1. NCD Seminar, Lausanne, Switzerland
Harmful us of alcohol: meeting 2025 target
V. Poznyak
Coordinator, Management of Substance Abuse
World Health Organization
NCD Seminar, Lausanne, Switzerland
4 June 2013

3. Content Global burden of disease attributable to alcohol
Alcohol consumption and major NCDs: risks and benefits(?)
Reduction of harmful use of alcohol: what does it mean?
Effective strategies to reduce the harmful use of alcohol
Reaching the target of 10% reduction by 2025: what to measure?

4. Global burden of disease attributable to alcohol
Content
Global burden of disease attributable to alcohol
Alcohol consumption and major NCDs: risks and benefits(?)
Reduction of harmful use of alcohol: what does it mean?
Effective strategies to reduce the harmful use of alcohol
Reaching the target of 10% reduction by 2025: what to measure?

5. Several facts about alcohol use and alcohol-related harm (WHO, 2011)
Estimated ~2.5 billion people consume alcoholic beverages
on average 6.1 litres of pure alcohol per capita of adult (15+) population, including 1.8 litres (28.6%) of "unrecorded" alcohol
Estimated ~ 45% of the world adult population has never consumed alcohol
2.3 million deaths (3.8% of deaths in all age groups globally) are attributable to alcohol consumption
4.5% of global burden of disease (expressed in DALYs) is attributable to alcohol

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

7. Global distribution of alcohol-attributable deaths by disease or injury (WHO, 2011)

8. Global distribution of alcohol-attributable deaths and DALYs

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

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

11. Alcohol consumption and major NCDs: risks and benefits(?)
Content
Global burden of disease attributable to alcohol
Alcohol consumption and major NCDs: risks and benefits(?)
Reduction of harmful use of alcohol: what does it mean?
Effective strategies to reduce the harmful use of alcohol
Reaching the target of 10% reduction by 2025: what to measure?

12. Alcohol and noncommunicable diseases
NCD priority conditions
Cardiovascular diseases
Ischaemic heart disease
Ischaemic strokes
Haemorrhagic and other strokes
Cancers
Chronic respiratory diseases
Diabetes
NC conditions according to the alcohol- attributable burden of disease
Alcohol use disorders
Liver cirrhosis/diseases
Cardiovascular diseases
Cancers

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

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

15. 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

16. Prevalence of heavy episodic drinking among past-year female drinkers for 2004 (WHO, 2011)

17. Dose-response relationship (RR) for alcohol and cardiovascular diseases (2)
Hypertensive disease (Taylor et al, 2009)
Men: 25 g/day: 1.25 ( ), 50 g/day: 1.62 ( );
Women: <5 g/day: 0.82 ( ); 25 g/day: 1.24 ( ), 50 g/day: 1.81 ( )
Haemorrhagic and other non-ischaemic stroke (Reynolds et al, 2003):
<12 g/day: 0.79 ( ); g/day: 0.98 ( ); g/day: 1.19 ( ); > 60 g/day: 2.18 ( ).

18. Dose-response relationship (RR) for alcohol and cancers
Mouth, nasopharynx, other pharynx and oropharynx (Corrao et al, 2004)
25 g/day: 1.86 ( ); 50 g/day: 3.11 ( )
Oesophagus (Corrao et al, 2004)
25 g/day: 1.39 ( ); 50 g/day: 1.93 ( ) (Corrao et al, 2004)
Colon and rectum (Corrao et al, 2004)
25 g/day: 1.05 ( ); 50 g/day: 1.10 ( )
Liver (Corrao et al, 2004)
25 g/day: 1.19 ( ); 50 g/day: 1.40 ( )
Breast (female) (Hamajima et al, 2002)
35-44 g/day: 1.32 ( ); ≥45 g/day: 1.46 ( ), RR increased by 7.1% for each extra 10 g of alcohol consumed on a daily basis

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

20. 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.

21. IARC Monograph on the Evaluation of Carcinogenic Risks to Humans, Vol
IARC Monograph on the Evaluation of Carcinogenic Risks to Humans, Vol. 100E (2012)
Alcohol consumption is carcinogenic to humans (Group 1)
Ethanol in alcoholic beverages is carcinogenic to humans (Group 1)
Acetaldehyde associated with the consumption of alcoholic beverages is carcinogenic to humans (Group 1)

22. International Agency for Research on Cancer (IARC, 2010) grouping of agents depending on evidence of their carcinogenicity
Group 3
Group 2B
Inadequate
Group 2A
Limited
Group 1
In humans
Sufficient
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 Not classifiable
Group Probably not carcinogenic to humans

23. Ethanol metabolism and carcinogenesis (Helmut K
Ethanol metabolism and carcinogenesis (Helmut K. Seitz & Felix Stickel, Nature Reviews Cancer 7, )

24. 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): e )

25. Alcohol and liver cirrhosis: mortality and morbidity in men and women (CRA 2010)

26. 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 ( ), deleterious at > 60 g/day: 1.01 ( );
Women: 24 g/day – nadir: 0.60 ( ), deleterious at > 50 g/day: 1.02 ( ).
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.

27. 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

28. Alcohol and TB
Relative risk of TB infection for heavy drinking/AUD – 2.94 (95% CI: )
About 10% of the TB cases worldwide were estimated to be attributable to alcohol

29. 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

30. 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.

31. Reduction of harmful use of alcohol: what does it mean?
Content
Global burden of disease attributable to alcohol
Alcohol consumption and major NCDs: risks and benefits(?)
Reduction of harmful use of alcohol: what does it mean?
Effective strategies to reduce the harmful use of alcohol
Reaching the target of 10% reduction by 2025: what to measure?

32. 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.

33. Definition of "harmful use of alcohol" in the WHO global strategy
World Health Organization
Definition of "harmful use of alcohol" in the WHO global strategy
3 June 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

35. 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.

36. 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

37. Effective strategies to reduce the harmful use of alcohol
Content
Global burden of disease attributable to alcohol
Alcohol consumption and major NCDs: risks and benefits(?)
Reduction of harmful use of alcohol: what does it mean?
Effective strategies to reduce the harmful use of alcohol
Reaching the target of 10% reduction by 2025: what to measure?

38. 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.

39. World Health Organization
Cost-effectiveness of alcohol control strategies in WHO regions
Source: Anderson, Chisholm, Fuhr (Lancet, 2009)
World Health Organization
3 June 2018

40. "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

41. 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.

42. 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.

43. 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.

44. 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.

45. Association between government effectiveness and alcohol policy score (J. P. Mackenbach, M. McKee, 2013).

46. Reaching the target of 10% reduction by 2025: what to measure?
Content
Global burden of disease attributable to alcohol
Alcohol consumption and major NCDs: risks and benefits(?)
Reduction of harmful use of alcohol: what does it mean?
Effective strategies to reduce the harmful use of alcohol
Reaching the target of 10% reduction by 2025: what to measure?

47. 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.

48. Reduction in harmful use of alcohol (by 2025)
10% reduction in total adult per capita consumption
or/and
10% reduction in prevalence of Heavy Episodic Drinking
10% reduction in alcohol-related morbidity and mortality

49. Recorded adult per capita consumption, in litres of pure alcohol, by WHO region and the world, 1990–2005 (WHO GISAH, 2010)

50. Five-year change in recorded adult per capita consumption, 2001–2005 (WHO GISAH, 2010)

51. Alcohol-related mortality indicators
Core indicators:
Age-standardized death rates for liver cirrhosis (per )
(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

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

53. Potential algorithm for "reduction in harmful use of alcohol"
Reduction of "harmful use of alcohol":
A. Not less than 10% reduction in total adult per capita consumption (APC)
Evidence of at least 10% reduction of prevalence of HED among adult population (15+)
Evidence of at least 10% reduction in alcohol- related morbidity and mortality (where alcohol is a sufficient cause). Considered as not a viable option.
Algorithm: (1) A, if HED and alcohol-related morbidity and mortality are stable or reduced; (2) B, if APC and alcohol- related morbidity and mortality are stable or reduced, (3) C, if APC and HED are stable or reduced.

54. Further information at
Thank you
Further information at