1. Políticas Públicas em Alcohol Prof. Dr. Ronaldo Laranjeira Universidade Federal de São Paulo

2. Chosing effective strategies Need for a systematic procedure to evaluate the evidence, compare alternativa interventions and assess the fbenefits to society of different approaches

4. Proportion of alcohol consumers in WHO sub- regions

6. Drinking Pattern Values for Selected WHO Regions

8. 12 leading selected risk factors as causes of disease burden measured in DALYs Developed countries Developing countries High Mortality Low Mortality 1 UnderweightAlcohol(6.2%)Tobacco (12.2%) 2 Unsafe sexBlood pressure Blood pressure 3 Unsafe waterTobacco (4.0%)Alcohol (9.2%) 4 Indoor smokeUnderweightCholesterol 5 Zinc deficiencyBody mass index Body mass index 6 Iron deficiencyCholesterolLow fruit & veg intake 7 Vitamin A deficiencyLow fruit & veg intake Physical inactivity 8 Blood pressureIndoor smoke - solid fuels Illicit drugs (1.8%) 9 Tobacco (2.0%)Iron deficiency Unsafe sex 10 CholesterolUnsafe waterIron deficiency 11 Alcohol Unsafe sexLead exposure 12 Low fruit & veg intake Lead exposureChild sexual abuse

9. World Deaths in 2000 attributable to selected leading risk factors Number of deaths (000s)

10. World Disease burden (DALYs) in 2000 attributable to selected leading risk factors Number of Disability-Adjusted Life Years (000s)

11. World Disease burden (DALYs) in 2000 attributable to Addictive Substances related Risks Number of Disability-Adjusted Life Years (000s)

12. World Deaths in 2000 attributable to Addictive Substances related Risks Number of deaths (000s)

13. World Deaths in 2000 attributable to Addictive Substances related Risks Number of deaths (000s)

14. WHO Regions Deaths in 2000 attributable to selected leading risk factors Number of deaths (000s)

15. WHO Regions Disease burden (DALYs) in 2000 attributable to selected leading risk factors Number of Disability-Adjusted Life Years (000s)

16. Burden of disease attributable to addictive substances related risks: ALCOHOL (% DALYs in each subregion) 0.5-0.9% 1-1.9% 2-3.9% 4-7.9% <0.5% 8-15.9% Proportion of DALYs attributable to selected risk factor

17. Burden of disease attributable to addictive substances related risks: TOBACCO (% DALYs in each subregion) Proportion of DALYs attributable to selected risk factor 0.5-0.9% 1-1.9% 2-3.9% 4-7.9% <0.5% 8-15.9%

18. Proportion of DALYs attributable to selected risk factor <0.5% 0.5-0.9% 1-1.9% 2-3.9% Burden of disease attributable to addictive substances related risks: ILLICIT DRUGS (% DALYs in each subregion)

23. Conclusions The burden of licit and illicit drug problems is increasingly evident. From a public health perspective tobacco and alcohol use carry much higher burdens that illicit drug use. Alcohol and drug polices need to address the relative harms of these substances. In the management of psychoactive substance problems (prevention and treatment) more attention should be paid to epidemiologic evidence and developments in neuroscience.

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

25. Patterns of drinking 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 Applied to two areas: injuries and CHD.

26. 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

27. 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

28. 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

29. Alcohol-related disorders Chronic disease: –Conditions arising during perinatal period*: low birth weight –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, stroke –Gastrointestinal diseases*: liver cirrhosis Injury: –Unintentional injury: motor vehicle accidents, drownings, falls, poisonings, other unintentional injuries –Intentional injury: self-inflicted injuries, homicide, other intentional injuries * AAF based on volume of drinking only

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

31. 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

32. Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS) Developing countries Developed countries High mortalityLow mortality Underweight14.9% Alcohol6.2 %Tobacco12.2 % Unsafe sex10.2 %Blood pressure5.0 %Blood pressure10.9 % Unsafe water & sanitation 5.5 % Tobacco4.0 %Alcohol9.2 % Indoor smoke (solid fuels) 3.6 %Underweight3.1 %Cholesterol7.6 % Zinc deficiency3.2 %Body mass index2.7 %Body mass index7.4 % Iron deficiency3.1 %Cholesterol2.1 % Low fruit & vegetable intake 3.9 % Vitamin A deficiency3.0 %Low fruit & vegetable intake1.9 %Physical inactivity3.3 % Blood pressure2.5 % Indoor smoke from solid fuels 1.9 % Illicit drugs1.8 % Tobacco2.0 % Iron deficiency1.8 %Unsafe sex0.8 % Cholesterol1.9 %Unsafe water & sanitation1.8 %Iron deficiency0.7 %

33. 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

34. 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

35. 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!!!

36. Global Alcohol Policy WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM

37. Declarations of interest  Used to be Regional Advisor for both alcohol and tobacco policy, WHO Regional Office for Europe  Scientist and policy advisor for Eurocare

38. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM Structure of presentation 1.Eurocare 2.The problem of alcohol 3.Some solutions for alcohol policy 4.Expectations of the WHO 5.What NGOs can bring

39.  Eurocare was formed in 1990 as an alliance of non-governmental organisations concerned with the impact of the European Union on alcohol policy in Member States  Starting with 9 member organisations in 1990, it now has 46 members from 12 EU States, 5 non EU States and 3 International Organisations with members in 26 European countries Brief Description of Eurocare:

40.  Eurocare promotes the implementation of evidence based alcohol policy and provides support to its member organizations  Key publications include:  Alcohol problems and the family, 1998  The beverage alcohol industry’s social aspects organizations: A public health warning, 2002  Drinking and driving in Europe, 2003 Brief Description of Eurocare:

41.  Eurocare will be implementing a 3 year European Commission funded project (Alcohol Policy Network in the Context of a larger Europe: Bridging the Gap):  Creating an alcohol policy network in 27 European Member States and applicant countries, Norway and Switzerland  Preparing a report on alcohol in Europe  Preparing an advocacy training manual  Convening a European conference, Bridging the Gap, Warsaw, Poland, 16-19 June 2004  Convening two summer advocacy schools, Slovenia 2005 and Catalonia 2006. Brief Description of Eurocare:

42. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM

43. These are net costs, accounting for heart disease They do not include social harms They do not include financial costs

44. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM

47. At the community level:  Drinking and driving  Intoxication

48. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM WHO Region % dependent on alcohol North and Central Africa 0.7 Southern Africa 1.6 North America 5.1 Latin America 3.5 South America 3.2 Middle East 0.0 Western Asia 0.0 Western Europe 3.4 Central Europe 0.8 Caucasus and Central Asia 0.2 Former Soviet Union 4.8 South-East Asia 0.4 Indian sub-continent 0.8 Australasia and Japan 2.1 Western Pacific, including China 0.9

49. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM Healthy Public Policy: Taxation Bans on advertising and marketing

50. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM Strengthening Community Action: Drink driving Educational and prevention programmes Manage availability

51. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM Helping individuals: Brief interventions in primary care Treatment for dependence

52. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Match resources to the size of the problem The purpose of alcohol policy is to reduce the harm done by alcohol. The greater the harm, the greater the need for policy. 4% of GBD; 5 th in list of risk factors

53. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? There is a strong team But, it seems divided and unclear at present

54. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Strong Regional Offices Seems a posteriority rather than a priority

55. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Need a simple metric (like a billion deaths from smoking) Globally, every drinker loses on average 11 days of healthy life per year.

56. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Do we need a FCAC? Or some other mechanism to mobilize action?

57. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Make the science clear

58. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Calculate the economic burden

59. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Estimate the social burden

60. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Get some powerful partners (?World Bank)

61. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? In dealing with the alcohol industry, ENSURE that WHO sticks to its guidelines

62. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Disseminate and implement these guidelines throughout: The organization The Regional Offices The Collaborating centres The country offices

63. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? The industry argues that they have a place at the policy table. They don’t.

64. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? The industry argues that they are a public health body. They are not.

65. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Don’t be duped by the alcohol industry and their social aspects organizations.

66. Effective policy Ineffective policy Opposed by social aspects organizations Supported by social aspects organizations Taxation Negative elasticities between price of alcohol and cirrhosis, fatal and non-fatal traffic accidents and intentional injuries (as price goes up, harm goes down) 1 Takes the view that taxation has no impact on alcohol-related harm; takes the view that the solution to the problem of misuse does not lie in restrictions which penalize everyone for the mistakes of a minority 3 Legal drinking age Increased drinking ages reduce traffic fatalities; reduced drinking ages lead to increases in assaults 2 Suggests that there is no consensus as to whether or not minimal drinking ages are desirable 4 ; opposed to increasing legal drinking ages believing that it does not address those who abuse the product 3 Outlet density Increased outlet density associated with traffic accidents, assaults and liver cirrhosis 2 Opposed to limiting outlet density believing that it does not address those who abuse the product 3 Days and Hours of sale Closure of stores associated with reduced alcohol related violence; extended trading hours associated with increases in road traffic accidents and alcohol-related violence 2 Believes that programmes that restrict days and hours of sale are ineffective and do not go to the heart of the problem of alcohol-related violence; opposed to restricting days and hours of sale believing that they do not address those who abuse the product 3 Proof of age schemes Evidence for the impact of policy measures such as proof of age schemes is not available Supports campaigns against underage access, such as proof of age schemes 5  X X X X Price and the availability of alcohol

67. Effective policy Ineffective policy Opposed by social aspects organizations Supported by social aspects organizations Physical environment Changing the physical environment of drinking places reduces alcohol related violence 1 Takes the position that the vast majority of drinking episodes do not involve violence, and most violence does not involve drinking, but recognizes that in some individuals and groups, a pattern of behaviour may include both abusive drinking and violence; offers no concrete proposals 2 Social environment Decreasing the permissiveness of the environment (better staff control; less discount drinks) reduces alcohol-related violence 1 Server training with legal sanctions Responsible server programs supported by legal sanctions reduce harms from intoxication 1 Opposed to legal sanctions; accepts that server training leads to a reduction in licensee liability for damages resulting from illegal service by trained servers 3. Server training without legal sanctions Responsible server programs not supported by legal sanctions do not reduce harms from intoxication 1 Trains servers not to sell to underage drinkers, but without legal sanctions 4 X X  Creating safer drinking environments

68. Effective policy Ineffective policy Opposed by social aspects organizations Supported by social aspects organizations Community action based on both environmental and educational approaches Comprehensive locally based community prevention programs have led to 10% reductions in alcohol involved car crashes, 25% reductions in fatal crashes and 43% reductions in alcohol related violence 1 Opposed to environmental approaches, believing that they do not address those who abuse the product. Locally based community prevention programs based only on educational approaches Have limited or no effect 1 Describes school based alcohol education, and drink driving education programmes as community based programmes 6 Legal restrictions Although difficult to evaluate, there is evidence for a link between advertising and consumption at individual and aggregate level; econometric analysis suggest that advertising restrictions reduce motor vehicle fatalities 2 Takes the view that there is insufficient evidence to support an association between advertising and levels or patterns of drinking; opposed to legislative marketing restrictions Alcohol education in schools In general no, or very limited impact on use of alcohol; no evidence for an impact on harm 3 Promotes and funds school based educational programme, in which “the pleasure of drinking responsibly is part of a balanced lifestyle” 7 Public education campaigns In general no, or very limited impact on use of alcohol; no evidence for an impact on harm 4 Stresses the importance of educational programmes as the key policy choice to reduce alcohol- related harm 6 Self-regulation Considerable evidence that self regulatory codes are not adhered to 5 ; The production and dissemination of self-regulatory codes a core area of work,8,9 X X     Prevention and education programmes

69. Effective policy Ineffective policy Opposed by social aspects organizations Supported by social aspects organizations Legal drinking age Increased drinking age in US reduced traffic accidents by 5%-28% 1 Suggests that there is no consensus as to whether or not minimal drinking ages are desirable 2 ; opposed to increasing legal drinking ages believing that it does not address those who abuse the product (i.e. drink driving) 3 Regulating the conditions of sale Extending trading hours increases traffic accidents; targeted programmes at high risk premises reduce accidents 1 Believes that programmes that restrict days and hours of sale are ineffective and do not go to the heart of the problem of alcohol-related accidents; opposed to restricting days and hours of sale believing that they do not address those who abuse the product (i.e. drink driving) 3 Random breath testing High visibility can reduce deaths by between one third and one half 1 Generally opposed to high visibility random breath testing 4 Reducing legal BAC limit Reduces drink driving and fatalities across all levels of BAC 1 Opposed to any reductions in legal BAC limits 5 Public education campaigns No evidence for a beneficial effect on alcohol-related crashes 1 Believes that educational programmes are the core component of drink driving programmes 6 Interventions by servers, hosts and peers Ineffective, although increased protection of drinking peers 1 Works with the hotel, restaurant, cafe and bar sectors to develop anti-drink driving initiatives 3 Alternative transportation programmes Limited evidence suggests ineffective 1 Alternative transportation programmes (designated river campaigns) are priority projects 6 X X X X    Drink driving programmes

70. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? There cannot be common ground on drinking and driving

71. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM Eurocare recommendation: 6.Because of limited evidence for their effectiveness in reducing drinking and driving, public education efforts to persuade drinkers not to drive after drinking, programmes to encourage servers to prevent intoxicated individuals from driving, and organized efforts to make provisions for alternative transportation should not be the main cornerstones of drinking and driving policy.

72. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? There should be no discussion on self-regulation

73.  It serves the needs of the industry  The reality is based on complaints rather than compliance  The advertisements still go ahead anyway  There is no enforcement  It is not independent, and reflects the ‘intentions’ of the advertisers  Does not reflect the marketing to young people We should not waste any more time on self-regulation

74. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? The Smirnoff day off speaks much louder to politicians than all the research

75. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Encourage litigation

76. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Policy Action Plans: Globally Regionally Country wide Regional Local

77. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Community Action Database of community programmes

78. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can WHO (and its MS) do? Health sector Be clear and consistent on nomenclature (ICD 10) Promote brief interventions Reorient health care

79. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can the NGO sector do? We are your friends; But also your watchdog

80. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can the NGO sector do? Support you in any or all of the above Promote and disseminate the science that empowers alcohol policy Develop advocacy and promote advocacy skills Monitor the alcohol industry

81. WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM What can the NGO sector do? And do we write formally to the WHO after this consultation, or what?

82. Thank you for your attention WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM

83. 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 J ü rgen T. Rehm PhD Addiction Research Institute Zurich, Switzerland

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

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

86. WHO’s Comparative Risk Assessment (CRA) 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; Sexual and reproductive health risks: unsafe sex, lack of contraception; 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; Occupational risks: risk factors for injury, carcinogens, airborne particulates, ergonomic stressors, noise; Other selected risks to health: unsafe health care injections, childhood sexual abuse.

87. 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)

88. Prevalence data 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 and adult per capita consumption data for more than 50% of countries

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

90. Patterns of drinking 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 Applied to two areas: injuries and CHD.

91. 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

92. 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

93. 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

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

95. Alcohol-related disorders Chronic disease: –Conditions arising during perinatal period*: low birth weight –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, stroke –Gastrointestinal diseases*: liver cirrhosis Injury: –Unintentional injury: motor vehicle accidents, drownings, falls, poisonings, other unintentional injuries –Intentional injury: self-inflicted injuries, homicide, other intentional injuries * AAF based on volume of drinking only

96. Estimating AAFs: 5. Alcohol-attributable depression 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 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 Finally, halved AAFs to account for lack of control of confounders

97. 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

98. 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

99. 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

100. 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

101. Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS) Developing countries Developed countries High mortalityLow mortality Underweight14.9% Alcohol6.2 %Tobacco12.2 % Unsafe sex10.2 %Blood pressure5.0 %Blood pressure10.9 % Unsafe water & sanitation 5.5 % Tobacco4.0 %Alcohol9.2 % Indoor smoke (solid fuels) 3.6 %Underweight3.1 %Cholesterol7.6 % Zinc deficiency3.2 %Body mass index2.7 %Body mass index7.4 % Iron deficiency3.1 %Cholesterol2.1 % Low fruit & vegetable intake 3.9 % Vitamin A deficiency3.0 %Low fruit & vegetable intake1.9 %Physical inactivity3.3 % Blood pressure2.5 % Indoor smoke from solid fuels 1.9 % Illicit drugs1.8 % Tobacco2.0 % Iron deficiency1.8 %Unsafe sex0.8 % Cholesterol1.9 %Unsafe water & sanitation1.8 %Iron deficiency0.7 %

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

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

104. Trends in alcohol consumption

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

106. Relationship between alcohol consumption and alcohol problems Alcohol problems arise from: –Intoxication occasions –Repeated episodes of intoxication –Steady heavy drinking Protective effect from consistent moderate drinking –This 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

107. Social and health benefits of drinking Social benefits of drinking largely unquantifiable –Alcohol’s role as integrative, bonding or socially lubricative substance Health benefits of alcohol –Protective effect for CHD evident at individual level at as low as one drink every other day –Protection not found at the aggregate level 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 consumption

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

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

110. Alcohol and development: benefits? Quality improvement –Industrialization leads to greater uniformity and reliability of product 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 product –Alcohol unlikely to make much contribution to exports

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

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

113. Preventive interventions: individual-based Encouraging alternatives –Little evidence of effectiveness of lasting effects –Too many alternatives go well with alcohol, e.g. soft drinks –Do contribute to improving quality of life for disadvantaged populations Treatment and mutual help –Part of a humane societal response –Brief 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 problems

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

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

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

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

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

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

120. 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!!!

121. Target groups (cont.) Of the 32 interventions and strategies evaluated, 16 are targeted at the GP, 12 at HR, and 4 at HD. Interventions directed at the general population have higher effectiveness ratings thatn those targeted at other groups. Interventions directed at the general population and high-risk groups tend to be less costly to implement and maintain than interventions with harmful drinkers

122. Table 16.1. Ratings of policy-relevant stategies and interventions StrategyEffective- ness Breadth of research support Cross-cultural testing Cost to implement Target group Total ban on sales+++ ++HighGP Alcohol taxes+++ LowGP Training bar staff against aggression ++++++ModerateHR Alcohol education in schools 0+++++HighHR Random breath tests++++++ModerateGP Mandatory treatment of drinking-drivers ++++ModerateHD

123. Ratings of policy-relevant stategies and interventions – PHYSICAL AVAILABILITY StrategyEffective- ness Breadth of research support Cross-cultural testing Cost to implement Target group Total ban on sales+++ ++HighGP Minimum legal purchase age +++ ++LowHR Government Monopoly +++ ++LowGP Hours and days of sale restrictions ++ LowGP Restrictions on density of outlets +++++++LowGP Server Liability+++++LowTG

124. Ratings of policy-relevant stategies and interventions – ALTERING DRINKING CONTEXT StrategyEffective- ness Breadth of research support Cross-cultural testing Cost to implement Target group Outlet policy to not serve intoxicated patrons ++++++ModerateHR Training bar staff+++ModerateHR Voluntary codes of bar practice 0++LowHR Enforcement of on- premise regulations and legal requirements +++ HighHR Promoting alcohol free activities and events 0+++HighGP Community mobilization ++ +HighGP

125. Ratings of policy-relevant stategies and interventions – DRINKING-DRIVING StrategyEffective- ness Breadth of research support Cross-cultural testing Cost to implement Target group Sobriety check points+++++ ModerateGP Random breath test++++++ModerateGP Lowered BAC level+++ ++LowGP License Suspension++ ModerateHR Low BAC for young++++++LowHR Designated drivers and ride services 0++ModerateHR

126. Ratings of policy-relevant stategies and interventions – TREATMENT AND EARLY INTERVENTION StrategyEffectiv e-ness Breadth of research support Cross- cultural testing Cost to implem ent Target group Brief intervention +++++ Moderat e HR Alcohol Problems Treatment ++++ HighHD Self-help++++LowHD Mandatory treatment of repeat drinking drivers ++++Moderat e HD

127. Ratings of policy-relevant stategies and interventions – EDUCATION AND PERSUATION StrategyEffectiv e-ness Breadth of research support Cross- cultural testing Cost to implem ent Target group Alcohol education in schools 0+++++HighHR College student education 0++HighHR Public service messages 0+++++Moderat e GP Warning labels0+++LowGP

128. Ratings of policy-relevant stategies and interventions – REGULATING ALCOHOL PROMOTION StrategyEffecti ve- ness Breadth of researc h support Cross- cultural testing Cost to imple ment Target group Advertising Bans +++ LowGP Advertising content controls 000Moder ate GP

129. Ratings of policy-relevant stategies and interventions – TAXATION AND PRICING StrategyEffecti ve- ness Breadth of researc h support Cross- cultural testing Cost to imple ment Target group ALCOHOL TAXES +++ LOWGP

130. Integrated alcohol policies Our ratings suggest that a combination of pjysical availability limits at the general population level, certain drinking-driving countermeasures directed at all three target groups, and brief interventions directed at high-risk drinkers will offer the best value as the foundation for a comprehensive alcohol policy approach

131. The strong strategies Availability restrictions Taxation Enforcement Good research support Applicable in most countries Relatively inexpensive to implement and sustain

132. Essential Elements of Effective Prevention of Alcohol Problems Public Support Enforcement Policies and Laws Prevention

133. Implementing Alcohol Control Strategies in Brazil A.Strengthen alcohol surveillance systems 1.Epidemiologic surveys: household, school, roadside, emergency room, special events, alcohol sales and service practices, industry marketing, etc. 2.Increase expertise in behavioral health research methods and analysis. 3.Create and staff a Brazilian alcohol research center and develop an integrative and multi- disciplinary research strategy.

134. Alcohol is a drug which is: 1. Mind altering 2. Tolerance producing 3. Addictive These basic facts are not changed by alcohol industry advertising.

135. Drug “Capture” Rate Percent of Users Who Become Clinically Dependent Tobacco31.9% Heroin23.1% Cocaine16.7% Alcohol 15.4% Stimulants11.2% Marijuana 9.1% Source: National Comorbidity Survey Anthony, Warner, and Kessler

136. Global Burden of Disease (Disability-Adjusted Life Years) Attribution TobaccoAlcoholIllicit Drugs Worldwide 4.1%4.0%0.8% North America 8 - 15.9% 4 - 7.9%2 - 3.9% South America 2 - 3.9% 8 - 15.9% 1 - 1.9% Source: World Health Report 2002 World Health Organization

137. Global Market – Alcohol Spirits Sales Exceed 2 Billion Cases Annually CountryCase Volume China725 million cases Russia350 India249 Brazil195 Japan176 United States135 Korea79 Thailand76 Germany60 France37 Source: Mark Brown, President Sazerac Company, Inc. March 4, 2003

138. Product Categories – Alcohol Spirits Product CategoryCase Volume Baijiu725 million cases Vodka400 Whisky205 Cachaca200 Rum115 Brandy82 Shochu70 Soju70 Liqueurs51 Source: Mark Brown, President Sazerac Company, Inc. March 4, 2003

139. U.S. Economic Costs of ATOD Use, 1995 Total Costs = $415 Billion Sources: Harwood, Fountain, & Livermore, NIDA & NIAAA, 1998 Rice (unpublished) Institute for Health and Aging, UCSF, 1995

140. Most U.S. adults do not drink or drink infrequently. Frequency of Drinking Among U.S. Adults 21 and Older, 2002 (past 30 days) Source: NSDUH, 2002 Number of Drinking Days

141. Most U.S. adults do not drink at a hazardous level. Drinking Patterns among U.S. Adults 21 and Older, 2002 (past 30 days) Source: NSDUH, 2002

142. Binge drinkers are 23% of the population, but consume 76% of the alcohol. U.S. Binge Drinkers, 2002 Source: NSDUH, 2002

143. Most young people do not drink. 15- to 17-year-olds Drinking occasions 01 to 45 or more Drinking Among Youth, 2002 (past 30 days) 18% 72% 10% Among the 28% of 15-17 year olds who drink, 65% drank heavily at least once in the past month. Source: NSDUH, 2002

144. Strategy Options: 1.Personal change strategies – change people 2.Alcohol control strategies – control alcohol availability

145. Personal Change Strategies The U.S. has spent a fortune trying to “change people” through programs for adults, youth and children to: 1.Provide alcohol education 2.Change attitudes about drinking 3.Provide early intervention and treatment services for individuals with alcohol problems, and for their families

146. Research Evidence of Effectiveness: Personal Change Strategies 1.With few exceptions, these programs have not been effective in preventing societal alcohol problems. 2.As for the exceptions, these programs are too expensive to be implemented across society. 3.Despite this evidence, programs implementing personal change strategies are the most popular, most prevalent, and best funded prevention efforts in the U.S.

147. Alcohol Control Strategies: Essential Components changes in social norms policy interventions deterrence and enforcement

148. Alcohol Control Strategies: The Role of Public Health Education in Changing Social Norms 1.Raise societal awareness and concern about alcohol problems. 2.Educate the society that these problems can be prevented. 3.Inform the society about specific policy controls and deterrence strategies that are effective. 4.Publicize successes.

149. Alcohol Control Strategies: Effective Public Health Education Strategies for Changing Social Norms 1.Rely on research epidemiology. 2.Develop a strategic plan to educate society incrementally and sequentially. 3.Stay on message. 4.Utilize mass media.

150. Sequence of U.S. Public Awareness of Alcohol Problems Pre 1960 1960-1970 1970-1980 1980-1990 1990-2000 2000- Duh – what problems? Addiction, public drunkenness, social disorder Youth drinking Drinking and driving, fetal alcohol effects Alcohol industry behavior Violence and crime?

151. Alcohol Control Strategies Policy Interventions To prevent alcohol problems, policy interventions must focus on the Availability of alcohol. Effective policies address the –Price –Place –Product –Promotion… …of alcohol products

152. Percent of U.S. Population (18+ years of age) favoring alcohol policies designed to reduce alcohol problems among youth Proposed PolicyFavor Strongly Favor Somewhat Oppose Somewhat Oppose Strongly Increase alcohol tax by 5 cents to fund prevention programs 65.016.85.712.6 Restrict alcohol ads to make drinking less appealing to youth 52.626.010.510.8 Conduct compliance checks to reduce illegal sales to minors 46.519.09.525.0 Require registration of beer kegs 39.921.315.323.5 Source: Harwood, et al, 1998

153. Percent of U.S. Population (18+ years of age) favoring restrictions on drinking in public locations Public locationBan drinking By permit only No restrictions Parks63.027.39.8 Concerts51.234.114.6 Beaches53.128.718.2 Stadiums/arenas47.829.622.6 Source: Harwood, et al, 1998

154. Impact of enforcement on alcohol-related traffic fatalities Percentage traffic fatalities related to alcohol (1977-1999)

155. Essential Elements of Effective Prevention of Alcohol Problems Public Support Enforcement Policies and Laws Prevention

156. Implementing Alcohol Control Strategies in Brazil A.Strengthen alcohol surveillance systems 1.Epidemiologic surveys: household, school, roadside, emergency room, special events, alcohol sales and service practices, industry marketing, etc. 2.Increase expertise in behavioral health research methods and analysis. 3.Create and staff a Brazilian alcohol research center and develop an integrative and multi- disciplinary research strategy.

157. Every Ounce of Alcohol Sold in the United States Generates $2.25 in Public Sector Costs Alcohol – Related Violence$1.00 Drinking Driving Problems.85 Other Costs.40 $2.25 Alcohol ProblemCost per Ounce Total Societal Costs, including Public Sector Costs: $6.00/ounce Source: Ted Miller, Ph.D. PIRE

158. Societal Costs – Alcohol Sales Source: Ted Miller, Ph.D. PIRE Sales Unit Public Sector Costs Total Societal Costs Beer – Six Pack $7.30 $19.45 Wine – Fifth Bottle $7.50 $20.00 Spirits – Fifth Bottle $23.00 $61.45

159. Challenges Confronting the Community Prevention Coordinator A.Provide “translation” services between: 1.Researchers 2.Public health professionals 3.Community organizers 4.Policy makers 5.Alcohol industry 6.Alcohol law enforcement B.Provide “honest broker” services for each of the above groups. C.Keep a low profile!

160. Implementing Alcohol Control Strategies B.Establish a Brazilian technical assistance center for implementation of alcohol control strategies 1.Organize services by problems, not by control policies (violence, youth drinking, traffic safety, noise and neighborhood disruption, etc.). 2.Local communities are the first priority for services. 3.Develop and implement a public health education strategy to change social norms. 4.Respond quickly to “unscheduled opportunities”.

161. Implementing Alcohol Control Strategies C.Increase enforcement of existing alcohol control policies. 1.Public health and law enforcement are not traditional allies – build relationships! 2.Support creation of law enforcement units which specialize in enforcement of alcohol laws. 3.Document, and then acknowledge publicly, the results of alcohol law enforcement.

162. Community Prevention Case Studies 1.Paulinia: alcohol price controls  Price/Enforcement 2.Salinas: alcohol control at special events  Place/Social Norms 3.Salinas: reducing alcohol outlet density  Place 4.Diadema: limiting alcohol sales  Place, Social Norms, Enforcement

163. Case Studies: Alcohol Prevention Research in Brazil Presentation Outline 1.What was your research interest? 2.What were your fears and concerns beginning your research? 3.What was the major difficulty you faced in conducting your research? 4.What was the biggest assistance you received in conducting your research? 5.What was the biggest unexpected “surprise” you encountered? 6.What is your advice to those who come along next in conducting research in your area?

164. Alcohol Prevention Research in Brazil Research Topic Bar surveys and underage buyer surveys Municipal school surveys Collaboration with municipal officials Utilizing municipal records for evaluation, and roadside driver surveys Local and national household surveys, and emergency room surveys Alcohol industry structure and marketing practices Researcher Marcos Romano Denise Vieira Nino Meloni Sergio Duailibi Ronaldo Laranjeira Illana Pinsky

165. Science more accessible to policy-makers Policy changes should be made with caution and with a sense of experimentation to determine whether they have their intended effects Interdisciplinary research is capable of playing a critical role in the progress of public health by applying the methodologies of the medical, behavioural, social and population sciences

166. The precautionary principle A general public health concept “To take preventive action even in the face of uncertainty” To shift the burden of proof to the proponents of a potentially harmful actitivy To offer alternatives to harmful actions To increase public involvement in decision- making Decision-making must be guided by the likelihood of risk, rather than the potential for profit

167. Extraordinary oportunities Multiple Changes can be made rationally Combine rationally selected strategies into an integrated overall policy The research base is strong Policies can be implemented at multiple levels Public awareness and support can be strengthened International collaboration can be enhanced