Políticas Públicas
em Alcohol
Prof. Dr. Ronaldo Laranjeira
Universidade 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
G lo b a l S u p p ly o f P u re
M illio n s o f h e cto litr e s
100
B e v e ra g e A lc o h o l
90
80
70
60
50
40
30
20
10
0
1961
1965
1969
1973
1977
1981
1985
1989
1993
1997
Ye ar
B a rle y B e e r
S p irit s
W in e
O ther
Proportion of alcohol consumers in WHO subregions
Region
AFR-D
AFR-E
AMR-A
AMR-B
AMR-D
EMR-B
EMR-D
EUR-A
EUR-B
EUR-C
SEAR-B
SEAR-D
WPR-A
WPR-B
% alcohol consumption
38
44
67
66
62
10
5
87
62
86
21
14
84
57
Adult (15+) Per Capita Alcohol Consumption
in Selected Latin American Countries
12
10
Litres
8
6
4
2
0
1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997
Year
Brazil
Mexico
Venezuela
Drinking Pattern Values for
Selected WHO Regions
Region
Pattern value
Afr D
Afr E
Amr A
Amr B
Amr D
Eur A
Sear B
Sear D
2.48
3.09
2.00
3.14
3.10
1.34
2.50
2.95
Prevalence (%) of problematic illicit drug use in the past
12 months among persons 15 years and above according
to 14 WHO regions
Opioids
Cocaine
Europe A
0.11
0.18
Europe B
0.09
0.01
Europe C
0.19
0.01
America A
0.13
0.78
America B
0.03
0.24
America D
0.07
0.43
Emirates B
0.55
Emirates D
0.41
SE Asia B
0.04
SE Asia D
0.15
W. Pacific A
0.04
0.28
W Pacific B
0.02
Africa D
0.09
0.26
Africa E
0.01
0.05
Note: UNDCP-derived estimates
Amphetamine
0.24
0.10
0.04
0.20
0.20
0.11
0.02
0.14
0.10
0.22
0.34
0.31
0.12
12 leading selected risk factors as causes of disease burden
measured in DALYs
Developing countries
Developed countries
High Mortality
Low Mortality
1 Underweight
Alcohol (6.2%)
2 Unsafe sex
Blood pressure
3 Unsafe water
Tobacco (4.0%)
4 Indoor smoke
Underweight
5 Zinc deficiency
Body mass index
6 Iron deficiency
Cholesterol
7 Vitamin A deficiency
Low fruit & veg intake
8 Blood pressure
Indoor smoke - solid fuels
9 Tobacco (2.0%)
Iron deficiency
10 Cholesterol
Unsafe water
11 Alcohol
Unsafe sex
12 Low fruit & veg intake Lead exposure
Tobacco (12.2%)
Blood pressure
Alcohol (9.2%)
Cholesterol
Body mass index
Low fruit & veg intake
Physical inactivity
Illicit drugs (1.8%)
Unsafe sex
Iron deficiency
Lead exposure
Child sexual abuse
World
Deaths in 2000 attributable to selected leading risk factors
Blood pressure
Tobacco
Cholesterol
Underweight
Unsafe sex
Fruit and vegetable intake
High Body Mass Index
Physical inactivity
Alcohol
Unsafe water, sanitation, and hygiene
Indoor smoke from solid fuels
Iron deficiency
Urban air pollution
Zinc deficiency
Vitamin A deficiency
Unsafe health care injections
Occupational risk factors for injury
0
1000
2000
3000
4000
5000
Number of deaths (000s)
6000
7000
8000
World
Disease burden (DALYs) in 2000 attributable to selected leading risk
factors
Underweight
Unsafe sex
Blood pressure
Tobacco
Alcohol
Unsafe water, sanitation, and hygiene
Cholesterol
Indoor smoke from solid fuels
Iron deficiency
High Body Mass Index
Zinc deficiency
Fruit and vegetable intake
Vitamin A deficiency
Physical inactivity
Occupational risk factors for injury
Lead exposure
Illicit drugs
0
20000
40000
60000
80000 100000 120000 140000 160000
Number of Disability-Adjusted Life Years (000s)
World
Disease burden (DALYs) in 2000 attributable to
Addictive Substances related Risks
Tobacco
High Mortality Developing
Countries
Low Mortality Developing
Countries
Developed Countries
Alcohol
Illicit drugs
0
10000
20000
30000
40000
50000
60000
Number of Disability-Adjusted Life Years (000s)
70000
World
Deaths in 2000 attributable to
Addictive Substances related Risks
Tobacco
High Mortality Developing Countries
Alcohol
Low Mortality Developing Countries
Developed Countries
Illicit drugs
0
1000
2000
3000
Number of deaths (000s)
4000
5000
World
Deaths in 2000 attributable to
Addictive Substances related Risks
Tobacco
High Mortality Developing Countries
Alcohol
Low Mortality Developing Countries
Developed Countries
Illicit drugs
0
1000
2000
3000
Number of deaths (000s)
4000
5000
WHO Regions
Deaths in 2000 attributable to selected leading risk factors
1800
1600
Alcohol
1400
Illicit drugs
Number of deaths (000s)
Tobacco
1200
1000
800
600
400
200
0
AFR
AMR
EMR
EUR
SEAR
WPR
WHO Regions
Disease burden (DALYs) in 2000 attributable to selected leading risk
factors
Tobacco
Alcohol
Illicit drugs
Number of Disability-Adjusted Life Years (000s)
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
AFRO
AMRO
EMRO
EURO
SEARO
WPRO
Burden of disease attributable to
addictive substances related risks:
ALCOHOL
(% DALYs in each subregion)
Proportion of DALYs attributable
to selected risk factor
<0.5%
0.5-0.9%
1-1.9%
2-3.9%
4-7.9%
8-15.9%
Burden of disease attributable to
addictive substances related risks:
TOBACCO
(% DALYs in each subregion)
Proportion of DALYs attributable
to selected risk factor
<0.5%
0.5-0.9%
1-1.9%
2-3.9%
4-7.9%
8-15.9%
Burden of disease attributable to
addictive substances related risks:
ILLICIT DRUGS
(% DALYs in each subregion)
Proportion of DALYs attributable
to selected risk factor
<0.5%
0.5-0.9%
1-1.9%
2-3.9%
Percentage of total global mortality and DALYs attributable to tobacco,
alcohol and illicit drugs
Risk factor
High mortality
developing
countries
Males
Females
Low mortality
developing
countries
Males
Females
Developed
countries
Males
Global
Females
Mortality
Tobacco
Alcohol
Illicit drugs
7.5
2.6
0.5
1.5
0.6
0.1
12.2
8.5
0.6
2.9
1.6
0.1
26.3
8.0
0.6
9.3
-0.3
0.3
8.8
3.2
0.4
DALYs
Tobacco
Alcohol
Illicit drugs
3.4
2.6
0.8
0.6
0.5
0.2
6.2
9.8
1.2
1.3
2.0
0.3
17.1
14.0
2.3
6.2
3.3
1.2
4.1
4.0
0.8
Attributable mortality by risk factor, sex and mortality stratum (‘000) in the Americas
Addictive
substances
Very low child, very
low adult
Low child, low
adult
High child, high
adult
Males
Females
Males
Females
Males
Females
Tobacco
352
294
163
58
5
1
Alcohol
27
-22
207
39
22
6
Illicit
drugs
10
7
7
4
1
0
Source: WHO (2002). World health report 2002.
Attributable DALYs by risk factor, sex and mortality stratum (‘000) in the Americas
Addictive
substances
Very low child, very
low adult
Low child, low adult
High child, high adult
Males
Females
Males
Females
Males
Females
Tobacco
3,567
2,606
2,190
813
51
14
Alcohol
2,925
702
7,854
1,443
789
170
797
410
758
323
199
71
Illicit drugs
Source: WHO (2002). World health report 2002.
Estimates of mortality attributed to illicit drug use in 14
WHO regions
Europe A
Europe B
Europe C
America A
America B
America D
Emirates B
Emirates D
SE Asia B
SE Asia D
W Pacific A
W Pacific B
Africa D
Africa E
Total
AIDS
6,236
733
773
10,698
5,349
1,035
962
4,273
1,586
57,011
1,310
10,122
4,003
1,334
105,425
Opioid
overdose
5,527
1,281
6,895
6,397
1,845
498
3,881
12,852
955
22,989
825
2,909
1,891
407
69,152
Suicide via
opioids
2,355
1,465
4,156
2,034
922
78
673
2,015
576
14,982
1,251
456
1,191
64
32,216
Trauma
3,387
651
830
4,057
2,342
716
813
2,954
797
3,128
1,028
9,295
2,768
922
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
Aspects of alcohol used in estimating alcohol
attributable fraction (AAF) for different
conditions
Volume
of drinking
Alcoholattributable
conditions*
Physical
diseases
(except CHD)
*AAF = 1 by definition
Drinking pattern
hazard score
(predominance of
intoxication)
Coronary
heart
disease
Injuries
Prior alcohol
dependence
Depression
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.
2.
3.
4.
5.
Alcohol-specific categories
Chronic health conditions
CHD
Depression
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 countries
High mortality
Developed countries
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 %
Global mortality burden (deaths in 1000s) attributable to alcohol by
major disease categories - 2000
Males
Females
Total
% of all alcoholattributable
deaths
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
% of all deaths
which are alcohol-attributable
In comparison:
estimate for
5.6%
0.6%
3.2%
1990: 1.5%
Disease conditions
Conditions arising during the
perinatal period
Global burden of disease (DALYs in 1000s) attributable to alcohol
by major disease categories - 2000
Males
Females
Total
% of all alcoholattributable
DALYs
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
6.5%
1.3%
4.0%
1990: 3.5%
Disease conditions
Conditions arising during the
perinatal period
% of all DALYs which are
alcohol-attributable
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!!!
WORKING IN EUROPE FOR THE PREVENTION OF
ALCOHOL RELATED HARM
Global Alcohol Policy
WORKING IN EUROPE FOR THE PREVENTION OF
ALCOHOL RELATED HARM
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 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
Brief Description of Eurocare:
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
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
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,
WORKING IN EUROPE FOR THE PREVENTION OF
ALCOHOL RELATED HARM
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ALCOHOL RELATED HARM
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 HARM
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ALCOHOL RELATED HARM
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ALCOHOL RELATED HARM
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ALCOHOL RELATED HARM
At the community level:
 Drinking and driving
 Intoxication
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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
WORKING 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 HARM
Strengthening Community Action:
 Drink driving
 Educational and prevention
programmes
 Manage availability
WORKING IN EUROPE FOR THE PREVENTION OF
ALCOHOL RELATED HARM
Helping individuals:
 Brief interventions in primary care
 Treatment for dependence
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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
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
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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 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 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 HARM
What can WHO (and its MS) do?
Make the science clear
WORKING 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 HARM
What can WHO (and its MS) do?
Estimate the social burden
WORKING 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 HARM
What can WHO (and its MS) do?
In dealing with the alcohol industry,
ENSURE that WHO sticks to its
guidelines
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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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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.
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.
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.
Price and the availability of alcohol
Effective
policy
Ineffective
policy
Opposed by
Supported by
social aspects
organizations
social aspects
organizations
X
X
X
X
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

Creating safer drinking environments
Effective
policy
Ineffective
Opposed by
Supported by
social aspects
organizations
social aspects
organizations
X
policy
Physical environment Changing the
physical environment of drinking
places reduces alcohol related
violence1
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
X
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
Opposed to legal sanctions; accepts
that server training leads to a

.
Prevention and education programmes
Effective
policy
Opposed by
Supported by
social aspects
organizations
social aspects
organizations
X
Ineffective
policy
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
Locally based community prevention
programs based only on educational
approaches Have limited or no effect1

X
Opposed to environmental approaches,
believing that they do not address those
who abuse the product.



Describes school based alcohol
education, and drink driving
education programmes as community
based programmes6
Drink driving programmes
Effective
policy
Opposed by
Supported by
social aspects
organizations
social aspects
organizations
X
Ineffective
X
policy
X
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
X



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ALCOHOL RELATED HARM
What can WHO (and its MS) do?
There cannot be common ground on
drinking and driving
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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.
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ALCOHOL RELATED HARM
What can WHO (and its MS) do?
There should be no discussion on
self-regulation
We should not waste any more time 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
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
WORKING 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 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 HARM
What can WHO (and its MS) do?
Community Action
Database of community programmes
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
WORKING 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 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 HARM
What can the NGO sector do?
And do we write formally to the
WHO after this consultation, or
what?
WORKING IN EUROPE FOR THE PREVENTION OF
ALCOHOL RELATED HARM
Thank you for
your attention
Alcohol in Development and in
Health and Social Policy
David Jernigan PhD
Center on Alcohol Marketing and Youth
Georgetown University
Washington, D.C.
dhj@georgetown.edu
Robin Room PhD
Center for Social Research on Alcohol and Drugs
University of Stockholm
Stockholm, Sweden
Jürgen T. Rehm PhD
Addiction Research Institute
Zurich, Switzerland
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
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.”
=
f(prevalence,
pattern weight,
relative risk)
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 metaanalyses (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 in
litre pure alcohol 2000 (based on CRA)
Adult per capita consumption 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
Aspects of alcohol used in estimating alcohol
attributable fraction (AAF) for different
conditions
Volume
of drinking
Alcoholattributable
conditions*
Physical
diseases
(except CHD)
*AAF = 1 by definition
Drinking pattern
hazard score
(predominance of
intoxication)
Coronary
heart
disease
Injuries
Prior alcohol
dependence
Depression
Estimating AAFs
1.
2.
3.
4.
5.
Alcohol-specific categories
Chronic health conditions
CHD
Depression
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
Global mortality burden (deaths in 1000s) attributable to alcohol by
major disease categories - 2000
Males
Females
Total
% of all alcoholattributable
deaths
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
% of all deaths
which are alcohol-attributable
In comparison:
estimate for
5.6%
0.6%
3.2%
1990: 1.5%
Disease conditions
Conditions arising during the
perinatal period
Global burden of disease (DALYs in 1000s) attributable to alcohol
by major disease categories - 2000
Males
Females
Total
% of all alcoholattributable
DALYs
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
6.5%
1.3%
4.0%
1990: 3.5%
Disease conditions
Conditions arising during the
perinatal period
% of all DALYs which are
alcohol-attributable
Disability-Adjusted life Years (DALYs)
attributable to ten leading risk factors, 2000
World
DALYs
(millions)
High mortality
developing
countries
Low mortality
developing
countries
Developed countries
% 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 countries
High mortality
Developed countries
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:
»
»
»
2.
Service system utilization by “problem drinkers”
•
California urban/suburban/rural county
»
»
»
»
»
3.
Health care costs $139 million
Social work costs
$125 million
Criminal justice and fire costs $390 million
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
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 consumption
Figure 2: Adult (15+) Per Capita Alcohol Consumption
by Macro-Region
7
6
Litres
5
4
3
2
1
0
1961
Asia
1964
1967
1970
1973
1976
Central and South America
1979
1982
1985
Year
Sub-Saharan
Africa
1988
1991
Developed
1994
1997
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 schoolbased 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 alcoholinvolved 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
Effectiveness
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
Effectiveness
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
Effectiveness
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 onpremise regulations
and legal
requirements
++
+
++
High
HR
0
++
+
High
GP
++
++
+
High
GP
Promoting alcohol
free activities and
events
Community
mobilization
Ratings of policy-relevant stategies and
interventions – DRINKING-DRIVING
Strategy
Effectiveness
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
INTERVENTION
Strategy
Effectiv
e-ness
Breadth
of
research
support
Crosscultural
testing
Cost to
implem
ent
Target
group
Brief
intervention
++
+++
+++
Moderat
e
HR
Alcohol
Problems
Treatment
+
+++
+++
High
HD
Self-help
+
+
++
Low
HD
Mandatory
treatment of
repeat drinking
drivers
+
++
+
Moderat
e
HD
Ratings of policy-relevant stategies and
interventions – EDUCATION AND PERSUATION
Strategy
Effectiv
e-ness
Breadth
of
research
support
Crosscultural
testing
Cost to
implem
ent
Target
group
Alcohol
education in
schools
0
+++
++
High
HR
College
student
education
0
+
+
High
HR
Public service
messages
0
+++
++
Moderat
e
GP
Warning labels
0
+
++
Low
GP
Ratings of policy-relevant stategies and
interventions – REGULATING ALCOHOL
PROMOTION
Strategy
Effecti Breadth Crossveof
cultural
ness researc testing
h
support
Advertising
+
++
++
Bans
Cost
to
imple
ment
Target
group
Low
GP
Advertising
content
controls
Moder
ate
GP
0
0
0
Ratings of policy-relevant stategies and
interventions – TAXATION AND PRICING
Strategy
Effecti Breadth Crossveof
cultural
ness researc testing
h
support
ALCOHOL +++
+++
+++
TAXES
Cost
to
imple
ment
Target
group
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
Policies
and
Laws
Enforcement
Prevention
Public Support
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 multidisciplinary 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
Heroin
Cocaine
Alcohol
Stimulants
Marijuana
Source:
National Comorbidity Survey
Anthony, Warner, and Kessler
31.9%
23.1%
16.7%
15.4%
11.2%
9.1%
Global Burden of Disease
(Disability-Adjusted Life Years)
Attribution
Tobacco
Alcohol Illicit Drugs
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%
Worldwide
Source:
World Health Report 2002
World Health Organization
Global Market – Alcohol Spirits
Sales Exceed 2 Billion Cases Annually
Country
Case Volume
China
Russia
India
Brazil
Japan
United States
Korea
Thailand
Germany
France
725 million cases
350
249
195
176
135
79
76
60
37
Source: Mark Brown, President
Sazerac Company, Inc.
March 4, 2003
Product Categories – Alcohol Spirits
Product Category
Baijiu
Vodka
Whisky
Cachaca
Rum
Brandy
Shochu
Soju
Liqueurs
Source:
Case Volume
725 million cases
400
205
200
115
82
70
70
51
Mark Brown, President
Sazerac Company, Inc.
March 4, 2003
U.S. Economic Costs of ATOD Use, 1995
Total Costs = $415 Billion
Alcohol-$167 Billion
27%
40%
33%
Tobacco-$138 Billion
Illicit Drugs-$110 Billion
Sources: Harwood, Fountain, & Livermore, NIDA & NIAAA, 1998
Rice (unpublished) Institute for Health and Aging, UCSF, 1995
Most U.S. adults do not drink
or drink infrequently.
Frequency of Drinking Among U.S. Adults 21 and Older,
2002 (past 30 days)
60%
46%
40%
26%
20%
13%
9%
6%
0%
0
1 to 4
5 to 10
11 to 21
Number of Drinking Days
Source: NSDUH, 2002
21+
Most U.S. adults do not drink
at a hazardous level.
Drinking Patterns among U.S. Adults 21 and Older, 2002
(past 30 days)
7%
Nondrinker
16%
Nonbingers
46%
Infrequent Bingers
31%
Frequent Bingers
Source: NSDUH, 2002
Binge drinkers are 23% of the population,
but consume 76% of the alcohol.
U.S. Binge Drinkers, 2002
100%
76%
80%
60%
40%
23%
20%
0%
Population
Source: NSDUH, 2002
Alcohol
Most young people do not drink.
Drinking Among Youth, 2002 (past 30 days)
15- to 17-year-olds
10%
Drinking occasions
18%
0
1 to 4
5 or more
72%
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 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
Percent of U.S. Population (18+ years of
age) favoring alcohol policies designed to
reduce alcohol problems among youth
Proposed Policy
Favor
Strongly
Favor
Somewhat
Oppose
Somewhat
Oppose
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 locations
Public location
Ban
drinking
By permit
only
No 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
Percentage traffic fatalities related to alcohol
(1977-1999)
45
40
35
30
25
77
9
1
79
9
1
81
9
1
83
9
1
85
9
1
87
9
1
89
9
1
91
9
1
93
9
1
Percent alcohol-related
95
9
1
97
9
1
99
9
1
Essential Elements of Effective
Prevention of Alcohol Problems
Policies
and
Laws
Enforcement
Prevention
Public Support
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 multidisciplinary research strategy.
Every Ounce of Alcohol Sold in the
United States Generates $2.25 in Public
Sector Costs
Alcohol Problem
Alcohol – Related Violence
Drinking Driving Problems
Other Costs
Cost per Ounce
$1.00
.85
.40
$2.25
Total Societal Costs, including Public Sector Costs: $6.00/ounce
Source: Ted Miller, Ph.D.
PIRE
Societal Costs – Alcohol Sales
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
Source: Ted Miller, Ph.D.
PIRE
Challenges Confronting the
Community Prevention Coordinator
A. Provide “translation” services between:
1.
2.
3.
4.
5.
6.
Researchers
Public health professionals
Community organizers
Policy makers
Alcohol industry
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 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?
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 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 decisionmaking
• 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