1. Module 2- epidemiology of alcohol use
Part One- Alcohol Policy and Public Health
Epidemiology is an area of public health that studies the causes of disease and the variations in disease rates among population groups. In this module we describe the epidemiology of alcohol use globally and across the Americas. The typical frequency of drinking and the amount of alcohol consumed per occasion vary enormously, not only among world regions and countries, but also over time and between different population groups. As will be shown in this module, variations in these “patterns” of drinking affect rates of alcohol-related problems, and have implications for the choice of alcohol policy measures.
Module 2- epidemiology of alcohol use
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2. Learning Objectives
Upon completion of this module you will have an understanding of:
The epidemiology of alcohol use globally and across the Americas.
How “patterns” of drinking affect rates of alcohol-related problems.
The implications of these “patterns” for the choice of alcohol policy measures
Upon completion of this module you will be able to describe the epidemiology of alcohol use globally and across the Americas, the way in which “patterns” of drinking affects rates of alcohol-related problems, and the implications of these “patterns” for the choice of alcohol policy measures
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3. Average adult per capita consumption Liters of pure alcohol, 2005
Total consumption (recorded and unrecorded) 2005
0-3
3-6
6-9
9-12
12-15
15-21
Two aspects of alcohol consumption are of particular importance for comparisons across populations and across time. First, total alcohol consumption in a population is an important indicator of the number of individuals who are exposed to high amounts of alcohol. Adult per capita alcohol consumption is, to a considerable extent, related to the prevalence of heavy use, which in turn is associated with the occurrence of negative effects.
Recorded alcohol consumption is highest in the economically developed regions of the world such as North America, Australia, and Europe, but Latin American levels are not far behind, being higher than the global average. In contrast, consumption is generally lower in Africa and parts of Asia, and particularly low in historically Muslim states and the Indian subcontinent. In many parts of the world a significant fraction or the majority of the population abstains from alcohol. In most societies, men are much more likely than women to be drinkers.
Looking at trends in per capita alcohol consumption worldwide, there seems to have been a decline in drinking in many of the high alcohol consumption countries from the early 1970s to the early 2000s. This is particularly the case in the traditional wine-producing countries of Europe, such as France, Italy, and Portugal, where the decrease is mostly due to reductions in wine consumption. Similar trends are also seen in the wine-producing countries of South America such as Argentina and Chile. In other developed countries with relatively high per capita alcohol consumption, a smaller but still significant decrease has been observed over the same period, for instance in Canada and in the US.
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4. Drinking Patterns
Drinking patterns refer to the typical amount, setting and variability of alcohol consumption in a population
Countries in Latin America and the Caribbean have a drinking pattern characterized by high alcohol intake per occasion, fiesta drinking, drinking in public places, and not drinking with meals
The relationship between total alcohol consumption and harm is modified by the number of drinkers in a population and by the way in which alcohol is consumed, so called “patterns of drinking”. Drinking patterns refer to the amount and variability of alcohol consumption, as well as the setting and the type of beverage consumed. Of importance are those drinking patterns in which a large number of drinks are consumed in a relatively small period of time (say, 5 or more drinks in 2 hours). This type of heavy episodic drinking leads to psychomotor impairment through intoxication. Drinking patterns are important because they have a direct effect on the drinker’s blood alcohol level and other aspects of a person’s drinking that are likely to lead to harm, especially injuries and trauma. In general, the countries in Latin America and the Caribbean have a drinking pattern characterized by high alcohol intake per occasion, fiesta drinking, drinking in public places, and not drinking with meals.
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5. WHO Patterns of Drinking Score (PDS)
Calculating PDS: drinking variables
Usual quantity of alcohol consumed per occasion
Festive/fiesta drinking
Proportion of drinking when drinkers get drunk
Proportion of drinkers who drink daily or nearly daily
Drinking with meals
Drinking in public places
Pattern 1 (least risky) – 4 (higher burden of disease)
The World Health Organization has created a way to estimate the extent to which the pattern of drinking in a particular country is hazardous to health based on six different variables: the quantity of alcohol consumed by a drinker on a given occasion; festive drinking at fiestas or community celebrations; the proportion of drinking occasions when drinkers get drunk; the proportion of drinkers who get drunk daily or nearly daily; drinking with meals versus drinking outside of meals and drinking in public locations. The WHO country ratings of drinking patterns range from 1 to 4, with a pattern score of one representing the least risky drinking behavior and 4 representing the most risky behavior. In general, the higher the "pattern score", the greater the alcohol-attributable burden of disease.
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6. Drinking Pattern Values for Selected WHO Regions
Africa D (e.g., Nigeria, Algeria)
2.48
Africa E (e.g., Ethiopia, So. Africa)
3.09
Americas A (e.g., Canada, USA)
2.00
Americas B (e.g., Brazil, Mexico)
3.14
Americas D (e.g., Bolivia, Peru)
3.10
Europe A (e.g., Germany, France)
1.34
SE Asia B (e.g., Indonesia, Thailand)
2.50
SE Asia D (e.g., Bangladesh, India)
2.95
Although many countries have not undertaken appropriate general population surveys on alcohol consumption and patterns of drinking, key informants have provided information to WHO which has been used to estimate the typical pattern of drinking in a country.
AMR A had the lowest mean pattern value in the American region, followed by AMERICAS B and D, which were roughly equal. This confirms previous research, which shows that drinking patterns are worse for developing countries, such as those in Central America, whereas countries in North America tend to have less detrimental pattern scores of around 2. Both pattern score and unrecorded alcohol consumption play a significant role in determining alcohol-attributable mortality and burden. Also of note is that both AMERICAS A and B are predominantly beer drinking cultures, whereas AMERICAS D consumed both spirits and beer in roughly equal amounts. The most populous countries in each region are interesting in terms of their effect on the overall values for the sub region and region, specifically for AMERICAS B and AMERICAS D, since AMERICAS A (specifically the US) drives much of the average for the region of the Americas as a whole.
Mexico has a typically very high abstention rate for AMERICAS B, and consequently lower per capita consumption than that of AMERICAS B and the entire American region. However, the pattern value reflects a harmful pattern of drinking among those who do drink. This is the opposite for Peru, where atypically low numbers of abstainers drive up the alcohol per capita consumption values. This, combined with a detrimental drinking pattern, leads to high rates of alcohol-related harm in these regions.
5 countries in the Americas have a drinking pattern score of 4: Belize, Ecuador, Guatemala, Mexico, and Nicaragua.
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7. Patterns of Alcohol Consumption, 2005
This map shows the distribution of drinking patterns across the world. The patterns range from 1 to 5, according to the levels of harm they cause at population level. As it can be seen, the pattern of drinking in many of the countries in the Americas have relatively high risk patterns of alcohol use, the average being 3.1.
Least risk
High risk
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8. Alcohol Consumption in the Americas
Wide regional variation in alcohol consumption, alcohol-related problems and the burden of disease and disability
Two thirds of males and a little over half of females 15 years of age and older are drinkers
In 2005, average total adult per capita consumption in the Americas was 8.67 liters, compared to 6.13 liters globally
Recent epidemiological research shows that there is wide regional variation in alcohol consumption, alcohol-related problems, and the burden of disease and disability attributable to alcohol throughout the Americas Region. The evidence shows that about two thirds of males and a little over half of females 15 years of age and older are drinkers. On average, per capita alcohol consumption is more than 50% above the global consumption. A relatively high level of per capita consumption combined with a high risk pattern of use accounts for the high burden of disease associated with alcohol use in the Region.
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9. Alcohol Consumption in Latin America, cont.
Percent of lifetime abstainers:
Men: 17.7%
Women: 35%
Average per capita consumption for drinkers only: 15 liters
Because these countries have a relatively high proportion of abstainers, per capita consumption for drinkers is considerably higher than per capita consumption for the population as a whole. Studies from a number of countries demonstrate that alcohol consumption is very unevenly distributed in a population and among drinkers. Most of the alcohol in a society is drunk by a relatively small minority of drinkers.
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10. Per Capita Consumption in Latin American Sub-Regions
Developed countries:
High per capita consumption
11.2% heavy drinkers
Developing countries with low mortality rates, such as Brazil, Mexico and Chile:
Per capita consumption similar to the developed countries
Developing countries with high mortality rates, such as Bolivia and Peru:
Lower average per capita consumption
The developed industrialized countries in the Region, such as the USA and Canada, have a high per capita consumption- about 9.3 liters of pure alcohol per capita for 15 year-olds and above. There is an estimated 11.2% of heavy drinkers and an average consumption of 14.3 liters per adult drinker. In developing countries with low mortality rates such as Brazil, Mexico, Chile, and others, per capita consumption is similar to the developed countries, at around 9 liters of pure alcohol per capita for 15 year-olds and above. The estimated percentage of heavy drinkers is somewhat lower, about 9.1%, with a similar average of per capita consumption of 14.1 liters per drinker, but the average pattern of drinking is higher- 3.1 liters for the entire Region of the Americas compared to 2.0 liters in the US and Canada. In developing countries with high mortality rates, such as Bolivia and Peru, average per capita consumption is lower, at 5.1 liters of pure alcohol per capita for 15 year-olds and above. These countries also see a lower percentage of heavy drinkers- about 2.7%- as well as their average consumption, which is around 7.6 liters.
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11. Beverage Types
Predominant beverage types tend to change relatively slowly in a culture
Whereas spirits drinking is often regarded as more problematic than drinking fermented beverages like wine or beer, the choice of beverage makes little difference in terms of most long-term health consequences
One aspect of the drinking pattern is the type of alcoholic beverage consumed. As noted in Module 1, there are many varieties of alcoholic beverages consumed throughout Latin America, with varying levels of alcohol content. In many places, one or two beverage types account for most of the alcohol consumption. Predominant beverage types tend to change relatively slowly in a culture, although there are historical exceptions. For example, in 1917, a major tax increase in Denmark suddenly altered the predominant alcoholic beverage from spirits to beer. The excise duty rate for distilled spirits was increased 12-fold and that of beer 2-fold. The consumption of distilled spirits decreased much more than that of beer, so the share of beer as a percent of total alcohol consumption increased, but there was definitely no substitution from distilled spirits to beer.
Historically, spirits drinking was often regarded as more problematic than drinking fermented beverages like wine or beer. From a medical perspective, the choice of beverage makes little difference in most long-term health consequences, such as liver cirrhosis and cancers of the mouth and upper digestive tract; it is the total amount of pure alcohol consumed, regardless of beverage type, that accounts for the toxic effects. But spirits drinking does bring some special problems. Fatal alcohol poisoning and aggressive behavior seem to be more strongly associated with spirits than with other types of alcoholic beverages. And yet, the harmful effects of specific beverages are less important than the specific cultural associations of different alcoholic beverages, and the drinking patterns associated with them.
In Latin America, traditional fermented beverages such as pulque (made from the maguey plant), and chicha (made from maize) play an important role in total alcohol consumption, with much of their production now industrialized. But nearly everywhere in the developing world, European-style lager beer is the prestige commodity among everyday alcoholic beverages. This style of beer, typically promoted and produced by multinational firms or their partners, shows growth in consumption levels in most parts of the developing world.
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12. The Drinking Context
Drinking in public places is particularly associated with heavy drinking and intoxication
The extent to which alcohol is consumed in public settings (i.e., pubs, bars, restaurants) rather than in private settings has implications for harmful consequences (particularly violence), as well as prevention strategies
Fiesta drinking, which is common in Indian cultures, increases the risk of alcohol-related problems such as injuries
The extent to which alcohol is consumed in public settings, such as pubs, bars, and restaurants, rather than in private settings, has implications for harmful consequences (particularly violence), as well as prevention strategies. Survey studies in several countries have found that drinking in public places, such as bars and football matches, is particularly associated with heavy drinking and intoxication. In particular, fiesta drinking, which is common in Indian cultures, increases the risk of alcohol-related problems such as injuries because drinking to intoxication is generally condoned.
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13. Heavy Episodic Drinking
Countries and population groups vary in the extent to which drinking to intoxication is a characteristic of the drinking pattern
They also differ in how intoxicated people get, and how people behave while intoxicated
Heavy episodic drinking, especially among young people, is particularly high in many countries in the region
Children in certain countries in the Americas are starting to drink alcohol at 10 years of age
Countries and population groups vary in the extent to which drinking to intoxication is a characteristic of the drinking pattern. Drinking patterns across groups also differ in how intoxicated people get, and how people behave while intoxicated. Heavy episodic drinking (often referred to as “ binge drinking”), especially among young people, is particularly high in many countries in the region. Studies suggest that children in certain countries in the Americas are starting to drink alcohol as young as 10 years of age. Intoxication is a particularly marked characteristic of drinking by teenagers and young adults in many cultures. As they are relative neophytes to drinking, their episodes of intoxication may be particularly prone to harmful consequences. Fiestas are another occasion when heavy episodic drinking is prevalent, especially among adult males.
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14. Percentage of Students (13-15 Years Old) who Drank at Least One Drink Containing Alcohol on One or More of the Past 30 Days
Country
Males
Females
Argentina
55.4
49.0
Costa Rica
23.4
23.6
Dominica
54.9
54.0
Grenada
49.1
43.0
Guatemala
18.1
14.2
Guyana
46.9
25.9
Saint Lucia
59.2
52.2
St Vincent and the Grenadines
52.6
53.5
Suriname
35.6
30.0
Trinidad and Tobago
39.6
42.0
Uruguay
62.0
57.7
Drinking by secondary school students is prevalent in the Region, but varies considerably by gender, age and country. The highest rates of drinking are reported in Uruguay, Santa Lucia and Argentina.
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15. Gender, Age, and Other Factors
In Latin America, men are more likely to be drinkers and women abstainers
Among drinkers, men drink on average significantly more than women
Intoxication or heavy drinking episodes are more frequent among adolescents and young adults
Indigenous populations are vulnerable to hazardous drinking
A large research literature, based primarily on survey studies of drinking habits, has consistently shown that there are significant differences in drinking patterns between men and women, between younger and older people, and often between ethnic or religious groups. In Latin America, there are striking gender differences in whether a person drinks, with men more likely to be drinkers and women abstainers. Among drinkers, men drink on average significantly more than women do. Some studies have shown that the gender difference in drinking has diminished over time in some countries.
Moreover, men drink heavily, which is to say, drinking to intoxication or consuming large quantities per occasion, much more often than women. This is consistently reported in a variety of countries. Hence, there are more heavy drinkers and more heavy drinking occasions among men, and consequently harmful drinking is more likely to be characteristic of men than women.
Abstinence or infrequent drinking are more prevalent in older age groups. Of particular concern in many countries is hazardous drinking among youth. In most of the countries where alcohol consumption is widespread, such as the US, Canada, Brazil, and Chile, a large proportion of adolescents drink alcohol, at least from time to time.
Another vulnerable group is indigenous populations. Rates of abstention are often higher in indigenous minority groups than in the surrounding population, but these groups also often have a significantly higher alcohol intake than the general population. There is particular concern about the pattern of consumption among indigenous minority groups. Fewer indigenous people seem to drink daily but when it occurs, drinking tends to be more hazardous, with any drinking at all often implying drinking to intoxication, for example, at fiestas.
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16. Implications: Total Alcohol Consumption
A significant fraction (10-15%) of the drinkers in a population consumes more than twice the average of all drinkers
When per capita consumption increases, there tends to be an increase in the proportion of heavy drinkers, and prevalence of dependence and alcohol-related problems
People tend to influence each other’s drinking
Studies from a number of countries demonstrate that alcohol consumption is very unevenly distributed in a population and among drinkers; most of the alcohol in a society is drunk by a relatively small minority of drinkers. Studies of the distribution of alcohol consumption have also shown a significant regularity in the relationship between the mean consumption among drinkers and the consumption level in various consumer groups. Thus, the higher the mean consumption in a population, the higher the consumption level for the most modest drinkers in that population, or those in the 25th percentile, for the somewhat heavier drinkers, or those in the 50th and the 75th percentiles, as well as for the heaviest drinkers (those in the 90th or 95th percentile). This implies that there is a strong relationship between the total consumption of alcohol in a population and the prevalence of people who are heavy drinkers.
When total alcohol consumption increases in a society, there tends to be an increase in the prevalence of heavy drinkers, defined in terms of a high annual alcohol intake. Because heavy drinkers account for a significant proportion of total alcohol consumption, it would be difficult for the total consumption level to increase without an increase in their drinking. It is, however, not only the consumption among heavy drinkers that affects the total consumption and an increase in total consumption seems to imply an increase in consumption in all consumer groups.
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17. Implications: Pattern of Drinking
Intoxication linked to homicides, suicide, injuries, heart disease and social harm
In some countries hazardous drinkers account for as many problems as alcoholics because they are far more numerous
The pattern of drinking matters as well: intoxication has been linked to homicides, suicide, injuries, heart disease and social harm.
The differences in amounts and patterns of drinking between different countries and global regions imply differences in the composition and mixture of social and health problems from drinking, the issue to which we turn in the next module. The differences also imply that it may be appropriate for the mixture of prevention and intervention strategies to vary from one society to another.
In some countries hazardous drinkers account for as many problems as alcoholics because they are far more numerous.
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18. Summary
There are striking gender differences in whether a person drinks, with men more likely to be drinkers and women abstainers.
Among drinkers, men drink ‘heavily’ (i.e., to intoxication, or large quantities per occasion) much more often than women.
Abstinence is the norm in most Latin American countries.
Most of the alcohol in a society is consumed by a relatively small minority of drinkers.
When alcohol consumption levels increase in a country, there tends to be an increase in the prevalence of heavy drinkers.
The following points summarize what has been learned from alcohol epidemiology research:
There are striking gender differences in whether a person drinks, with men more likely to be drinkers and women abstainers.
Among drinkers, men drink ‘heavily’ (i.e., to intoxication, or large quantities per occasion) much more often than women.
Abstinence and infrequent drinking are more prevalent in older age groups, and frequent intoxication is more prevalent among young adults. Abstinence is the norm in most Latin American countries when counting the whole population of the region.
Most of the alcohol in a society is consumed by a relatively small minority of drinkers.
When alcohol consumption levels increase in a country, there tends to be an increase in the prevalence of heavy drinkers.
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19. QUESTIONS Module 2: Epidemiology of Alcohol Use
Please answer the following questions to test your knowledge of the epidemiology of alcohol use.
QUESTIONS
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20. Drinking patterns refer to the:
Blood alcohol level and variability of alcohol consumption
Variability of alcohol consumption, amount, and the change in consumption over time
Amount, setting and dependence
Amount, setting, and variability of alcohol consumption
As we have seen, drinking patterns have an important effect on alcohol-related harms. What aspects of alcohol consumption are accounted for in WHO’s definition of drinking patterns?
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21. Drinking patterns refer to the:
Blood alcohol level and variability of alcohol consumption
Variability of alcohol consumption, amount and type of beverage
Amount, setting and dependence
Amount, setting, and variability of alcohol consumption
In Slide 5, we identified the amount and variability of alcohol consumption, the setting, and the type of beverage consumed as the aspects of alcohol use that contribute to drinking patterns.
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22. Heavy drinking is highest among which group?
Older women
Older men
Young males
Young females
A great deal of epidemiological research has been done on the different drinking habits of specific age and gender groups within a country. Among which of these populations is heavy drinking most common?
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23. Heavy drinking is highest among which group?
Older women
Older men
Young males
Young females
In Slide 17, we mentioned research demonstrating that men on average drink significantly more than women do and that heavy drinking episodes are more frequent among adolescents and young adults. Young men compose the group most likely to engage in heavy drinking patterns.
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24. REFLECTION
What epidemiological data is available for your country? Who drinks, what, how, with what consequences?
What epidemiological data is available for your country? Who drinks, what, how, with what consequences?
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