1. Alcohol and Health in EU Accession Countries Jürgen Rehm Addiction Research Institute, Zürich, Switzerland Centre for Addiction and Mental Health, Toronto, Canada University of Toronto, Public Health Sciences, Canada October 2003

2. Comparative risk analysis (CRA) within the WHO GBD 2000 Study Disease burden attributable to 26 different risk factors Comparisons between risk factors are possible through standardized methodology Based on continuous risk factors where possible with comparisons to theoretical minimum and different scenarios Attributable and avoidable burden of disease

3. Methodology for estimating substance-use related burden of disease (adapted from World Health Report 2002)Part I Risk Factor Exposure VariableTheoretical Minimum Outcomes 1) Tobacco Current levels of smoking impact ratio (indirect indicator of accumulated smoking risk based on excess lung cancer mortality); oral tobacco use prevalence No tobacco useLung cancer, upper aerodigestive cancer, all other cancers, chronic obstructive pulmonary disease (COPD), other respiratory diseases, all vascular diseases, and other medical causes in adults > 30; fire injuries, maternal outcomes and perinatal conditions Alcohol Current alcohol consumption volumes and patterns No alcohol use (specific sub- groups may have non-zero minimum) IHD, stroke, hypertensive disease, diabetes, liver cancer, mouth and oropharynx cancer, breast cancer, oesophagus cancer, other cancers, liver cirrhosis, epilepsy, alcohol use disorders, depression, intentional and unintentional injuries; selected other cardiovascular diseases and cancers, social consequences Note that for some patterns and volume combinations beneficial effects were modeled Illicit Drugs Current use of amphetamine, cocaine, heroin or other opioids and intravenous drug use No illicit drug useHIV/AIDS, overdose, drug use disorder, suicide, and trauma; other neuropsychological diseases, social consequences, Hepatitis B & C 1) Outcomes in italic are those that are likely to be causal but not quantified due to lack of sufficient evidence on prevalence and/or hazard size

4. Methodology for estimating substance-use related burden of disease (adapted from World Health Report 2002)Part II Risk Factor Sources of Exposure EstimatesSources for Hazard Estimates Tobacco WHO GBD lung cancer mortality database based on complete (approx. 70 countries) or partial (approx. 40 countries) vital registration and International Agency for Research on Cancer (IARC) data; exposure was indirectly estimated for most countries using lung cancer mortality as an indicator of accumulated smoking (Peto et al., 1992) American Cancer Society – Cancer Prevention Study II prospective study of risk factors for mortality in more than one million Americans (Garfinkel, 1985; Peto et al., 1992) and retrospective study of one million deaths in 24 urban centres and 74 rural areas of China (Liu et al., 1994) Alcohol WHO Global Status Report on Alcohol (incl. Production and trade data) on average alcohol consumption (WHO, 1999); systematic review of country surveys on abstinence and levels of alcohol consumption including contacting researchers for unpublished data; systematic review of literature and multiple regional expert consultation for unrecorded consumption; survey data as well as primary key-informant questionnaires on patterns of drinking Published systematic reviews and meta-analyses of health effects plus statistical modelling for role of patterns on CHD and injuries (Rehm et al., in press) Illicit Drugs Systematic review of literature and databases of United Nations International Drug Control Program (UNDCP; see www.undcp.org) and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA; see www.emcdda.org) Updated systematic review of literature on cause- specific and all-cause standardized mortality ratio; UNAIDS (www.unaids.com) estimates for HIV incidence among drug users (based on prevalence surveys among high-risk groups)

5. Causal model of alcohol consumption, intermediate mechanisms, and long-term consequences * Independent of intoxication or dependence

6. PatternLink to disease burden Heavy drinking occasions 1: High usual quantity of alcohol per occasion Heavy drinking occasions lead to increase in injuries (Greenfield, 2001; Rossow et al., 2001), even after adjustment for average volume of consumption. Also, heavy drinking occasions have been shown to lead to detrimental cardiovascular outcomes (CVD; Rehm et al., in press a, submitted), again after adjustment for average volume. There are physiological explanations for, the relationship of heavy drinking occasions both to injury (Eckardt et al., 1998) and to CVD (McKee & Britton, 1998). Usual quantity per occasion, festive drinking and drinking to intoxication are different forms of operationalization of heavy drinking. All have been used in the literature and linked to burden outcomes. Ceteris paribus, the higher the frequency of heavy drinking occasions, the higher the alcohol-related disease burden. Heavy drinking occasions 2: Festive drinking common – at fiestas or community celebrations Heavy drinking occasions 3: Proportion of drinking occasions when drinkers get drunk Patterns of Drinking included in Comparative Risk Analysis (CRA)Part I

7. Patterns of drinking included in Comparative Risk Analysis (CRA)Part II Proportion of drinkers who drink daily or nearly daily The fewer occasions in which a given amount of alcohol is consumed, the more detrimental the consequences (e.g. Walsh & Rehm, 1996; see also Puddey et al., 1999; Room et al., in press). Thus, given a fixed average volume of consumption, the higher the proportion of daily drinking, the lower the expected burden. Drinking with meals – how common it is to drink with meals Drinking with meals has been shown in epidemiological and biological research to be less detrimental than drinking at other times (e.g. Trevisan et al., 2001a; Gentry, 2000; Ramchandani et al., 2001). Thus, ceteris paribus, the higher proportion of alcohol consumed with meals, the lower the alcohol-related disease burden. Drinking in public places – how common it is to drink in public places Drinking in public often requires transportation, and thus has been linked to traffic accidents and injuries (e.g. Fahrenkrug et al., 1994). Also, there may be psychological consequences like risky shift. Thus, the higher the proportion of alcohol consumed in public, the higher the alcohol-related disease burden. Again, this holds only when volume and other influencing factors are held constant.

8. Adult per capita consumption in litre pure alcohol 2000 (based on CRA)

9. Pattern of drinking 2000 (based on CRA)

10. Alcohol related disease and injury Chronic disease: 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, cardiac arrhythmias, heart failure, stroke Castrointestinal diseases: Esophageal varices, Gastro-esophageal hemorrhage, Liver cirrhosis, Cholelithiasis, Acute pancreatitis, Chronic pancreatitits Conditions arising during perinatal period:Spontaneous abortion, Low birth weight, Psoriasis, Prematurity, Intrauterine growth-retardation Injury: Unintentional injury Intentional injury

11. Alcohol-related global burden of disease

12. Comparison with other Major Risks (Mortality) Numbers also include oral tobacco use

13. Comparison with other Major Risks (Burden of Disease) Numbers also include oral tobacco use

14. Average volume in l/year Average volume of alcohol consumption in Europe 2000 (per capita in l/year)

15. Patterns of drinking in European countries 2000 Drinking patterns

16. Estimated alcohol consumption and patterns of drinking in accession countries 2000 Country Adult per capita alcohol consumption Unrecorded consumption Pattern value Percentage male abstainers Percentage female abstainers Czech Republic 15.01.02.03.18.1 Estonia11.75.03.05.010.0 Hungary17.44.03.06.621.4 Latvia16.57.03.015.046.2 Lithuania11.44.93.015.046.2 Malta7.91.02.0?? Poland12.65.03.011.625.7 Slovakia19.37.03.05.121.6 Slovenia13.45.23.031.255.4

17. and in comparison to other parts:(1) Eur A:Western European established market economies with lowest mortality Total consumption:12.89 l per capita Unrecorded:1.29 l per capita Drinking patterns:1.3l per capita Abstainer:females19% / males 10%

18. and in comparison to other parts:(2) Eur C:Russia and surrounding countries with low child, high adult mortality Total consumption:13.91 l per capita Unrecorded:5.25 l per capita Drinking patterns:3.6l per capita Abstainer:females19% / males 11%

19. and in comparison to other parts:(3) Eur B:( Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Georgia, Kyrgyzstan, Poland, Romania, Slovakia, The Former Yugoslav Republic of Macedonia, Tajikistan, Turkmenistan, Turkey, Uzbekistan, Yugoslavia) with low child, low adult mortality Total consumption:8.29 l per capita Unrecorded:3.43 l per capita Drinking patterns:2.9l per capita Abstainer:females48% / males 28%

20. Alcohol-attributable disease burden in deaths (in 1000s) in 2000 by WHO region. Source: Rehm et al. in press

21. Alcohol-attributable disease burden in DALYs (in 1000s) in 2000 by WHO region. Source: Rehm et al. in press

22. WHO Member States by mortality strata, 1999 Adult mortality (Probability of death between age 15-59 yrs) Child mortality (Probability of death under 5 years of age)