1. Alcohol in Development and in Health and Social Policy David Jernigan PhD Center on Alcohol Marketing and Youth Georgetown University Washington, D.C. dhj@georgetown.edu Robin Room PhD Center for Social Research on Alcohol and Drugs University of Stockholm Stockholm, Sweden Jürgen T. Rehm PhD Addiction Research Institute Zurich, Switzerland

2. Presentation Overview To what extent is alcohol harmful or beneficial to health and social well- being? To what extent is alcohol harmful or beneficial to health and social well- being? Alcohol’s role in the global burden of disease Alcohol’s role in the global burden of disease Alcohol and social harms Alcohol and social harms Relationship between alcohol production, consumption, benefits and problems Relationship between alcohol production, consumption, benefits and problems Monitoring alcohol problems Monitoring alcohol problems Preventing and reducing alcohol problems Preventing and reducing alcohol problems

3. WHO’s Comparative Risk Assessment Collaborating Group 27 groups: 27 groups: Core, metholodology, etc. groupCore, metholodology, etc. group 26 risk factor groups26 risk factor groups Alcohol group: Alcohol group: J Rehm, R Room, M Monteiro, G Gmel, K Graham, N Rehn, C T Sempos, U Frick, D JerniganJ Rehm, R Room, M Monteiro, G Gmel, K Graham, N Rehn, C T Sempos, U Frick, D Jernigan

4. WHO’s Comparative Risk Assessment (CRA) Childhood and maternal undernutrition: underweight, iron deficiency, vitamin A deficiency, zinc deficiency; Childhood and maternal undernutrition: underweight, iron deficiency, vitamin A deficiency, zinc deficiency; Other diet-related risks and physical inactivity: blood pressure, cholesterol, overweight, low fruit and vegetable intake, physical inactivity; Other diet-related risks and physical inactivity: blood pressure, cholesterol, overweight, low fruit and vegetable intake, physical inactivity; Sexual and reproductive health risks: unsafe sex, lack of contraception; Sexual and reproductive health risks: unsafe sex, lack of contraception; Addictive substance use: tobacco, alcohol, illicit drugs; Addictive substance use: tobacco, alcohol, illicit drugs; Environmental risks: unsafe water, sanitation and hygiene, urban air pollution, indoor smoke from solid fuels, lead exposure, climate change; Environmental risks: unsafe water, sanitation and hygiene, urban air pollution, indoor smoke from solid fuels, lead exposure, climate change; Occupational risks: risk factors for injury, carcinogens, airborne particulates, ergonomic stressors, noise; Occupational risks: risk factors for injury, carcinogens, airborne particulates, ergonomic stressors, noise; Other selected risks to health: unsafe health care injections, childhood sexual abuse. Other selected risks to health: unsafe health care injections, childhood sexual abuse.

5. The epidemiological model Attributable fractions =f(prevalence,pattern weight,relative risk) Defined as: With a given outcome exposure factor, and population, the attributable fraction is the proportion by which the incidence rate of the outcome would be reduced if the distribution of exposure would change to an alternative distribution: “When an exposure is believed to be a cause of a given disease, the attributable fraction is the proportion of the disease in the specific population that would be eliminated in the absence of the exposure.” Four drinking categories (old English et al. terminology: abstainer, moderate, hazardous, harmful) are distinguished. Prevalence for all four categories are taken from surveys Steps to derive at pattern weight: 1. Determine pattern value from survey of key informants, and/or survey data where available. 2. Conduct hierarchical linear analyses on mortality using per capita consumption gross-national product, year (level 1 variables) and pattern values (level 2 variable) as determining factors (separate by age and sex). 3. Construct pattern weight based on intercept and regression weight for patterns. Relative Risk estimates for each drinking category are either taken directly from meta- analyses (chronic diseases) or indirectly from meta-analyses of attributable fractions (injuries)

6. Prevalence data Adult per capita consumption estimates for countries totaling 90% of world’s population Adult per capita consumption estimates for countries totaling 90% of world’s population Survey data from 69 countries, covering 80% of world’s population Survey data from 69 countries, covering 80% of world’s population Survey and adult per capita consumption data for more than 50% of countries Survey and adult per capita consumption data for more than 50% of countries

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

8. Patterns of drinking Countries assigned hazardous drinking scores, a numeric indicator of hazard per litre of alcohol consumed Countries assigned hazardous drinking scores, a numeric indicator of hazard per litre of alcohol consumed Information drawn from research literature supplemented by key informant questionnaires Information drawn from research literature supplemented by key informant questionnaires Applied to two areas: injuries and CHD. Applied to two areas: injuries and CHD.

9. Dimensions of patterns of drinking High usual quantity of alcohol per occasion Festive drinking common – at fiestas or community celebrations Proportion of drinking occasions when drinkers get drunk Low proportion of drinkers who drink daily or nearly daily Less common to drink with meals Common to drink in public places

10. Pattern of drinking 2000 (based on CRA) Patterns of drinking 1.00 to 2.00 2.00 to 2.50 2.50 to 3.00 3.00 to 4.00

11. Volume of drinking Drinking pattern hazard score (predominance of intoxication) Prior alcohol dependence Depression Injuries Coronary heart disease Physical diseases (except CHD) Alcohol- attributable conditions* Aspects of alcohol used in estimating alcohol attributable fraction (AAF) for different conditions *AAF = 1 by definition

12. Estimating AAFs 1. Alcohol-specific categories 2. Chronic health conditions 3. CHD 4. Depression 5. Injuries

13. Alcohol-related disorders Chronic disease: Chronic disease: Conditions arising during perinatal period*: low birth weightConditions arising during perinatal period*: low birth weight Cancer*: lip & oropharyngeal cancer, esophageal cancer, liver cancer, laryngeal cancer, female breast cancerCancer*: lip & oropharyngeal cancer, esophageal cancer, liver cancer, laryngeal cancer, female breast cancer Neuropsychiatric diseases: alcohol use disorders, unipolar major depression, epilepsyNeuropsychiatric diseases: alcohol use disorders, unipolar major depression, epilepsy Diabetes*Diabetes* Cardiovascular diseases: hypertension, coronary heart disease, strokeCardiovascular diseases: hypertension, coronary heart disease, stroke Gastrointestinal diseases*: liver cirrhosisGastrointestinal diseases*: liver cirrhosis Injury: Injury: Unintentional injury: motor vehicle accidents, drownings, falls, poisonings, other unintentional injuriesUnintentional injury: motor vehicle accidents, drownings, falls, poisonings, other unintentional injuries Intentional injury: self-inflicted injuries, homicide, other intentional injuriesIntentional injury: self-inflicted injuries, homicide, other intentional injuries * AAF based on volume of drinking only

14. Estimating AAFs: 5. Alcohol-attributable depression Started with estimated rates of alcohol dependence in each region (derived from pooled psychiatric epidemiological studies) Started with estimated rates of alcohol dependence in each region (derived from pooled psychiatric epidemiological studies) Used some of same studies to derive proportion of cases with both depression and alcohol problems where alcohol onset was prior to onset of depression Used some of same studies to derive proportion of cases with both depression and alcohol problems where alcohol onset was prior to onset of depression Regressed these proportions on rates of alcohol dependence to establish upper-limit estimates Regressed these proportions on rates of alcohol dependence to establish upper-limit estimates To eliminate effect of co-occurrences due to chance, rate of alcohol use disorders then subtracted from these estimates To eliminate effect of co-occurrences due to chance, rate of alcohol use disorders then subtracted from these estimates Finally, halved AAFs to account for lack of control of confounders Finally, halved AAFs to account for lack of control of confounders

15. Alcohol-related global burden of disease Alcohol-attributable mortality 0.35 to 1.00 1.00 to 4.00 4.00 to 6.00 6.00 to 8.00 8.00 to 20.00

16. Disease conditionsMales Females Total % of all alcohol- attributable deaths Conditions arising during the perinatal period 2130% Malignant neoplasm2698635520% Neuro-psychiatric conditions91191116% Cardiovascular diseases392-12426815% Other non-communicable diseases (diabetes, liver cirrhosis) 1934924213% Unintentional injuries4849257732% Intentional injuries2064224814% Alcohol-related mortality burden all causes 1,6381661,804100.0% All deaths29,23226,62955,861 In comparison: estimate for 1990: 1.5% % of all deaths which are alcohol-attributable 5.6%0.6%3.2% Global mortality burden (deaths in 1000s) attributable to alcohol by major disease categories - 2000

17. Disease conditionsMales Females Total % of all alcohol- attributable DALYs Conditions arising during the perinatal period 68551230% Malignant neoplasm3,1801,0214,2017% Neuro-psychiatric conditions18,0903,81421,90438% Cardiovascular diseases4,411-4283,9837% Other non-communicable diseases (diabetes, liver cirrhosis) 3,6958604,5558% Unintentional injuries14,0082,48716,49528% Intentional injuries5,9451,1177,06212% Alcohol-related disease burden all causes (DALYs) 49,3978,92658,323100% All DALYs755,176689,993 1,445,169 In comparison: estimate for 1990: 3.5% % of all DALYs which are alcohol-attributable 6.5%1.3% 4.0% Global burden of disease (DALYs in 1000s) attributable to alcohol by major disease categories - 2000

18. Disability-Adjusted life Years (DALYs) attributable to ten leading risk factors, 2000 WorldHigh mortality developing countries Low mortality developing countries Developed countries DALYs (millions) % total MalesFemalesMalesFemalesMalesFemales Underweight1389.514.91533.30.4 Unsafe sex926.39.4111.21.60.51.1 Blood pressure644.42.62.44.95.111.210.6 Tobacco594.13.40.66.21.317.16.2 Alcohol5842.60.59.82143.3 Unsafe water, sanitation, hygiene 543.75.55.61.71.80.4 Cholesterol402.81.9 2.2287 Indoor smoke from solid fuels 392.63.73.61.52.30.20.3 Iron deficiency352.42.83.51.52.20.51 Overweight332.30.612.33.26.98.1

19. Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS) Developing countries Developed countries High mortality Low mortality Underweight14.9%Alcohol 6.2 % Tobacco 12.2 % Unsafe sex 10.2 % Blood pressure 5.0 % Blood pressure 10.9 % Unsafe water & sanitation 5.5 % Tobacco 4.0 % Alcohol 9.2 % Indoor smoke (solid fuels) 3.6 % Underweight 3.1 % Cholesterol 7.6 % Zinc deficiency 3.2 % Body mass index 2.7 % Body mass index 7.4 % Iron deficiency 3.1 % Cholesterol 2.1 % Low fruit & vegetable intake 3.9 % Vitamin A deficiency 3.0 % Low fruit & vegetable intake 1.9 % Physical inactivity 3.3 % Blood pressure 2.5 % Indoor smoke from solid fuels 1.9 % Illicit drugs 1.8 % Tobacco 2.0 % Iron deficiency 1.8 % Unsafe sex 0.8 % Cholesterol 1.9 % Unsafe water & sanitation 1.8 % Iron deficiency 0.7 %

20. Alcohol-related social harms Child abuse – 8.6%-63% Child abuse – 8.6%-63% Domestic violence – 26%-76% Domestic violence – 26%-76% Family budget – 1%-11% overall Family budget – 1%-11% overall Greater for families with frequent drinkersGreater for families with frequent drinkers E.g. Delhi – 24% of budgets of families with frequent drinkers E.g. Delhi – 24% of budgets of families with frequent drinkers Problems for youth: Problems for youth: Criminal behaviorCriminal behavior Failure to achieve educational qualificationsFailure to achieve educational qualifications

21. Measuring social harms 1. Cost of illness studies E.g. Scotland: E.g. Scotland: Health care costs $139 million Health care costs $139 million Social work costs$125 million Social work costs$125 million Criminal justice and fire costs $390 million Criminal justice and fire costs $390 million 2. Service system utilization by “problem drinkers” California urban/suburban/rural county California urban/suburban/rural county 41% in criminal justice system 41% in criminal justice system 8% in social welfare system 8% in social welfare system 42% in general health care system 42% in general health care system 3% in public mental health system 3% in public mental health system 6% in public alcohol or drug treatment system 6% in public alcohol or drug treatment system 3. Survey research Canada – harms from someone else’s drinking Canada – harms from someone else’s drinking 7.2% pushed, hit or assaulted 7.2% pushed, hit or assaulted 6.2% friendships harmed 6.2% friendships harmed 7.7% family or marriage difficulties 7.7% family or marriage difficulties

22. Trends in alcohol consumption

23. Relationship between alcohol production and consumption Alcohol production and consumption Alcohol production and consumption Most alcohol consumed near point of productionMost alcohol consumed near point of production 8% of recorded alcohol production enters into international trade 8% of recorded alcohol production enters into international trade Consumption tends to be concentrated in minority of population, e.g.Consumption tends to be concentrated in minority of population, e.g. USA: 10% drinks 61% of the alcohol USA: 10% drinks 61% of the alcohol New Zealand: 5% drinks 1/3 of the alcohol New Zealand: 5% drinks 1/3 of the alcohol

24. Relationship between alcohol consumption and alcohol problems Alcohol problems arise from: Alcohol problems arise from: Intoxication occasionsIntoxication occasions Repeated episodes of intoxicationRepeated episodes of intoxication Steady heavy drinkingSteady heavy drinking Protective effect from consistent moderate drinking Protective effect from consistent moderate drinking This pattern rare in developed countries, even less common in developing societiesThis pattern rare in developed countries, even less common in developing societies Bottom line: level of alcohol problems in a society will tend to rise with level of alcohol consumption Bottom line: level of alcohol problems in a society will tend to rise with level of alcohol consumption

25. Social and health benefits of drinking Social benefits of drinking largely unquantifiable Social benefits of drinking largely unquantifiable Alcohol’s role as integrative, bonding or socially lubricative substanceAlcohol’s role as integrative, bonding or socially lubricative substance Health benefits of alcohol Health benefits of alcohol Protective effect for CHD evident at individual level at as low as one drink every other dayProtective effect for CHD evident at individual level at as low as one drink every other day Protection not found at the aggregate levelProtection not found at the aggregate level Could be some drinkers shift to more heart-healthy pattern, as others change to more dangerous patterns Could be some drinkers shift to more heart-healthy pattern, as others change to more dangerous patterns Leads to conclusion that there are no net benefits at the population level from any policy that seeks to increase alcohol consumptionLeads to conclusion that there are no net benefits at the population level from any policy that seeks to increase alcohol consumption

26. Alcohol and development Alcohol consumption tends to rise with economic development, absent mitigating factors (e.g. religion) Alcohol consumption tends to rise with economic development, absent mitigating factors (e.g. religion) Four modes of production of alcohol: Four modes of production of alcohol: Traditional/indigenousTraditional/indigenous Industrialized traditional/indigenousIndustrialized traditional/indigenous Industrialized cosmopolitanIndustrialized cosmopolitan Globalized cosmopolitanGlobalized cosmopolitan Trend is towards the latter, particularly in distilled spirits and beer Trend is towards the latter, particularly in distilled spirits and beer

27. Alcohol and development: benefits? Employment and income generation Employment and income generation Direct employment declines with industrializationDirect employment declines with industrialization Indirect employment may increase in wholesaling and distribution, but less likely in retail sectorIndirect employment may increase in wholesaling and distribution, but less likely in retail sector Government revenue – justifiable for: Government revenue – justifiable for: Economic efficiency – correct for negative externalitiesEconomic efficiency – correct for negative externalities Public health – reduce consumptionPublic health – reduce consumption Revenue raising – as high as 24% of some state revenuesRevenue raising – as high as 24% of some state revenues

28. Alcohol and development: benefits? Quality improvement Quality improvement Industrialization leads to greater uniformity and reliability of productIndustrialization leads to greater uniformity and reliability of product Sourcing of inputs and balance of payment issues Sourcing of inputs and balance of payment issues Import substitution constrained by size of domestic market – also may require import of inputs as opposed to finished productImport substitution constrained by size of domestic market – also may require import of inputs as opposed to finished product Alcohol unlikely to make much contribution to exportsAlcohol unlikely to make much contribution to exports

29. Alcohol and development: benefits? MNCs and technology transfer MNCs and technology transfer “Turnkey” technologies increasing“Turnkey” technologies increasing Design, R&D and engineering expertise remains in headquarters countriesDesign, R&D and engineering expertise remains in headquarters countries Encouragement of packaging and distribution networks Encouragement of packaging and distribution networks Early form of foreign direct investment Early form of foreign direct investment If increased alcohol supply will not worsen public health and safety situation regarding alcoholIf increased alcohol supply will not worsen public health and safety situation regarding alcohol

30. Preventive interventions: individual-based Education and persuasion Education and persuasion Little evidence of effectiveness of school-based programs beyond the short-termLittle evidence of effectiveness of school-based programs beyond the short-term Media campaigns unlikely to change behavior, but may increase support for more effective policiesMedia campaigns unlikely to change behavior, but may increase support for more effective policies Deterrence Deterrence Effective in reducing drinking-drivingEffective in reducing drinking-driving Speed and certainty of punishment crucial to effectivenessSpeed and certainty of punishment crucial to effectiveness

31. Preventive interventions: individual-based Encouraging alternatives Encouraging alternatives Little evidence of effectiveness of lasting effectsLittle evidence of effectiveness of lasting effects Too many alternatives go well with alcohol, e.g. soft drinksToo many alternatives go well with alcohol, e.g. soft drinks Do contribute to improving quality of life for disadvantaged populationsDo contribute to improving quality of life for disadvantaged populations Treatment and mutual help Treatment and mutual help Part of a humane societal responsePart of a humane societal response Brief interventions, self-help effective and result in net savings in social and health costsBrief interventions, self-help effective and result in net savings in social and health costs Treatment alone is not a cost-effective means of reducing alcohol-related problemsTreatment alone is not a cost-effective means of reducing alcohol-related problems

32. Preventive interventions: environmentally-based Insulating use from harm Insulating use from harm Server and manager training can reduce drinking-driving, violenceServer and manager training can reduce drinking-driving, violence Provision of public transport, relocation of drinking places away from residences can also be effectiveProvision of public transport, relocation of drinking places away from residences can also be effective General protections, e.g. airbags, sidewalks, are effectiveGeneral protections, e.g. airbags, sidewalks, are effective “Designated driver” programs lack evidence of effectiveness“Designated driver” programs lack evidence of effectiveness

33. Preventive interventions: environmentally-based Regulating availability, conditions of use Regulating availability, conditions of use ProhibitionsProhibitions Difficult to enforce Difficult to enforce Minimum-age drinking laws (partial prohibition)Minimum-age drinking laws (partial prohibition) Effective if enforced Effective if enforced Taxation and other price increasesTaxation and other price increases Demand for alcohol generally inelastic Demand for alcohol generally inelastic Can be effective if market is under control Can be effective if market is under control

34. Preventive interventions: environmentally-based Regulating availability, conditions of use Regulating availability, conditions of use Limiting sales outlets, hours and conditions of saleLimiting sales outlets, hours and conditions of sale Research literature shows effectiveness of measures making alcohol purchase less convenient Research literature shows effectiveness of measures making alcohol purchase less convenient Monopolies on production or saleMonopolies on production or sale Retail monopolies have greater public health effects Retail monopolies have greater public health effects Production monopolies assist in control of market Production monopolies assist in control of market Production restrictionsProduction restrictions Can be effective but difficult to enforce Can be effective but difficult to enforce Limits on advertising and promotionLimits on advertising and promotion Some evidence bans are effective Some evidence bans are effective “Unmeasured” activities increasing, and difficult to regulate “Unmeasured” activities increasing, and difficult to regulate

35. Other policy concerns Social and religious movements, civil society and NGOs can be key Social and religious movements, civil society and NGOs can be key Alcohol policy needs to be societal, integrated and consistent Alcohol policy needs to be societal, integrated and consistent International trade agreements need to make exception for alcohol as “no ordinary commodity” International trade agreements need to make exception for alcohol as “no ordinary commodity”

36. Monitoring alcohol consumption Per capita alcohol consumption (age 15+) Per capita alcohol consumption (age 15+) Number of abstainers: Number of abstainers: Pattern of drinking: Pattern of drinking: frequency of getting drunk or drinking >60 grams of ethanol (5+ drinks),frequency of getting drunk or drinking >60 grams of ethanol (5+ drinks), usual quantity per drinking session,usual quantity per drinking session, fiesta drinking,fiesta drinking, drinking in public places,drinking in public places, not drinking with meals, and not drinking dailynot drinking with meals, and not drinking daily frequencies and percentages of all alcohol drunk on >40g. days for men and >20g. days for womenfrequencies and percentages of all alcohol drunk on >40g. days for men and >20g. days for women Youth use Youth use

37. Monitoring alcohol problems alcohol-involved traffic crashes/injuries alcohol-involved traffic crashes/injuries alcohol-involved crimes alcohol-involved crimes hospitalizations and deaths from strongly alcohol- involved causes: hospitalizations and deaths from strongly alcohol- involved causes: liver disease (if rates of hepatitis B and C are low),liver disease (if rates of hepatitis B and C are low), alcohol-specific causes such as alcoholic liver disease, alcohol dependence, and alcoholic psychosisalcohol-specific causes such as alcoholic liver disease, alcohol dependence, and alcoholic psychosis other alcohol-related problems: other alcohol-related problems: problems with family, friendships, work, police, financial, health, alcohol dependenceproblems with family, friendships, work, police, financial, health, alcohol dependence problems from others’ drinking: problems from others’ drinking: family, friendships, work, injury, property loss, public nuisancefamily, friendships, work, injury, property loss, public nuisance

38. The Future Increase in alcohol-related burden for two reasons: –The disease categories related to alcohol are relatively increasing: chronic disease, accidents and injuries –Alcohol consumption is increasing in the most populous parts of the world –Patterns are stable if not getting worse If there are no interventions!!!