Global Trends in Alcohol Consumption, Related Harm
and Policy Responses
V. Poznyak Management of Substance Abuse
Department of Mental Health and Substance Abuse
The First National Conference on Alcohol Consumption and Related Problems in ThailandBangkok, 13 July 2005
Total alcohol adult (15+) per capita consumption in the world
(2000)
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2004. All rights reserved
World Health OrganizationDepartment of Mental Health and Substance Abuse
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
Global trends in alcohol consumption in 1961-1999 (unweighted
means)
0
1
2
3
4
5
6
1961 1967 1973 1979 1985 1991 1997
Years
Beer
Wine
Spirits
Total
Figure 1. Adult (15+) Per Capita Alcohol Consumption by Development Status
0
1
2
3
4
5
6
7
1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997
Year
Litr
es
Developed Developing Former Soviet
Alcohol consumption by developmental status in 1961-
1999
Recorded alcohol consumption in WHO regions in 1961-1999 (population
weighted means)
0
2
4
6
8
10
12
14
16
18
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
Year
litr
es o
f p
ure
alc
oh
ol
SEARO
WPRO
EURO
EMRO
AMRO
AFRO
Adult per capita consumption in WHO South-East Asian and Western Pacific
Regions
1960 1970 1980 1990 2000YEAR
0
2
4
6
8
adult p
er
capita c
onsum
pt ion in l p
ure
al c
ohol
WPR_BWPR_ASEAR_DSEAR_B
Patterns of alcohol consumption in the world (2000)
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2004. All rights reserved
World Health OrganizationDepartment of Mental Health and Substance Abuse
Patterns o f drinking
1.00 to 2 .00
2.00 to 2 .50
2.50 to 3 .00
3.00 to 4 .00
Mechanisms relating alcohol use to health and social problems (adapted from Babor et al.,
2003)
Chronic disease
Accidents/injuries
(acute disease)
Acutesocial
problems
Chronicsocial
problems
IntoxicationToxic and other
biochemicaleffects
Dependence
Pattern of alcohol use
Amount of alcohol use
World Health Organization
Disability-Adjusted Life Year (DALY)
Definition: DALY is an integrated indicator that shows the number of life years that are lost due to premature deaths or cases of disability occurring in a particular year
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
Disease burden (DALYs) in 2000 attributable to selected leading risk
factors
Number of Disability-Adjusted Life Years (000s)
0 20000 40000 60000 80000 100000 120000 140000 160000
Urban air pollution
Childhood sexual abuse
Unsafe health care injections
Illicit drugs
Lead exposure
Risk factors for injury
Physical inactivity
Vitamin A deficiency
Low 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
High Mortality Developing Countries
Low Mortality Developing Countries
Developed Countries
Disease burden (DALYs) in 2000 attributable to selected leading risk factors (world)
Number of Disability-Adjusted Life Years (000s)
Source: WHR, 2002
World Health Organization
High MortalityDeveloping Countries
Low MortalityDeveloping Countries
= Major NCD risk factors
1 Underweight Alcohol Tobacco 2 Unsafe sex Blood pressure Blood pressure
3 Unsafe water Tobacco Alcohol 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 9 Tobacco Iron deficiency Unsafe sex 10 Cholesterol Unsafe water Iron deficiency 11 Alcohol Unsafe sex Lead exposure 12 Low fruit & veg intake Lead exposure Childhood sexual abuse
DevelopedCountries
Leading 12 selected risk factors as causes of disease burden
World Health Organization
Burden of Disease Attributable to Alcohol
0.5-0.9%
1-1.9%
2-3.9%
4-7.9%
<0.5%
8-15.9%
Proportion of DALYsattributable to
selected risk factor
World Health Organization
Alcohol-related mortality and disease burden in different WHO regions
WHO region Percent of total mortality Percent of total disease burden
Men Women Men Women
Europe AEurope B Europe C
S-E Asia BS-E Asia D
W-Pacific AW-Pacific B…World
3.2 9.7 18.0
4.1 2.3
3.7 8.5 … 5.6
-4.1 2.7 5.1
0.9 2.8
-5.4 1.3 … 0.6
11.1 10.2 21.5 5.3 2.8
8.1 9.1 … 6.5
1.6 2.5 6.5
1.0 0.4
0.6 1.8 … 1.3
Percentage of total global mortality and DALYs attributable to psychoactive
substances Risk factor
High mortality developing countries
Low mortality developing countries
Developed countries
World
Men Women Men Women Men Women
MortalityTobaccoAlcoholIllicit drugsDALYsTobaccoAlcoholIllicit drugs
7.52.60.5
3.42.60.8
1.50.60.1
0.60.50.2
12.2 8.5 0.6 6.29.81.2
2.91.60.1
1.32.00.3
26.3 8.0 0.6
17.114.02.3
9.3-0.30.3
6.23.31.2
8.83.20.4
4.14.00.8
Global burden of disease (DALYs in 000) attributable to alcohol in 2000 (Rehm et al,
2003)Diseases and accidents
…CancerNeuropsychiatric disordersCardio-vascular diseasesOther non-commdiseases Unintentional injuriesIntentional injuries
Women
1021
3814
-428
860
24871117
Men
3180
18090
4411
3695
140085945
Total
4201
21904
3983
4555
164957062
% of alcohol-related disease burden
7
38
7
8
28 12
Percentage of global DALYs attributable to different neuropsychiatric conditions (WHO,
2002)Neuropsychiatric conditions
Total DALYs193,278,495
Percentage100%
Unipolar depressive disorder
67,294,858 35%
Alcohol use disordersSchizophreniaBipolar disorderAlzheimer disease and other dementiasMental retardationMigraineDrug use disordersEpilepsyPanic disorder…
20,330,90916,149,01013,952,00610,396,902
9,956,313 7,666,232 7,387,679 7,327,500 6,757,894…
11%8%7%5%
5%4%4%4%3%…
Prevalence of alcohol use disorders in 2000
(Global Burden of Disease Study)76.4 million people worldwide with alcohol use disorders (ICD-10 F10.1 and F10.2 - harmful use of alcohol and alcohol dependence)– 63.7 million men
– 12.7 million women (F:M=1:5)
Source: Colin D. Mathers, Claudia Stein, Doris Ma Fat et al (2001). Global Burden of Disease 2000: Version 2 methods and results. GPE Discussion paper 50; Geneva, WHO.
World Health Organization
Approaches to Reduce the Burden Associated with Alcohol Use
• Reduction of exposure to alcohol and its harmful metabolites (shifting population distributions of exposure)– Frequency– Quantity– Period of substance use (delayed onset of
substance use) – Pattern of use
• Reduction of high risk exposure to alcoholWorld Health Organization
a: Burden at To attributable to prior exposure
b: Burden caused by other factors only
A conceptual model of attributable and avoidable risk (Murray et al., 2004)
Types of alcohol policy measures• Population-based policies
– Aimed at altering levels of alcohol consumption among the population e.g. through taxation, advertising, availability restrictions, regulation of density of outlets, hours and days of sale.
• Problem-directed policies– Aimed at specific alcohol-related problems such as
drinking driving (e.g. promoting widespread random breath testing). These policies are more focused and thus, are less likely to affect the non-problem drinker.
• Direct interventions– Policies aimed at individual drinkers, such as brief
interventions or rehabilitation programmes.Basis: Godfrey & Maynard (1995)
Reductions in male death rates if alcohol consumption per capita reduced by 1
litre
Reductions in male death rates if alcohol consumption per capita reduced by 1
litre
-12
-10
-8
-6
-4
-2
0
AccidentsCirrhosisHomicideHeartSuicideAll causes
Source: Norström & Skog 2001
World Health Organization
Alcohol: No Ordinary CommodityResearch and Public Policy (OUP/WHO, 2003)
• Thomas Babor• Raul Caetano• Sally Casswell• Griffith Edwards• Norman Giesbrecht• Kathryn Graham• Joel Grube• Paul Gruenewald
• Linda Hill• Harold Hodler• Ross Homel
• Esa österberg
• Jürgen Rehm• Robin Room• Ingeborg Rossow
World Health Organization
Alcohol policy-relevant strategies and interventions (Babor et al, 2003)
• Regulating physical availability
• Taxation and pricing
• Altering the drinking context
• Education and persuasion
• Regulating alcohol promotion
• Drinking-driving countermeasures
• Treatment and early interventions
World Health Organization
Choosing the right intervention (Babor et al, 2003)
• Effectiveness + ++ +++– Quality of scientific information
• Breadth of research support + ++ +++– Quantity and consistency of the evidence available
• Cross-cultural testing + ++ +++– Applicability to different countries, regions and
subgroups• Cost to implement and sustain Low Moderate High
World Health Organization
Regulating physical availability
• Total ban on sales
• Minimum legal purchase age
• Rationing
• Government monopoly on retail sales
• Hours and days of sale restrictions
• Restrictions on density of outlets
• Server liability
• Different availability by alcohol strength
World Health Organization
Implementation of restrictions on availability of alcoholic beverages
• Minimum age requirements – No age limit in 15% of countries for drinking beer on the premises and
no minimum age for purchasing takeaway beer in 12% of countries.
• State monopolies and licensing systems– 15% of countries have state monopoly on off-premise sale of beer, wine
or spirits. – 73% have licensing systems for at least one beverage and 12% had no
restrictions on takeaway alcohol sales.
• Restrictions on off-premise retail sale– only 25% of countries that reported sales restrictions stated that the
restrictions were fully enforced.
Global Status Report: Alcohol Policy. WHO, 2004
Taxation and pricing
• Taxes on alcohol beverages– General sales tax (VAT) (average
worldwide 16.6%)
– Alcohol-specific taxes• Excise tax (average percentage of retail price) • Excise or tax stamps on beverage containers or
bottles
World Health Organization
Definition of alcoholic beverage• An integral part of alcohol legislation as that
definition sets the limit for when the laws apply and to what beverages they apply.
• Definitions ranged from 0.1 – 12.0% alcohol by volume, with the mean being 1.95% (median 1.2%, SD = 1.93).
• Legal limit can be exploited in advertising. Global Status Report: Alcohol Policy. WHO, 2004
Frequency of low, middle and high alcohol-specific tax on alcohol
Alcohol-specific tax Beer (n=65) Wine (n=60)
Low (<10%) 23.1 28.3
Middle (10-29%) 52.3 43.3
High (>30%) 24.6 28.3
Alcohol- specific tax Spirits (n=60)
Low (<30%) 36.7
Middle (30-49%) 33.3
High (>50%) 30.0
Price and taxation
In 16 countries, a beer is cheaper than a soft drink. In most countries, between one and three soft drinks can be bought for the price of one beer. The rationale for looking at the price of beer and soft drinks (beer-cola ratio) is that one aspect of pricing policy of alcoholic beverages by governments can be to encourage the consumption of non-alcoholic drinks.
Global Status Report: Alcohol Policy. WHO, 2004
Altering the drinking context• Outlet policy not to serve intoxicated
• Training bar staff and managers to prevent and better manage aggression
• Voluntary codes of bar practice
• Enforcement of on-premise regulations and legal requirements
• Promoting alcohol-free activities and events
• Community mobilization
World Health Organization
Education and persuasion• Alcohol education in schools
• College student education
• Public service messages
• Warning labels
World Health Organization
Regulating alcohol promotion• Advertising bans and restrictions
– Total bans– Partial restrictions– Voluntary agreements
• Advertising content controls• Restrictions on sponsorships
– Youth events– Sport events
• Enforcement of advertising and sponsorship restrictions
World Health Organization
Drinking-driving countermeasures• Sobriety check points
• Random breath testing (RBT)
• Lowering BAC limits
• Administrative licence suspension
• Low BAC for young drivers ("zero tolerance")
• Graduated licensing for novice drivers
• Designated drivers and ride services
World Health Organization
Drink driving legislation
• Earlier general laws against drink driving have been replaced in most countries by more effective laws forbidding driving while above a specified blood alcohol concentration (BAC) level.
• In almost 40% of countries, the legal limit is around 0.5 per mille (50 mg of ethanol in each litre of blood). The limit was lower in nearly 30% of countries and higher in over 25%.
• Close to one-third of countries that have a BAC limit do not perform Random Breath Testing (RBT) as a measure of enforcing the drink driving legislation. Countries with a higher legal BAC perform RBT checks less frequently.
Global Status Report: Alcohol Policy. WHO, 2004
Treatment and early interventions
• Brief interventions with at-risk drinkers
• Treatment of alcohol use disorders
• Mutual help/self-help attendance
• Mandatory treatment of repeat drinking-
drivers
World Health Organization
Comparison of different alcohol policy related measures (Babor et al, 2003)
Strategy or intervention…
Minimum legal
purchase age
Gvt. monopoly of
retail sales
Restrictions on
hours/days of sale
Outlet density
restrictions
Alcohol taxes
Effect.
+++
+++
++
++
+++
Res. Supp.
+++
+++
++
+++
+++
Cross-cult.
+++
++
++
++
+++
Cost
Low
Low
Low
Low
Low
Comparison of different alcohol policy related measures (continued)
Strategy or intervention…Sobriety checkpoints
Lowered BAC limits
License suspension
for driving under
influence
Graduated licensing
Brief interventions
for hazardous
drinkers
Effect.
++
+++
++
++
++
Res. Supp.
+++
+++
++
++
+++
Cross-cult.
+++
++
++
++
+++
Cost
Moderate
Low
Moderate
Low
Moderate
A mix of alcohol policies needed
• Definition of alcoholic beverage (low enough to include most alcoholic beverages consumed)
• Government control over retail sale • Sales restrictions• Culturally appropriate age limit• Blood alcohol concentration level limit• Comparative promotion of lower or non-alcoholic
beverage consumption• Taxation• Advertising and sponsorship controls• Restricting drinking in public places
P Pa O
Distal Socio-Economic Causes
Proximal CausesPhysiological and
PathophysiologicalCauses
Outcomes
P Pa O
P Pa
1
2
3
1
2
3
1
2
D
D
D
1
2
3
Simplified causal web linking exposures and outcomes
Monitoring Alcohol Consumption and Related Harm (WHO, 2000)
• Chronic harms (liver disease, alcohol dependence, alcohol psychoses, some cancers etc.)
• Acute harms (fatal road crashes, suicides, alcohol poisonings, assaults etc)
• Volume of alcohol consumption• High risk alcohol consumption (patterns of drinking)
Alcohol: no ordinary commodity
• Alcohol use associated with substantial mortality and morbidity
• Availability and markets of alcohol beverages should be differentially controlled
• The public health interests should supersede commercial and national interests
• Public health should be taken into account in trade negotiations involving psychoactive substances
• International coordination, cooperation and support necessary• To be effective public health policies should target also mode,
patterns and context of alcohol and other substance use • Societies have obligation to provide treatment and care for
those with alcohol use disorders
World Health Organization
Evidence-based Policy Responses
"… Many gaps remain to be filled in our understanding of the issues related to substance use and dependence but… we already know a great deal about the nature of these problems that can be used to shape policy responses".
LEE Jong-wook, WHO Director
General
World Health Organization
WHA resolution "Public health problems caused by harmful use of
alcohol" (2005)
REQUESTS Member States:
to develop, implement and evaluate effective strategies and programmes for reducing the negative health and social consequences of harmful use of alcohol
World Health Organization
Thank you for your attention
www.who.int/substance_abuse/Management of Substance Abuse
WHO Department of Mental Health and Substance Abuse
World Health Organization