Políticas Públicas em Alcohol
Prof. Dr. Ronaldo LaranjeiraUniversidade Federal de São Paulo
Chosing effective strategies
• Need for a systematic procedure to evaluate the evidence, compare alternativa interventions and assess the fbenefits to society of different approaches
Global Supply of Pure Beverage Alcohol
0
10
20
30
40
50
60
70
80
90
100
1961 1965 1969 1973 1977 1981 1985 1989 1993 1997
Year
Mill
ion
s o
f h
ect
olit
res
Barley Beer Spirits Wine Other
Proportion of alcohol consumers in WHO sub-regions
Region % alcohol consumption
AFR-DAFR-EAMR-AAMR-BAMR-DEMR-BEMR-DEUR-AEUR-BEUR-CSEAR-BSEAR-DWPR-AWPR-B
384467666210 587628621148457
Adult (15+) Per Capita Alcohol Consumption in Selected Latin American Countries
0
2
4
6
8
10
12
1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997Year
Lit
res
Brazil Mexico Venezuela
Drinking Pattern Values for Selected WHO Regions
Region Pattern value
Afr DAfr EAmr AAmr BAmr DEur ASear BSear D
2.483.092.003.143.101.342.502.95
Prevalence (%) of problematic illicit drug use in the past12 months among persons 15 years and above accordingto 14 WHO regions
Opioids Cocaine AmphetamineEurope A 0.11 0.18 0.24Europe B 0.09 0.01 0.10Europe C 0.19 0.01 0.04America A 0.13 0.78 0.20America B 0.03 0.24 0.20America D 0.07 0.43 0.11Emirates B 0.55 - 0.02Emirates D 0.41 - 0.14SE Asia B 0.04 - 0.10SE Asia D 0.15 - -W. Pacific A 0.04 0.28 0.22W Pacific B 0.02 - 0.34Africa D 0.09 0.26 0.31Africa E 0.01 0.05 0.12Note: UNDCP-derived estimates
12 leading selected risk factors as causes of disease burden measured in DALYs
Developed countriesDeveloping countries High Mortality Low Mortality
1 Underweight Alcohol (6.2%) Tobacco (12.2%)2 Unsafe sex Blood pressure Blood pressure
3 Unsafe water Tobacco (4.0%) Alcohol (9.2%) 4 Indoor smoke Underweight Cholesterol 5 Zinc deficiencyBody mass index Body mass index 6 Iron deficiency Cholesterol Low fruit & veg intake 7 Vitamin A deficiency Low fruit & veg intake Physical inactivity 8 Blood pressure Indoor smoke - solid fuels Illicit drugs (1.8%) 9 Tobacco (2.0%) Iron deficiency Unsafe sex 10 Cholesterol Unsafe water Iron deficiency 11 Alcohol Unsafe sex Lead exposure 12 Low fruit & veg intake Lead exposure Child sexual abuse
0 1000 2000 3000 4000 5000 6000 7000 8000
Occupational risk factors for injury
Unsafe health care injections
Vitamin A deficiency
Zinc deficiency
Urban air pollution
Iron deficiency
Indoor smoke from solid fuels
Unsafe water, sanitation, and hygiene
Alcohol
Physical inactivity
High Body Mass Index
Fruit and vegetable intake
Unsafe sex
Underweight
Cholesterol
Tobacco
Blood pressure
WorldDeaths in 2000 attributable to selected leading risk factors
Number of deaths (000s)
0 20000 40000 60000 80000 100000 120000 140000 160000
Illicit drugs
Lead exposure
Occupational risk factors for injury
Physical inactivity
Vitamin A deficiency
Fruit and vegetable intake
Zinc deficiency
High Body Mass Index
Iron deficiency
Indoor smoke from solid fuels
Cholesterol
Unsafe water, sanitation, and hygiene
Alcohol
Tobacco
Blood pressure
Unsafe sex
Underweight
WorldDisease burden (DALYs) in 2000 attributable to selected leading risk
factors
Number of Disability-Adjusted Life Years (000s)
0 10000 20000 30000 40000 50000 60000 70000
Illicit drugs
Alcohol
Tobacco
High Mortality DevelopingCountries
Low Mortality DevelopingCountries
Developed Countries
WorldDisease burden (DALYs) in 2000 attributable to
Addictive Substances related Risks
Number of Disability-Adjusted Life Years (000s)
0 1000 2000 3000 4000 5000
Illicit drugs
Alcohol
Tobacco
High Mortality Developing Countries
Low Mortality Developing Countries
Developed Countries
WorldDeaths in 2000 attributable to
Addictive Substances related Risks
Number of deaths (000s)
0 1000 2000 3000 4000 5000
Illicit drugs
Alcohol
Tobacco
High Mortality Developing Countries
Low Mortality Developing Countries
Developed Countries
WorldDeaths in 2000 attributable to
Addictive Substances related Risks
Number of deaths (000s)
0
200
400
600
800
1000
1200
1400
1600
1800
AFR AMR EMR EUR SEAR WPR
Tobacco
Alcohol
Illicit drugs
WHO RegionsDeaths in 2000 attributable to selected leading risk factors
Num
ber o
f dea
ths
(000
s)
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
AFRO AMRO EMRO EURO SEARO WPRO
Tobacco
Alcohol
Illicit drugs
WHO RegionsDisease burden (DALYs) in 2000 attributable to selected leading risk
factors
Num
ber o
f Dis
abili
ty-A
djus
ted
Life
Yea
rs (0
00s)
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 attributableto selected risk factor
Burden of disease attributable to addictive substances related risks:
TOBACCO(% DALYs in each subregion)
Proportion of DALYs attributableto selected risk factor
0.5-0.9%
1-1.9%
2-3.9%
4-7.9%
<0.5%
8-15.9%
Proportion of DALYs attributableto 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)
Percentage of total global mortality and DALYs attributable to tobacco,alcohol and illicit drugs
High mortalitydevelopingcountries
Low mortalitydevelopingcountries
Developedcountries
Risk factor
Males Females Males Females Males Females
Global
MortalityTobaccoAlcoholIllicit drugs
DALYsTobaccoAlcoholIllicit drugs
7.52.60.5
3.42.60.8
1.50.60.1
0.60.50.2
12.28.50.6
6.29.81.2
2.91.60.1
1.32.00.3
26.38.00.6
17.114.02.3
9.3-0.30.3
6.23.31.2
8.83.20.4
4.14.00.8
Attributable mortality by risk factor, sex and mortality stratum (‘000) in the Americas
Very low child, verylow adult
Low child, lowadult
High child, highadultAddictive
substancesMales Females Males Females Males Females
Tobacco
Alcohol
Illicitdrugs
352
27
10
294
-22
7
163
207
7
58
39
4
5
22
1
1
6
0
Source: WHO (2002). World health report 2002.
Attributable DALYs by risk factor, sex and mortality stratum (‘000) in the Americas
Very low child, verylow adult
Low child, low adult High child, high adultAddictivesubstances
Males Females Males Females Males Females
Tobacco
Alcohol
Illicit drugs
3,567
2,925
797
2,606
702
410
2,190
7,854
758
813
1,443
323
51
789
199
14
170
71
Source: WHO (2002). World health report 2002.
Estimates of mortality attributed to illicit drug use in 14WHO regions
AIDSOpioid
overdoseSuicide via
opioids TraumaEurope A 6,236 5,527 2,355 3,387Europe B 733 1,281 1,465 651Europe C 773 6,895 4,156 830America A 10,698 6,397 2,034 4,057America B 5,349 1,845 922 2,342America D 1,035 498 78 716Emirates B 962 3,881 673 813Emirates D 4,273 12,852 2,015 2,954SE Asia B 1,586 955 576 797SE Asia D 57,011 22,989 14,982 3,128W Pacific A 1,310 825 1,251 1,028W Pacific B 10,122 2,909 456 9,295Africa D 4,003 1,891 1,191 2,768Africa E 1,334 407 64 922Total 105,425 69,152 32,216 33,689
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.
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
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.
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
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
Volume of drinking
Drinking patternhazard score
(predominance ofintoxication)
Prior alcohol dependence
DepressionInjuriesCoronary
heartdisease
Physicaldiseases
(except CHD)
Alcohol-attributableconditions*
Aspects of alcohol used in estimating alcohol attributable fraction (AAF) for different
conditions
*AAF = 1 by definition
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
Estimating AAFs
1. Alcohol-specific categories
2. Chronic health conditions
3. CHD
4. Depression
5. Injuries
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
Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS)
Developing countriesDeveloped countries
High mortality Low mortality
Underweight 14.9% 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 %
Disease conditions Males Females Total% of all alcohol-
attributable deaths
Conditions arising during the perinatal period
2 1 3 0%
Malignant neoplasm 269 86 355 20%
Neuro-psychiatric conditions 91 19 111 6%
Cardiovascular diseases 392 -124 268 15%
Other non-communicable diseases (diabetes, liver cirrhosis)
193 49 242 13%
Unintentional injuries 484 92 577 32%
Intentional injuries 206 42 248 14%
Alcohol-related mortality burden all causes
1,638 166 1,804 100.0%
All deaths 29,232 26,629 55,861 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
Disease conditions Males Females Total% of all alcohol-
attributable DALYs
Conditions arising during the perinatal period
68 55 123 0%
Malignant neoplasm 3,180 1,021 4,201 7%
Neuro-psychiatric conditions 18,090 3,814 21,904 38%
Cardiovascular diseases 4,411 -428 3,983 7%
Other non-communicable diseases (diabetes, liver cirrhosis)
3,695 860 4,555 8%
Unintentional injuries 14,008 2,487 16,495 28%
Intentional injuries 5,945 1,117 7,062 12%
Alcohol-related disease burden all causes (DALYs)
49,397 8,926 58,323 100%
All DALYs 755,176 689,993 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
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!!!
Global Alcohol Policy
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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
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
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: Brief Description of Eurocare:
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: Brief Description of Eurocare:
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: Brief Description of Eurocare:
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
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These are net costs, accounting for heart disease
They do not include social harms
They do not include financial costs
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
At the community level:
Drinking and driving
Intoxication
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
Healthy Public Policy:
Taxation
Bans on advertising and marketing
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
Strengthening Community Action:
Drink driving
Educational and prevention programmes
Manage availability
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
Helping individuals:
Brief interventions in primary care
Treatment for dependence
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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; 5th in list of risk factors
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What can WHO (and its MS) do?
There is a strong team
But, it seems divided and unclear at present
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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.
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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?
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
What can WHO (and its MS) do?
Make the science clear
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
What can WHO (and its MS) do?
Calculate the economic burden
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
What can WHO (and its MS) do?
Estimate the social burden
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
What can WHO (and its MS) do?
Get some powerful partners
(?World Bank)
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
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What can WHO (and its MS) do?
The industry argues that they have a place at the policy table.
They don’t.
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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.
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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.
Effective Effective
policypolicy
Ineffective Ineffective
policypolicy
OpposedOpposed by by social aspects social aspects organizationsorganizations
SupportedSupported by by social aspects social aspects organizationsorganizations
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 minority3
Legal drinking age Increased drinking ages reduce traffic fatalities; reduced drinking ages lead to increases in assaults2
Suggests that there is no consensus as to whether or not minimal drinking ages are desirable4 ; opposed to increasing legal drinking ages believing that it does not address those who abuse the product3
Outlet density Increased outlet density associated with traffic accidents, assaults and liver cirrhosis2
Opposed to limiting outlet density believing that it does not address those who abuse the product3
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 violence2
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 product3
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 schemes5
X
X
XX
Price and the availability of alcoholPrice and the availability of alcohol
Effective Effective
policypolicy
Ineffective Ineffective
policypolicy
OpposedOpposed by by social aspects social aspects organizationsorganizations
SupportedSupported by by social aspects social aspects organizationsorganizations
Physical environment Changing the physical environment of drinking places reduces alcohol related violence1
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 proposals2
Social environment Decreasing the permissiveness of the environment (better staff control; less discount drinks) reduces alcohol-related violence1
Server training with legal sanctions Responsible server programs supported by legal sanctions reduce harms from intoxication1
Opposed to legal sanctions; accepts that server training leads to a reduction in licensee liability for damages resulting from illegal service by trained servers3
.
Server training without legal sanctions Responsible server programs not supported by legal sanctions do not reduce harms from intoxication1
Trains servers not to sell to underage drinkers, but without legal sanctions4
X
X
Creating safer drinking environmentsCreating safer drinking environments
Effective Effective
policypolicy
Ineffective Ineffective
policypolicy
OpposedOpposed by by social aspects social aspects organizationsorganizations
SupportedSupported by by social aspects social aspects organizationsorganizations
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 violence1
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 effect1
Describes school based alcohol education, and drink driving education programmes as community based programmes6
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 fatalities2
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 harm3
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 harm4
Stresses the importance of educational programmes as the key policy choice to reduce alcohol-related harm6
Self-regulation Considerable evidence that self regulatory codes are not adhered to5;
The production and dissemination of self-regulatory codes a core area of work,8,9
X
X
Prevention and education programmesPrevention and education programmes
Effective Effective
policypolicy
Ineffective Ineffective
policypolicy
OpposedOpposed by by social aspects social aspects organizationsorganizations
SupportedSupported by by social aspects social aspects organizationsorganizations
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 desirable2; 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 accidents1
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 half1
Generally opposed to high visibility random breath testing4
Reducing legal BAC limit Reduces drink driving and fatalities across all levels of BAC1
Opposed to any reductions in legal BAC limits5
Public education campaigns No evidence for a beneficial effect on alcohol-related crashes1
Believes that educational programmes are the core component of drink driving programmes6
Interventions by servers, hosts and peers Ineffective, although increased protection of drinking peers1
Works with the hotel, restaurant, cafe and bar sectors to develop anti-drink driving initiatives3
Alternative transportation programmes Limited evidence suggests ineffective1
Alternative transportation programmes (designated river campaigns) are priority projects6
XX
X
X
Drink driving programmesDrink driving programmes
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
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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.
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
What can WHO (and its MS) do?
There should be no discussion on self-regulation
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-regulationWe should not waste any more time on self-regulation
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
What can WHO (and its MS) do?
Encourage litigation
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
What can WHO (and its MS) do?Community Action
Database of community programmes
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
What can the NGO sector do?
We are your friends;
But also your watchdog
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARMWORKING 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?
Thank you for your attention
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
WORKING IN EUROPE FOR THE PREVENTION OF ALCOHOL RELATED HARM
Alcohol in Development and in Health and Social Policy
David Jernigan PhDCenter on Alcohol Marketing and Youth
Georgetown UniversityWashington, D.C.
Robin Room PhDCenter for Social Research on Alcohol and Drugs
University of StockholmStockholm, Sweden
Jürgen T. Rehm PhDAddiction Research Institute
Zurich, Switzerland
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
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
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.
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 When an exposure is believed to be a cause of believed to be a cause of a given disease, the a given disease, the attributable fraction is attributable fraction is the proportion of the the proportion of the disease in the specific disease in the specific population that would be population that would be eliminated in the absence eliminated in the absence of the exposure.”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)
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
Adult per capita consumption inlitre pure alcohol 2000 (based on CRA)
Adult per cap ita consum ption 2000
0.21 to 2 .85
2.85 to 4 .45
4.45 to 6 .41
6.41 to 9 .47
9.47 to 13.08
13.08 to 19.30
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.
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
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
Volume of drinking
Drinking patternhazard score
(predominance ofintoxication)
Prior alcohol dependence
DepressionInjuriesCoronary
heartdisease
Physicaldiseases
(except CHD)
Alcohol-attributableconditions*
Aspects of alcohol used in estimating alcohol attributable fraction (AAF) for different
conditions
*AAF = 1 by definition
Estimating AAFs
1. Alcohol-specific categories
2. Chronic health conditions
3. CHD
4. Depression
5. Injuries
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
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
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
Disease conditions Males Females Total% of all alcohol-
attributable deaths
Conditions arising during the perinatal period
2 1 3 0%
Malignant neoplasm 269 86 355 20%
Neuro-psychiatric conditions 91 19 111 6%
Cardiovascular diseases 392 -124 268 15%
Other non-communicable diseases (diabetes, liver cirrhosis)
193 49 242 13%
Unintentional injuries 484 92 577 32%
Intentional injuries 206 42 248 14%
Alcohol-related mortality burden all causes
1,638 166 1,804 100.0%
All deaths 29,232 26,629 55,861 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
Disease conditions Males Females Total% of all alcohol-
attributable DALYs
Conditions arising during the perinatal period
68 55 123 0%
Malignant neoplasm 3,180 1,021 4,201 7%
Neuro-psychiatric conditions 18,090 3,814 21,904 38%
Cardiovascular diseases 4,411 -428 3,983 7%
Other non-communicable diseases (diabetes, liver cirrhosis)
3,695 860 4,555 8%
Unintentional injuries 14,008 2,487 16,495 28%
Intentional injuries 5,945 1,117 7,062 12%
Alcohol-related disease burden all causes (DALYs)
49,397 8,926 58,323 100%
All DALYs 755,176 689,993 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
Disability-Adjusted life Years (DALYs) attributable to ten leading risk factors, 2000
World High mortality developing countries
Low mortality developing countries
Developed countries
DALYs(millions)
% total % total % total % total
Males Females Males Females Males Females
Underweight 138 9.5 14.9 15 3 3.3 0.4 0.4
Unsafe sex 92 6.3 9.4 11 1.2 1.6 0.5 1.1
Blood pressure 64 4.4 2.6 2.4 4.9 5.1 11.2 10.6
Tobacco 59 4.1 3.4 0.6 6.2 1.3 17.1 6.2
Alcohol 58 4 2.6 0.5 9.8 2 14 3.3
Unsafe water, sanitation, hygiene
54 3.7 5.5 5.6 1.7 1.8 0.4 0.4
Cholesterol 40 2.8 1.9 1.9 2.2 2 8 7
Indoor smoke from solid fuels
39 2.6 3.7 3.6 1.5 2.3 0.2 0.3
Iron deficiency 35 2.4 2.8 3.5 1.5 2.2 0.5 1
Overweight 33 2.3 0.6 1 2.3 3.2 6.9 8.1
Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS)
Developing countriesDeveloped countries
High mortality Low mortality
Underweight 14.9% 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 %
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
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
Trends in alcohol consumptionFigure 2: Adult (15+) Per Capita Alcohol Consumption
by Macro-Region
0
1
2
3
4
5
6
7
1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997
Year
Lit
res
Asia Central and South America Sub-Saharan Africa Developed Former Soviet
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
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
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
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
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
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
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
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
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
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
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
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
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”
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
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
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!!!
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
Table 16.1. Ratings of policy-relevant stategies and interventions
Strategy Effective-ness
Breadth of research support
Cross-cultural testing
Cost to implement
Target
group
Total ban on sales +++ +++ ++ High GP
Alcohol taxes +++ +++ +++ Low GP
Training bar staff against aggression
+ +++ ++ Moderate HR
Alcohol education in schools
0 +++ ++ High HR
Random breath tests +++ ++ + Moderate GP
Mandatory treatment of drinking-drivers
+ ++ + Moderate HD
Ratings of policy-relevant stategies and interventions – PHYSICAL AVAILABILITY
Strategy Effective-ness
Breadth of research support
Cross-cultural testing
Cost to implement
Target
group
Total ban on sales +++ +++ ++ High GP
Minimum legal purchase age
+++ +++ ++ Low HR
Government Monopoly
+++ +++ ++ Low GP
Hours and days of sale restrictions
++ ++ ++ Low GP
Restrictions on density of outlets
++ +++ ++ Low GP
Server Liability +++ + + Low TG
Ratings of policy-relevant stategies and interventions – ALTERING DRINKING CONTEXT
Strategy Effective-ness
Breadth of research support
Cross-cultural testing
Cost to implement
Target
group
Outlet policy to not serve intoxicated
patrons
+ +++ ++ Moderate HR
Training bar staff + + + Moderate HR
Voluntary codes of bar practice
0 + + Low HR
Enforcement of on-premise regulations
and legal requirements
++ + ++ High HR
Promoting alcohol free activities and
events
0 ++ + High GP
Community mobilization
++ ++ + High GP
Ratings of policy-relevant stategies and interventions – DRINKING-DRIVING
Strategy Effective-ness
Breadth of research support
Cross-cultural testing
Cost to implement
Target
group
Sobriety check points
++ +++ +++ Moderate GP
Random breath test +++ ++ + Moderate GP
Lowered BAC level +++ +++ ++ Low GP
License Suspension ++ ++ ++ Moderate HR
Low BAC for young +++ ++ + Low HR
Designated drivers and ride services
0 + + Moderate HR
Ratings of policy-relevant stategies and interventions – TREATMENT AND EARLY
INTERVENTIONStrategy Effectiv
e-nessBreadth
of research support
Cross-cultural testing
Cost to implem
ent
Target
group
Brief intervention
++ +++ +++ Moderate
HR
Alcohol Problems
Treatment
+ +++ +++ High HD
Self-help + + ++ Low HD
Mandatory treatment of
repeat drinking drivers
+ ++ + Moderate
HD
Ratings of policy-relevant stategies and interventions – EDUCATION AND PERSUATION
Strategy Effective-ness
Breadth of
research support
Cross-cultural testing
Cost to implem
ent
Target
group
Alcohol education in
schools
0 +++ ++ High HR
College student
education
0 + + High HR
Public service messages
0 +++ ++ Moderate
GP
Warning labels 0 + ++ Low GP
Ratings of policy-relevant stategies and interventions – REGULATING ALCOHOL
PROMOTIONStrategy Effecti
ve-ness
Breadth of
research
support
Cross-cultural testing
Cost to
implement
Target
group
Advertising Bans
+ ++ ++ Low GP
Advertising content controls
0 0 0 Moderate
GP
Ratings of policy-relevant stategies and interventions – TAXATION AND PRICING
Strategy Effective-
ness
Breadth of
research
support
Cross-cultural testing
Cost to
implement
Target
group
ALCOHOL TAXES
+++ +++ +++ LOW GP
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
The strong strategies
• Availability restrictions
• Taxation
• Enforcement
Good research support
Applicable in most countries
Relatively inexpensive to implement and sustain
Essential Elements of Effective Prevention of Alcohol Problems
Public Support
EnforcementPolicies and Laws
Prevention
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.
Alcohol is a drug which is:
1. Mind altering
2. Tolerance producing
3. Addictive
These basic facts are not changed by alcohol industry advertising.
Drug “Capture” Rate
Percent of Users Who Become Clinically Dependent
Tobacco 31.9%Heroin 23.1%Cocaine 16.7%Alcohol 15.4%Stimulants 11.2%Marijuana 9.1%
Source: National Comorbidity SurveyAnthony, Warner, and Kessler
Global Burden of Disease(Disability-Adjusted Life Years)
Attribution
Tobacco Alcohol Illicit 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
Global Market – Alcohol Spirits Sales Exceed 2 Billion Cases Annually
Country Case Volume
China 725 million casesRussia 350India 249Brazil 195Japan 176United States 135Korea 79Thailand 76Germany 60France 37
Source: Mark Brown, President
Sazerac Company, Inc.
March 4, 2003
Product Categories – Alcohol Spirits
Product Category Case Volume
Baijiu 725 million casesVodka 400Whisky 205Cachaca 200Rum 115Brandy 82Shochu 70Soju 70Liqueurs 51
Source: Mark Brown, President
Sazerac Company, Inc.
March 4, 2003
U.S. Economic Costs of ATOD Use, 1995
Total Costs = $415 Billion
40%
33%
27%Alcohol-$167 Billion
Tobacco-$138 Billion
Illicit Drugs-$110 Billion
Sources: Harwood, Fountain, & Livermore, NIDA & NIAAA, 1998Rice (unpublished) Institute for Health and Aging, UCSF, 1995
Most U.S. adults do not drink or drink infrequently.
46%
26%
13%9%
6%
0%
20%
40%
60%
0 1 to 4 5 to 10 11 to 21 21+
Frequency of Drinking Among U.S. Adults 21 and Older, 2002 (past 30 days)
Source: NSDUH, 2002
Number of Drinking Days
Most U.S. adults do not drink at a hazardous level.
46%
31%
16%
7%Nondrinker
Nonbingers
Infrequent Bingers
Frequent Bingers
Drinking Patterns among U.S. Adults 21 and Older, 2002(past 30 days)
Source: NSDUH, 2002
Binge drinkers are 23% of the population, but consume 76% of the alcohol.
23%
76%
0%
20%
40%
60%
80%
100%
Population Alcohol
U.S. Binge Drinkers, 2002
Source: NSDUH, 2002
Most young people do not drink.
15- to 17-year-olds
Drinking occasions
0 1 to 4 5 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
Strategy Options:
1. Personal change strategies – change people
2. Alcohol control strategies – control alcohol availability
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
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.
Alcohol Control Strategies:Essential Components
• changes in social norms
• policy interventions
• deterrence and enforcement
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.
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.
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?
Alcohol Control StrategiesPolicy 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
Percent of U.S. Population (18+ years of age) favoring alcohol policies designed to
reduce alcohol problems among youthProposed Policy Favor
StronglyFavor
SomewhatOppose
SomewhatOppose Strongly
Increase alcohol tax by 5 cents to fund prevention programs
65.0 16.8 5.7 12.6
Restrict alcohol ads to make drinking less appealing to youth
52.6 26.0 10.5 10.8
Conduct compliance checks to reduce illegal sales to minors
46.5 19.0 9.5 25.0
Require registration of beer kegs
39.9 21.3 15.3 23.5
Source: Harwood, et al, 1998
Percent of U.S. Population (18+ years of age) favoring restrictions on drinking in
public locationsPublic location Ban
drinkingBy permit
onlyNo restrictions
Parks 63.0 27.3 9.8
Concerts 51.2 34.1 14.6
Beaches 53.1 28.7 18.2
Stadiums/arenas 47.8 29.6 22.6
Source: Harwood, et al, 1998
Impact of enforcement on alcohol-related traffic
fatalities
25
30
35
40
45
Percent alcohol-related
Percentage traffic fatalities related to alcohol(1977-1999)
Essential Elements of Effective Prevention of Alcohol Problems
Public Support
EnforcementPolicies and Laws
Prevention
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.
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 Problem Cost per Ounce
Total Societal Costs, including Public Sector Costs: $6.00/ounce
Source: Ted Miller, Ph.D.
PIRE
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
Challenges Confronting the Community Prevention Coordinator
A. Provide “translation” services between:1. Researchers2. Public health professionals3. Community organizers4. Policy makers5. Alcohol industry6. Alcohol law enforcement
B. Provide “honest broker” services for each of the above groups.
C. Keep a low profile!
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”.
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.
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
Case Studies:Alcohol Prevention Research in Brazil
Presentation Outline1. 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?
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
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
The precautionary principleA 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
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
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