1. PART ONE- ALCOHOL POLICY AND PUBLIC HEALTH
Virtual Course on Public Health Policy for Alcohol and Other Substance Use
PART ONE- ALCOHOL POLICY AND PUBLIC HEALTH
From a public health perspective, alcohol plays a major role in the causation of disability, disease and death on a global scale. With the increasing globalization of alcohol production, trade, and marketing, alcohol control policy needs to be understood not only from a national perspective but also from an international purview. The same is true of alcohol science, particularly policy research. In the past 50 years considerable progress has been made in the scientific understanding of the relationship between alcohol and health. Not only are the causal mechanisms for alcohol’s health effects better known today, we also have a much better scientific understanding of which policies advance public health and which do not. Ideally, the cumulative research evidence should provide a scientific basis for public debate and governmental policymaking. The purpose of this, the first part of the Virtual Course, is to describe the scientific basis for alcohol policy from a public health perspective.
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2. Module 1- Alcohol and Society
Part One- Alcohol Policy and Public Health
The theme of this module is Alcohol and Society. The goal is to provide a historical perspective on alcohol’s role in society from a public health perspective. After describing the origins and nature of alcohol and drinking customs in the Americas, we consider the implications of the commercial availability of alcohol in society, and the need for a public health approach to alcohol-related problems.
Alcoholic beverages have been used in human societies at least since the beginning of recorded history. Fermented beverages were prepared and consumed in most parts of the world before the European colonial expansion, which changed the cultural position of alcohol nearly everywhere. New forms of alcoholic beverages were introduced, and a product prepared within the household and community was gradually transformed into an industrial commodity available at any time and virtually any place. As part of the contemporary dynamic of globalization, the process of conversion of alcoholic beverages into industrial and commercial products continues today in much of the developing world.
Module 1- Alcohol and Society
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3. Learning Objectives
Upon completion of this module you will be able to:
Provide an overview of the history of alcohol’s role in society from a public health perspective
Understand the implications of the commercial availability of alcohol in society
Understand the need for a public health approach to alcohol-related problems
Upon completion of this module you will have an understanding of the history of alcohol’s role in society from a public health perspective, the implications of the commercial availability of alcohol in society, and the need for a public health approach to alcohol-related problems.
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4. Alcohol in Pre-Colonial History
An established part of the Indian cultures of Central and South America
An important part of harvest festivals, weddings, burials and religious events
Fermented beverages like chicha and pulque had relatively low amounts of alcohol, so drunken-ness was probably uncommon among the Aztecs and Mayan Indians
Alcohol use was an established part of the Indian cultures of Central and South America well before the arrival of the Spanish conquerors in the 16th century. As with the ancient Mediterranean civilizations, drinking was an important element of various communal occasions, such as harvest festivals, weddings, burials, and religious celebrations. In South America the main alcoholic drink was chicha, a type of wine fermented from ingredients such as apples, strawberries, yucca, oats, and maize. Sacred to the Mayan civilization of Central America was a beverage called balche. Fermented from a combination of honey and tree bark, balche is still prepared today by the people of the Mexican Yucatan. The Aztecs drank a beverage called pulque, which was made from the juice of an agave cactus. Both chichi and pulque had relatively low amounts of alcohol.
The Aztecs considered their pulque a gift from the gods. Although drunkenness was forbidden on most occasions, worshippers at major religious celebrations and holy days were expected to get drunk to avoid displeasing the gods. Given the low alcohol content of their beverages and the strict control Indian civilizations exercised over drunkenness, it is unlikely that alcohol problems as we know them were common.
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5. Historical Roots of Latin American Drinking Practices
The Indians of Tecospa, near Mexico City, offer a contemporary example of the historical roots of Latin American drinking practices. From the time of the Aztecs pulque has been considered a holy beverage and an integral part of their communal life. Pregnant women sometimes take an extra serving of pulque for “the one inside” them, and the dead are buried with tortillas and pulque to sustain them on their journey to the next world. Believing that pulque is a healthful drink that promotes harmony and contentment, they typically drink in groups of friends and family members. Drinking begins with ritual toasts and counter-toasts, and often ends when most of the party collapses. In contrast to their nonviolent behavior during their communal drinking, Tecospans often become involved in drunken disputes when they attend fairs and fiestas in the surrounding market towns. The intake of strong distilled alcohols and different patterns of consumption and social controls in the urban areas help to explain this behavioral change. Besides that, other factors also influence the impact of alcohol on these vulnerable communities, such as the levels of poverty, little access to health, education, and other fundamental services, besides the influence of their colonial past.
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6. The Colonial Period
Wine and spirits introduced by Spanish traders in the 1600s and 1700s
Drinking customs of the indigenous societies changed to higher alcohol content beverages: mezcal, tequila and rum
When Spanish traders appeared in the 1600s and 1700s, they introduced wine and spirits, and the drinking customs of the indigneous societies began to change. In combination with the conquest and destruction of the various indigenous civilizations, the introduction of these new beverages altered their drinking patterns.
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7. The Culture of Machismo
Prevalence of heavy episodic drinking among current drinkers by country
Contemporary drinking is often explained in terms of the so-called culture of manliness, or machismo, determined by how well one can hold one’s liquor. Drunkenness is tolerated and even encouraged among men, though it is not considered proper for women to drink, especially in public. There are few restrictions on the production and sale of alcohol, reflecting a very tolerant attitude. This tolerance is exemplified by the consumption of high doses of alcohol on single occasions (binge drinking), such as the complete abandonment that characterizes drinking during carnivals and other festival periods. At times such as just before the beginning of Lent, the whole community enters into a week-long period of outdoor celebration and uninhibited drinking, while the provision of protective actions (health services, security, etc) is insufficient or absent.
Alcohol and Public Health in the Americas, 2007, PAHO
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8. Contemporary Drinking Preferences
Distribution of recorded adult per capita consumption of alcoholic beverages (%), by WHO region and the world, 2005a
European and American-type distilled beverages are used in virtually all countries in Latin America today. Even in the rural areas these beverages are now consumed as much as the traditional chichi and pulque. The major distilled alcohols of Latin America are mescal, tequila, and rum. Mescal and tequila are distilled from the agave cactus, yielding a colorless liquor of about 45% alcohol.
Rum, produced from the by-products of sugar-cane mills in nearly all Caribbean countries, is perhaps the most powerful alcohol produced in Latin America, sometimes reaching strength of 90% alcohol. In Peru, pisco, a brandy, is considered the national drink.
Latin American countries differ considerably in their beverage preferences. Argentina and Chile have developed large wine industries and rank among the top ten wine-consuming nations of the world. In contrast, Mexico, Brazil, Colombia, Paraguay and Venezuela are predominantly beer-drinking countries. In some of the Caribbean countries, rum is a major part of the export economy and is also consumed in high amounts.
a Best estimates of 2005 using average recorded alcohol consumption (minus tourist consumption)
Global Status Report on Alcohol and Health, 2011, WHO
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9. Alcohol is a Commodity…
Alcoholic beverages are an important commodity embedded culturally, politically and economically
The production and sale of commercial alcoholic beverages generates:
Profits for farmers, manufacturers, advertisers and investors
Employment for people in bars and restaurants
Tax revenues for the government
As the history of alcohol illustrates, alcoholic beverages are an important commodity that is embedded culturally, politically and economically in Latin American societies. Today, the production and sale of commercial alcoholic beverages generates profits for farmers, manufacturers, advertisers, and investors as well as employment for people in bars and restaurants. Another societal benefit is tax revenues for the government.
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10. …But Alcohol is Not an Ordinary Commodity
The benefits connected with the production, sale, and use of this commodity come at an enormous cost to society
Three important mechanisms explain alcohol’s ability to cause medical, psychological and social harm:
Physical toxicity
Intoxication
Dependence
However, the enormous health and social costs of consuming alcohol outweigh its economic benefits and contribute to the view of public health professionals that alcohol cannot be considered an “ordinary commodity.” Three important mechanisms explain alcohol’s ability to cause medical, psychological, and social harm. They are: physical toxicity, intoxication, and dependence.
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11. How toxic effects, intoxication, and dependence are related to drug dose, use patterns and mode of drug administration, and in turn mediate the consequences of drug use for the individual drug user.
Psychoactive
Dose
Pattern/Volume
Type of Substance
Mode of
administration
Intoxication
Toxic effects
Dependence
Alcohol is a toxic substance in terms of its direct and indirect effects on a wide range of body organs and systems. With chronic drinking and repeated intoxication, a syndrome of interrelated behavioural, physical, and cognitive symptoms develops, called alcohol dependence. The mechanisms of toxicity, intoxication, and dependence are related to the ways in which people consume alcohol, called ‘patterns of drinking’. Drinking patterns that lead to elevated blood alcohol levels result in problems associated with acute intoxication, such as accidents, injuries, and violence. Drinking patterns that promote frequent and heavy alcohol consumption are associated with chronic health problems such as liver cirrhosis, cardiovascular disease, and depression. Sustained drinking may also result in alcohol dependence, which impairs a person’s ability to control the frequency and amount of drinking. For these reasons, alcohol is no ordinary consumer substance.
Chronic Disease
Accidents/injuries
(acute disease)
Acute Social
Problems
Chronic Social Problems
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12. Continuum of Alcohol Harm
It is helpful to think about alcohol related harms on a continuum with, at one side, no risk when there is no consumption; fairly unproblematic behaviors, well-anchored in cultural practices (i.e. drinking a can of beer in a barbecue) that result in little or no harm; then with the increase of consumption and depending on the way alcohol is used, the context and other variables, an increase in risk and harms, up to the point where the person has a diagnosable condition according to standardized diagnostic criteria, including harmful use and dependence. It is also important to know that during a lifetime, people move along the continuum, either to increase or decrease harms to self or others. Current abstinence, for example, include those people who stopped drinking because they were having problems and they may be different in terms of their health status, as compared to lifetime abstainers.
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13. Alcohol Research: Challenges
Multiple determinants related to health and disease processes
Individual, environmental and social influences determine behavior of alcohol consumption
Lack of integrative approach including genetic, neurobiological, psycho-social and environmental influences
The research about the multiple determinants related to health and disease processes have advanced in the past decades, helping to understand the distinct trajectories between different behaviors, and to explain individual, environmental and societal influences in determining changes between initiation and moderate alcohol use, to problematic use and dependent behavior. However, in spite of the knowledge accumulated, an integrative approach about how genetic, neurobiological, and macro-level psycho-social and environmental influences interact has not been achieved yet, and represent a multidisciplinary challenge to scientists today.
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14. Questions Module 1: Alcohol and Society
Answer the following questions to test your knowledge of alcohol’s role in society.
Questions
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15. Alcohol is not considered an ordinary commodity because:
It is embedded culturally and economically.
It generates tax revenue and profits.
It generates employment.
It causes harm to the purchaser.
Earlier in this module we discussed the features that separate alcohol from other common commodities. Why is alcohol not considered an ordinary commodity?
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16. Alcohol is not considered an ordinary commodity because:
It is embedded culturally and economically.
It generates tax revenue and profits.
It generates employment.
It causes harm to the purchaser.
As we mentioned in Slide 10, alcohol is different from many other goods because it can cause medical, psychological, and social harm.
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17. Reflection
How would you describe alcohol consumption in your society, historically and currently?
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