Transcript Tabellen GBD 2000 addictive substances

Alcohol in Development and
in Health and Social Policy
David Jernigan PhD
Center on Alcohol Marketing and Youth
Georgetown University
Washington, D.C.
[email protected]
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
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To what extent is alcohol harmful or
beneficial to health and social wellbeing?
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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
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27 groups:
• Core, metholodology, etc. group
• 26 risk factor groups
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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)
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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
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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
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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
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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
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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
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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
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Child abuse – 8.6%-63%
Domestic violence – 26%-76%
Family budget – 1%-11% overall
• Greater for families with frequent drinkers
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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
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E.g. Scotland:
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2.
Service system utilization by “problem drinkers”
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California urban/suburban/rural county
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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
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Canada – harms from someone else’s drinking
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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
5
Litres
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
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Alcohol production and consumption
• Most alcohol consumed near point of
production
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8% of recorded alcohol production enters
into international trade
• Consumption tends to be concentrated
in minority of population, e.g.
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USA: 10% drinks 61% of the alcohol
New Zealand: 5% drinks 1/3 of the alcohol
Relationship between alcohol
consumption and alcohol problems
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Alcohol problems arise from:
• Intoxication occasions
• Repeated episodes of intoxication
• Steady heavy drinking
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Protective effect from consistent moderate
drinking
• This pattern rare in developed countries, even
less common in developing societies
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Bottom line: level of alcohol problems in
a society will tend to rise with level of
alcohol consumption
Social and health benefits of
drinking
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Social benefits of drinking largely
unquantifiable
• Alcohol’s role as integrative, bonding or socially
lubricative substance
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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
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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
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Alcohol consumption tends to rise with
economic development, absent mitigating
factors (e.g. religion)
Four modes of production of alcohol:
•
•
•
•
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Traditional/indigenous
Industrialized traditional/indigenous
Industrialized cosmopolitan
Globalized cosmopolitan
Trend is towards the latter, particularly in
distilled spirits and beer
Alcohol and development:
benefits?
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Employment and income generation
• Direct employment declines with
industrialization
• Indirect employment may increase in
wholesaling and distribution, but less likely in
retail sector
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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?
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Quality improvement
• Industrialization leads to greater uniformity
and reliability of product
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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?
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MNCs and technology transfer
• “Turnkey” technologies increasing
• Design, R&D and engineering expertise
remains in headquarters countries
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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
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Education and persuasion
• Little evidence of effectiveness of school-based
programs beyond the short-term
• Media campaigns unlikely to change behavior,
but may increase support for more effective
policies
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Deterrence
• Effective in reducing drinking-driving
• Speed and certainty of punishment crucial to
effectiveness
Preventive interventions:
individual-based
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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
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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
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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
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Regulating availability, conditions of
use
• Prohibitions
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Difficult to enforce
• Minimum-age drinking laws (partial
prohibition)
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Effective if enforced
• Taxation and other price increases
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Demand for alcohol generally inelastic
Can be effective if market is under control
Preventive interventions:
environmentally-based
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Regulating availability, conditions of use
• Limiting sales outlets, hours and conditions of
sale
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Research literature shows effectiveness of measures
making alcohol purchase less convenient
• Monopolies on production or sale
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Retail monopolies have greater public health effects
Production monopolies assist in control of market
• Production restrictions
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Can be effective but difficult to enforce
• Limits on advertising and promotion
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Some evidence bans are effective
“Unmeasured” activities increasing, and difficult to
regulate
Other policy concerns
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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
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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
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Youth use
Monitoring alcohol problems
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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
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other alcohol-related problems:
• problems with family, friendships, work, police, financial,
health, alcohol dependence
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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!!!