1. Global patterns and problems, and building a concerted response Robin Room School of Population Health, University of Melbourne Turning Point Alcohol & Drug Centre, Fitzroy, Victoria Centre for Social Research on Alcohol & Drugs, Stockholm University robinr@turningpoint.org.au Presented at Alcohol Policy 15, Washington, DC 5 Dec. 2010

2. Global patterns and problems (Alcohol: No Ordinary Commodity, 2 nd ed. and beyond) Alcohol in the Global Burden of Disease – work on the GBD for 2005 (led by Jürgen Rehm with myself as coleader)  With the help of many others: Core group: G. Borges (Mexico), G. Gmel (Switzerland), K. Graham (Canada), B. Grant (US, NIAAA), C. Parry (South Africa), V. Poznyak (Belarus, WHO) and T. Vos as guidance from steering committee  Exposure: M. Rylett, A. Fleischmann, G. Gmel, T. Kehoe  Risk Relations:  Causality: Meeting in Cape Town (CDC, WHO, MRC South Africa)  Meta-analyses: D. Baliunas, H. Irving, N. Joharchi, S. Mohapatra, J. Patra, M. Roerecke, A. Samokhvalov, P. Shuper, B. Taylor  Systematic reviews: P. Anderson, C. Cherpitel, T. Greenfield, K. Lönnroth, M. Neuman

3. Societal Factors Drinking culture Alcohol Policy Drinking environment Health care system Population group Gender Age Poverty Marginalization (individual) Currently used model for alcohol Comparative Risk Analysis 2005

4. Rates of abstention, 2006 Prevalence of abstention in World 2005 0.00 - 0.20 0.20 - 0.40 0.40 - 0.60 0.60 - 0.80 0.80 - 1.00 Lighter and greener = more abstainers Globally, there are more abstainers than drinkers among adults Per-drinker consumption varies much less than abstainer rates

5. Total consumption in litres pure alcohol 2005 0 - 3 3 - 6 6 - 9 9 - 12 12 - 15 15 - 21 Total consumption, recorded & unrecorded, 2005 Darker = higher Highest in Russia & Europe, high in Latin America, growing in middle-income countries

6. 1: Least hazardous; Regular drinking, often with meals and without heavy drinking bouts 4: Most hazardous: Infrequent but heavy drinking Least hazardous in southern Europe, Japan; more hazardous in Russia and much of developing world More and less hazardous patterns of drinking

7. Chronic and infectious disease: Infectious disease: TB, pneumonia, HIV/AIDS HIV incidence still under review! Cancer: Mouth & oropharyngeal cancer, esophageal cancer, liver cancer, colorectal cancer, female breast cancer Neuropsychiatric diseases: Alcohol use disorders, unipolar major depression, primary epilepsy Diabetes Cardiovascular diseases: Hypertensive diseases, ischemic heart disease, ischemic stroke, hemorrhagic stroke, atrial fibrillation Gastrointestinal diseases: Liver cirrhosis, pancreatitis Conditions arising during perinatal period: Low birth weight, FAS Injury: Most unintentional and intentional injury Alcohol-attributable disease and injury 2005 (green mainly protective)

8. New developments with respect to causality: inclusion of alcohol-attributable disease categories  Colorectal cancer included (IARC; Baan et al., 2007)  Tuberculosis/pneumonia incidence and worsening the disease course included  HIV incidence discussed but not included; enough evidence for alcohol worsening the disease course  Pancreatitis and conduction disorders (cardiac dysrhythmias) included (new disease categories in GBD)  Diverse new GBD injury categories (most injury categories have been causally linked to alcohol consumption)  Revision of determination of risk relationship between alcohol consumption and primary epilepsy (excluding “alcohol withdrawal seizures” – in collaboration with epilepsy experts in GBD)

9. Rate of alcohol-attributable infectious disease, 2004 (in DALYs per 100,000 adult population) 0 - 50 50 - 150 150 - 300 300 - 700 700 - 1100 Green = low; Dark brown = high Problems particularly in much of the developing world and Russia Alcohol-attributable Infectious diseases

10. Alcohol-attributable disease and injury 2005 (green mainly protective) Chronic and infectious disease: Infectious disease: TB, pneumonia, HIV/AIDS HIV incidence still under review! Cancer: Mouth & oropharyngeal cancer, esophageal cancer, liver cancer, colorectal cancer, female breast cancer Neuropsychiatric diseases: Alcohol use disorders, unipolar major depression, primary epilepsy Diabetes Cardiovascular diseases: Hypertensive diseases, ischemic heart disease, ischemic stroke, hemorrhagic stroke, atrial fibrillation Gastrointestinal diseases: Liver cirrhosis, pancreatitis Conditions arising during perinatal period: Low birth weight, FAS Injury: Most unintentional and intentional injury

11. Adding in another dimension: alcohol’s harm to others  Global burden of disease estimates are essentially concerned with harm to the drinker  Alcohol also harms others, both individually and collectively  Cost of alcohol studies (in the cost-of-illness tradition) count in some costs to others – from crime, drunk driving – and to society  Other harms and costs to others not measured  In our recent Australian study, adding in costs to specific others doubled the costs

12. Why so little and late an emphasis for alcohol? (e.g., compared to tobacco)  The effects are not confined to health – brings in other professions and institutions; effects are often immediate rather than delayed  Heavily moralised territory (e.g., violence against women, child abuse)  focus on individual responsibility and away from environmental/population perspectives  The long shadow of the temperance era  2+ generations of reaction against Prohibition  Particularly in public health, since PH and temperance paradigms were so close  The challenge: counting harm to others in the policy rationale while pointing to population-level solutions rather than punitive individualistic policies

13. Building a concerted response, based on evidence Parallel tracks -- local, national, global Develop the evidence of the extent and nature of particular alcohol-related problems Plan and implement policies/interventions to reduce rates of problems Evaluate the effects of a policy change –Planned experiments – usually “quasi-experiments” with controls –“Natural experiments” (= no research input on the design) Build provision (and funding) for evaluation into any policy change Adjust policy/intervention in view of the evaluations

14. Example 1: reducing tobacco deaths (the Australian experience) – High taxes – Advertising bans and controls – Smoking bans: workplaces; restaurants and pubs, etc. – Graphic warnings, media campaign – Enforcement of age limits; regulations of sales outlets – Nicotine replacement products – Brief interventions by health professionals – Countering tobacco industry influences – International Framework Convention on Tobacco Control –  28 million cigarettes in 1980; 20 million in 1997 (Yet Australian efforts were critiqued by California program leaders: “a monumental paucity of funds and political will”, MJA 178:313-4, 2003.)

15. Example 2: driving down traffic casualties in Victoria, Australia Compulsory seatbelts 1970 Random breath-testing 1976 Cameras for red lights 1983; speed 1986 “Speed kills” campaign; bike helmets mandatory 1990 Mobile radars 1996 Lowered speed limit in residential areas; anti-speed measures 2001-2002  Deaths in 1970: 1061 ; in 2003: 330

16. Characterizing success Clear goals: reducing the harm to a minimum – Consensus that the existing burden is unacceptable Professionals as advocates A long-term perspective– in terms of decades Cross-sector collaboration – e.g. for transport safety: Transport Industry Safety Group: coroner, road & transport industry, community and regulatory bodies Initiatives in terms of what is possible at the time, cumulating over time Sometimes the unthinkable becomes possible – e.g., a smoking ban in pubs

17. Joining the policy dialogue – roles for professionals and researchers The limits of technocracy Experience-based policy advocacy – Alcohol and drug counselors – Emergency service & other doctors and nurses – Mental health clinicians – Police and community response staff – Social workers, family counselors, clergy at community levels: – Licensing decisions about on- and off-licenses – Community planning to minimize alcohol-related harms at regional and national levels: – Supporting preventive legislation – Encouraging enforcement or laws and regulations; supporting funding for it at the international level: – Pushing for exclusion of alcohol from free trade agreements – Supporting a strong leading role for WHO in reducing alcohol problems