1. approaches to reducing the harmful use of alcohol
4th International Seminar on the Public Health Aspects of Noncommunicable Diseases, Lausanne, 7-12 March 2011
Global and national
approaches to reducing
the harmful use of alcohol
Mr Dag Rekve
Technical Officer
Management of Substance Abuse
Department of Mental Health and Substance Abuse
World Health Organization

2. Total adult per capita consumption (world)

3. Lifetime prevalence of abstention (world)

4. Patterns of drinking

5. Causal model of alcohol consumption, intermediate mechanisms and health consequences

6. Risks and consequences
Risk to individual drinker 
Impact on people other than the drinker
Overall health burden
Impact on productivity
Alcohol, health and economic development 6 6

7. Too big burden to be neglected

8. Global distribution of alcohol-attributable deaths and DALYs

9. Different perspectives
Percent of total
Risk factor

10. Distribution of alcohol-attributable male deaths (of all male deaths)

11. Emerging important issues
Alcohol exposure and incidence and clinical course of infectious diseases
Alcohol exposure and harms to others including FAS/FASD
The positive effects of alcohol consumption and possible implications for policy decisions
Potential movements in abstention rates and changes in female drinking patterns

12. Effective counter measures exist
Effective measures:
regulating the marketing of alcoholic beverages, (in particular to younger people);
regulating and restricting availability of alcohol;
enacting appropriate drink-driving policies;
reducing demand through taxation and pricing mechanisms;
raising awareness and support for policies;
providing accessible and affordable treatment for people with alcohol-use disorders; and
implementing screening programmes and brief interventions for hazardous and harmful use of alcohol

13. The question is how to do it

14. Plus numerous regional resolutions, strategies and frameworks
Important milestones
October 2002: World Health Report 2002
May 2005: WHA58.26
May 2007: WHA60
May 2008: WHA61.4
May 2010: WHA63.13
Plus numerous regional resolutions, strategies and frameworks

15. The development of the strategy
Stage I. Broad consultation process
Web-based consultation
Consultation with economic operators
Consultation with NGOs and health professionals
Consultation with UN agencies and IGOs
Stage II. Draft strategy development
Regional technical consultations with Member States (February – May 2009) in 6 WHO regions
Draft development by the Secretariat in collaboration and consultation with Member States (May – October 2009)
126th session of the Executive Board
WHA 63
ting.

16. The content of the strategy
The global strategy:
complements and supports public health policies in Member States;
gives guidance for action at all levels;
sets priority areas for global action;
contains a portfolio of policy options and measures that could be considered for implementation and adjusted as appropriate at the national level

17. WHO global strategy: Five objectives
(a) raised global awareness of the magnitude and nature of the health, social and economic problems caused by harmful use of alcohol, and increased commitment by governments to act to address the harmful use of alcohol;
(b) strengthened knowledge base on the magnitude and determinants of alcohol- related harm and on effective interventions to reduce and prevent such harm;
(c) increased technical support to, and enhanced capacity of, Member States for preventing the harmful use of alcohol and managing alcohol-use disorders and associated health conditions;
(d) strengthened partnerships and better coordination among stakeholders and increased mobilization of resources required for appropriate and concerted action to prevent the harmful use of alcohol;
(e) improved systems for monitoring and surveillance at different levels, and more effective dissemination and application of information for advocacy, policy development and evaluation purposes.

18. WHO global strategy: Five objectives
Achieving the five objectives will require global, regional and national actions on the levels, patterns and contexts of alcohol consumption and the 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, such as children, adolescents, women of child- bearing age, pregnant and breastfeeding women, indigenous peoples and other minority groups or groups with low socioeconomic status.

19. WHO Global Strategy: National policies and measures
Member States have a primary responsibility for formulating, implementing, monitoring and evaluating public policies to reduce the harmful use of alcohol. Such policies require a wide range of public health-oriented strategies for prevention and treatment.
All countries will benefit from having a national strategy and appropriate legal frameworks to reduce harmful use of alcohol, regardless of the level of resources in the country.
Sustained political commitment, effective coordination, sustainable funding and appropriate engagement of subnational governments as well as from civil society and economic operators are essential for success.
Health ministries have a crucial role in bringing together the other ministries and stakeholders needed for effective policy design and implementation.

20. Global strategy: recommended ten 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

21. Area 1. Leadership, awareness and commitment
Sustainable action requires strong leadership and a solid base of awareness and political will and commitment.
The commitments should ideally be expressed through adequately funded comprehensive and intersectoral national policies that clarify the contributions, and division of responsibility, of the different partners involved.
The policies must be based on available evidence and tailored to local circumstances, with clear objectives, strategies and targets.
The policy should be accompanied by a specific action plan and supported by effective and sustainable implementation and evaluation mechanisms.
The appropriate engagement of civil society and economic operators is essential.

22. Area 1. Leadership, awareness and commitment
For this area policy options and interventions include:
(a) developing or strengthening existing, comprehensive national and subnational strategies, plans of action and activities to reduce the harmful use of alcohol;
(b) establishing or appointing a main institution or agency, as appropriate, to be responsible for following up national policies, strategies and plans;
(c) coordinating alcohol strategies with work in other relevant sectors, including cooperation between different levels of governments, and with other relevant health-sector strategies and plans;
(d) ensuring broad access to information and effective education and public awareness programmes among all levels of society about the full range of alcohol-related harm experienced in the country and the need for, and existence of, effective preventive measures;
(e) raising awareness of harm to others and among vulnerable groups caused by drinking, avoiding stigmatization and actively discouraging discrimination against affected groups and individuals.

23. GLOBAL ACTION
Given the magnitude and the complexity of the problem, concerted global efforts must be in place to support Member States in the challenges they face at the national level.
International coordination and collaboration create the synergies that are needed and provide increased leverage for Member States to implement evidence-based measures.
WHO, in cooperation with other organizations in the United Nations system and other international partners will:
(a) provide leadership;
(b) strengthen advocacy;
(c) formulate, in collaboration with Member States, evidence-based policy options;
(d) promote networking and exchange of experience among countries;
(e) strengthen partnerships and resource mobilization;
(f) coordinate monitoring of alcohol-related harm and the progress countries are making to address it.

24. Global action: key components
Public health advocacy and partnership
Technical support and capacity building
Production and dissemination of knowledge
Resource mobilization

25. World Health Assembly Resolution WHA63.13
URGES Member States:
(1) to adopt and implement the global strategy to reduce the harmful use of alcohol as appropriate in order to complement and support public health policies in Member States to reduce the harmful use of alcohol, and to mobilize political will and financial resources for that purpose; …
REQUESTS the Director-General:
(2) to collaborate with and provide support to Member States, as appropriate, in implementing the global strategy to reduce the harmful use of alcohol and strengthening national responses to public health problems caused by the harmful use of alcohol;…

26. The implementation of the global strategy to reduce the harmful use of alcohol
Strong global and regional leadership
Effective mechanisms for coordination and collaboration between all levels
Appropriate engagement of relevant stakeholders
Sufficient recourses available

27. The role of WHO national counterparts for implementation of the global strategy
establish the working mechanisms and plans for the global network;
elaborate priority areas and implementation plans for reducing the harmful use of alcohol at the global level;
discuss priority areas and plans for implementing the global strategy at the regional level;
discuss monitoring and reporting on the implementation of the global strategy at different levels;

28. WHO global counterparts network 1. meeting 8-11 February 2011

29. Technical support and capacity building
Implementation structures for the Global strategy to reduce harmful use of alcohol
Global network of
WHO counter-parts
WHO
Secretariat
Global level
Coordinating council
Task force on Public health advocacy and partnership
Chair of the global network
Chairs of regional networks
Chairs of task forces
WHO Secretariat
Chairs of working groups
Task force on
Technical support and capacity building
Task force on Resource mobilization
Task force on Production and dissemination of knowledge
International partners and other stakeholders
Technical working group(s) on selected target areas for national action

30. Challenges of Monitoring
Unreliable or invalid data
Incomparable data
Establishing uniform definitions
Need for historical data
Resources

31. Framework for monitoring and evaluation

32. Data collection, analysis and dissemination

33. Conclusion – "a going concern"
Harmful use of alcohol should be a "going concern" at local, national, regional and global levels with political and professional attention and allocation of resource in line with the magnitude of the problem.
The words are now in place and the global and regional strategies represent a unique opportunity to establish a global and regional fundament for such a going concern

34. Thank you for your attention!
Exit the maze of harmful use of alcohol for better global health

35. XTRAS

36. Structure of presentation
Risk to individual drinker 
Impact on people other than the drinker
Overall health burden
Impact on productivity
Alcohol, health and economic development 36 36

37. Structure of presentation
Risk to individual drinker 
Impact on people other than the drinker
Overall health burden
Impact on productivity
Alcohol, health and economic development 37 37

38. Risk to individual drinker
Intoxicating effects 
Immunosuppressant effects
Carcinogenic effects
Teratogenic effects
Neurotoxic effects
Dependence producing properties 38 38

39. Risk to individual drinker
Intoxicating effects 
Immunosuppressant effects
Carcinogenic effects
Teratogenic effects
Neurotoxic effects
Dependence producing properties 39 39

40. Intoxicating effects
As an intoxicant, alcohol is a causal factor for intentional and unintentional injuries, including:
interpersonal violence
suicide
homicide
crime and drink-driving fatalities
and a contributory factor for risky sexual behaviour, sexually transmitted diseases and HIV infection 40 40

41. Intoxicating effects
The risk of a motor vehicle accident injury related to the amount of alcohol consumed during the last 3 hours.
The risk of a non-motor vehicle accident injury related to the amount of alcohol consumed during the last 3 hours.
Source: Taylor et al, 2009 41 41

42. Immunosuppressant effects
Alcohol is an immunosuppressant, increasing the risk of communicable diseases, including pneumonia, tuberculosis, and possibly HIV/AIDS incidence.
[Alcohol also leads to HIV/AIDS progression due to poor treatment compliance] 46 46

43. Immunosuppressant effects
Including alcohol-related infectious diseases would increase the present estimates of alcohol-attributable global disease burden by 13% (from 4.6% to 5.2%), and African disease burden by 50% (from 1.4% to 2.1%). 47 47

44. Carcinogenic effects Overall evaluation
Alcoholic beverages are carcinogenic to humans (Group 1).
Ethanol in alcoholic beverages is carcinogenic to humans (Group 1). 48 48

45. Carcinogenic effects
As a carcinogen, alcohol increases the risk of cancers of the oral cavity and pharynx, oesophagus, stomach, colon, rectum, liver and female breast in a linear dose–response relationship 49 49

46. Risk of female breast cancer
Source: Allen et al, 2009 50 50

47. Relation with cardiovascular disease
Systematic reviews find that alcohol, with a dose response relationship, increases the risk of:
Hypertension
Arial fibrillation
Haemorrhagic stroke 51 51

48. Relation with cardiovascular disease
Systematic reviews find that alcohol has a J-shaped-relationship , with the risk of:
Ischaemic heart disease
Ischaemic stroke
Compared with abstainers, light drinkers have reduced risk; beyond the bottom of the ‘J’ the risk increases with a dose-response relationship 52 52

49. Relation with cardiovascular disease
The protective effect:
Is no different between exclusively beer or wine drinkers
Does not exist for young adult drinkers
Is less for very older drinkers
Is less the longer the period of follow-up
Disappears the more the abstaining group includes ex-drinkers
Disappears when light drinkers report at least one heavy drinking occasion per month 53 53

50. Relation with cardiovascular disease
Most of the protective effect can be achieved by a consumption of 5g alcohol (half a drink) a day
More protection can be achieved by engaging in other healthier behaviours (e.g., healthy diet, more physical activity) 54 54

51. Relation with cardiovascular disease
Compared with light drinkers, abstainers, in general, have a higher proportion of other risk factors for heart disease:
More overweight
More anxiety
Lower socio-economic status 56 56

52. Risk of death by patterns of drinking, Swedish men <55 years old
Source: Romelsjö et al, 2010 57 57

53. Lifetime risk of alcohol-related death, Australian population
Source: National Health and Medical Research Council, Australia, 2009 58 58

54. Annual risk of alcohol-related chronic death, net of protective effects, EURO population59 59

55. Structure of presentation
Risk to individual drinker 
Impact on people other than the drinker
Overall health burden
Impact on productivity
Alcohol, health and economic development 60 60

56. Impact on people other than the drinker
Alcohol harms people other than the drinker:
Injuries, violence and crime
Violence in the family
Using up a relative or colleagues’ time and resources
Using up taxes 61 61

57. Impact on people other than the drinker
The greater the exposure to heavy drinkers the greater the negative impact on the health and well-being of the person exposed 62 62

58. Costs of alcohol to Australian society (Billions of dollars)
Source: Laslett et al 2010

59. Costs of alcohol to Australian society (Billions of dollars)
Source: Laslett et al 2010

60. Structure of presentation
Risk to individual drinker 
Impact on people other than the drinker
Overall health burden
Impact on productivity
Alcohol, health and economic development 66 66

61. Disability adjusted life year (DALY)
Overall health burden
Disability adjusted life year (DALY)
Measures a combination of ill-health (adjusted for the severity of ill-health) and premature death
It measures a gap between how healthy we are and how healthy we could be 67 67

62. Top 10 risk factors for DALYs (world)68 68

63. Top 10 risk factors for DALYs (high income countries)69 69

64. Top 10 risk factors for DALYs (middle income countries)70 70

65. Top 10 risk factors for DALYs (low income countries)71 71

66. Death rate and risk of men dying in Russia75 75

67. Death rate and risk of men dying in Russia76 76

68. Alcohol-related death rate and risk of men dying in Russia77 77

69. Per cent of all deaths due to alcohol in Russia

70. Structure of presentation
Risk to individual drinker 
Impact on people other than the drinker
Overall health burden
Impact on productivity
Alcohol, health and economic development 80 80

71. Top 10 risk factors for DALYs
(age group years) 81 81

72. Economic costs per head (2007 $US PPP) attributable alcohol by cost category82 82

73. Structure of presentation
Risk to individual drinker 
Impact on people other than the drinker
Overall health burden
Impact on productivity
Alcohol, health and economic development 83 83

74. Adult abstainers (%) by economic wealth (GDP PPP I$1000) across the world (2005)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
abstainer (last year)
lifetime abstainer
M=1 denotes the
midpoint of the
respective interval,
in the example
between I$ 0 and
1,000; M=45
denotes the interval
between I$ 40,000
and 50,000; etc. 84 84

75. Drinkers (%) by daily income within WHO Regions
Blakely et al 2004 85 85

76. Adult per capita consumption by (litres pure alcohol)
by economic wealth (GDP PPP I$1000)
across the world, 2005 2 4 6 8 10 12 14 16
M=1
M=3
M=5
M=7
M=9
M=11
M=13.5
M=17.5
M=25
M=35
M=45
M=1 denotes the midpoint of the respective interval, in the example between I$ 0 and
1,000; M=45 denotes the interval between I$ 40,000 and 50,000; etc. 86 86

77. Alcohol-attributable DALYs for the same level of alcohol consumption by economic wealth across 14 WHO Regions 87 87

78. Alcohol is a major risk factor for: Non-communicable diseases
Main conclusions
Alcohol is a major risk factor for:
Non-communicable diseases
Chronic diseases
Injuries
Mental and behavioural disorders; and
A contributory risk factor for communicable diseases 88 88

79. Main conclusions
The absolute risk of dying from an alcohol-related condition increases linearly from zero consumption; heavy drinking occasions worsen all risks 89 89

80. Main conclusions
Adding in the harms to people other than the drinker effectively doubles the social cost of alcohol 90 90

81. for 15-59 year olds, it is the number one cause
Main conclusions
Even though 45% of the world’s population do not drink, alcohol is the world’s 3rd most important risk factor of ill-health and premature death;
for year olds, it is the number one cause 91 91

82. Main conclusions
Three-quarters of the economic costs due to alcohol come from lost productivity, some 1.7% of GDP. 92 92

83. Main conclusions
Both between and within countries, per gram of alcohol consumed, poorer people are more likely to die than richer people. 93 93

84. Preventable deaths
1,700,000 94 94