drinking often affect others besides the drinker. While men do the bulk of the drinking worldwide, women The most effective approach to reduce alcohol-related problems is disproportionately suffer the consequences, including alcohol- to implement a comprehensive set of measures to reduce alcohol related domestic violence and reduced family budgets. Heavy consumption and related problems. Policy options include price alcohol use takes a particular toll on the young, and has been increases, restrictions on availability ( i.e. limits on the times and linked to high rates of youthful criminal behavior, injury, and conditions of alcoholic beverage sales or service, minimum-age impaired ability to achieve educational qualifications. Many limits), strong drink-driving legislation and ready access to deaths and much disease and suffering could be prevented by treatment. Some countries have succeeded in reducing per capita reducing alcohol use and related problems. consumption substantially, and consequently have reduced liver cirrhosis deaths, a common indicator of alcohol-related problems Alcohol-related harm. The level of harm from alcohol is related to in a society. Efforts to reduce alcohol consumption and related the pattern, including level, of drinking in a country. Time series problems face formidable obstacles: alcohol dependence; social analyses in western Europe find that overall mortality rises by pressures; aggressive alcohol marketing and promotion; other 1.3% for every extra liter of pure alcohol consumed per capita. pressing health problems competing for limited resources. But But for Russia, where intoxication and hazardous drinking are more prominent, the corresponding figure is 2.7%. Patterns and levels of alcohol consumption, alcohol dependency and alcohol Global distribution of burden of disease abuse are determined by many factors: availability, income per attributable to 20 leading selected risk factors Underweight capita, retail process, individual factors (genetic and Unsafe sex environmental) such as age of first use, family history, education, High blood pressure Tobacco peer group pressure, psychosocial factors, cultural and historical Alcohol Unsafe water, S&H context, and government policies, such as taxation and restrictions High cholesterol Indoor smoke from solid fuels on advertisement and promotion. Iron deficiency High BMI Zinc deficiency Developing high mortality Alcohol and poverty. Alcohol-related mortality is often highest Low fruit and vegetables Developing lower mortality Vitamin A deficiency Developed among the poorest people in a society (Mäkelä, 1999a). Alcohol Physical inactivity Occupational injury risks is often a significant part of family expenditure: Romanians spent Lead exposure Illicit drugs an average of 11% of family income on alcohol in 1991, Unsafe health care injections Lack of contraception Zimbabwean households averaged 7%. However, national Childhood sexual abuse averages conceal the impact on families of drinkers: families with 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% Attributable DALYs (% total 1.44 billion) frequent-drinking husbands in Delhi spent 24% of family income Source: World Health Report 2002 November 2003 Effective Interventions to reduce death, disease, disability and social problems related to alcohol abuse Objective: Reduce death, disease, disability, and social problems caused by alcohol abuse. INTERVENTIONS BENEFICIARIES/TARGET GROUP PROCESS INDICATORS Higher taxes on alcoholic beverages drinkers (heavier drinkers particularly affected) price of alcoholic beverages potential drinkers (especially youth) (adjust for inflation) tax as % of final sales price Non-price measures Deterrence through sanctions on drinkers, traffic crash victims drinking-driving laws, regulations, drinking-driving, such as laws against driving extent to which respected/enforced while at or above a defined blood-alcohol level Regulating availability through minimum youth (minimum legal purchase age) laws, regulations, extent to which legal purchase age; government monopoly respected/enforced of retail sales; restrictions on hours or days drinkers (heavier drinkers often of sale, density of outlets, or availability particularly affected) level of government control of market by alcoholic strength (i.e. lack of smuggling, illegal production and/or sale, etc.) number and trends in number of outlets Harm reduction via greater implementation general public laws, regulations, extent to which of general safety measures such as seatbelts, bar/tavern staff and drinkers respected/enforced airbags, sidewalks, as well as bar/tavern incentives for server and manager server and manager training training programs Comprehensive bans on advertising and drinkers and potential drinkers (especially youth) laws, regulations, extent to which promotion of all alcoholic beverages, their societal attitudes to drinking respected/enforced logos and brand names1. Better consumer information: drinkers and potential drinkers knowledge of health risks, attitudes counter-advertising, media coverage, societal attitudes to drinking towards drinking research findings Help for heavy drinkers who wish to quit heavier and problematic drinkers number of persons in treatment, or reduce their drinking, including access to treatment waiting lists treatment for alcohol dependence, whether professional or voluntary (e.g. Alcoholics Anonymous) Impact / surveillance Indicators for alcohol use and problems (from survey data except as indicated): Per capita alcohol consumption: average consumption of alcohol by persons 15 and older (from production, sales and/or taxation statistics, with survey data on unrecorded consumption as needed), as well as per capita consumption of higher risk drinks, e.g. very cheap or high strength categories, proportion of beer sold >3.5%, or other local high risk drink Number of abstainers: percentage of male and female adult population who do not drink 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; frequency of days when consumption exceeds 40g for men and 20g for women; percentage of country's total alcohol consumption that is above 40g for men and 20g for women. youth use: % at age 12, at age 15, at age 18 who currently drink any alcoholic beverage (defined as having drunk any alcoholic beverage on one or more days in a set period); similarly, % who drink 60+ grams of ethanol on a single occasion in the period; frequency of drinking 60+ grams alcohol-involved traffic crashes/injuries: (police or health statistics) alcohol-involved crimes: (police statistics) 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, acute intoxication and alcoholic psychosis (mortality and hospitalization statistics) other alcohol-related problems: problems with family, friendships, work, police, financial, health, alcohol dependence (as reported by the drinker in population surveys) problems from others' drinking: family, friendships, work, injury, property loss, public nuisance (as reported in population surveys) 1. If full bans are impossible, strong restrictions and significant counter-advertising should be pursued. there are many good practices that can be replicated with political What about the health benefits from alcohol use? A protective will, and broad support. effect for coronary heart disease (CHD) from moderate alcohol consumption has been documented in men over forty. The data on Global action. The overall trend is towards stricter laws and whether a similar effect exists for women remain contradictory. In increased enforcement in some areas such as drinking-driving. younger age groups, alcohol consumption at all levels increases Provision of treatment for drinking problems has increased in mortality, and the net effect of alcohol at population level is many places in recent decades. But national and local alcohol negative in all regions. controls have been undercut by a tendency at the global level to treat alcohol as an ordinary commodity, and to weaken or Are some alcohol beverages more harmful than others? The eliminate effective controls in the interests of liberalizing markets pattern of drinking is more important than the type of beverage. and trade. Trade agreements, structural adjustment programs, and There is little basis for treating various types of alcoholic GATT/WTO dispute settlements usually fail to recognize alcohol's beverages differently with respect to trade, control or investment special status as a commodity which adversely affects health. In decisions. The consequences of alcohol use are similar, regardless this context, actions like the World Bank Group's decision in 2000 of the type of alcoholic beverage. The predominant beverage of to take "public health issues and social policy concerns" into young adult males in a society (e.g. beer in the US) usually has account in considering investments in alcoholic beverage the strongest relation to alcohol problems. production are important first steps. (See World Bank Group Note Should alcohol be treated like other commodities? No. Alcohol on Alcohol Beverages).There is a need for strengthened global should be classified as a special substance because of its action and commitment to reduce alcohol abuse and address the dependency producing properties and severity of associated related health and social effects. problems (WHO). Regional action. Regional commitment to reducing alcohol abuse has been evident, for instance during the 1990s in Europe, where What works? the World Health Organization European Regional Office led 53 A comprehensive set of policy options, including: European nations in adopting aggressive goals for reducing alcohol use and problems. As a result, many countries in that I Drinking-driving countermeasures have proven effective in a region have strengthened alcohol policies and interventions. wide range of countries and cultures; especially "per se laws" However, elsewhere in the world, efforts at alcohol control lag far that set maximum levels for blood alcohol concentrations for behind alcohol's significance as a risk factor in poverty and drivers, with random breath-testing and clear and immediate health. sanctions such as loss of driving privileges, and/or fines. National action. Alcohol control efforts are often dispersed among I Regulation and enforcement are key. Unless measures are Ministries, including Health, Social Welfare, Education, Traffic, enforced, they will have little impact. Public education helps Justice, Finance, Agriculture, Labor and Industry, Trade, and even build a social normative consensus that increases compliance Tourism and Culture and Sports, without effective coordination. and supports strong enforcement. The magnitude of artisanal Furthermore, much of the responsibility for alcohol control is often production and smuggled beverages is often underestimated provincial/regional or local, and coordination between levels of and has to be considered in regulatory actions to limit access. government is also often an issue. Religious and women's Countries need a strong regulatory framework governing organizations, physician associations and other public health alcohol availability. Many developing societies have minimal groups, NGOs, youth and other groups play key roles in some alcohol regulatory structures, leaving a large gap as traditional countries. Ministries of Finance and tax authorities are important systems of social control of drinking erode. because higher alcohol taxes are one of the most effective ways to I Price increases are among the most effective tools to reduce use, while in most cases increasing government revenue. reduce/deter use of alcohol by young people. Minimum age Other stakeholders include media, retailers, and sports groups drinking laws and restrictions on availability are also effective, (sponsorship). but may be costly to enforce. Q&A about alcohol: I Government monopolies of all or part of the retail or wholesale Does the level of alcohol consumption in populations matter? Yes. market have often been effective mechanisms for implementing The levels of alcohol-related problems tend to rise and fall with alcohol control measures. The usual disadvantages of changes in per capita alcohol consumption (Edwards et al., 1994; government monopolies are offset in the case of alcohol by Babor et al., 2003). many factors: (a) the limited number of sales outlets and restricted hours of opening common with such monopolies constrain alcohol consumption and problems; (b) a stable and I Brief outpatient interventions aimed at changing attitudes and professional staff help avoid sales to the under-aged and drinking behavior are as effective in most circumstances as already drunk; and (c) private profit motivations for expanding longer and more intensive treatment. Treatment for alcohol sales are absent. problems is an important part of an integrated national alcohol policy. Treatment can be effective for those who seek it. But for I Education and public information campaigns have not been the population as a whole, treatment is not a cost-effective found to be effective on their own in reducing alcohol use or means of reducing societal rates of alcohol problems. problems. These campaigns can build awareness of alcohol problems and support for effective policies and interventions, but are not cost-effective unless linked with proven interventions such as higher taxes, restrictions on availability, minimum-age limits, and drinking-driving counter-measures. World Health Organization. Reducing Risks, Promoting Healthy Resources Lives. World Health Report 2002. Geneva, WHO. (epidemiology People in the World Bank, IMF and WHO data) Mariam Claeson (mclaeson@worldbank.org) Joana Godinho Other References (Jgodinho@worldbank.org), Florence Baingana Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, (Fbaingana@worldbank.org) Graham K, Grube JW, Gruenewald PJ, Hill L, Holder H, Homel R, IMF fiscal department (Peter Heller and Emil Sunley): taxation Österberg E, Rehm J, Room R, Rossow I. Alcohol: No Ordinary related issues. Commodity. Oxford, OUP, 2003. WHO: Leanne Riley (rileyl@who.int) Ezzati, M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL and the Comparative Risk Assessment Collaborating Group. Key Documents and Data Selected major risk factors and global and regional burden of disease. Lancet, 360:1347-1360, 2002. Claeson et al. World Bank Group Note on Alcohol Beverages, 2000 http://www.miga.org/screens/policies/arp/arp.pdf Jernigan D. Alcohol and Young People. Geneva: WHO, 2001. http://www.stir.ac.uk/departments/humansciences/appsocsci/dru Pyne HH, Claeson M, Correia Gender Dimensions of Alcohol gs/alcyouth.pdf consumption and alcohol related problems in Latin America and the Caribbean. The World Bank, 2002. Jernigan D, Room R. "Alcohol in Development and in Health and Social Policy", World Bank Discussion Papers Series, 2003, World Health Organization. International guide for monitoring available at www.worldbank.org/hnp/publications alcohol consumption and related harm. Geneva, WHO, Department of Mental Health and Substance Dependence, Room R, Jernigan D, Carlini Cotrim B, Gureje O, Mäkelä K, WHO/MSD/MSB/00.4, 2000. Marshall M, Medina Mora ME, Monteiro M, Parry C, Partanen J, Riley L, Saxena S. Alcohol in developing societies: a public health World Health Organization. Global Status Report on Alcohol. approach. Helsinki and Geneva, Finnish Foundation for Alcohol Geneva, WHO, Substance Abuse Department, Studies and WHO, 2003. WHO/HSC/SAB/99.11, 1999. Web resources World Health Organization. Global Alcohol Database. Geneva, http://www.stir.ac.uk/departments/humansciences/appsocsci/dru available on the world-wide web at www.who.int/alcohol, gs/library.htm#recen database of country-level statistics on alcohol use, problems and policies. http://www.bks.no/biblio.htm Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp