NCD Seminar, Lausanne, Switzerland Public health policies and approaches for reducing the harmful use of alcohol V. Poznyak Coordinator, Management of Substance Abuse World Health Organization NCD Seminar, Lausanne, Switzerland 3 June 2014

Content "Harmful use of alcohol": definitions Alcohol consumption and alcohol-attributable burden of disease Alcohol consumption and major NCDs: risks and potential benefits Effective strategies to reduce the harmful use of alcohol Reaching the target of 10% reduction by 2025: what to measure?

Harmful use of alcohol: definitions Definition of "harmful use of alcohol" in ICD-10: "a pattern of alcohol use that is causing damage to health, and the damage may be physical (as in cases of liver cirrhosis) or mental (as in cases of depressive episodes secondary to heavy consumption of alcohol)" (ICD-10; WHO, 1992). Global strategy to reduce the harmful use of alcohol (WHO, 2010): " the concept of the harmful use of alcohol is broad and encompasses the drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society at large, as well as the patterns of drinking that are associated with increased risk of adverse health outcomes."

World Health Organization "Harmful use of alcohol" in the Global strategy to reduce the harmful use of alcohol 23 March 2018 Drinking that causes detrimental health and social consequences for the drinker ("harmful use") people around the drinker and society at large. Patterns of drinking that are associated with increased risk of adverse health outcomes ("hazardous use") Level and pattern of alcohol consumption Heavy episodic drinking

World Health Organization Prevention and treatment interventions for substance use and substance use disorders 23 March 2018 ABSTENTION & LOWER RISK SUBSTANCE USE HAZARDOUS AND HARMFUL USE DEPENDENCE Primary Prevention Brief Interventions Treatment

Several facts about alcohol consumption in the world in 2010 (WHO, 2014) Estimated ~2.6 billion people 15+ consumed alcoholic beverages in their life Estimated ~1.9 billion people 15+ consumed alcoholic beerages in the last 12 months on average 6.2 litres of pure alcohol per capita of adult (15+) population, including 1.5 litres (24.8%) of "unrecorded" alcohol 17.2 litres among drinkers (37.5 g/day, in different WHO regions 30-57 g per day among men and 10-29 g among women) Estimated ~ 48% of the world adult population has never consumed alcohol, ~ 62% - in the last 12 months.

Too big alcohol-attributable disease burden by any measure (WHO, 2009)

Alcohol-attributable disease burden in 1990 and 2010 for both sexes (Lim et al, Lancet, 2012; 380: 2224-60) 1990 2010

Several facts about global burden of disease attributable to alcohol in 2012 (WHO, 2014) 3.3 million deaths (5.9% of deaths in all age groups globally) are attributable to alcohol consumption 7.6% for men 4.0% for women 139 million DALYs lost or 5.1% of the global burden of disease expressed in DALYs is attributable to alcohol.

Global distribution of alcohol-attributable deaths by disease or injury (WHO, 2014)

Global distribution of alcohol-attributable DALYs by disease or injury (WHO, 2014)

Alcohol and noncommunicable diseases NCD priority conditions Cardiovascular diseases Ischaemic heart disease Ischaemic strokes Haemorrhagic and other strokes Cancers Chronic respiratory diseases Diabetes NCC according to the alcohol-attributable burden of disease Alcohol use disorders Cardiovascular diseases and diabetes Gastrointestinal diseases Cancers

All global deaths/DALYs Alcohol-attributable fractions for selected causes of death, disease and injury, 2012 (WHO, 2014) All global deaths/DALYs Liver cirrhosis 50/50 Oral cavity and pharynx cancers 30/31 Pancreatitis 25/27 Laryngeal cancer 23/24 Oesophageal cancer 22/23 Liver cancer 12/12 Haemorrhagic stroke 11/11 Colorectal cancer 10/10 Hypertensive heart disease 8/10 Breast cancer 8/8 Ischaemic heart disease 7/5

Dose-response relationship (RR) for alcohol and cardiovascular diseases (2) Hypertensive disease (Taylor et al, 2009) Men: 25 g/day: 1.25 (1.28-1.47), 50 g/day: 1.62 (1.46-1.81); Women: <5 g/day: 0.82 (0.73-0.93); 25 g/day: 1.24 (0.87-1.77), 50 g/day: 1.81 (1.13-2.90) Haemorrhagic and other non-ischaemic stroke (Reynolds et al, 2003): <12 g/day: 0.79 (0.60-1.05); 12-24 g/day: 0.98 (0.77-1.25); 24-60 g/day: 1.19 (0.80 -1.79); > 60 g/day: 2.18 (1.48-3.20).

Dose-response relationship between alcohol consumption and the risk of coronary heart disease (Corrao et al, Preventive Medicine, 2004, 38, 5, 613-619)

Dose-response relationship (RR) for alcohol and cardiovascular diseases (1) Ischaemic heart disease (Corrao et al, 2000) Men: 25 g/day – nadir: 0.75 (0.73-0.77); deleterious at 113 g/day: 1.08 (1.00-1.16) Heavy drinking occasions (> 60 g per occasion): 1.45 (1.24-1.70) compared no non-heavy drinking occasions (Roerecke et Rehm, 2010). Ischaemic stroke (Reynolds et al, 2003) <12 g/day: 0.80 (0.67-0.96); 12-24 g/day: 0.72 (0.57-0.91); 24-60 g/day: 0.96 (0.79-1.18); > 60 g/day: 1.69 (1.34-2.15); Hazardous patterns of drinking negate potential beneficial effects of low-risk alcohol consumption

Cardioprotective effect of moderate alcohol consumption disappears when, on average, light to moderate drinking is mixed with irregular heavy drinking occasions. Heavy drinking occasions: More than 60 g of pure alcohol per occasion at least monthly

Prevalence of heavy episodic drinking among current drinkers (%, 15+), 2010 (WHO, 2014)

Alcohol consumption and risk of ischaemic heart and cerebrovascular diseases Confounding remains a problem in research on alcohol and CVD with existing limitations for RCTs Alcohol is a substance that is: Psychoactive and dependence-producing Intoxicating Toxic with unfavorable profile of acute effects on nervous system (median lethal dose close to high dose consumption) Low risk patterns of drinking are not common, particularly in low and middle income countries

Dose-response relationship (RR) for alcohol and cancers Mouth, nasopharynx, other pharynx and oropharynx (Corrao et al, 2004) 25 g/day: 1.86 (1.76-1.96); 50 g/day: 3.11 (2.85-3.39) Oesophagus (Corrao et al, 2004) 25 g/day: 1.39 (1.36 -1.42); 50 g/day: 1.93 (1.85-2.00) (Corrao et al, 2004) Colon and rectum (Corrao et al, 2004) 25 g/day: 1.05 (1.01 -1.09); 50 g/day: 1.10 (1.03-1.18) Liver (Corrao et al, 2004) 25 g/day: 1.19 (1.12 -1.27); 50 g/day: 1.40 (1.25-1.56) Breast (female) (Hamajima et al, 2002) 35-44 g/day: 1.32 (1.19 -1.45); ≥45 g/day: 1.46 (1.33-1.61), RR increased by 7.1% for each extra 10 g of alcohol consumed on a daily basis

Dose-response relationship between alcohol consumption and the risk of female breast cancer (Hamajima et al, Br J Cancer 2002; 87: 1234-45)

IARC Monograph on the Evaluation of Carcinogenic Risks to Humans, Vol IARC Monograph on the Evaluation of Carcinogenic Risks to Humans, Vol. 100E (2012) There is sufficient evidence in humans for the carcinogenicity of alcohol consumption Alcohol consumption causes cancers of the oral cavity, pharynx, larynx, esophagus, colorectum, liver (hepatocellular carcinoma) and female breast. Also, an association has been observed between alcohol consumption and cancer of the pancreas. There is sufficient evidence in humans for the carcinogenicity of acetaldehyde associated with the consumption of alcoholic beverages.

Odds Ratios for Esophageal Cancer at Different Amounts of Alcohol Consumption in Relation to the Flushing Response (Brooks et al, 2009, PLoS Med 6(3): e1000050)

Dose-response relationship between alcohol consumption and the risk of diabetes mellitus (Baliunas et al, 2009; Rehm et al, 2010) Men: 22 g/day – nadir: 0.87 (0.76-1.00), deleterious at > 60 g/day: 1.01 (0.71-1.44); Women: 24 g/day – nadir: 0.60 (0.52-0.69), deleterious at > 50 g/day: 1.02 (0.83-1.26). However, glucose intolerance is frequent in alcohol use disorders, and alcohol is reported as the second leading cause of acute pancreatitis and important contributing causal factor to chronic pancreatitis.

Alcohol and lower respiratory infections Relative risk for pneumonia – 1.3 at alcohol consumption of 60 g/day 3-8 fold increase in risk of pneumonia in alcohol dependence

Communication of NCD-related risks It is impossible to predict the risks of initiation of drinking in persons who never used alcoholic beverages. No rationale whatsoever to recommend drinking alcohol as prevention intervention. Heavy episodic drinking (binge drinking) is detrimental to health irrespective of a disease or health condition under consideration Any recommendation on the levels of alcohol consumption should be based on assessment of individual risks, taking into consideration age, gender, health status and drinking history Reduction in levels of alcohol consumption and prevalence of heavy episodic drinking in populations will bring public health benefits.

Global strategy to reduce the harmful use of alcohol Developed through a long and intense collaboration between the WHO Secretariat and Member States. Incorporates, when relevant and appropriate, the outcomes of consultations with stakeholders, including the industry and NGOs. Represents a unique consensus among WHO 194 Member States on ways to tackle harmful use of alcohol at all levels.

What actions needed to reduce the harmful use of alcohol? Global, regional and national actions on: levels of alcohol consumption patterns of alcohol consumption contexts of alcohol consumption wider social determinants of health Special attention needs to be given to reducing harm to people other than the drinker and to populations that are at particular risk from harmful use of alcohol.

Recommended ten target areas for policy measures and interventions (WHO, 2010) Leadership, awareness and commitment Health services' response Community action Drink-driving policies and countermeasures Availability of alcohol Marketing of alcoholic beverages Pricing policies Reducing the negative consequences of drinking and alcohol intoxication Reducing the public health impact of illicit alcohol and informally produced alcohol Monitoring and surveillance

Effective prevention policy measures exist Regulating and restricting availability of alcoholic beverages; Reducing demand through taxation and pricing mechanisms; Regulating the marketing of alcoholic beverages (in particular to younger people); Enacting appropriate drink-driving policies; Raising awareness and support for effective policies. Implementing screening programmes and brief interventions for hazardous and harmful use of alcohol.

"Best buys" for tackling harmful use of alcohol (WHO, 2011) Risk factor   (DALYs, in millions; % global burden) a Interventions / actions ( * core set of 'best buys', others are 'good buys') Avoidable burden (DALYs averted, millions) Cost-effectiveness b ( US$ per DALY prevented) [Very = < GDP per person; Quite = < 3* GDP per person Less = >3* GDP per person] Implementation cost (US$ per capita) [Very low = < US$0.50; Quite low = < US$ 1 Higher = > US$ 1] Feasibility (health system constraints) Alcohol use (> 50m DALYs; 4.5% global burden) Restrict access to retailed alcohol * Combined effect: 5-10 m DALYs averted (10-20% alcohol burden) Very cost-effective Very low cost Highly feasible Enforce restrictions and bans on alcohol advertising* Raise taxes on alcohol * Enforce drink driving laws (breath-testing) Quite cost-effective Quite low cost Intersectoral action Offer counselling to drinkers Feasible in primary care

Policy options to reduce the harmful use of alcohol (WHO, 2010) (1) Awareness To be effective, education about alcohol needs to go beyond providing information about the risks … to promoting the availability of effective interventions and mobilizing public opinion and support for effective alcohol policies. Health services response Early identification and brief advice for persons with hazardous and harmful alcohol use. CBT and pharmacological therapies for alcohol dependence and related problems Consideration should also be given to integrated treatment for co-morbid conditions, such as for hypertension …, and to self-help groups.

Policy options to reduce the harmful use of alcohol (WHO, 2010) (2) Community action programmes Media advocacy Mobilizing public opinion to address local determinants of increased levels of harmful use of alcohol Drink-driving countermeasures Low BAC levels (0.02 and 0.05) Intensive random and selective breath testing Setting lower limits for BAC (including a zero level) for young or novice drivers Administrative suspension of the driver’s licence Mandatory counselling or treatment for alcohol-related conditions Use of an ignition interlock for repeat drink drivers.

Policy options to reduce the harmful use of alcohol (WHO, 2010) (3) Availability of alcohol Legal framework for reducing the physical availability of alcohol Restrictions on both the sale and serving of alcohol Minimum age for purchase of alcohol Licensing system for the sale of alcohol Reducing density of alcohol outlets Reducing the hours or days of sale of alcoholic beverages. Marketing of alcoholic beverages Regulatory frameworks (preferably with a legislative basis) Provision for third party review of complaints about violations Sanctions and the threat of sanctions to ensure compliance.

Evidence for the effectiveness of interventions (WHO, 2010) (continued) Pricing policies Price increases through taxation mechanisms Setting minimum price for unit of alcohol. Reducing the negative consequences of drinking and alcohol intoxication Safety-oriented design of premises Employment of security staff Management policies and training of staff related to responsibe serving backed by enforcement by police or liquor-licence inspectors Products with lower alcohol content Health warnings on alcohol product containers.

NCD global monitoring framework: alcohol-related targets and indicators One target: At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context. Indicators: Total (recorded and unrecorded) alcohol per capita (15+ years old) consumption within a calendar year in litres of pure alcohol, as appropriate, within the national context Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context.

Reduction in harmful use of alcohol 10% reduction in total adult per capita consumption or/and 10% reduction in prevalence of Heavy Episodic Drinking (defined as 60 g or more of pure alcohol on at least one single occasion at least monthly) 10% reduction in alcohol-related morbidity and mortality

Five-year change in recorded adult per capita consumption, 2006–2010 (WHO, 2014)

Why adult per capita consumption? Coherence with global policy frameworks: Political Declaration on NCDs: "Recognize also the critical importance of reducing the level of exposure of individuals and populations to the common modifiable risk factors for non-communicable diseases … and their determinants…;" Global strategy to reduce the harmful use of alcohol: Global, regional and national actions on: levels of alcohol consumption patterns of alcohol consumption contexts of alcohol consumption wider social determinants of health

APC: public health and epidemiological relevance Adult per capita consumption (APC) is the key epidemiological indicator of alcohol exposure in populations The key indicator for estimating alcohol-attributable burden of disease Corresponds to the linear dose-response relationships of levels of alcohol consumption with a number of key health conditions APC reflects overall prevalence of alcohol consumption in population and pattern of drinking: most alcohol is consumed in hazardous or harmful patterns of drinking

Cumulative Distribution of Alcohol Consumption in the United States World Health Organization 23 March 2018 Cumulative Distribution of Alcohol Consumption in the United States — 65% of the population are drinkers * Males reported drinking 74% and females 26% of all alcohol consumed 73 % of the alcohol is consumed by 10 population Individuals who reported drinking at least one drink in past 12 months - 20 40 60 80 100 30 50 70 90 Percentile Group (High to Low) Percent of Consumption This slide illustrates the distribution of alcohol consumption in the United States. While the U.S. has a lower per capita consumption than many other countries, problems arise from the fact that a small percentage of the population consumes most of the alcohol. NIAAA National Epidemiological Survey on Alcohol and Related Conditions (NESARC) (2001-2002).

Availability of data and feasibility of data collection and analysis WHO monitors APC in time-series for all Member States using data from the governments, economic operators and their data analysis, FAO, epidemiological research. Baseline available. Improving estimation of unrecorded alcohol consumption. More valid and reliable data than for patterns of drinking (survey or modeling based) or alcohol-related harm. For heavy episodic drinking huge measurement challenges

Alcohol-related mortality indicators Core indicators: Age-standardized death rates for liver cirrhosis (per 100 000) (Age-standardized death rates for road traffic accidents) Expanded indicators: Alcohol-attributable YLL Age-standardized death rates of poisoning Age-standardized death rates of alcohol poisoning Age-standardized death rates for violence Age-standardized death rates for alcohol liver cirrhosis Age-standardized death rates for alcohol-related traffic accidents

Alcohol-related morbidity indicators Alcohol dependence, 12-month prevalence Alcohol use disorders, 12-month prevalence Alcohol psychoses, incidence per 100 000 in a given year Hospital discharges, alcohol-related injuries and poisoning (100 000) Hospital discharges, alcoholic liver disease (per 100 000) Treatment admissions (inpatient), alcohol dependence Treatment admissions (inpatient), alcohol psychoses Road traffic injuries involving alcohol (per 100 000)

Options for setting national targets for "reduction in harmful use of alcohol" A. In countries with high stable levels of alcohol per capita consumption: no less than 10% reduction in total alcohol per capita (15+) consumption (APC) In countries with increasing trends of alcohol consumption: arrest increasing trends and stabilize APC Reduction in the overall alcohol exposure Prevention of reduction of proportion of abstainers In countries with stable APC and excellent monitoring systems: evidence of at least 10% reduction of prevalence of HED among adult population (15+).

Conclusions (1) Only 38.3% of world population consumed alcohol in the past 12 months in 2010, consuming on average 17.2 litres per capita (15+) or 37.5 g/day Alcohol consumption is a contributing cause of deaths and disability in cancers, cardiovascular and gastrointestinal diseases 3.3 million deaths or 5.9% of all deaths and 5.1% of all DALYs in 2012 attributable to alcohol consumption 7.6% of all deaths among men and 4% of all deaths among women

Conclusions (2) Prevention of harmful use of alcohol is one of plausible strategies to prevent NCD mortality and morbidity Implies, among drinkers, low levels of consumption and absence of heavy episodic drinking Psychoactive and dependence producing properties of alcohol makes low risk drinking for all impossible Alcohol consumption: "Less is better for public health" Reduction in harmful and hazardous drinking in populations Global policy framework for alcohol control: Global strategy to reduce the harmful use of alcohol (WHO, 2010)

Conclusions (3) Effective and cost-effective strategies to reduce the harmful use of alcohol include: Pricing policies Restricting availability of alcohol Comprehensive restrictions or bans on alcohol advertisements Drink-driving policies Brief-interventions for hazardous and harmful drinking National targets to reduce the harmful use of alcohol should include the levels and patterns of alcohol consumption measured as: Total (recorded and unrecorded) alcohol per capita consumption Prevalence of heavy episodic drinking (in countries with well developed monitoring and surveillance systems)

Further information at Thank you Further information at http://www.who.int/substance_abuse/