AROUND 1 IN 25 DEATHS WORLDWIDE ATTRIBUTABLE TO ALCOHOL

Worldwide, 1 in 25 deaths and 5% of years lived with disability are attributable to alcohol consumption. Disease burden is closely related to average volume of alcohol consumption, and, for every unit of exposure, is strongest in poor people and in those who are marginalised from society. These are among the conclusions of the first in a Series of three papers on alcohol in a recent edition of the UK medical journal, The Lancet. The paper on global mortality was written by Dr Jürgen Rehm, Centre for Addiction and Mental Health, Toronto, Canada, and colleagues.

The industrialisation of production and globalisation of marketing and promotion of alcohol have increased both the amount of worldwide consumption and the harms associated with it. Alcohol-use disorders, especially for men, are among the most disabling disease categories for the global burden of disease. And while there have been some positive effects on cardiovascular disease associated with regular drinking, these beneficial effects have been controversial and are far outweighed by the detrimental effects of alcohol on disease and injury. The authors say that two different dimensions of alcohol consumption affect health: average drinking volume, and patterns of drinking including binge/heavy drinking.

Some diseases and injuries are caused by alcohol by definition, eg, (alcohol-use disorders, alcoholic liver disease) meaning they would not exist if alcohol were not consumed. A wide range of other diseases and injuries has been deemed to have an alcohol attributable effect, eg, mouth and throat cancer, colorectal cancer, breast cancer, depression, stroke, road traffic accidents, violence, poisoning, and many others.

The authors found that, globally, average alcohol consumption is the equivalent of 6.2L of pure ethanol per year, or around 12 units per person per week (1 unit = 10 ml ethanol). In Europe, the figure is higher at 11.9 L ethanol per person per year or 21.5 units per week. Corresponding figures for North America are 9.4L/18 units; The Americas as a whole 8.7L/17 units; and the WHO eastern Mediterranean region was the lowest at 0.7L/1.3 units per week. The authors say: “In all regions worldwide, men consume more alcohol than do women, although the exact ratio varies, with women in high-income countries consuming a larger proportion than those in low-income countries. In the interpretation of these numbers, we should keep in mind that most of the adult population worldwide actually abstains from drinking alcohol (45% of men and 66% of women), most of them for their lifetime.”

For 2004 (the latest year with comparable data available on a global level) 3.8% of all global deaths (around 1 in 25) were attributable to alcohol - 6.3% for men and 1.8% for women. Most of the deaths caused by alcohol were through injuries, cancer, cardiovascular disease, and liver cirrhosis. Overall, alcoholattributable deaths have increased since 2000 mainly because of increases in the number of womendrinking. In people under 60 years, the proportion of alcoholattributable deaths was higher at 5.3%. Europe had the highest proportion of deaths related to alcohol, with 1 in 10 deaths directly attributable. Within Europe, the former Soviet Union countries had the highest proportion at 15%, or around one in seven deaths. Relative to volume of alcohol consumed per head, the rates of alcohol-attributable mortality were higher in developing countries, especially southeast Asia. Globally, alcohol-attributable mortality rates for men were more than five times those for women.

In contrast with other traditional risk factors such as high blood pressure or cholesterol, the alcoholattributable disease burden lies more with younger people than older populations. Of all years lived with disability attributable to alcohol, 34% were experienced by people aged 15-29 years, 31% by those 30-44 years, and 22% by those aged 45-59 years.

The authors provide two countrybased analyses, including a highincome (France, USA, Scotland, Canada) vs middle-income (South Korea, Thailand), looking at costs attributable to alcohol. Among their findings were that alcoholattributable cost per head in highincome countries ranged from I$358in Scotland to I$837 in the USA; in middle-income countries, South Korea (I$524) had more than four times greater alcoholattributable cost per head than did Thailand (I$122). All countries spent more than 1% of their GDP PPP, with the highest in the USA (2·7%) in the selected high-income countries, and in Korea (3·3%) in the selected middle-income countries. A further analysis of the 10 most populated countries in the world gives a breakdown of different disease categories and the proportion of years lived with disability due to alcohol in each.

The authors say: “Globally, the effect of alcohol on burden of disease is about the same size as that of smoking in 2000, but it is greatest in developing countries... This finding is not surprising since global consumption is increasing, especially in the most populous countries of India and China.” They conclude: “We face a large and increasing alcohol-attributable burden at a time when we know more than ever about which strategies can effectively and costeffectively control alcohol-related harms. The next papers of this series will therefore discuss ways in which to decrease this burden.”

MAKING ALCOHOL BOTH MORE EXPENSIVE AND LESS AVAILABLE, AND BANNING ADVERTISING, ARE HIGHLY COST-EFFECTIVE STRATEGIES TO REDUCE ALCOHOL-RELATED HARM

Of the interventions to reduce alcohol-related harm, making alcohol both more expensive and less available, and banning advertising are the most costeffective strategies. School-based education does not reduce harm, although it does have a role in providing information. The various measures to reduce alcohol-related harm are detailed in the second paper in The Lancet series on Alcohol and Global Health, written by Dr Peter Anderson, University of Maastricht, Netherlands, and colleagues.

The authors review the effect of alcohol policy for the nine policy target areas included in the report by WHO to the 2008 World Health Assembly. On availability, the authors say that extending alcohol sale times can redistribute the times alcohol-related incidents occur, but does not reduce them. Reducing days or hours of alcohol sale leads to fewer alcohol problems, including murder and assault. A rise in alcohol prices leads to less alcohol consumption and related harm in both highincome and low-income countries. Policies that increase alcohol prices delay the start of drinking, slow young people’s progression towards drinking large amounts, and reduce young people’s heavy drinking and binge drinking activity.

As well as availability and affordability, the authors found that brief advice at a family doctor’s surgery was an effective healthcare intervention for those with hazardous and harmful alcohol use but not yet severely dependent. Establishment of a legal blood-alcohol limit, and reducing it, is effective in reducing drinkdriving casualties, as is intense random roadside breath-testing by police. Other measures with evidence of effectiveness are a lower or zero bloodalcohol limit for new drivers, driving licence suspension, and an ignition interlock which prevents a car being started when the driver is intoxicated.

The authors then looked at the cost effectiveness of policies in these nine areas, and concluded that reducing availability, increasing price and banning advertising were the most cost-effective measures to reduce alcohol-related harm. The authors say: “Taxation policies cost fairly little to implement but reap substantial health returns.”

The authors recommend six key policy approaches for countries in which alcohol is normally available:

Minimum tax rates for all alcoholic beverages, at least proportional to alcoholic content, should be introduced and increased regularly in line with inflation.
Government monopolies for retail alcohol sales should be established, with a minimum purchase age of 18-21 years; if not feasible, a licensing system should be introduced restricting outlet density and hours of sale.
A ban on direct and indirect alcohol advertising.
Legal concentrations of blood alcohol for driving should be established, and gradually reduced.
Widespread simple help should be made available in general practices and other primary healthcare facilities.
Educational programmes should not be implemented in isolation, but to increase awareness ahead of implementation of other more effective intervention packages.

They conclude: “Making alcohol more expensive and less available, and banning alcohol advertising, are highly cost-effective strategies to reduce harm. In settings with high amounts of unrecorded production and consumption, increasing the proportion of alcohol that is taxed could be a more effective pricing policy than a simple increase in tax.”

INTERNATIONAL FRAMEWORK CONVENTION ON ALCOHOL CONTROL, SIMILAR TO THAT FOR TOBACCO, IS NEEDED TO CONFRONT ALCOHOL DISEASE BURDEN

Despite clear evidence of the major contribution alcohol makes to the global burden of disease and to substantial economic costs, focus on alcohol control is inadequate internationally and in most countries. International health policy, in the form of a Framework Convention on Alcohol Control (FCAC), is needed to counterbalance the global conditions promoting alcoholrelated harm and to support and encourage national action.

This is part of the call to action in the third paper in The Lancet Alcohol series, written by Professor Sally Casswell, Massey University, Auckland, New Zealand, and Dr Thaksaphon Thamarangsi, Ministry of Public Health, Bangkok, Thailand.

The authors say: “Expansion of industrial production and marketing of alcohol is driving alcohol use to rise, both in emerging markets and in young people in mature alcohol markets. Cost-effective and affordable interventions to restrict harm exist, and are in urgent need of scaling up. Most countries do not have adequate policies in place. Factors impeding progress include a failure of political will, unhelpful participation of the alcohol industry in the policy process, and increasing difficulty in free-trade environments to respond adequately at a national level. An effective national and international response will need not only governments, but also non-governmental organisations to support and hold government agencies to account.”

The paper contains a number of key messages:

Countries spend more than 1% of their GDP on the economic costs attributable to alcohol

Relative to its harm, alcohol is not high on the global health agenda

The role of vested interests (eg, alcohol producers) in hindering public health responses to alcohol harm is similar to that seen for tobacco

Cost-effective interventions exist (eg, availability and affordability) and are focused on total populations

Some governments have implemented effective policy but a strengthened response is needed

WHO and other agencies, as well as NGOs, are showing increased concern and engagement with alcohol

An FCAC, similar to that for alcohol, is needed to spur national action.

In the call to action which concludes the paper, the authors call on: governments to formulate and implement alcohol control policies on the basis of costeffectiveness; on NGOs/civil society to push alcohol up the agenda; on academics to research control policies, working independently of commercial interests; on WHO member states to call on WHO to begin developing the FCAC; on WHO and other appropriate agencies to provide technical support to low- and middle-income countries to develop, implement and assess alcohol control polices; on global and regional non-governmental organisation networks to support the FCAC process; and on the alcohol industry to withdraw subversive efforts to influence effective policy development, health promotion efforts, and research agendas.

The authors conclude: “To enable this response we need: an active process of negotiation in which the international focus on alcohol is expanded; national governments to be supported and strong in their response; and non-governmental advocacy to increase both internationally and nationally. Use of international law to achieve a forum for cooperation and negotiation - an FCAC - is essential, and the initial steps that have been undertaken urgently need to be scaled up.”

ALCOHOL MUST BE GIVENPOLITICAL PRIORITY

In a Comment which accompanies the alcohol Series, Professors Robert Beaglehole and Ruth Bonita, University of Auckland, New Zealand, say that, despite the parallels between alcohol and tobacco, ‘there seems to be little immediate chance of WHO or member states supporting the complex process of developing a Framework Convention on Alcohol Control’. They say: “To gain traction, this framework will need dedicated support and pressure from a few committed countries, supported by a strong global network of non-governmental organisations. Non-governmental organisations in the alcohol field need to strengthen their international presence and learn from the tobacco-control area.”

They conclude: “The power imbalance between industry and health groups is a key reason for the continuing neglect of alcohol as a global health issue. Other impediments include the absence of clarity on the alcohol control message, the political context that gives priority to an individual’s responsibility for health, and the close connection of alcohol with many aspects of social and cultural norms. Generation of political priority for alcohol as a global health issue is the crucial next step.”

MINIMUM ALCOHOL PRICE OF 50 PENCE PER UNIT COULD LEAD TO 100,000 FEWER HOSPITAL ADMISSIONS PER YEAR IN UK

In a second Comment which accompanies the alcohol series, Professor Ian Gilmore, President of the Royal College of Physicians(RCP), discusses the industry friendly policies that have led to a 33-fold increase in alcohol consumption in Thailand over just 40 years.

He also discusses the recent suggestion by England’s Chief Medical Officer Sir Liam Donaldson to set a minimum price of 50 pence (0.5GBP) per unit, which was flatly rejected by the Prime Minister Gordon Brown - on the basis it would punish sensible, moderate drinkers due to the excesses of a small minority. Professor Gilmore says: “However, setting a minimum price of 50 pence per unit would likely increase the average weekly spend on alcohol of moderate drinkers by only 23 pence per week, but would decrease the consumption by underage and heavy drinkers by 7.3% and 10.3% respectively. The estimated benefits would be a reduction of 100,000 hospital admissions per year in England and a decade’s health saving of £1.37 billion.”

The RCP has recently formed the UK Alcohol Health Alliance, bringing together 25 nongovernmental organisations with an interest in alcohol misuse - to agree policy priorities. Professor Gilmore says: “We need to replicate this sort of model within nations and across nations.”

He concludes: “A Framework Convention on Alcohol Control seems a long way off, but it will not happen unless health professionals speak out to give our governments the courage to adopt life-saving policies that tackle price, availability, and marketing of alcohol. This Series of three remarkable articles leaves no excuse for avoiding the issues - we must speak out.”

Russia: alcohol responsible for more than 1 in 2 premature deaths

A new study reported in the Lancet calculates that more than half of all the premature deaths in Russian adults aged 15-54 are attributable to alcohol.

The study concludes that sudden changes in alcohol drinking patterns account for most of the large fluctuations in Russian mortality since 1984, and tobacco and excessive alcohol use account for the large difference in adult mortality between Russia and Western Europe. The study is authored by Professor David Zaridze, Russian Cancer Centre, Moscow, Professor Sir Richard Peto, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UK, and colleagues.

The study looked at mortality in three typical Russian industrial cities-Tomsk, Barnaul, and Biysk. The addresses of some 60,000 residents who had died at ages 15- 74 years in the period 1990-2001 were visited during 2001-05. For 50,066 of them a family member was still present, and from 97% (48,557) of these, information was provided on the deceased’s past alcohol use and other lifestyle factors. A total of 43,802 deaths (cases) were from external causes or from diseases that the authors judged beforehand could well be substantially affected by alcohol or tobacco; the 5475 deaths from other diseases acted as controls. The main case-control analyses are restricted to ever-drinkers, and the relative risks (RRs) compare the reference category (defined as usual weekly consumption always less than 250ml vodka and maximum daily consumption also less than 250ml vodka) versus other drinkers, classified by usual weekly vodka consumption into three categories: less than 500ml, 500- 1499ml, and 1.5L or more (mean 2.7 litres).

The researchers found that, in men, the greatest absolute excesses of alcohol-associated mortality were in the deaths from accidents and violence (RR 5.9 for the highest versus the lowest alcohol consumption category); alcohol poisoning (RR 21.7); and acute heart disease other than heart attack (which included some from mis-certified alcohol poisoning) (RR 3.0). There were also excesses of throat cancer (3.5) and liver cancer (2.1). A further five disease groups had RRs of more than 3.0 in the highest alcohol category: tuberculosis (4.1), pneumonia (3.3), liver disease (6.2), pancreatic disease (6.7), and ill-specified conditions (ie, deaths where the person certifying the death did not find out what disease had caused it) (RR 7.7).

After correction for reporting errors, alcohol-associated excesses accounted for 52% of all study deaths at ages 15-54 years (men 8182 [59%] of 13968; women 1565 [33%] of 4751), and 18% of those at age 55-74 years. The authors say: “Allowance for [the] under-representation [in our study] of extreme drinkers would further increase alcohol-associated proportions. Large fluctuations in mortality from these ten strongly alcohol-associated causes were the main determinants of recent fluctuations in overall mortality in the study region and in Russia as a whole.” The authors argue that the excess mortality from liver cancer, throat cancer, liver disease, and pancreatic disease is largely or wholly because alcohol caused the disease that caused death. The excess mortality from tuberculosis and pneumonia may be partly a result of increased exposure to infection, reduced immune competence, or decreased likelihood of cure.

The authors suggest that, without alcohol, mortality rates in Russia would be much less than double the rates in Western Europe. However, the actual Russian mortality rate in people aged 15-54 years was more than five times (for men) and three times (for women) the rate in Western Europe. They say: “This ... is consistent with alcohol being responsible for about three quarters of all male Russian deaths at ages 15-54 years and about half of all female Russia deaths at these ages - ie, [proportions] even greater than in our study population.”

They end: “We conclude that alcohol is the main cause (and perhaps the only major cause) of the large fluctuations in Russian adult mortality since 1980, and that alcohol and tobacco account for most or all of the large difference in premature adult mortality between Russia and western Europe.” In an accompanying Comment, Dr Robin Room, Turning Point Alcohol & Drug Centre, Melbourne, and University of Melbourne, Australia, and Dr Jürgen Rehm, Centre for Addiction and Mental Health, Toronto, Canada, say: “In estimating that more than 50% of all adult premature deaths are attributable to alcohol, the study is a stark reminder that most of these deaths are avoidable with more effective alcohol policies. The findings are a wake-up call that needs to be heeded both in national policy making and at international levels as WHO moves toward the institution of a Global Alcohol Strategy. In view of the ongoing globalisation of the alcohol market, a framework convention for alcohol control, analogous to the tobacco convention, would contribute to reducing the alcohol-attributable disease burden not only for Russia, but also worldwide.”

A linked Editorial in the Lancet concludes, that in addition to implementing the proven policies outlined in The Lancet Alcohol Series (see separate releases), ‘Russia must stop or tax the illicit production of spirits, believed to account for at least 50% of consumption in the country. This in turn means confrontation with organised criminals and corrupt officials. But the time has never been better for Russia to shake off the chains of alcohol. The country has strong and ambitious leaders, the recently launched National Priority Project for health can provide a framework, and income from vast energy reserves can offset costs. All that is needed is the political will to make public health a priority.”