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Alcohol, Gender, Culture and Harms in
the Americas and a Case For Action

PanAmerican Health Organization (PAHO)
World Health Organization (WHO)

The PAHO Multicentric Study Final Report was published in 2007 (ISBN 978 92 75 128282). The project was coordinated by Dr Maristela G Monteiro, Regional Advisor on Alcohol and Substance Abuse at PAHO in collaboration with Professor Dr Jurgen Rehm from the Centre for Addiction an dMental Health, Canada. BenjaminTaylor was the leading author of the report.

The investigators and their teams from Argentina, Belize, Brazil, Canada, Costa Rica, Mexico, Nicaragua, Peru, Uruguay and the USA participated in the planning, implementation, analysis and dissemination of the data. The project received a grant from the PAHO program on Information and Knowledge Management as well as from other WHO sources and a voluntary contribution for CAMH.

“This new survey data highlights the importance of disaggregating subregionalWHO data to the country level in order to see differences in consumption and corresponding risk of alcohol–attributable outcomes at the country level and thus inform countryspecific alcohol policies capable of addressing the specific alcohol consumption profiles and problems.”

Executive Summary PAHO Multicentric Study Final Report

The Report contains a detailed overview of the regional data and its relationships to mortality and morbidity in the Americas. The relative risk estimates are considered to be “the most current and best possible for the individual countries and the region, and should be extremely valuable for informing alcohol policy accordingly”.

Summary of main results from this limited preliminary analysis and discussions points:

Overall consumption in the Americas is high compared to global averages.

  • Alcohol consumption and the prevalence of dangerous drinking behaviour (heavy episodic drinking) are high among young men and women in all countries in the Americas.
  • The alcohol-attributable burden of disease of young adults is especially high, particularly in America B and D.
  • The alcohol-attributable burden for young people, both men and women, is high.
  • Neuropsychiatric diseases constitute a major proportion of years of life lost and disability adjusted life-years.

Practices to reduce per capita consumption (Babor et al., 2003; Anderson & Baumberg, 2006) should apply to the Americas, such as taxation and availability restrictions. These availability restrictions include measures to increase the minimum age to drink alcohol, alcohol retail outlet density and hours of operation, availability at sporting events, and minimizing alcohol advertisements and marketing (Anderson & Baumberg, 2006; Rehm et al., 2004; Babor et al., 2003; Giesbrecht & Greenfield, 2003). With respect to taxation, there is clear evidence that consumers react to prices for goods including alcohol. Newer economic literature found this behaviour even in people with alcohol dependence (see chapter 6 in Babor et al. 2003). Given the relatively low tax rate in most of the American countries (especially in South and Central America) and given the high consumption of countries such as Canada, Belize, and Brazil, an increase of the taxation of alcoholic beverages should be a priority for alcohol policy in this region given its effect on consumption and its cost-effectiveness (Chisholm et al., 2004; 2006).

The second and third major findings of this brief analysis found that young people consume much of the alcohol, consume it in a more dangerous way, and more often suffer two alcohol-related acute outcomes (injury and fighting) than older age cohorts. Given this consumption behaviour, the alcohol-attributable burden of disease for acute outcomes is especially high.

A number of policy options are particularly effective in reducing the alcohol consumption in this group, such as price increases and raising the age at which young people can legally purchase liquor in, on- and off-licence establishments (Babor et al., 2003). Enforcement of such minimum drinking age laws in developing and developed countries alike is a limitation of this approach that needs to be taken account of for such measures to be effective (Giesbrecht & Greenfield, 2003).

Neuropsychiatric diseases constitute a major proportion of the alcohol-attributable burden. Within this category, alcohol use disorders make up the highest proportion of this category (Rehm & Monteiro 2005), especially in Americas B and D. The use of the screening and brief interventions in primary health care to increase referral to treatment services, along with the organization of an integrated health system, provides effective treatment for alcohol dependence and harmful use of alcohol (Babor et al. 2001). Self-help groups such as AA and social services should be linked to treatment services to support recovery and rehabilitation. There are a number of effective treatments for alcohol dependence, including cognitive behaviour therapies (Marques & Formigoni 2001;Morgenstern et al. 2001; Hoyer et al. 2001), brief intervention/counselling (Mundt 2006), and pharmacotherapy (Chick et al. 2000), and combinations of these together (Anton et al. 1999), which can be offered through various outpatient or inpatient services. (pages 42 and 43)

This project is rightly described as a ‘landmark endeavour’ and will undoubtedly form the cornerstone for future regional and national actions.

In terms of global responses the report calls for further evaluation of policy in ‘developing nations, across races, and within cultures’ (p 44) a call that will resonate with GAPA.

Another landmark publication - ‘Case for Action’ on ‘Alcohol and Public Health in the Americas’ (PAHO 2007) captures the essence of the actions required to reduce alcoholrelated harm. Based on the latest reviews (Babor et al.2003 and WHO Expert Committee WHA A60/142007), chapter 5 sets out “10 Building Blocks to Reduce Alcohol Related Harm” recognising at the same time the on going challenges facing policy makers and those who have the task of implementing policy.

One of the greatest challenges to effective implementation is the relentless expansion of the global market. Over 50% of the global market of alcoholic beverages is now under the control of the top 10 global producers and international trade agreements continue to classify alcohol as an ‘ordinary’ commodity.

The ‘Case forAction’ states that the enforcement of trade agreements by the WorldTrade Organization “has lead to a weakening of public health-based alcohol controls in developed and developing nations” (Caetano and Laranjeiras, 2006; Monteiro and Levav, 2006) and that “Health professionals and policy makers need to become more involved in trade policy formulation and to determine how current trade rules affect not only the present but also the future of health” .