Alcohol and Noncommunicable Diseases Dr Vladimir Poznyak Coordinator, Management of Substance Abuse Department of Mental Health and Substance Abuse 2nd International Seminar on Public Health Aspects of Noncommunicable Diseases, Lausanne-Geneva, August 2010

Disease burden (DALYs) in 2000 attributable to selected leading risk factors (world) Number of Disability-Adjusted Life Years (000s) Source: WHR, 2002

Leading 12 selected risk factors as causes of disease burden (Source: WHO, 2002) = Major NCD risk factors High Mortality Developing Countries Low Mortality Developing Countries Developed Countries 1 Underweight Alcohol Tobacco 2 Unsafe sex Blood pressure Blood pressure 3 Unsafe water Tobacco Alcohol 4 Indoor smoke Underweight Cholesterol 5 Zinc deficiency Body mass index Body mass index 6 Iron deficiency Cholesterol Low fruit & veg. intake 7 Vitamin A deficiency Low fruit & veg intake Physical inactivity 8 Blood pressure Indoor smoke - solid fuels Illicit drugs 9 Tobacco Iron deficiency Unsafe sex 10 Cholesterol Unsafe water Iron deficiency 11 Alcohol Unsafe sex Lead exposure 12 Low fruit & veg intake Lead exposure Childhood sexual abuse

Setting the scene: DALYs (000) lost in the world due to different risk factors in 2004 (WHO, 2009)

Disease burden attributable to different risk factors in World Bank income groups

World Health Organization Adult per capita consumption in litres of pure alcohol 2002 (Data source: WHO Global Information System on Alcohol and Health) World Health Organization 17 July 2018 6

World Health Organization 17 July 2018 Prevalence of abstention in the world 2002 (Data source: WHO Global Information System on Alcohol and Health ) 7

World Health Organization 17 July 2018 Prevalence of abstention in the world 2004 (Preliminary data. Source: WHO Global Information System on Alcohol and Health ) 8

Deaths (000) in the world in 2004 due to different risk factors (WHO, 2009)

Deaths attributable to alcohol consumption (WHO, 2009) World Health Organization Deaths attributable to alcohol consumption (WHO, 2009) 17 July 2018 In 2004 estimated 2.5 million people died worldwide of alcohol- related causes 320 000 young people between 15 and 29 years of age 2.5 million deaths accounted for 3.8% of global mortality in all age groups 6.2% in men 1.1% in women Leading disease categories for alcohol-attributable deaths Unintentional and intentional injuries Cancers Cardiovascular diseases Liver cirrhosis

Alcohol-attributable DALYs by disease or injury for the year 2004

Prevalence of alcohol use disorders worldwide World Health Organization 17 July 2018 Prevalence of alcohol use disorders worldwide In 2000 - 76.4 million people worldwide with alcohol use disorders (ICD-10 F10.1 and F10.2 - harmful use of alcohol and alcohol dependence) 63.7 million men 12.7 million women (F:M=1:5) Source: Colin D. Mathers, Claudia Stein, Doris Ma Fat et al (2001). Global Burden of Disease 2000: Version 2 methods and results. GPE Discussion paper 50; Geneva, WHO. In 2004 12-month prevalence of alcohol dependence varied: - from 0.4% to 17.6% among men 18-65 years old - from 0 to 3.5% among women 18-65 years old Source: T. Kehoe et al, 2006 (preliminary data); J. Rehm et al, in press

Alcohol and noncommunicable diseases Priority NCDs in terms of alcohol-attributable global burden of disease Alcohol use disorders Liver cirrhosis Cardiovascular diseases Cancers Priority NCD conditions for WHO Cardiovascular diseases Ischaemic heart disease Ischaemic strokes Haemorrhagic and other strokes Cancers Chronic respiratory diseases Diabetes

Causal pathways for alcohol-related health outcomes and consequences (Schmidt et al, in press. ) In: Blas E, Sivasankara Kurup A, eds. Priority public health conditions: from learning to action on social determinants of health. Geneva, World Health Organization, 2010.

Dose-response relationship (RR) for alcohol and cardiovascular diseases 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) 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) compared to non: 1.45 (1.24-1.70) (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); 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)

World Health Organization Cardiovascular Mortality According to Quantity and Frequency of Alcohol Consumption (Mukamal, K. J. et al. J Am Coll Cardiol 2010;55:1328-1335) 17 July 2018

World Health Organization Comparison Between Curves on Cardiovascular and All-Cause Mortality in Cardiovascular Disease Patients 17 July 2018 Costanzo, S. et al. J Am Coll Cardiol 2010;55:1339-1347

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)

PAF (%) for alcohol consumption as a risk factor to cancers worldwide (Danaei et al, Lancet, 2005; 366: 1784–93)

International Agency for Research on Cancer (IARC) grouping of agents depending on evidence of their carcinogenicity Group 3 Group 2B Inadequate Group 2A Limited Group 1 Sufficient In humans In experimental animals Group 1 Carcinogenic to humans (ethanol, alcoholic beverages, acetaldehyde) Group 2A Probably carcinogenic to humans Group 2B Possibly carcinogenic to humans Group 3 Not classifiable Group 4 Probably not carcinogenic to humans

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).

But…. Confounding remains a problem 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

Lifetime risk of injury mortality per 1,000 among men in Canada (Taylor et al, Am J Epidemiol 2008; 168: 1119-1125) Consumption per occasion (grams of pure alcohol)

Lifetime risk of injury mortality per 1,000 among women in Canada (Taylor et al, Am J Epidemiol 2008; 168: 1119-1125)

Source: Rehm J., Eschmann S., 2002

Communication of NCD-related risks It is impossible to predict the risks of initiation of drinking in persons who never used alcoholic beverages 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

Assessment of hazardous and harmful use of alcohol Drinking quantity and frequency Has consumed 5 or more standard drinks (or 60 gm alcohol)* on any given occasion in the last 12 months Drinks on average more than 2 drinks per day Drinks every day of the week Drinking related physical, psychological or social harm Accidents, driving while intoxicated Relationship problems Liver disease / stomach ulcers Legal/financial problems Sex while intoxicated Alcohol-related violence

WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) Developed by international group of researchers Initially 12 item and now (V3.0) 8 item instrument Screens for health risks & problems associated with any psychoactive substance use Designed to provide lifetime and current (past 3 months) estimates of substance use and related risk

Cost-effectiveness of interventions to reduce the harmful use of alcohol Most cost-effective strategies and interventions include: Reducing the physical availability of alcohol that encompasses restrictions on both the sale and serving of alcohol Pricing policies with alcohol excise taxation and its enforcment Drink-driving policies and countermeasures (RBT) Control of advertising of alcohol (comprehensive advertising ban) Brief interventions with at risk drinkers. Cost-effectiveness of interventions depend on several factors, including: Abstention rates in a population Implementation of policy measures and interventions (infrastructure, coverage, enforcement) Availability of informally and illegally produced alcohol

63rd World Health Assembly (17-21 May, 2010) Endorsed the Global strategy to reduce the harmful use of alcohol in the WHA resolution 63.13

World Health Organization The WHO global strategy to reduce the harmful use of alcohol endorsed by the 63rd WHA resolution World Health Organization World Health Organization 17 July, 2018 17 July 2018 …the global strategy for reducing the harmful use of alcohol is a true breakthrough. This strategy gives you a large and flexible menu of evidence-based policy options for addressing a problem that damages health in rich and poor countries alike. The strategy sends a powerful message: countries are willing to work together to take a tough stand against the harmful use of alcohol. Dr Margaret Chan Director-General World Health Organization Closing speech at WHA63 34

Setting the scene: defining "harmful use of alcohol" In the context of this strategy, 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. The harmful use of alcohol compromises both individual and social development. It can ruin the lives of individuals, devastate families, and damage the fabric of communities.

Recommended target areas for policy measures and interventions 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

Further information at WHO Department of Mental Health and Substance Abuse Management of Substance Abuse Further information at http://www.who.int/substance_abuse/