1. 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 Thailand Bangkok, 13 July 2005

2. 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 Organization Department of Mental Health and Substance Abuse

3. Global trends in alcohol consumption in 1961-1999 (unweighted means)

4. Alcohol consumption by developmental status in 1961-1999

6. Recorded alcohol consumption in WHO regions in 1961-1999 (population weighted means) 0 2 4 6 8 10 12 14 16 18 19611963196519671969197119731975197719791981198319851987198919911993199519971999 Year litres of pure alcohol SEARO WPRO EURO EMRO AMRO AFRO

7. Adult per capita consumption in WHO South- East Asian and Western Pacific Regions

8. 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 Organization Department of Mental Health and Substance Abuse

9. Mechanisms relating alcohol use to health and social problems (adapted from Babor et al., 2003) World Health Organization

10. 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

11. Disease burden (DALYs) in 2000 attributable to selected leading risk factors Number of Disability-Adjusted Life Years (000s)

12. 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

13. High Mortality Developing Countries Low Mortality Developing Countries = Major NCD risk factors 1 UnderweightAlcoholTobacco 2 Unsafe sexBlood pressure Blood pressure 3 Unsafe waterTobacco Alcohol 4 Indoor smokeUnderweightCholesterol 5 Zinc deficiencyBody mass index Body mass index 6 Iron deficiencyCholesterolLow fruit & veg. intake 7 Vitamin A deficiencyLow fruit & veg intake Physical inactivity 8 Blood pressureIndoor smoke - solid fuels Illicit drugs 9 TobaccoIron deficiency Unsafe sex 10 CholesterolUnsafe waterIron deficiency 11 AlcoholUnsafe sexLead exposure 12 Low fruit & veg intake Lead exposureChildhood sexual abuse Developed Countries Leading 12 selected risk factors as causes of disease burden World Health Organization

14. 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 DALYs attributable to selected risk factor World Health Organization

15. Alcohol-related mortality and disease burden in different WHO regions WHO regionPercent of total mortalityPercent of total disease burden MenWomenMenWomen Europe A Europe B Europe C S-E Asia B S-E Asia D W-Pacific A W-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

16. Percentage of total global mortality and DALYs attributable to psychoactive substances Risk factor High mortality developing countries Low mortality developing countries Developed countries World MenWomenMenWomenMenWomen Mortality Tobacco Alcohol Illicit drugs DALYs Tobacco Alcohol Illicit drugs 7.5 2.6 0.5 3.4 2.6 0.8 1.5 0.6 0.1 0.6 0.5 0.2 12.2 8.5 0.6 6.2 9.8 1.2 2.9 1.6 0.1 1.3 2.0 0.3 26.3 8.0 0.6 17.1 14.0 2.3 9.3 -0.3 0.3 6.2 3.3 1.2 8.8 3.2 0.4 4.1 4.0 0.8

17. Global burden of disease (DALYs in 000) attributable to alcohol in 2000 (Rehm et al, 2003) Diseases and accidents … Cancer Neuropsychiatric disorders Cardio-vascular diseases Other non-comm diseases Unintentional injuries Intentional injuries Women 1021 3814 -428 860 2487 1117 Men 3180 18090 4411 3695 14008 5945 Total 4201 21904 3983 4555 16495 7062 % of alcohol- related disease burden 7 38 7 8 28 12

18. Percentage of global DALYs attributable to different neuropsychiatric conditions (WHO, 2002) Neuropsychiatric conditions Total DALYs 193,278,495 Percentage 100% Unipolar depressive disorder 67,294,85835% Alcohol use disorders Schizophrenia Bipolar disorder Alzheimer disease and other dementias Mental retardation Migraine Drug use disorders Epilepsy Panic disorder … 20,330,909 16,149,010 13,952,006 10,396,902 9,956,313 7,666,232 7,387,679 7,327,500 6,757,894 … 11% 8% 7% 5% 4% 3% …

19. 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

20. 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 alcohol World Health Organization

21. 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)

22. 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)

23. Reductions in male death rates if alcohol consumption per capita reduced by 1 litre Source: Norström & Skog 2001 World Health Organization

24. Alcohol: No Ordinary Commodity Research 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 ö sterberg Jürgen Rehm Robin Room Ingeborg Rossow World Health Organization

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Frequency of low, middle and high alcohol-specific tax on alcohol Alcohol-specific taxBeer (n=65)Wine (n=60) Low(<10%)23.128.3 Middle(10-29%)52.343.3 High(>30%)24.628.3 Alcohol- specific taxSpirits (n=60) Low(<30%)36.7 Middle(30-49%)33.3 High(>50%)30.0

32. 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

33. 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

34. Education and persuasion Alcohol education in schools College student education Public service messages Warning labels World Health Organization

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. Simplified causal web linking exposures and outcomes

43. 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)

44. 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

45. 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

46. 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

47. 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