The link between alcohol-attributable harm and sustainable development J. Rehm Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Canada WHO Collaborating Centre, CAMH, Canada Institute of Medical Science, University of Toronto (UoT), Canada  Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany Department of Psychiatry, UoT, Canada Dalla Lana School of Public Health, UoT, Canada

Lots of potential links between alcohol consumption, attributable harm and sustainable development goals

Focus on two aspects Alcohol use -> alcohol-attributable health harm -> decrease in good health and well-being Implicit: alcohol policy -> reduce alcohol harm -> increase in good health and well-being Alcohol use -> alcohol harm (both health harm and other harm) -> increase in inequality Implicit: alcohol policy -> reduce alcohol harm -> decrease in inequality

Alcohol, health and sustainable development goal of good health and well-being Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

Alcohol overall was responsible for 5 Alcohol overall was responsible for 5.9% of all global deaths (every 17th death)! Links and mechanisms Alcohol consumption Other harmful consumption Linked to > 250 ICD health & injury categories via different dimensions of consumption Reduction of use & attributable harm via effective prevention Increase of good health & well-being Heavy use over time (alcohol use disorders) Interventions (treatment) and prevention (see left) Reduction of alcohol use, attributable harm Increase of good health & well-being

The reality does not match expectations for prevention Despite almost yearly success declarations, global strategies and alcohol actions plans of WHO, alcoholic beverages have become more affordable in recent years (in terms of proportion of real income spent per standard drink, and in terms of physical availability) and bans of marketing and advertisement are scarce. Moreover, trends in consumption in several countries and regions seem to be independent of policy (explained by “saturation” or the like). Thus in WHO European region and more so in the EU alcohol consumption declined despite higher availability over the past 25 years. And the links between per capita consumption and burden are also not as strong as we thought!

Comparisons of standardized alcohol-attributable mortality for major causes of death, 1990 vs. 2014, in different parts of the WHO European Region (rates per 100,000)

Trends in age-standardized rates of mortality due to alcohol-attributable cardiovascular disease in the WHO European Region and selected subregions, 1990-2014 (rates per 1 000 000)

Trends in age-standardized rates of mortality due to alcohol-attributable injury in the WHO European Region and selected subregions, 1990-2014 (rates per 1 000 000) Here is the second problem!

Non-ischaemic CVD   Heavy drinking occasions Volume of alcohol consumption Injury Ischaemic disease Liver diseases Alcohol use disorders Cancer Protective relation The thickness of the arrows indicate strength of relationship Infectious disease Main dimensions of alcohol use impacting on major attributable disease outcomes

The impact on inequalities An example and some more general data

Quantifying socioeconomic differences in alcohol-attributable burden: the example of HIV/AIDS mortality in South Africa HIV/AIDS is the most important cause of death (50% of all deaths in adults 15 to 49) Among adults (15 to 49) alcohol use is second most important risk factor for burden of disease Per capita consumption among drinkers is high Socioeconomic differences are vast with a Gini coefficient above 60 Institute for Health Metrics and Evaluation (IHME). GBD Compare, Seattle, WA: IHME, University of Washington; URL:http://vizhub.healthdata.org/gbd-compare/. Accessed: 2016-09-27.

Quantifying to overall relative risk of dying from HIV/AIDS in low compared to high SES in South Africa Depending on the measure of SES, persons of low SES have a 1.1 to 1.6 fold HIV/AIDS mortality risk Probst, C., Parry, C., & Rehm, J. (2016). Socioeconomic differences in HIV mortality in South Africa: a systematic review and meta-analysis. Tropical Medicine & International Health [IF 2.5], 21(7), 846-55.

Measuring socioeconomic status: a multidimensional concept Traditional measures of SES such as education, income and or occupation have strong pitfalls as they depend on age, sex, or disclosure To date the most adequate measure for South Africa - and probably many other LMIC - is an asset score

Quantifying alcohol use in different SES, age, and sex groups Prevalence of abstention is higher in low SES Quantity of alcohol consumed among drinkers is higher in low SES High SES Low SES

Age-standardized HIV/AIDS mortality rates attributable to alcohol use by SES and sex in South Africa in 2012 For both sexes the mortality rate ratio is about 7 This is considerably higher than the 1.5 fold risk for overall HIV-mortality in low vs. high SES

And for Europe … Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality. Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem. CONCLUSIONS: Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries. PLoS Med. 2015 Dec 1;12(12):e1001909. doi: 10.1371/journal.pmed.1001909. eCollection 2015. Inequalities in Alcohol-Related Mortality in 17 European Countries: A Retrospective Analysis of Mortality Registers. Mackenbach JP1, Kulhánová I1, Bopp M2, Borrell C3, Deboosere P4, Kovács K5, Looman CW1, Leinsalu M6,7, Mäkelä P8, Martikainen P9, Menvielle G10, Rodríguez-Sanz M3, Rychtaříková J11, de Gelder R1.

Affordability and inequality The more affordability increased, the higher the change in absolute inequality (Mackenbach et al., 2015) -> consequence: reduce affordability!

Conclusions Alcohol consumption is one key impact factor on sustainable development It affects population health negatively, it increases inequalities, and is also linked negatively to reaching other SDGs! The attributable harm from alcohol consumption could be reduced, if effective interventions (prevention and treatment) are initiated. However, we need to rethink some approaches and stop repeating dogmas which have proven to be not effective or not enforceable in current political environments.