World Bank pronounces on Alcohol

The World Bank has released a fact sheet on alcohol, as part of its "Public Health at a Glance" series of summaries that aim to provide World Bank staff and others with quick, easy access to the state of the art in key areas of public health, preventive and curative services. The fact sheet is designed to be useful to project teams in the Bank and to others making investment decisions designed to improve health and nutrition.

In March 2000, the World Bank Group adopted a Note on Alcohol Beverages (www.miga.org/screens/policies/arp/arp.htm). In the Note, the Bank decided to increase its efforts to prevent alcohol-related problems in client countries and to take the public health situation regarding alcohol into account when considering investments in alcohol production. Since the Note was adopted, there have been no new investments by the Bank in alcohol production. We are grateful to the World Bank for permission to reprint the fact sheet.

Why is reducing alcohol-related problems a priority?

Alcohol abuse is one of the leading causes of death and disability worldwide. Alcohol abuse is responsible for 4 percent of global deaths and disability, nearly as much as tobacco and five times the burden of illicit drugs (WHO). In developing countries with low mortality, alcohol is the leading risk factor for males, causing 9.8% of years lost to death and disability. Alcohol abuse contributes to a wide range of social and health problems, including depression, injuries, cancer, cirrhosis, dependence, family disruption and loss of work productivity. Health and social problems from drinking often affect others besides the drinker. While men do the bulk of the drinking worldwide, women disproportionately suffer the consequences, including alcohol-related domestic violence and reduced family budgets. Heavy alcohol use takes a particular toll on the young, and has been linked to high rates of youthful criminal behaviour, injury, and impaired ability to achieve educational qualifications. Many deaths and much disease and suffering could be prevented by reducing alcohol use and related problems.

Alcohol-related harm.

The level of harm from alcohol is related to the pattern, including level, of drinking in a country. Time series analyses in western Europe find that overall mortality rises by 1.3% for every extra litre of pure alcohol consumed per capita. But for Russia, where intoxication and hazardous drinking are more prominent, the corresponding figure is 2.7%. Patterns and levels of alcohol consumption, alcohol dependency and alcohol abuse are determined by many factors: availability, income per capita, retail process, individual factors (genetic and environmental) such as age of first use, family history, education, peer group pressure, psychosocial factors, cultural and historical context, and government policies, such as taxation and restrictions on advertisement and promotion.

Alcohol and poverty.

Alcohol-related mortality is often highest among the poorest people in a society (Mäkelä, 1999a). Alcohol is often a significant part of family expenditure: Romanians spent an average of 11% of family income on alcohol in 1991, Zimbabwean households averaged 7%. However, national averages conceal the impact on families of drinkers: families with frequent-drinking husbands in Delhi spent 24% of family income on alcohol, compared to 2% in other families. Surveys among the urban poor in Sri Lanka found that 30% of families used alcohol and spent more than 30% of their income on it.

Alcohol and youth.

Alcohol is of particular risk to adolescents and young adults: in Latin America and Eastern Europe respectively, 36% and 41% of deaths among 15-29 year olds were due to alcohol use. Effective policies and prevention for youth have immediate payoffs, in addition to longer-term effects from forestalling development of alcohol dependence or alcohol-related chronic diseases.

Approaches to reducing alcohol abuse

The most effective approach to reduce alcohol-related problems is to implement a comprehensive set of measures to reduce alcohol consumption and related problems. Policy options include price increases, restrictions on availability (i.e. limits on the times and conditions of alcoholic beverage sales or service, minimum-age limits), strong drink-driving legislation and ready access to treatment. Some countries have succeeded in reducing per capita consumption substantially, and consequently have reduced liver cirrhosis deaths, a common indicator of alcohol-related problems in a society. Efforts to reduce alcohol consumption and related problems face formidable obstacles: alcohol dependence; social pressures; aggressive alcohol marketing and promotion; other pressing health problems competing for limited resources. But there are many good practices that can be replicated with political will, and broad support.

Global action: The overall trend is towards stricter laws and increased enforcement in some areas such as drinking-driving. Provision of treatment for drinking problems has increased in many places in recent decades. But national and local alcohol controls have been undercut by a tendency at the global level to treat alcohol as an ordinary commodity, and to weaken or eliminate effective controls in the interests of liberalising markets and trade. Trade agreements, structural adjustment programs, and GATT/WTO dispute settlements usually fail to recognise alcohol’s special status as a commodity which adversely affects health. In this context, actions like the World Bank Group’s decision in 2000 to take “public health issues and social policy concerns” into account in considering investments in alcoholic beverage production are important first steps. (See World Bank Group Note on Alcohol Beverages).There is a need for strengthened global action and commitment to reduce alcohol abuse and address the related health and social effects.

Regional action: Regional commitment to reducing alcohol abuse has been evident, for instance during the 1990s in Europe, where the World Health Organisation European Regional Office led 53 European nations in adopting aggressive goals for reducing alcohol use and problems. As a result, many countries in that region have strengthened alcohol policies and interventions. However, elsewhere in the world, efforts at alcohol control lag far behind alcohol’s significance as a risk factor in poverty and health.

Q&A about alcohol:

Does the level of alcohol consumption in populations matter? Yes. The levels of alcohol-related problems tend to rise and fall with changes in per capita alcohol consumption (Edwards et al., 1994; Babor et al., 2003).

What about the health benefits from alcohol use? A protective effect for coronary heart disease (CHD) from moderate alcohol consumption has been documented in men over forty. The data on whether a similar effect exists for women remain contradictory. In younger age groups, alcohol consumption at all levels increases mortality, and the net effect of alcohol at population level is negative in all regions.
Are some alcohol beverages more harmful than others? The pattern of drinking is more important than the type of beverage. There is little basis for treating various types of alcoholic beverages differently with respect to trade, control or investment decisions. The consequences of alcohol use are similar, regardless of the type of alcoholic beverage. The predominant beverage of young adult males in a society (e.g. beer in the US) usually has the strongest relation to alcohol problems.

Should alcohol be treated like other commodities? No. Alcohol should be classified as a special substance because of its dependency producing properties and severity of associated problems (WHO).

What works?
A comprehensive set of policy options, including:

• Drinking-driving countermeasures have proven effective in a wide range of countries and cultures; especially “per se laws” that set maximum levels for blood alcohol concentrations for drivers, with random breath-testing and clear and immediate sanctions such as loss of driving privileges, and/or fines.

• Regulation and enforcement are key. Unless measures are enforced, they will have little impact. Public education helps build a social normative consensus that increases compliance and supports strong enforcement. The magnitude of artisanal production and smuggled beverages is often underestimated and has to be considered in regulatory actions to limit access. Countries need a strong regulatory framework governing alcohol availability. Many developing societies have minimal alcohol regulatory structures, leaving a large gap as traditional systems of social control of drinking erode.

• Price increases are among the most effective tools to reduce/deter use of alcohol by young people. Minimum age drinking laws and restrictions on availability are also effective, but may be costly to enforce.

• Government monopolies of all or part of the retail or wholesale market have often been effective mechanisms for implementing alcohol control measures. The usual disadvantages of government monopolies are offset in the case of alcohol by many factors:

• (a) the limited number of sales outlets and restricted hours of opening common with such monopolies constrain alcohol consumption and problems;

• (b) a stable and professional staff help avoid sales to the under-aged and already drunk; and

• (c) private profit motivations for expanding sales are absent.

• Education and public information campaigns have not been found to be effective on their own in reducing alcohol use or problems. These campaigns can build awareness of alcohol problems and support for effective policies and interventions, but are not cost-effective unless linked with proven interventions such as higher taxes, restrictions on availability, minimum-age limits, and drinking-driving counter-measures.

• Brief outpatient interventions aimed at changing attitudes and drinking behaviour are as effective in most circumstances as longer and more intensive treatment. Treatment for alcohol problems is an important part of an integrated national alcohol policy. Treatment can be effective for those who seek it. But for the population as a whole, treatment is not a cost-effective means of reducing societal rates of alcohol problems.

Resources
People in the World Bank, IMF and WHO
Mariam Claeson (mclaeson@worldbank.org)

Joana Godinho (Jgodinho@worldbank.org),
Florence Baingana (Fbaingana@worldbank.org)

IMF fiscal department (Peter Heller and Emil Sunley): taxation related issues.

WHO: Leanne Riley (rileyl@who.int)

Key Documents and DataClaeson et al. World Bank Group Note on Alcohol Beverages, 2000 www.miga.org/screens/policies/arp/arp.pdf

Pyne HH, Claeson M, Correia Gender Dimensions of Alcohol consumption and alcohol related problems in Latin America and the Caribbean. The World Bank, 2002.

World Health Organisation. International guide for monitoring alcohol consumption and related harm. Geneva, WHO, Department of Mental Health and Substance Dependence, WHO/MSD/MSB/00.4, 2000.

World Health Organisation. Global Status Report on Alcohol. Geneva, WHO, Substance Abuse Department, WHO/HSC/SAB/99.11, 1999.

World Health Organisation. Global Alcohol Database. Geneva, available on the world-wide web at www.who.int/alcohol, database of country-level statistics on alcohol use, problems and policies.

World Health Organisation. Reducing Risks, Promoting Healthy Lives. World Health Report 2002. Geneva, WHO. (epidemiology data)

Other References
Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, Grube JW, Gruenewald PJ, Hill L, Holder H, Homel R, Österberg E, Rehm J, Room R, Rossow I. Alcohol: No Ordinary Commodity. Oxford, OUP, 2003.

Ezzati, M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL and the Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet, 360:1347-1360, 2002.

Jernigan D. Alcohol and Young People. Geneva: WHO, 2001. www.stir.ac.uk/departments/humansciences/ appsocsci/drugs/alcyouth.pdf

Jernigan D, Room R. “Alcohol in Development and in Health and Social Policy”, World Bank Discussion Papers Series, 2003, available at www.worldbank.org/hnp/publications

Room R, Jernigan D, Carlini Cotrim B, Gureje O, Mäkelä K, Marshall M, Medina Mora ME, Monteiro M, Parry C, Partanen J, Riley L, Saxena S. Alcohol in developing societies: a public health approach. Helsinki and Geneva, Finnish Foundation for Alcohol Studies and WHO, 2003.

Web resources
www.stir.ac.uk/departments/humansciences/appsocsci/drugs/
library.htm#recen
www.bks.no/biblio.htm