Robin Room

Alcohol: No ordinary commodity research and public policy

From a public health perspective, alcohol is a major contributor to morbidity and mortality. This book describes recent advances in alcohol research which have direct relevance for the development of effective alcohol policies at the local, national and international levels. The central purpose of the book is to empower those responsible for public health and social welfare.

Alcohol and public health

Alcoholic beverages, and the problems they engender, have been familiar fixtures in human societies since the beginning of recorded history. We review advances in alcohol science in terms of three topics: the epidemiology of alcohols role in health and illness; the treatment of alcohol use disorders in a public health perspective; and policy research and options. Research has contributed substantially to our understanding of the relation of drinking to specific disorders, and has shown that the relation between alcohol consumption and health outcomes is complex and multidimensional. Alcohol is causally related to more than 60 different medical conditions. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco and hypertension. Treatment research shows that early intervention in primary care is feasible and effective, and a variety of behavioural and pharmacological interventions are available to treat alcohol dependence. This evidence suggests that treatment of alcohol-related problems should be incorporated into a public health response to alcohol problems. Additionally, evidence-based preventive measures are available at both the individual and population levels, with alcohol taxes, restrictions on alcohol availability, and drinking-driving countermeasures among the most effective policy options. Despite the scientific advances, alcohol problems continue to present a major challenge to medicine and public health, in part because population-based public health approaches have been neglected in favour of approaches oriented to the individual that tend to be more palliative than preventative.

THE RELATION BETWEEN DIFFERENT DIMENSIONS OF ALCOHOL CONSUMPTION AND BURDEN OF DISEASE - AN OVERVIEW

AIMS As part of a larger study to estimate the global burden of disease and injury attributable to alcohol: to evaluate the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injuries; to quantify relationships identified as causal based on published meta-analyses; to separate the impact on mortality versus morbidity where possible; and to assess the impact of the quality of alcohol on burden of disease. METHODS Systematic literature reviews were used to identify alcohol-related diseases, birth complications and injuries using standard epidemiological criteria to determine causality. The extent of the risk relations was taken from meta-analyses. RESULTS Evidence of a causal impact of average volume of alcohol consumption was found for the following major diseases: tuberculosis, mouth, nasopharynx, other pharynx and oropharynx cancer, oesophageal cancer, colon and rectum cancer, liver cancer, female breast cancer, diabetes mellitus, alcohol use disorders, unipolar depressive disorders, epilepsy, hypertensive heart disease, ischaemic heart disease (IHD), ischaemic and haemorrhagic stroke, conduction disorders and other dysrhythmias, lower respiratory infections (pneumonia), cirrhosis of the liver, preterm birth complications and fetal alcohol syndrome. Dose-response relationships could be quantified for all disease categories except for depressive disorders, with the relative risk increasing with increased level of alcohol consumption for most diseases. Both average volume and drinking pattern were linked causally to IHD, fetal alcohol syndrome and unintentional and intentional injuries. For IHD, ischaemic stroke and diabetes mellitus beneficial effects were observed for patterns of light to moderate drinking without heavy drinking occasions (as defined by 60+ g pure alcohol per day). For several disease and injury categories, the effects were stronger on mortality compared to morbidity. There was insufficient evidence to establish whether quality of alcohol had a major impact on disease burden. CONCLUSIONS Overall, these findings indicate that alcohol impacts many disease outcomes causally, both chronic and acute, and injuries. In addition, a pattern of heavy episodic drinking increases risk for some disease and all injury outcomes. Future studies need to address a number of methodological issues, especially the differential role of average volume versus drinking pattern, in order to obtain more accurate risk estimates and to understand more clearly the nature of alcohol-disease relationships.

The Global Distribution of Average Volume of Alcohol Consumption and Patterns of Drinking

Aims: To make quantitative estimates on a global basis of exposure of disease-relevant dimensions of alcohol consumption, i.e. average volume of alcohol consumption and patterns of drinking. Design: Secondary data analysis. Measurements: Level of average volume of drinking was estimated by a triangulation of data on per capita consumption and from general population surveys. Patterns of drinking were measured by an index composed of several indicators for heavy drinking occasions, an indicator of drinking with meals and an indicator of public drinking. Average volume of consumption was assessed by sex and age within each country, and patterns of drinking only by country; estimates for the global subregions were derived from the population-weighted average of the countries. For more than 90% of the world population, per capita consumption was known, and for more than 80% of the world population, survey data were available. Findings: On the country level, average volume of alcohol consumption and patterns of drinking were independent. There was marked variation between WHO subregions on both dimensions. Average volume of drinking was highest in established market economies in Western Europe and the former Socialist economies in the Eastern part of Europe and in North America, and lowest in the Eastern Mediterranean region and parts of Southeast Asia including India. Patterns were most detrimental in the former Socialist economies in the Eastern part of Europe, in Middle and South America and parts of Africa. Patterns were least detrimental in Western Europe and in developed countries in the Western Pacific region (e.g., Japan). Conclusions: Although exposure to alcohol varies considerably between regions, the overall exposure by volume is quite high and patterns are relatively detrimental. The predictions for the future are not favorable, both with respect to average volume and to patterns of drinking.

Stigma, social inequality and alcohol and drug use

A heavy load of symbolism surrounds psychoactive substance use, for reasons which are discussed. Psychoactive substances can be prestige commodities, but one or another aspect of their use seems to attract near--universal stigma and marginalization. Processes of stigmatization include intimate process of social control among family and friends; decisions by social and health agencies; and governmental policy decisions. What is negatively moralized commonly includes incurring health, casualty or social problems, derogated even by other heavy users; intoxication itself; addiction or dependence, and the loss of control such terms describe; and in some circumstances use per se. Two independent literatures on stigma operate on different premises: studies oriented to mental illness and disability consider the negative effects of stigma on the stigmatized, and how stigma may be neutralized, while studies of crime generally view stigma more benignly, as a form of social control. The alcohol and drug literature overlap both topical areas, and includes examples of both orientations. Whole poverty and heavy substance use are not necessary related, poverty often increases the harm for a given level of use. Marginalization and stigma commonly add to this effect. Those in treatment for alcohol or drug problems are frequently and disproportionately marginalized. Studies of social inequality and substance use problems need to pay attention also to processes of stigmatization and marginalization and their effect on adverse outcomes.

Alcohol as a Risk Factor for Global Burden of Disease

Aim: To make quantitative estimates of the burden of disease attributable to alcohol in the year 2000 on a global basis. Design: Secondary data analysis. Measurements: Two dimensions of alcohol exposure were included: average volume of alcohol consumption and patterns of drinking. There were also two main outcome measures: mortality, i.e. the number of deaths, and disability-adjusted life years (DALYs), i.e. the number of years of life lost to premature mortality or to disability. All estimates were prepared separately by sex, age group and WHO region. Findings: Alcohol causes a considerable disease burden: 3.2% of the global deaths and 4.0% of the global DALYs in the year 2000 could be attributed to this exposure. There were marked differences by sex and region for both outcomes. In addition, there were differences by disease category and type of outcome; in particular, unintentional injuries contributed most to alcohol-attributable mortality burden while neuropsychiatric diseases contributed most to alcohol-attributable disease burden. Discussion/Conclusions: The underlying assumptions are discussed and reasons are given as to why the estimates should still be considered conservative despite the considerable burden attributable to alcohol globally.

Global burden of disease from alcohol, illicit drugs and tobacco

The use of alcohol, tobacco and illicit drugs entails considerable burden of disease: in 2000, about 4% of the global burden as measured in disability adjusted life years was attributable to each alcohol and tobacco, and 0.8% to illicit drugs. The burden of alcohol in the above statistic was calculated as net burden, i.e. incorporating the protective health effects. Tobacco use was found to be the most important of 25 risk factors for developed countries in the comparative risk assessment underlying the data. It had the highest mortality risk of all the substance use categories, especially for the elderly. Alcohol use was also important in developed countries, but constituted the most important of all risk factors in emerging economies. Alcohol use affected younger people than tobacco, both in terms of disability and mortality. The burden of disease attributable to the use of legal substances clearly outweighed the use of illegal drugs. A large part of the substance-attributable burden would be avoidable if known effective interventions were implemented.

WHO Study on the reliability and validity of the alcohol and drug use disorder instruments: overview of methods and results

The WHO Study on the reliability and validity of the alcohol and drug use disorder instruments in an international study which has taken place in centres in ten countries, aiming to test the reliability and validity of three diagnostic instruments for alcohol and drug use disorders: the Composite International Diagnostic Interview (CIDI), the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and a special version of the Alcohol Use Disorder and Associated Disabilities Interview schedule-alcohol/drug-revised (AUDADIS-ADR). The purpose of the reliability and validity (R&V) study is to further develop the alcohol and drug sections of these instruments so that a range of substance-related diagnoses can be made in a systematic, consistent, and reliable way. The study focuses on new criteria proposed in the tenth revision of the International Classification of Diseases (ICD-10) and the fourth revision of the diagnostic and statistical manual of mental disorders (DSM-IV) for dependence, harmful use and abuse categories for alcohol and psychoactive substance use disorders. A systematic study including a scientifically rigorous measure of reliability (i.e. 1 week test-retest reliability) and validity (i.e. comparison between clinical and non-clinical measures) has been undertaken. Results have yielded useful information on reliability and validity of these instruments at diagnosis, criteria and question level. Overall the diagnostic concordance coefficients (kappa, kappa) were very good for dependence disorders (0.7-0.9), but were somewhat lower for the abuse and harmful use categories. The comparisons among instruments and independent clinical evaluations and debriefing interviews gave important information about possible sources of unreliability, and provided useful clues on the applicability and consistency of nosological concepts across cultures.

The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together.

Alcohol consumption causes injury in a dose-response manner. The most common mode of sustaining an alcohol-attributable injury is from a single occasion of acute alcohol consumption, but much of the injury literature employs usual consumption habits to assess risk instead. An analysis of the acute dose-response relationship between alcohol and injury is warranted to generate single occasion- and dose-specific relative risks. A systematic literature review and meta-analysis was conducted to fill this gap. Linear and best-fit first-order model were used to model the data. Usual tests of heterogeneity and publication bias were run. Separate meta-analyses were run for motor vehicle and non-motor vehicle injuries, as well as case-control and case-crossover studies. The risk of injury increases non-linearly with increasing alcohol consumption. For motor vehicle accidents, the odds ratio increases by 1.24 (95% CI: 1.18-1.31) per 10-g in pure alcohol increase to 52.0 (95% CI: 34.50-78.28) at 120 g. For non-motor vehicle injury, the OR increases by 1.30 (95% CI: 1.26-1.34) to an OR of 24.2 at 140 g (95% CI: 16.2-36.2). Case-crossover studies of non-MVA injury result in overall higher risks than case-control studies and the per-drink increase in odds of injury was highest for intentional injury, at 1.38 (95% CI: 1.22-1.55). Efforts to reduce drinking both on an individual level and a population level are important. No level of consumption is safe when driving and less than 2 drinks per occasion should be encouraged to reduce the risk of injury.

Changing the density of alcohol outlets to reduce alcohol-related problems

Increasingly, it seems, legal and political debates regarding the granting of new liquor licences are turning to the issue of whether the number and density of alcohol outlets makes a difference in rates of alcohol consumption and alcohol-related harm. But what is the state of the evidence on this question? In this Harm Reduction Digest Livingston, Chikritzhs and Room review the research literature on the effects of density of alcohol sales outlets on alcohol consumption and alcohol-related problems; suggest a new way of conceptualising the relationships; and discuss the implications for reducing alcohol-related harm.