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WHO Expert Committee Report on Problems Related to Alcohol Consumption 2007

Summary of key findings and recommendations In its introduction to the report the Expert Committee draws attention to both its 1979 Report and the 1998 World Health Declaration.

The 1979 Report recognised the wide diversity of the medical and social ills and human suffering resulting from alcohol consumption; the limited efficacy and high cost of existing treatment or management of problems; and the high prevalence of alcohol problems in the world. It recommended that prevention be given clear priority and the development of inexpensive and cost effective treatment. The report noted that damage from alcohol was closely related to the level of consumption of both individuals and population. It recommended that governments should begin to reduce consumption by reducing availability; take educational and other measures to reduce demand; adopt national alcohol policies; bring the serious public health consequences and the high social and economic costs of alcohol consumption to the attention of national, regional and international authorities when alcohol trade policies are being reviewed and negotiated.

The 1998 World Health Declaration reaffirmed WHO’s commitment to the principle that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being; the improvement of the health and well being of people is the ultimate aim of social and economic development and the importance of reducing social and economic inequalities in improving the health of the whole population.

Terminology
In its present report the Committee considers as equivalent terms “alcohol related harm” and “problems related to alcohol consumption”. They refer to a wide range of social and health problems both to drinkers and others at individual and collective levels. The term “harmful use of alcohol” is included in the aforementioned terms since it refers to a condition where an individual has experienced physical or psychological harm from his or her drinking. In a public health perspective it has a wider meaning in the broader understanding of health and in the harm caused to others. In its frame of reference the Committee adopted the whole range of harms related to alcohol consumption and the policies and measures that would reduce such problems and harms.

Types of harm
The Committee recognises that the use of “alcoholic beverages carries with it some potential for social and health harm, both to the drinker and others”. The three main mechanisms of harm are intoxication, dependence and toxicity.

Alcohol is related to more than 60 different disorders, among which are: breast cancer among women with no evidence of a threshold and an increasing risk with increasing consumption; a potent teratogen – foetal alcohol syndrome; an impact on brain development by exerting an effect at the cellular and molecular levels – the report states “adolescents and young people are particularly vulnerable to the harmful effects of alcohol. It can particularly effect the part of the brain involved in the learning process – the hippocampus”; liver damage; carcinogenic; adverse immunological consequences leading to increased incidence of infectious diseases.

With regard to heart disease the report recognises that the effects of alcohol are both positive and negative. For regular light drinkers as little as a drink every other day appears to have a preventive effect. Although the report cautions: “the finding remains controversial and appears to be confined to males over the age of 45 years and females post menopause. However heavy drinking levels are associated with increased rates of heart attacks. Even in societies where heart disease is a very important cause of death, the overall number of lost years of life attributable to drinking outweighs the saved years attributed to protective effects”.

Alcohol’s toxic effects can harm any system or organ of the body; exacerbate pre-existing mental and physical disorders; adversely interact with other prescribed and illicit drugs; be associated with a wide range of intentional and unintentional injuries; and produce a dependence syndrome with an abuse liability comparable to other dependence producing substances that are internationally controlled.

Based on data available for 2002 the Committee reviewed the overall net impact on the burden of disease (see tables 1,2 and 3). Alcohol is estimated to cause 3.7% of all deaths and 4.4% of the global burden of disease. This is after the health protective effects were taken into account. It is acknowledged that a wide variety of adverse consequences of drinking are not covered in the estimates such as adverse consequences for persons other than the drinker, lack of data in relation to communicable diseases and the consequences of social harm.

Although substantial progress has been made in estimating global health harm, the Committee recognised the need for further development in four priority areas:

i) the development of measurements of alcohol’s role in social harms;

ii) the measurements of harms from drinking to third parties;

iii) epidemiological studies of alcohol’s contribution to infectious disease morbidity and mortality and

iv) implementation of a routine basis in health emergency service of measurements of alcohol involvement in injuries.

Abstinence and Indigenous groups
Less than one half of the world’s adult population (2 billion people) use alcohol. Abstention rates are higher among females (66%) than among males (45%). If abstention rates decline with increasing affluence and exposure to global marketing, substantial rises can be expected in levels of consumption. The Committee expressed the view that there is “an important public health interest in encouraging abstinence and protecting the choice to abstain”.

Studies of indigenous peoples show significantly higher alcohol intake than in the surrounding general population although rates of abstention are often higher. However, among indigenous populations patterns of drinking tend to be more hazardous. Poor living and working conditions together with increased access and availability of commercial alcohol, lack of education, health and treatment services has led to a high morbidity and mortality from alcohol related causes in indigenous communities. The Committee noted the success of some indigenous communities to reduce alcohol problems and commented, “These efforts often involve persuading the enveloping society to set aside usual market freedoms, and allow the community to restrict promotion and availability of alcoholic beverages”.

Impact on the Poor
Poor people suffered a disproportionate burden of harm. Their lack of resources show them less able than the affluent to ‘purchase social or spatial buffering of their behaviour’. The Committee states: “Public health action to reduce drinking and associated harm also serves the interest of reducing health disparities between richer and poorer individuals and populations.”

Effective Strategies to Reduce Alcohol Related Harm
Since the previous report the Committee recognises that there has been accumulated a substantial literature on the impact of various alcoholic policies and measures. Whilst cost effective studies are not well enough established as a reliable guide, the Committee took the effectiveness of the evidence as its primary guide. It also maintained that whilst the effectiveness of policies had been evaluated in the context of high-income countries, some measures had been evaluated in the context of low income countries.

The Committee sets out the strategies available to reduce alcohol related harm which are well know to alcohol policy advocates: tax and price; control of availability; restrictions on sale; drinking context and marketing; drink riving and early intervention strategies. Some pertinent findings of the review are:

Price. Limited data from low and middle - income countries show a similar pattern in the relationship between price and consumption as in high – income countries. Increasing alcohol taxes can be used to reduce consumption and harm, whilst at the same time increasing government income. Young people’s consumption is sensitive to tax. The amount heavy drinkers consume is affected by price. Lowering alcohol taxes and prices leads to increased consumption. In Europe special taxes on spirit based sweet pre mixed drinks (alcopops) has led to a reduction in sales. Alcohol taxes are a highly cost effective strategy for reducing alcohol related harm.

Advertising. Recent research has shown that where young people are exposed in markets to a greater availability of advertising - exposure appears cumulative - and young people are more likely to increase their drinking as they moved into their mid twenties. Drinking declined earlier in those who were less exposed.

Reliance on self- regulation does not prevent the kind of marketing which has an impact on young people.

“Unless industry processes related to alcohol advertising standards come under a legal framework, and are monitored and reviewed by a government agency, governments may find that allowing self regulation by the industry results in a loss of policy control of the marketing of a product that seriously affects public health”.

Drink Driving measures. Establishing a maximum blood alcohol concentration and random breath testing has proved to be most effective. Adoption of such measures has also strengthened the public will. In low income countries injuries to intoxicated pedestrians are more common than driver and passenger injuries.

Early Intervention. People who drink alcohol excessively place a disproportionate burden on health social and criminal justice systems compared with light drinkers or abstainers. Also a disproportionate amount of the intangible cost of excessive drinking on families and the workplace. Such intervention the committee feels has potential to fulfil three goals i) humanitarian approach to alleviation of human suffering ii) a method of reducing alcohol consumption and harm in the population and iii) reducing alcohol related health care costs. For people with more severe alcohol dependence they will require more intensive approaches.

Education. Although there is evidence, in relation to school based programmes, of positive effects on increased knowledge about alcohol, no evidence has been found for a sustained effect on behaviour. Public information campaigns are an ‘ineffective antidote to the high quality pro drinking messages that appear far more frequently in the media’ There has been no evidence of whether drinking guidelines have any impact on alcohol related harm.

Considering the effects of alcohol marketing measures on young people, the committee recommends that WHO supports and assists governments:

  • to effectively regulate the marketing of alcoholic beverages, including effective regulation or banning of advertising and of sponsorship of cultural and sports events, in particular those that have an impact on younger people;
  • to designate statutory agencies to be responsible for monitoring and enforcing marketing regulations;
  • to work together to explore establishing a mechanism to regulate the marketing of alcoholic beverages, including effective regulation or banning of advertising and sponsorship, at the global level.

Within the context of a public health approach to alcohol related problems, the committee recommends that WHO support governmental bodies at national and subnational levels, and in particular in low-and middle-income countries:

  • to give high priority to the prevention of harmful use of alcohol, with an increased investment in the implementation of policies known to be effective;
  • to continue to review the nature and extent of the problems caused by the harmful use of alcohol in their populations, the resources and infrastructures already available producing the incidence , prevalence and impact of these problems, and the possible constraints in establishing new policies and programmes;
  • to formulate, develop and implement adequately financed action plans on alcohol with clear objectives, strategies and targets
  • to establish or reinforce mechanisms and focal points to co-ordinate the work of public health stakeholders;
  • to implement and evaluate evidence-based policies and programmes using existing structures where feasible.

Investment in Young People
The importance of investment in young people for socioeconomic development is recognised by the committee. The determinants of harmful drinking among young people and increasing the human capital of young people should be addressed. The increasing promotion of alcoholic beverages in culture and the arts particularly the massive investment of product placement in movies, television, music and videos is an international issue with public health significance for UNESCO action.

Sectors and Alcohol Policy
The Committee recognised that the alcohol industry has become increasingly involved in the alcohol policy area particularly through the funding of an international, regional and national network of social aspect organizations that sponsored industry friendly policies. The Committee expressed a note of caution that the “private sector should not be trying to do the work of governments which are particular guardians of the public interest”. The alcohol industry had a role in the implementation of programmes to provide server training, ensuring responsibility in adhering to the law in reducing hazardous drinking and preventing under age drinking.

The Committee recommends that:
“WHO continue its practice of no collaboration with various sectors of the alcohol industry. Any interaction should be confined to discussion of the contribution the alcohol industry can make to the reduction of alcohol related harm only in the context of their role as producers, distributors and marketers of alcohol, and not in terms of alcohol policy development or health promotion.”

Public health and health care workers have a leading role in reducing harm by integrating assessment and interventions on harmful drinking into health care systems and by informed advocacy for alcohol policies. They should be a catalyst for change and recognise the significance of mass media coverage on agenda setting for policy makers.

Non Governmental Organizations have an important role in the development of alcohol policy and action.The Committee emphasised: “the importance of the participation of civil society organisations without conflict of interests in alcohol policy development, as a counter- influence to the vested interests, which might otherwise dominate political decision making.”

The Expert Committee recommends that “WHO strengthen its process of consultation and collaboration with nongovernmental organizations which are free of potential conflict of interest with the public health interest.”

1. The World Health Report 2002. Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002.