Alcohol in Development and Alcohol in Development and in Health and Social Policyin Health and Social Policy

David Jernigan PhDDavid Jernigan PhDCenter on Alcohol Marketing and YouthCenter on Alcohol Marketing and Youth

Georgetown UniversityGeorgetown UniversityWashington, D.C.Washington, D.C.

dhj@georgetown.edudhj@georgetown.edu

Robin Room PhDRobin Room PhDCenter for Social Research on Alcohol and DrugsCenter for Social Research on Alcohol and Drugs

University of StockholmUniversity of StockholmStockholm, SwedenStockholm, Sweden

JJürgen ürgen T. Rehm PhDT. Rehm PhDAddiction Research InstituteAddiction Research Institute

Zurich, SwitzerlandZurich, Switzerland

Presentation OverviewPresentation Overview

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

Alcohol’s role in the global burden of diseaseAlcohol’s role in the global burden of disease Alcohol and social harmsAlcohol and social harms

Relationship between alcohol production, Relationship between alcohol production, consumption, benefits and problemsconsumption, benefits and problems

Monitoring alcohol problemsMonitoring alcohol problems Preventing and reducing alcohol Preventing and reducing alcohol

problemsproblems

WHO’s Comparative Risk WHO’s Comparative Risk Assessment Collaborating GroupAssessment Collaborating Group

27 groups:27 groups:• Core, metholodology, etc. groupCore, metholodology, etc. group• 26 risk factor groups26 risk factor groups

Alcohol group:Alcohol group:• J Rehm, R Room, M Monteiro, G Gmel, K J Rehm, R Room, M Monteiro, G Gmel, K

Graham, N Rehn, C T Sempos, U Frick, D Graham, N Rehn, C T Sempos, U Frick, D Jernigan Jernigan

WHO’s Comparative Risk WHO’s Comparative Risk Assessment (CRA)Assessment (CRA)

Childhood and maternal undernutritionChildhood and maternal undernutrition: underweight, iron : underweight, iron deficiency, vitamin A deficiency, zinc deficiency; deficiency, vitamin A deficiency, zinc deficiency;

Other diet-related risks and physical inactivityOther diet-related risks and physical inactivity: blood : blood pressure, cholesterol, overweight, low fruit and vegetable pressure, cholesterol, overweight, low fruit and vegetable intake, physical inactivity;intake, physical inactivity;

Sexual and reproductive health risksSexual and reproductive health risks: unsafe sex, lack of : unsafe sex, lack of contraception;contraception;

Addictive substance useAddictive substance use: tobacco, alcohol, illicit drugs;: tobacco, alcohol, illicit drugs; Environmental risksEnvironmental risks: unsafe water, sanitation and hygiene, : unsafe water, sanitation and hygiene,

urban air pollution, indoor smoke from solid fuels, lead urban air pollution, indoor smoke from solid fuels, lead exposure, climate change;exposure, climate change;

Occupational risksOccupational risks: risk factors for injury, carcinogens, : risk factors for injury, carcinogens, airborne particulates, ergonomic stressors, noise;airborne particulates, ergonomic stressors, noise;

Other selected risks to healthOther selected risks to health: unsafe health care injections, : unsafe health care injections, childhood sexual abuse. 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 dataPrevalence data

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

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

Survey Survey andand adult per capita adult per capita consumption data for more than 50% consumption data for more than 50% of countriesof 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

Patterns of drinking Patterns of drinking

Countries assigned hazardous Countries assigned hazardous drinking scores, a numeric indicator drinking scores, a numeric indicator of hazard per litre of alcohol of hazard per litre of alcohol consumedconsumed

Information drawn from research Information drawn from research literature supplemented by key literature supplemented by key informant questionnaires informant questionnaires

Applied to two areas: injuries and Applied to two areas: injuries and CHD.CHD.

Dimensions of patterns of drinkingDimensions 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)

Patterns of drinking

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

conditionsconditions

*AAF = 1 by definition

Estimating AAFsEstimating AAFs

1.1. Alcohol-specific categoriesAlcohol-specific categories

2.2. Chronic health conditionsChronic health conditions

3.3. CHDCHD

4.4. DepressionDepression

5.5. InjuriesInjuries

Alcohol-related disordersAlcohol-related disorders Chronic disease:Chronic disease:

• Conditions arising during perinatal period*:Conditions arising during perinatal period*: low birth low birth weightweight

• Cancer*: Cancer*: lip & oropharyngeal cancer, esophageal cancer, lip & oropharyngeal cancer, esophageal cancer, liver cancer, laryngeal cancer, female breast cancerliver cancer, laryngeal cancer, female breast cancer

• Neuropsychiatric diseases: Neuropsychiatric diseases: alcohol use disorders, alcohol use disorders, unipolar major depression, epilepsyunipolar major depression, epilepsy

• Diabetes*Diabetes*• Cardiovascular diseases: Cardiovascular diseases: hypertension, coronary heart hypertension, coronary heart

disease, strokedisease, stroke• Gastrointestinal diseases*:Gastrointestinal diseases*: liver cirrhosis liver cirrhosis

Injury:Injury:• Unintentional injury: Unintentional injury: motor vehicle accidents, motor vehicle accidents,

drownings, falls, poisonings, other unintentional injuriesdrownings, falls, poisonings, other unintentional injuries• Intentional injuryIntentional injury:: self-inflicted injuries, homicide, other self-inflicted injuries, homicide, other

intentional injuriesintentional injuries* AAF based on volume of drinking only * AAF based on volume of drinking only

Estimating AAFs: Estimating AAFs: 5. Alcohol-attributable depression5. Alcohol-attributable depression

Started with estimated rates of alcohol dependence in Started with estimated rates of alcohol dependence in each region (derived from pooled psychiatric each region (derived from pooled psychiatric epidemiological studies)epidemiological studies)

Used some of same studies to derive proportion of cases Used some of same studies to derive proportion of cases with both depression and alcohol problems where alcohol with both depression and alcohol problems where alcohol onset was prior to onset of depressiononset was prior to onset of depression

Regressed these proportions on rates of alcohol Regressed these proportions on rates of alcohol dependence to establish upper-limit estimatesdependence to establish upper-limit estimates

To eliminate effect of co-occurrences due to chance, rate To eliminate effect of co-occurrences due to chance, rate of alcohol use disorders then subtracted from these of alcohol use disorders then subtracted from these estimatesestimates

Finally, halved AAFs to account for lack of control of Finally, halved AAFs to account for lack of control of confoundersconfounders

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

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

Disease conditions Males Females Total% of all alcohol-

attributable DALYs

Conditions arising during the perinatal period

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%

Other non-communicable diseases (diabetes, liver cirrhosis)

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

  World High mortality developing countries

Low mortality developing countries

Developed countries

  DALYs(millions)

% 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

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

Developing countriesDeveloping countriesDeveloped countriesDeveloped countries

High mortalityHigh mortality Low mortalityLow mortality

UnderweightUnderweight 14.9%14.9% AlcoholAlcohol 6.2 %6.2 % TobaccoTobacco 12.2 %12.2 %

Unsafe sexUnsafe sex 10.2 %10.2 % Blood pressureBlood pressure 5.0 %5.0 % Blood pressureBlood pressure 10.9 %10.9 %

Unsafe water & Unsafe water & sanitationsanitation 5.5 %5.5 % TobaccoTobacco 4.0 %4.0 % AlcoholAlcohol 9.2 %9.2 %

Indoor smoke (solid Indoor smoke (solid fuels)fuels) 3.6 %3.6 % UnderweightUnderweight 3.1 %3.1 % CholesterolCholesterol 7.6 %7.6 %

Zinc deficiencyZinc deficiency 3.2 %3.2 % Body mass indexBody mass index 2.7 %2.7 % Body mass indexBody mass index 7.4 %7.4 %

Iron deficiencyIron deficiency 3.1 %3.1 % CholesterolCholesterol 2.1 %2.1 % Low fruit & vegetable Low fruit & vegetable intakeintake 3.9 %3.9 %

Vitamin A deficiencyVitamin A deficiency 3.0 %3.0 % Low fruit & vegetable intakeLow fruit & vegetable intake 1.9 %1.9 % Physical inactivityPhysical inactivity 3.3 %3.3 %

Blood pressureBlood pressure 2.5 %2.5 % Indoor smoke from solid Indoor smoke from solid fuelsfuels 1.9 %1.9 % Illicit drugsIllicit drugs 1.8 %1.8 %

TobaccoTobacco 2.0 %2.0 % Iron deficiencyIron deficiency 1.8 %1.8 % Unsafe sexUnsafe sex 0.8 %0.8 %

CholesterolCholesterol 1.9 %1.9 % Unsafe water & sanitationUnsafe water & sanitation 1.8 %1.8 % Iron deficiencyIron deficiency 0.7 %0.7 %

Alcohol-related social harmsAlcohol-related social harms

Child abuse – 8.6%-63%Child abuse – 8.6%-63% Domestic violence – 26%-76%Domestic violence – 26%-76% Family budget – 1%-11% overallFamily budget – 1%-11% overall

• Greater for families with frequent drinkersGreater for families with frequent drinkers E.g. Delhi – 24% of budgets of families with frequent E.g. Delhi – 24% of budgets of families with frequent

drinkersdrinkers

Problems for youth:Problems for youth:• Criminal behaviorCriminal behavior• Failure to achieve educational qualificationsFailure to achieve educational qualifications

Measuring social harmsMeasuring social harms

1.1. Cost of illness studiesCost of illness studies E.g. Scotland:E.g. Scotland:

Health care costs $139 millionHealth care costs $139 million Social work costsSocial work costs $125 million$125 million Criminal justice and fire costs $390 millionCriminal justice and fire costs $390 million

2.2. Service system utilization by “problem drinkers”Service system utilization by “problem drinkers” California urban/suburban/rural countyCalifornia urban/suburban/rural county

41% in criminal justice system41% in criminal justice system 8% in social welfare system8% in social welfare system 42% in general health care system42% in general health care system 3% in public mental health system3% in public mental health system 6% in public alcohol or drug treatment system6% in public alcohol or drug treatment system

3.3. Survey researchSurvey research Canada – harms from someone else’s drinkingCanada – harms from someone else’s drinking

7.2% pushed, hit or assaulted7.2% pushed, hit or assaulted 6.2% friendships harmed6.2% friendships harmed 7.7% family or marriage difficulties7.7% family or marriage difficulties

Trends in alcohol consumptionTrends 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 Relationship between alcohol production and consumptionproduction and consumption

Alcohol production and consumptionAlcohol production and consumption• Most alcohol consumed near point of Most alcohol consumed near point of

productionproduction 8% of recorded alcohol production enters 8% of recorded alcohol production enters

into international tradeinto international trade

• Consumption tends to be concentrated Consumption tends to be concentrated in minority of population, e.g.in minority of population, e.g.

USA: 10% drinks 61% of the alcoholUSA: 10% drinks 61% of the alcohol New Zealand: 5% drinks 1/3 of the alcoholNew Zealand: 5% drinks 1/3 of the alcohol

Relationship between alcohol Relationship between alcohol consumption and alcohol problemsconsumption and alcohol problems

Alcohol problems arise from:Alcohol problems arise from:• Intoxication occasionsIntoxication occasions• Repeated episodes of intoxicationRepeated episodes of intoxication• Steady heavy drinkingSteady heavy drinking

Protective effect from consistent moderate Protective effect from consistent moderate drinkingdrinking• This pattern rare in developed countries, even This pattern rare in developed countries, even

less common in developing societiesless common in developing societies Bottom line: level of alcohol problems in a Bottom line: level of alcohol problems in a

society will tend to rise with level of society will tend to rise with level of alcohol consumptionalcohol consumption

Social and health benefits of Social and health benefits of drinkingdrinking

Social benefits of drinking largely Social benefits of drinking largely unquantifiableunquantifiable• Alcohol’s role as integrative, bonding or socially Alcohol’s role as integrative, bonding or socially

lubricative substancelubricative substance Health benefits of alcoholHealth benefits of alcohol

• Protective effect for CHD evident at individual Protective effect for CHD evident at individual level at as low as one drink every other daylevel at as low as one drink every other day

• Protection not found at the aggregate levelProtection not found at the aggregate level Could be some drinkers shift to more heart-healthy Could be some drinkers shift to more heart-healthy

pattern, as others change to more dangerous patternspattern, as others change to more dangerous patterns

• Leads to conclusion that there are no net Leads to conclusion that there are no net benefits at the population level from any policy benefits at the population level from any policy that seeks to increase alcohol consumptionthat seeks to increase alcohol consumption

Alcohol and developmentAlcohol and development

Alcohol consumption tends to rise with Alcohol consumption tends to rise with economic development, absent mitigating economic development, absent mitigating factors (e.g. religion)factors (e.g. religion)

Four modes of production of alcohol:Four modes of production of alcohol:• Traditional/indigenousTraditional/indigenous• Industrialized traditional/indigenousIndustrialized traditional/indigenous• Industrialized cosmopolitanIndustrialized cosmopolitan• Globalized cosmopolitanGlobalized cosmopolitan

Trend is towards the latter, particularly in Trend is towards the latter, particularly in distilled spirits and beerdistilled spirits and beer

Alcohol and development: benefits?Alcohol and development: benefits?

Employment and income generationEmployment and income generation• Direct employment declines with Direct employment declines with

industrializationindustrialization• Indirect employment may increase in Indirect employment may increase in

wholesaling and distribution, but less likely in wholesaling and distribution, but less likely in retail sectorretail sector

Government revenue – justifiable for: Government revenue – justifiable for: • Economic efficiency – correct for negative Economic efficiency – correct for negative

externalitiesexternalities• Public health – reduce consumptionPublic health – reduce consumption• Revenue raising – as high as 24% of some Revenue raising – as high as 24% of some

state revenuesstate revenues

Alcohol and development: benefits?Alcohol and development: benefits?

Quality improvementQuality improvement• Industrialization leads to greater uniformity Industrialization leads to greater uniformity

and reliability of productand reliability of product Sourcing of inputs and balance of payment Sourcing of inputs and balance of payment

issuesissues• Import substitution constrained by size of Import substitution constrained by size of

domestic market – also may require import of domestic market – also may require import of inputs as opposed to finished productinputs as opposed to finished product

• Alcohol unlikely to make much contribution to Alcohol unlikely to make much contribution to exportsexports

Alcohol and development: benefits?Alcohol and development: benefits?

MNCs and technology transferMNCs and technology transfer• ““Turnkey” technologies increasingTurnkey” technologies increasing• Design, R&D and engineering expertise Design, R&D and engineering expertise

remains in headquarters countriesremains in headquarters countries Encouragement of packaging and Encouragement of packaging and

distribution networksdistribution networks Early form of foreign direct investmentEarly form of foreign direct investment

• If increased alcohol supply will not worsen If increased alcohol supply will not worsen public health and safety situation regarding public health and safety situation regarding alcoholalcohol

Preventive interventions: Preventive interventions: individual-basedindividual-based

Education and persuasionEducation and persuasion• Little evidence of effectiveness of school-based Little evidence of effectiveness of school-based

programs beyond the short-termprograms beyond the short-term• Media campaigns unlikely to change behavior, Media campaigns unlikely to change behavior,

but may increase support for more effective but may increase support for more effective policiespolicies

DeterrenceDeterrence• Effective in reducing drinking-drivingEffective in reducing drinking-driving• Speed and certainty of punishment crucial to Speed and certainty of punishment crucial to

effectivenesseffectiveness

Preventive interventions: Preventive interventions: individual-basedindividual-based

Encouraging alternativesEncouraging alternatives• Little evidence of effectiveness of lasting Little evidence of effectiveness of lasting

effectseffects• Too many alternatives go well with alcohol, Too many alternatives go well with alcohol,

e.g. soft drinkse.g. soft drinks• Do contribute to improving quality of life for Do contribute to improving quality of life for

disadvantaged populationsdisadvantaged populations Treatment and mutual helpTreatment and mutual help

• Part of a humane societal responsePart of a humane societal response• Brief interventions, self-help effective and Brief interventions, self-help effective and

result in net savings in social and health costsresult in net savings in social and health costs• Treatment alone is not a cost-effective means Treatment alone is not a cost-effective means

of reducing alcohol-related problemsof reducing alcohol-related problems

Preventive interventions: Preventive interventions: environmentally-basedenvironmentally-based

Insulating use from harmInsulating use from harm• Server and manager training can reduce Server and manager training can reduce

drinking-driving, violencedrinking-driving, violence• Provision of public transport, relocation Provision of public transport, relocation

of drinking places away from residences of drinking places away from residences can also be effectivecan also be effective

• General protections, e.g. airbags, General protections, e.g. airbags, sidewalks, are effectivesidewalks, are effective

• ““Designated driver” programs lack Designated driver” programs lack evidence of effectivenessevidence of effectiveness

Preventive interventions: Preventive interventions: environmentally-basedenvironmentally-based

Regulating availability, conditions of Regulating availability, conditions of useuse• ProhibitionsProhibitions

Difficult to enforceDifficult to enforce

• Minimum-age drinking laws (partial Minimum-age drinking laws (partial prohibition)prohibition)

Effective if enforcedEffective if enforced

• Taxation and other price increasesTaxation and other price increases Demand for alcohol generally inelasticDemand for alcohol generally inelastic Can be effective if market is under controlCan be effective if market is under control

Preventive interventions: Preventive interventions: environmentally-basedenvironmentally-based

Regulating availability, conditions of useRegulating availability, conditions of use• Limiting sales outlets, hours and conditions of Limiting sales outlets, hours and conditions of

salesale Research literature shows effectiveness of measures Research literature shows effectiveness of measures

making alcohol purchase less convenientmaking alcohol purchase less convenient• Monopolies on production or saleMonopolies on production or sale

Retail monopolies have greater public health effectsRetail monopolies have greater public health effects Production monopolies assist in control of marketProduction monopolies assist in control of market

• Production restrictionsProduction restrictions Can be effective but difficult to enforceCan be effective but difficult to enforce

• Limits on advertising and promotionLimits on advertising and promotion Some evidence bans are effectiveSome evidence bans are effective ““Unmeasured” activities increasing, and difficult to Unmeasured” activities increasing, and difficult to

regulateregulate

Other policy concernsOther policy concerns

Social and religious movements, civil Social and religious movements, civil society and NGOs can be keysociety and NGOs can be key

Alcohol policy needs to be societal, Alcohol policy needs to be societal, integrated and consistentintegrated and consistent

International trade agreements need International trade agreements need to make exception for alcohol as “no to make exception for alcohol as “no ordinary commodity”ordinary commodity”

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

• frequency of getting drunk or drinking >60 grams of frequency of getting drunk or drinking >60 grams of ethanol (5+ drinks), ethanol (5+ drinks),

• usual quantity per drinking session, usual quantity per drinking session, • fiesta drinking, fiesta drinking, • drinking in public places, drinking in public places, • not drinking with meals, and not drinking dailynot drinking with meals, and not drinking daily• frequencies and percentages of all alcohol drunk on frequencies and percentages of all alcohol drunk on

>40g. days for men and >20g. days for women>40g. days for men and >20g. days for women Youth useYouth use

Monitoring alcohol problemsMonitoring alcohol problems alcohol-involved traffic crashes/injuries alcohol-involved traffic crashes/injuries alcohol-involved crimesalcohol-involved crimes hospitalizations and deaths from strongly alcohol-hospitalizations and deaths from strongly alcohol-

involved causes: involved causes: • liver disease (if rates of hepatitis B and C are low), liver disease (if rates of hepatitis B and C are low), • alcohol-specific causes such as alcoholic liver disease, alcohol-specific causes such as alcoholic liver disease,

alcohol dependence, and alcoholic psychosis alcohol dependence, and alcoholic psychosis other alcohol-related problems: other alcohol-related problems:

• problems with family, friendships, work, police, financial, problems with family, friendships, work, police, financial, health, alcohol dependence health, alcohol dependence

problems from others’ drinking:problems from others’ drinking:• family, friendships, work, injury, property loss, public family, friendships, work, injury, property loss, public

nuisancenuisance

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!!!