Download alcohol, social development and infectious disease

ALCOHOL, SOCIAL DEVELOPMENT AND
INFECTIOUS DISEASE
J. REHM1-4 , P. ANDERSON 5,6 , F. KANTERES 1,6 , A.V. SAMOKHVALOV 1 , J. PATRA 1
1
Public Health and Regulatory Policy, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
2
Dalla Lana School of Public Health, University of Toronto, Canada
3
Department of Psychiatry, University of Toronto, Canada
4
Epidemiological Research Unit, Klinische Psychologie & Psychotherapie, Technische Universität, Dresden,
Germany
5
Consultant in Public Health
6
Faculty of Health, Medicine, and Life Sciences at Maastricht University, Netherlands
1
TABLE OF CONTENTS
The epidemiological situation .......................................................................................................................................4
Alcohol as a risk factor for infectious disease............................................................................................................4
Box 1: Pathways from alcohol to TB ......................................................................................................................5
Box 2: biological pathways for the impact of alcohol consumption on incidence of pneumonia.........................6
The health burden of alcohol, globally and in the developing world ........................................................................6
The mortality burden attributable to alcohol........................................................................................................7
The burden of disease and injuries attributable to alcohol...................................................................................8
The role of development for alcohol-attributable burden of disease ...................................................................9
Country case studies on alcohol, social development and infectious disease burden................................................15
Two examples from sub-saharan africa: Nigeria and south Africa..........................................................................15
Brazil as an example from south america................................................................................................................16
Three examples from asia: China, india, thailand....................................................................................................17
Policy implications .......................................................................................................................................................19
The need for alcohol policy specifically dealing with alcohol-attributable infectious disease................................19
Alcohol policy in context..........................................................................................................................................20
Infrastructure for effective alcohol policy ...............................................................................................................21
Joining efforts to control two global epidemics ..................................................................................................21
Goals and targets.................................................................................................................................................21
Accountability......................................................................................................................................................22
Policy coherence..................................................................................................................................................22
Monitoring and surveillance................................................................................................................................22
The professional workforce .................................................................................................................................23
Financing action...................................................................................................................................................23
Alcohol Policy options..............................................................................................................................................23
Urban health and regulation of alcohol outlets ..................................................................................................24
2
Price and tax collection........................................................................................................................................24
Commercial communications ..............................................................................................................................25
Information and educational programmes .........................................................................................................26
Alcohol treatment as part of infectious disease treatment ....................................................................................27
Governance of alcohol policies................................................................................................................................28
Governance steps needed to reduce alcohol-related infectious diseases. Adapted from [70] ..............................30
3
THE EPIDEMIOLOGICAL SITUATION
ALCOHOL AS A RISK FACTOR FOR INFECTIOUS DISEASE
Alcohol is a major risk factor of global burden of disease and injury (GBoDI). Various estimates based on
the respective GBoDI updates indicated a major impact of alcohol consumption on mortality and burden
of disease [1-3]. In the only comparative analysis with more than 20 other risk factors, the net global
burden attributable to alcohol was estimated to be roughly equivalent to the burden of tobacco
smoking [4].
Infectious diseases were not included as part of any of the above analyses. This is on the one hand
astonishing, as Benjamin Rush as early as 1785 [5] concluded a causal impact of heavy spirits
consumption on infectious diseases such as tuberculosis (TB) and pneumonia. The association between
alcohol and these disease categories had been well confirmed in many studies thereafter [3;6] as well as
for HIV/AIDS as another important infectious disease outcome [7-9], but there were doubts about the
causality of the relationship between alcohol consumption and these outcomes (e.g., [10])
To further explore the relationship a technical meeting was organized by the South African Medical
Research Council and co-sponsored by the World Health Organization, CDC and UNAIDS at Cape Town in
July 2008 specifically to review evidence about a potential causal impact of alcohol consumption on
Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) and TB. After
reviewing the evidence from epidemiology, social sciences and immunology, the meeting concluded that
there was sufficient evidence for establishing a causal impact of alcohol on TB incidence [11]. Using the
same criteria, the relationship between alcohol consumption and pneumonia was also analysed, with
the conclusion, that there was sufficient evidence for concluding a causal relationship between alcohol
consumption and incidence of this disease category. We summarize the main underlying pathways
based on the literature below in two boxes.
Furthermore it was concluded that there is sufficient evidence for alcohol worsening the disease course
for both TB and HIV/AIDS [11]. The following main reasons were given:
•
There are strong and consistent associations between alcohol consumption and worse disease
outcomes (death, re-infection) for both TB and HIV/AIDS [TB: [12;13] HIV/AIDS: [14;15].
•
There are well-established pathways to explain these associations such as lower probability of
treatment adherence including lower adherence to medications schedules TB: [16;17] HIV: [18]
and weakening of the immune system (see boxes below).
•
For all of the above mechanisms there are dose response relationships clearly indicating that
more problematic alcohol consumption and abuse (including but not limited to dependence) are
linked to worse courses of disease progression (TB: [13;19] HIV [18;20;21].
4
BOX 1: PATHWAYS FROM ALCOHOL TO TB
Chronic heavy alcohol consumption is linked to the development of active tuberculosis (TB) in several
ways both by social and biological pathways. While about one-third of the people in the world are
infected with M. tuberculosis [22], ninety percent of these individuals will never develop the clinical
disease [23]. Chronic heavy alcohol users or people with an alcohol dependence have a higher risk in
acquiring the disease.
Social pathway: in general, the health impact of chronic alcohol consumption is higher in lower socioeconomic strata [24-28]. In turn, TB is more incident and prevalent in poorer areas, and among poorer
households [29]. Heavy alcohol use and especially dependence can lead to social exclusion and a
downward social mobility. Poverty and the associated living conditions such as crowding and
malnutrition facilitate infection and re-infection with TB. Studies have shown, that heavy drinking
emerges as a significant independent risk factor for incidence or re-infection of TB, even if other risk
factors are controlled for [6;8;9;30]. Heavy drinking thus can be seen as a causal pathway for infection or
re-infection with M. tuberculosis. The subsequent development of TB then is linked to alcohol’s role in
weakening the immune system.
Biological pathways are represented by impairment of both arms of the immune system, innate and
acquired, resulting in increased susceptibility to TB, its more severe clinical course and higher probability
of its reactivation [31-35].
Greater than 90% of inhaled M. tuberculosis bacteria are normally destroyed by alveolar macrophages
[36-39]. In vivo and in vitro studies have demonstrated that alcohol significantly hinders
antimycobacterial defenses by suppressing mobilization, adherence, phagocytosis, and superoxide
production of alveolar macrophages [36-39]. If alveolar macrophages are not able to kill M. tuberculosis,
the bacteria multiply within macrophages, and tubercles form in the lungs [40]. Another function of
alveolar macrophages - presenting microbial antigen to lymphocytes - is also inhibited by ethanol [41]
In addition, alcohol has been shown to reduce macrophage response to immune system modifiers (e.g.,
cytokines, including interleukin-6 (IL-6), IL-1β, TNF-α, and IL-8) and to prevent the protective effect
exerted by the cytokines [42;43]. Moreover, acute and chronic alcohol exposure may suppress the
capacity of monocytes to produce cytokines which directly inhibit bacterial growth and play a critical
role in cellular communication, activation, proliferation, and migration, as well as regulating
inflammation and healing mechanisms [43;44].
Finally, alcohol may adversely affect antigen-specific T-cell activation so that the Th2 population
(humoral immunity) dominates the Th1 population (cell-mediated immunity, responsible for overcoming
TB infection). This shift disturbs a balance between the two basic types of immune system,
compromising the immune defense and increasing susceptibility to TB as a result of alcohol exposure
[36-39;45].
Other sequelae of heavy drinking such as liver damage, nutritional deficiency, or hygienic factors are
also responsible for the impaired immunity associated with alcohol dependence [33;34;46;47].
In summary, there is adequate evidence for social and biological pathways in the impact of heavy
alcohol consumption on the occurrence of new TB cases.
5
BOX 2: BIOLOGICAL PATHWAYS FOR THE IMPACT OF ALCOHOL CONSUMPTION ON
INCIDENCE OF PNEUMONIA
The pathways for TB and community acquired pneumonia are quite similar. Thus, we will only refer to
the biological pathways for pneumonia here: alcohol consumption affects respiratory and immune
systems in several ways, making heavy drinkers susceptible to pulmonary bacterial infections.
Impairment of mechanical defence mechanisms involves diminished oropharyngeal tone resulting in
increased risk of aspiration and decreased bronchoalveolar lavage due to suppression of coughing and
decreased cilia motility [48;49].
Detrimental immunological effects of ethanol include combined deterioration of innate and acquired
immunity. Deterioration of innate immunity presents with decreased production of bactericidal
substances such as lysozyme, complement etc [50;51]; decreased phagocytic and antigen-presenting
activities of alveolar macrophages [36-39;41;52]; decreased recruitment of polymorphonuclear
leukocytes (PMN) due to suppression of chemoattractants production and impaired response of PMN to
chemotactic signals as well as impairment of functional activity of PMNs [43;44;50;53-55]; Inhibition of
bone marrow granulopoietic function due to suppression of granulopoietic cytokine production by
infected tissues and impairment of the granulopoietic progenitor cell response to the cytokine
stimulation [56;57].
Deterioration of acquired immunity includes development of lymphopenia, suppression of lymphoblast
transformation and blunted lymphocyte proliferative responses to specific antibodies [28;50]; and a
diminished number of CD4+ T-lymphocytes and a reduction in their capacity to produce IFN-γ and
impaired ability to develop specific antibodies following new antigen challenges [36-39;45].
Also heavy drinking often causes liver damage, nutritional deficiency, or results in poor personal
hygiene, which is also responsible for the impaired immunity associated with alcohol dependence
[33;34;46;47].
In summary, multiple detrimental effects of heavy drinking cause profound suppression of host
defensive mechanism and result in increased susceptibility to development of pneumonia.
THE HEALTH BURDEN OF ALCOHOL, GLOBALLY AND IN THE DEVELOPING WORLD
Having established alcohol, in particular heavy consumption and alcohol dependence as a risk factor for
infectious disease, we started to quantify this relation. The basis was the GBD 2004 update [58] and a
recent publication in Lancet which summarized the contributory causal role of alcohol for other disease
categories [3]; for general technical details see [59;60]. The specific assumptions for modeling the
impact of alcohol on infectious disease were as follows:
•
For TB, the conservative relative risk (RR) of 2.94 [95% CI: 1.89-4.59] was assumed based on the
meta-analysis of Lönnroth and colleagues [6] for all consumption above a threshold of 40g pure
alcohol consumption per day.
•
For pneumonia we conducted a preliminary meta-analysis of our own and found a continuous
RR of 1.10 (20g/day), 1.27 (50g/day) and 1.43 (75g/day) for men and 1.05 (10g/day), 1.15
(30g/day), 1.30 (55g/day) for women.
6
•
For HIV/AIDS we could not use the meta-analyses on alcohol and incidence of HIV, as we had
found no sufficient evidence for a causal relationship. However, we modelled the impact of
alcohol on antiretroviral medication adherence [18] and the subsequent consequences on
mortality [20]. The RR estimate of non-adherence on mortality in a Canadian sample was 3.13
[95% CI: 1.95-5.05]; [21]; the RR for < .80% adherence in a South African sample was 3.23 [95%
CI: 2.37-4.39]). A conservative RR of 3.0 was assumed, lower than both RRs from these two
studies above. The Annex 2 of the 2008 UNAIDS report on the global AIDS epidemic was used a
basis to determine the people in each country in antiretroviral therapy as a proportion of all
people in need of such therapies [61].
THE MORTALITY BURDEN ATTRIBUTABLE TO ALCOHOL
Table 1 provides an overview of the impact of alcohol consumption on deaths.
Table 1:
Deaths (in 1,000) attributable to alcohol by sex and disease category (2004)
Disease Category
WORLD
M
Tuberculosis
W
T
%M
%W
238
16
254
10.0%
3.3%
HIV/AIDS
27
21
48
1.1%
4.2%
Lower respiratory Infections
69
14
84
2.9%
2.9%
2
1
3
0.1%
0.3%
377
111
487
15.9%
22.3%
Maternal and perinatal conditions
(low birth weight)
Cancer
Diabetes mellitus
0
0
0
0.0%
0.1%
Neuropsychiatric disorders
109
25
135
4.6%
5.1%
Cardiovascular diseases
466
80
545
19.6%
16.1%
Cirrhosis of the liver
297
76
373
12.5%
15.3%
Unintentional injuries
556
110
666
23.4%
22.2%
Intentional injuries
232
40
272
9.8%
8.0%
2,373
495
2,868
100.0%
100.0%
-8
-4
-12
8.3%
3.2%
Cardiovascular diseases
-88
-128
-215
91.7%
96.8%
Total 'beneficial effects'
attributable to alcohol
-96
-132
-227
100.0%
100.0%
Total 'detrimental effects'
attributable to alcohol
Diabetes mellitus
All alcohol-attributable net
deaths
All deaths
Percentage of all net deaths
attributable to alcohol
2,278
363
2,641
31,063
27,674
58,738
7.3%
1.3%
4.5%
7
For comparison: [3]
6.3%
1.1%
3.8%
M – men; W - women
* numbers are rounded to the nearest thousand. Zero (0) indicates fewer than 500 alcohol-attributable deaths in the disease
category
The global mortality burden of infectious disease (overall 13.5% of the detrimental impact of alcohol) is
comparable with the mortality burden of liver cirrhosis (13.0%), and ranks right behind the three
categories where alcohol consumption impacts the most: unintentional injuries (23.2%), cardiovascular
disease (19.0%) and cancer (17.0%). For cardiovascular disorders there is also a marked beneficial effect
of light to moderate drinking, so taking this into consideration, the net effect of alcohol on infectious
disease mortality is only surpassed by its effect on unintentional injuries and cancer. Most of the effect
of alcohol on infectious disease occurs in low to middle income countries (see below for details). Within
the infectious disease category, there is a clear gender split: men are more impacted via TB, where
women have the largest impact via HIV non-adherence.
THE BURDEN OF DISEASE AND INJURIES ATTRIBUTABLE TO ALCOHOL
This picture changes, when GBoDI becomes the outcome (see Table 2).
Table 2:
GBoDI in DALYs (in 1,000) attributable to alcohol by sex and disease category (2004)
Disease Category
WORLD
M
Tuberculosis
W
T
%M
%W
5,516
470
5,986
8.0%
3.7%
HIV/AIDS
624
526
1,150
0.9%
4.2%
Lower respiratory Infections
917
190
1,107
1.3%
1.5%
64
55
119
0.1%
0.4%
4,732
1,536
6,268
6.9%
12.3%
Maternal and perinatal conditions
(low birth weight)
Cancer
Diabetes mellitus
Neuropsychiatric disorders
Cardiovascular diseases
0
28
28
0.0%
0.2%
23,265
3,417
26,682
33.7%
27.3%
5,985
939
6,924
8.7%
7.5%
Cirrhosis of the liver
5,502
1,443
6,945
8.0%
11.5%
Unintentional injuries
15,694
2,910
18,604
22.8%
23.2%
6,639
1,021
7,660
9.6%
8.1%
68,938
12,536
81,474
100.0%
100.0%
Intentional injuries
Total 'detrimental effects'
attributable to alcohol
Diabetes mellitus
-238
-101
-340
22.2%
8.1%
Cardiovascular diseases
-837
-1145
-1981
77.8%
91.9%
-1,075
-1,246
-2,321
100.0%
100.0%
Total 'beneficial effects'
attributable to alcohol
8
All alcohol-attributable net
DALYs
67,863
11,290
79,153
799,536
730,631
1,530,168
Percentage of all net DALYs
attributable to alcohol
8.5%
1.5%
5.2%
For comparison: [3] Rehm et
al., 2009 [Lancet, 373: 22232233]
7.6%
1.4%
4.6%
All DALYs
M – men; W - women
* numbers are rounded to the nearest thousand. Zero (0) indicates fewer than 500 alcohol-attributable DALYs in the disease
category
When non fatal outcomes are included, neuropsychiatric disorders, mainly alcohol dependence and
other alcohol use disorders, make up the proportionally largest part of the total detrimental effect of
alcohol (32.7%). Neuropsychiatric disorders often are disabling, but much less linked to fatal outcomes
compared to cancer or cardiovascular disorders. The only other large categories with more than 10% of
the total alcohol-attributable GBoDI were unintentional injuries (22.8),and infectious diseases (10.1).
In sum, infectious diseases constitute a sizable share of alcohol-attributable GBoDI. However, there are
huge variations in alcohol-attributable burden of disease and injury (BoDI) between different parts of
the world, and economic development is associated markedly with these differences.
THE ROLE OF DEVELOPMENT FOR ALCOHOL-ATTRIBUTABLE BURDEN OF DISEASE
Based on the regional categorization by Room and colleagues [62], we divide up the world in more
homogenous regions with respect to economic development and alcohol consumption. The associated
BoDI is summarize in Table 3.
9
Table 3:
Economic development status and alcohol-attributable BoDI in 2004 (net effect per category in 1,000 DALYs)
very high or high
mortality; lowest
consumption
Islamic middle east
and Indian
subcontinent
(EMR-D, SEAR-D)1
DALYs
1,134
20
429
%
10.5%
0.2%
4.0%
Developing Countries
very high or high
mortality; low
consumption
Poorest countries in
Africa and America
(AFR-D, AFR-E,
AMR-D)2
DALYs
3,860
56
622
%
29.8%
0.4%
4.8%
Developed countries
low mortality
very low mortality
Better-off developing
countries in America,
Asia, Pacific
(AMR-B, EMR-B,
SEAR-B, WPR-B)3
DALYs
%
2,030
6.3%
20
0.1%
3,343
10.3%
North America,
Western Europe,
Japan, Australasia
(AMR A, EUR A,
WPR A)4
DALYs
%
235
3.2%
7
0.1%
1,300
17.5%
Former Socialist:
low mortality
World
Eastern Europe and
Central Asia
(EUR B, EUR C)5
DALYs
984
16
574
%
6.3%
0.1%
3.7%
DALYs
8,243
119
6,268
%
10.4%
0.2%
7.9%
Infectious diseases
Perinatal conditions
Malignant neoplasms
Neuro-psychiatric
3,731
34.4%
2,099
16.2%
12,717
39.3%
4,446
60.0%
3,689
23.6%
26,682
33.7%
conditions
Cardiovascular
1,273
11.7%
612
4.7%
2,406
7.4%
-1,562
-21.1%
2,212
14.2%
4,942
6.2%
diseases
Other noncommunicable
987
9.1%
506
3.9%
2,463
7.6%
865
11.7%
1,814
11.6%
6,634
8.4%
diseases
Unintentional injuries
2,608
24.1%
3,266
25.2%
6,434
19.9%
1,565
21.1%
4,731
30.3%
18,604
23.5%
Intentional injuries
661
6.1%
1,915
14.8%
2,925
9.0%
558
7.5%
1,601
10.3%
7,660
9.7%
Total alcohol related
10,844 100.0%
12,936 100.0%
32,338
100.0%
7,414 100.0%
15,621 100.0%
79,153 100.0%
burden in DALYs
Total burden of
492,530
393,338
429,522
114,547
100,232
1,530,168
disease in DALYs
% of total disease
burden which is
2.2%
3.3%
7.5%
6.5%
15.6%
5.2%
alcohol related
Populous countries in the respective regions: 1 Pakistan [EMR-D], India[SEAR-D], Bangladesh[SEAR-D]; 2 Nigeria[AFR-D], Ethiopia[AFR-E], Peru[AMR-D]; 3 Brazil[AMR-B], Iran[EMR-B],
Indonesia[SEAR-B], China[WPR-B]; 4 Unites States[AMR-A], Germany[EUR-A], Japan[WPR-A]; 5. Poland [EUR-B]], Russian Federation[EUR-C], Ukraine[EUR-C]
Both TB and HIV/AIDS are more prevalent in the developing world. Alcohol-attributable burden is determined by the prevalence of disease, the prevalence of
alcohol consumption (especially in heavy drinking categories), and the risk relationships, the latter assumed to be the same between countries. So it is no
surprise that infectious diseases are proportionally most important in regions of the world which have high prevalence of infectious diseases and relatively high
drinking (see Table 4).
10
Table 4:
Economic development status and alcohol consumption indicators
Regions*
Developing countries
Very high or high mortality; lowest
consumption
Very high or high mortality; low
consumption
Low mortality emerging
economies
Developed countries
Very low mortality
EMR-D, SEAR-D (Islamic middle east
and Indian subcontinent)
AFR-D, AFR-E, AMR-D (poorest
countries in Africa and America)
AMR-B, EMR-B, SEAR-B, WPR-B
(better-off developing countries in
America, Asia, Pacific)
AMR A, EUR A, WPR A (North
America, western Europe, Japan,
Australasia)
EUR B, EUR C (eastern Europe and
central Asia)
Recorded
consumption†
Unrecorded
consumption‡
Total
consumption‡
Proportion
drinkers
Consumption
per drinker
Pattern
0.28
1.38
1.66
10.6%
21.74
2.9
4.37
2.64
7.02
39.2%
20.24
3.0
4.38
1.29
5.68
51.1%
11.51
2.4
9.31
1.32
10.63
72.5%
14.94
1.8
Former socialist: low mortality
7.05
4.64
11.69
67.4%
18.41
3.5
WORLD
4.43
1.72
6.15
45.5%
15.8
2.6
*Regional sub-groupings defined by WHO on basis of mortality levels (A=very low child and very low adult mortality; B=low child and low adult mortality; C=low child and high adult mortality; D=high
child and high adult mortality; E=very high child and very high adult mortality).
†Litres of pure alcohol per resident aged 15 and older per year. ‡Indicator of hazard per litre of alcohol consumed, composed of several indicators of heavy drinking occasions plus frequency of
drinking with meals (reverse scored) and in public places (1=least detrimental; 4=most detrimental).
11
Overall, the relationship between alcohol consumption, social and economic development, and disease
burden is complex, characterized by the following relationships:
1. Within low to middle income countries (up to about 20,000 I$ GDP PPP), the higher the
economic development, the more alcohol is consumed and the fewer abstainer (see Figures 1
and 2).
Figure 1:
Economic wealth (GDP PPP in 1,000 I$) and adult per capita consumption (in litres
pure alcohol for 2005)
16
14
12
10
8
6
4
2
0
M=1
M=3
M=5
M=7
M=9
M=11 M=13.5 M=17.5 M=25
M=35
M=45
M=1 denotes the midpoint of the respective interval, in the example between I$ 0 and
1,000; M=45 denotes the interval between I$ 40,000 and 50,000; etc.
12
Figure 2:
Economic wealth (GDP PPP in 1,000 I$) and abstention (in % of the adult population)
in 2005
100%
90%
80%
abstainer (last year)
70%
lifetime abstainer
60%
50%
M=1 denotes the
midpoint of the
respective interval,
in the example
between I$ 0 and
1,000; M=45
denotes the interval
between I$ 40,000
and 50,000; etc.
40%
30%
20%
10%
0%
2. The lower the economic development of a country or region, the higher the alcohol-attributable
mortality and BoDI per litre of pure alcohol (see Table 5).
WHO
Region
Burden
DALYs
in 1,000
Deaths
in 1,000
Adult
per capita
consumption
Burden per
litre per 1,000
inhabitants
Deaths per
litre per
10,000
inhabitants
GDP-PPP
in 2005
(per
capita)
Afr D
Afr E
Amr A
Amr B
Amr D
Emr B
Emr D
Eur A
Eur B
Eur C
Sear B
Sear D
Wpr A
Wpr B
World
3,912
7,723
3,488
9,123
1,301
262
554
3,088
2,892
12,728
3,327
10,291
837
19,626
79,153
142
276
62
282
35
8
16
34
116
521
95
332
36
684
2,641
7.2
6.9
9.4
8.4
7.4
1.0
0.6
12.1
7.5
14.9
2.3
1.9
9.4
6.0
6.2
2.76
5.03
1.38
3.36
3.63
2.62
4.00
0.72
2.29
4.28
6.51
5.95
0.67
2.71
2.79
1.00
1.80
0.24
1.04
0.96
0.78
1.19
0.08
0.92
1.75
1.86
1.92
0.29
0.95
0.93
2,127
1,941
40,468
9,110
4,208
12,877
2,740
30,087
8,839
10,095
3,835
1,955
30,996
4,552
9,543
13
The relationship is quite strong, amounting to -0.745 for BoDI and -0.781 for mortality; in other
words the explained variation is in both cases larger than 50%.
3. The lower the socioeconomic status of a person within a country, the higher the alcoholattributable disease burden. Three examples from different parts of the world should illustrate
this: in a study based in England, Scotland, and Wales in 1988-1994, [63], using male census
employment data linked to death records, showed that compared to professional workers,
unskilled workers had a relative risk (RR) of 4.47 for alcohol related mortality and specifically a
RR of 3.61 for chronic liver disease and cirrhosis. In Finland, [64], using census data linked to
death records for 2001-2005, found clear gradients for alcohol mortality linked to education
(basic vs. tertiary) where men had an RR of 3.52 and women an RR of 4.13, and linked to social
class (unskilled workers vs. upper white-collar) men had an RR of 1.57 and women an RR of 2.72.
This association has also been studied in Brazil, where in a mental health prevalence study
(n=1464). Andrade et al. (2002) [65] found that the lowest education group clearly had
increased rates of alcohol dependence syndrome, with a RR of 2.1 (95% CI 1-4.9). Recently and
focused on a larger context, Mackenbach et al. (2008) [66] found that in Europe as a whole,
inequalities in alcohol-related mortality account for 11% of inequalities in the rate of death from
any cause among men and 6% of those among women.
4. The lower the socioeconomic status of a person within a country, the higher the alcoholattributable disease burden per l of pure alcohol. This can be indirectly measured by higher RR
between low vs. high socioeconomic status for disease categories with high alcohol-attributable
proportions in comparison to other disease categories. In other words, alcohol does make a
difference in potentiating or increasing already existing differences between the mortality or
other health outcomes between socio-economic strata. Harrison and Gardiner [63] cited above,
also found that the RR for unskilled professionals for chronic liver disease & cirrhosis compared
with all cause mortality was 3.61 to 2.86. The study of Andrade and colleagues [65] showed that
the lowest education group had a significantly higher RR for alcohol dependence syndrome
when compared to any other psychiatric disorder, with a RR of 2.1 (95% CI: 1-4.9) compared to
an RR of 0.9 (95% CI: 0.6-1.3), a ratio of 2.33. In Russia, Shkolnikov and colleagues [67] found
that the lowest education group in comparison with the group with highest education had a
much higher RR for alcohol-related mortality than for all cause mortality, with RRs of 3.45 vs.
1.71, and of 4.63 vs. 1.45, for men and women respectively.
Infectious diseases are a special case: they are not only more common (= incident and prevalent) in less
developed countries, but also more common in poorer populations within these countries. Overall,
these populations on average have less heavy alcohol consumption than in high-income countries.
However, for those, who consume alcohol, the risk of infectious disease is considerably increased. This
explains why, in countries with overall high incidence or prevalence of infectious diseases and relatively
high consumption of alcohol, alcohol contributes over-proportionally to infectious disease burden. Take
Sub-Saharan Africa as an example (WHO region Africa): in this region, infectious diseases comprise more
than 35% of all alcohol-attributable deaths, and about 32% of the alcohol-attributable BoDI. Behind
these figures are the social conditions associated with poverty in these regions: crowding and high
14
density, unsafe water and sanitary conditions, and malnutrition. Infection of TB or pneumonia is
relatively likely here, if the immune system is compromised by heavy drinking.
COUNTRY CASE STUDIES ON ALCOHOL, SOCIAL DEVELOPMENT AND INFECTIOUS DISEASE
BURDEN
TWO EXAMPLES FROM SUB-SAHARAN AFRICA: NIGERIA AND SOUTH AFRICA
Table 6:
BoDI in DALYs (in 1,000) attributable to alcohol by sex and disease category
for Nigeria (2004)
Disease Category
M
551
241
91
NIGERIA
W
107
303
34
T
658
544
126
%M
31.1%
13.6%
5.2%
%W
13.8%
39.2%
4.4%
Tuberculosis
HIV/AIDS
Lower respiratory Infections
Maternal and perinatal conditions
4
4
8
0.2%
0.6%
(low birth weight)
Cancer
85
57
143
4.8%
7.4%
Diabetes mellitus
0
5
5
0.0%
0.7%
Neuropsychiatric disorders
255
58
313
14.4%
7.5%
Cardiovascular diseases
95
80
175
5.3%
10.4%
Cirrhosis of the liver
61
23
84
3.5%
3.0%
Unintentional injuries
275
70
345
15.5%
9.1%
Intentional injuries
115
32
146
6.5%
4.1%
Total 'detrimental effects'
1,775
773
2,548
100.0%
100.0%
attributable to alcohol
Total 'beneficial effects' attributable
0
0
0
0.0%
0.0%
to alcohol
All alcohol-attributable net DALYs
1,775
773
2,548
All DALYs
37,813
39,000
76,812
Percentage of all net DALYs
4.7%
2.0%
3.3%
attributable to alcohol
For comparison [3]
2.4%
0.8%
1.6%
M – men; W - women
* numbers are rounded to the nearest thousand.Zero (0) indicates fewer than 500 alcohol-attributable DALYs in the disease
category
Table 7:
BoDI in DALYs (in 1,000) attributable to alcohol by sex and disease category
for South Africa (2004)
Disease Category
M
Tuberculosis
SOUTH AFRICA
W
299
29
T
328
%M
19.9%
%W
7.2%
15
HIV/AIDS
388
224
612
25.8%
55.8%
Lower respiratory Infections
9
2
11
0.6%
0.5%
Maternal and perinatal conditions
(low birth weight)
1
1
2
0.1%
0.2%
Cancer
34
13
47
2.3%
3.2%
Diabetes mellitus
0
1
1
0.0%
0.4%
Neuropsychiatric disorders
150
43
193
10.0%
10.7%
Cardiovascular diseases
47
18
65
3.1%
4.5%
Cirrhosis of the liver
22
5
28
1.5%
1.4%
Unintentional injuries
210
30
240
14.0%
7.5%
Intentional injuries
343
35
379
22.8%
8.7%
Total 'detrimental effects'
attributable to alcohol
1,505
402
1,906
100.0%
100.0%
Total 'beneficial effects'
attributable to alcohol
0
0
0
All alcohol-attributable net
DALYs
1,505
402
1,906
All DALYs
10,403
10,210
20,613
Percentage of all net DALYs
attributable to alcohol
14.5%
3.9%
9.2%
For comparison [3]
7.8%
1.4%
4.6%
M – men; W - women
* numbers are rounded to the nearest thousand.Zero (0) indicates fewer than 500 alcohol-attributable DALYs in the disease
category
BRAZIL AS AN EXAMPLE FROM SOUTH AMERICA
Table 8:
BoDI in DALYs (in 1,000) attributable to alcohol by sex and disease category
for Brazil (2004)
Disease Category
Tuberculosis
HIV/AIDS
Lower respiratory Infections
Maternal and perinatal conditions
(low birth weight)
Cancer
Diabetes mellitus
Neuropsychiatric disorders
Cardiovascular diseases
Cirrhosis of the liver
Unintentional injuries
Intentional injuries
Total 'detrimental effects'
attributable to alcohol
Total 'beneficial effects' attributable
to alcohol
M
51
67
30
BRAZIL
W
4
31
10
T
55
98
40
%M
1.4%
1.9%
0.8%
%W
0.8%
5.7%
1.9%
4
3
8
0.1%
0.6%
93
0
1,091
290
281
750
882
51
1
237
52
37
66
52
145
1
1328
342
317
816
934
2.6%
0.0%
30.8%
8.2%
7.9%
21.2%
24.9%
9.4%
0.3%
43.5%
9.5%
6.7%
12.1%
9.5%
3,540
545
4,085
100.0%
100.0%
0
0
0
-
-
16
All alcohol-attributable net
3,540
545
4,085
DALYs
All DALYs
19,191
14,894
34,085
Percentage of all net DALYs
18.4%
3.7%
12.0%
attributable to alcohol
For comparison[3]
17.0%
3.1%
11.4%
M – men; W - women
* numbers are rounded to the nearest thousand.Zero (0) indicates fewer than 500 alcohol-attributable DALYs in the disease
category
THREE EXAMPLES FROM ASIA: CHINA, INDIA, THAILAND
Table 9:
BoDI in DALYs (in 1,000) attributable to alcohol by sex and disease category
for China (2004)
Disease Category
M
CHINA
W
10
15
10
T
%M
4.4%
0.6%
0.6%
%W
0.6%
0.9%
0.7%
Tuberculosis
621
630
HIV/AIDS
91
106
Lower respiratory Infections
91
101
Maternal and perinatal conditions
(low birth weight)
0
0
0
0.0%
0.0%
Cancer
2,180
403
2582
15.3%
25.7%
Diabetes mellitus
0
1
1
0.0%
0.1%
Neuropsychiatric disorders
6,752
271
7023
47.5%
17.3%
Cardiovascular diseases
1,148
54
1202
8.1%
3.5%
Cirrhosis of the liver
913
93
1006
6.4%
5.9%
Unintentional injuries
2,169
545
2714
15.3%
34.8%
Intentional injuries
245
165
410
1.7%
10.5%
Total 'detrimental effects'
attributable to alcohol
14,209
1,566
15,776
100.0%
100.0%
Total 'beneficial effects' attributable
to alcohol
0
0
0
All alcohol-attributable net
DALYs
14,209
1,566
15,776
All DALYs
103,668
82,985
186,653
Percentage of all net DALYs
attributable to alcohol
13.7%
1.9%
8.5%
For comparison[3]
12.9%
1.8%
8.0%
M – men; W - women
* numbers are rounded to the nearest thousand.Zero (0) indicates fewer than 500 alcohol-attributable DALYs in the disease
category
Table 10:
BoDI in DALYs (in 1,000) attributable to alcohol by sex and disease category
for India (2004)
Disease Category
INDIA
17
M
W
T
%M
9.8%
2.0%
1.8%
%W
1.2%
0.6%
0.6%
Tuberculosis
830
9
840
HIV/AIDS
169
5
174
Lower respiratory Infections
149
5
154
Maternal and perinatal conditions
(low birth weight)
8
9
16
0.1%
1.1%
Cancer
325
19
343
3.8%
2.3%
Diabetes mellitus
0
0
0
0.0%
0.0%
Neuropsychiatric disorders
2,947
310
3257
34.7%
38.3%
Cardiovascular diseases
993
6
999
11.7%
0.8%
Cirrhosis of the liver
826
46
872
9.7%
5.7%
Unintentional injuries
1,842
308
2150
21.7%
38.1%
Intentional injuries
403
92
495
4.7%
11.4%
Total 'detrimental effects'
attributable to alcohol
8,492
810
9,302
100.0%
100.0%
Total 'beneficial effects'
attributable to alcohol
0
0
0
All alcohol-attributable net DALYs
8,492
810
9,302
All DALYs
151,049
144,382
295,431
Percentage of all net DALYs
attributable to alcohol
5.6%
0.6%
3.1%
For comparison [3]
4.9%
0.5%
2.8%
M – men; W - women
* numbers are rounded to the nearest thousand.Zero (0) indicates fewer than 500 alcohol-attributable DALYs in the disease
category
Table 11:
BoDI in DALYs (in 1,000) attributable to alcohol by sex and disease category
for Thailand (2004)
Disease Category
M
Tuberculosis
HIV/AIDS
Lower respiratory Infections
Maternal and perinatal conditions
(low birth weight)
Cancer
Diabetes mellitus
Neuropsychiatric disorders
Cardiovascular diseases
Cirrhosis of the liver
Unintentional injuries
Intentional injuries
Total 'detrimental effects'
attributable to alcohol
Total 'beneficial effects'
attributable to alcohol
All alcohol-attributable net
78
211
8
THAILAND
W
4
11
1
T
82
222
9
%M
7.0%
18.9%
0.7%
%W
2.6%
7.3%
0.8%
0
100
0
420
39
88
147
28
0
22
1
48
7
27
24
4
0
121
1
468
46
115
171
32
0.0%
8.9%
0.0%
37.5%
3.5%
7.9%
13.1%
2.5%
0.1%
14.5%
0.5%
32.4%
5.0%
17.9%
16.1%
2.9%
1,119
149
1,268
100.0%
100.0%
0
1,119
0
149
0
1,268
-
-
18
DALYs
All DALYs
6,806
5,390
12,196
Percentage of all net DALYs
attributable to alcohol
16.4%
2.8%
10.4%
For comparison[3]
12.1%
2.5%
7.8%
M – men; W - women
* numbers are rounded to the nearest thousand.Zero (0) indicates fewer than 500 alcohol-attributable DALYs in the disease
category
POLICY IMPLICATIONS
THE NEED FOR ALCOHOL POLICY SPECIFICALLY DEALING WITH ALCOHOL-ATTRIBUTABLE
INFECTIOUS DISEASE
The epidemiological data reviewed in the previous sections has shown that alcohol consumption, in a
dose-response manner, but especially heavy drinking and alcohol use disorders, increases the risk of
contracting TB and pneumonia, as well as the progression of TB and HIV.Further, heavy drinking or
alcohol use disorders may impair the use of preventive services for infectious diseases and treatment
compliance (see above), as well as createrisk to others by those already affected [7].The relationship
between alcohol and the risk of infectious diseases can be confounded by poverty, social exclusion, and
social mixing patterns, including frequenting specific drinking establishments.
Data from the former Soviet Union provides evidence for population level effects [68].At the time of the
Gorbachev alcohol campaign, recorded and unrecorded alcohol consumption fell by 25% between 1984
and 1987 [69].Following socio-economic transition, consumption increased by 36% between 1987 and
1993.During the same time periods, standardized mortality rates for TB amongst 20-64 year old adults
decreased by 25% amongst Russian men and 20% amongst women, and then increased by 71% amongst
men and 42% amongst women.Although the increases were probably compounded by poverty and
social dislocation, deaths from alcohol-related conditions such as injuries and cardiovascular diseases
moved in parallel.
The global mortality burden of infectious disease (13.5% of the overall detrimental impact of alcohol) is
comparable with the mortality burden of liver cirrhosis (13.0%), ranking behind unintentional injuries
(23.2%), cardiovascular disease (19.0%) and cancer (17.0%).Most of the effect of alcohol on infectious
disease occurs in low and middle income countries.
The epidemiological data reviewed in the previous sections also show, on the one hand, that the
prevalence of drinking alcohol increases as incomes rise from very low amounts, and, on the other hand,
that heavy consumption and harm is associated with lower socioeconomic status and marginalisation.
Furthermore, heavy alcohol consumption contributes to lowered human capital, with a negative effect
of drinking on achievement in school and subsequent earnings [70]. Household expenditure on alcohol
exacerbates poverty, and resources directed to respond to social and health effects of alcohol impair
community development.
19
Thus, alcohol policy that reduces the volume of alcohol consumption, heavy drinking and episodic heavy
drinking will be likely to reduce the incidence and progression of alcohol-related infectious diseases.An
important component of policy will be treatment interventions in those with both alcohol use disorders
and alcohol-related infectious diseases to improve treatment compliance for infectious diseases.As we
will show below, good alcohol policy will lead to improved social development.And, given that alcohol
consumption and the harm done by alcohol is consequent to social and economic development, alcohol
policy should be an integral part of social and economic development policies in low and middle income
countries.
The rest of this section briefly describes alcohol policy in context, infrastructures needed for alcohol
policy, effective alcohol policy options, brief interventions and treatment of alcohol use disorders as part
of treatment for alcohol-related infectious diseases, and governance of alcohol policy. The section
concludes with a summary of step-wise approaches to alcohol policy that could impact on alcoholrelated infectious diseases and contribute to social and economic development, and a summary of
governance steps needed for effective alcohol policy as it relates to reducing alcohol-related infectious
diseases and to improving social and economic development.
ALCOHOL POLICY IN CONTEXT
Home and informal based production is an important part of alcoholic beverage production in many
low-income countries (see Table 4 above; [71;72]).Traditionally-produced beverages may benefit from
having lower alcohol content; but, they are commonly poorly monitored for quality and strength, and
they have led to health consequences related to harmful impurities and adulterants, particularly in
distilled beverages.Such informal production is commonly outside the reach of state controls and
taxation.The product is sold cheaply, and often to the poorer segments of society. There is also an
important market component of unrecorded alcohol, that is illegally produced and/or smuggled product
on a larger scale.When viewed from a public health and welfare perspective, it is important for the state
to gain effective control and oversight over informal alcohol production and distribution.Licensing and
inspection of production, whether it be a matter of cottage, of small factory or of full-scale industrial
production, is an important means of eliminating adulterants, and facilitates the use of one of the most
effective policy measures, alcohol taxation.But gaining such control can be a long process in the course
of social and economic development.
Traditional and indigenous beverages are also changing, becoming increasingly commercialised and
replaced by industrially produced, branded beverages or larger scale illegal operations [70].Alcohol
producers have been consolidated and globalised, such that the international market is now dominated
by a few large companies.Rationalisation and consolidation of production and distribution has resulted
in big profits, providing ample resources to spend on investment in emerging markets.International
companies are expanding their investment behind brands through increasing advertising, sponsorship,
and other forms of marketing that ensure recruitment of a continuing supply of drinkers.In countries
with growing economies and largely unregulated trade environments, increased penetration of alcohol
20
could lead to a rise in alcohol-related harm [59].The extent to which markets expand will depend on the
economic situation and its effect on disposable income.If these economies continue to expand, a change
in social and cultural conditions and expanded marketing are likely to lead to a rise in consumption and
increased alcohol-related harm.
INFRASTRUCTURE FOR EFFECTIVE ALCOHOL POLICY
In many low income countries, there is often little or no tradition of alcohol regulation by government.In
such countries, there is a need to build public health infrastructures for alcohol policy, including political
will and a demand for good governance, a need to appoint governmental officials responsible for
preventing and managing alcohol use disorders, a need to provide capacity building in alcohol policy and
research, and a need to ensure that knowledge of evidence is introduced into policy and programme
practice.Developed policies need to be comprehensive, minimizing any negative consequences due to
perverse incentives [73].A lack of transparency and information, poor organization and preparation for
the introduction of new policies and laws, a lack of financing, the presence of corruption, and public
distrust of authority are all impediments to the acceptance, implementation, and enforcement of
effective policy [74].Where a substantial part of alcohol consumption is unrecorded, a particular
emphasis should be for the state to gain effective control.
JOINING EFFORTS TO CONTROL TWO GLOBAL EPIDEMICS
Considerable increases in effect and efficiency could be found when the demonstrated associations
between alcohol and infectious diseases become the basis of joint policies and prevention and
treatment initiatives, as has been the case, for example, with HIV/AIDS and TB and with tobacco and TB
[75].Collaborative task forces could be created to provide policy and treatment guidance to managers of
country-based TB, HIV/AIDS and alcohol control programmes to plan and implement joint control
activities within the framework of existing and evolving strategies.Progress in implementing effective
population-based alcohol policies will reduce the prevalence of alcohol use disorders in the population
and will have an impact on TB and HIV/AIDS infection, morbidity and mortality rates. Alcohol control
programmes can also stress TB and HIV/AIDS related issues in information and advocacy campaigns
about the health dangers of alcohol, especially in countries where TB and HIV/AIDS are prevalent and
people have a clear perception of disease threat.A successful trialling of brief interventions and
treatments for alcohol use disorders in conjunction with TB and HIV/AIDS health programmes will
provide a basis for extending them to other health programmes where alcohol use contributes to or
exacerbates the disease or condition under treatment.
GOALS AND TARGETS
21
A national alcohol action plan or strategy that deals with the issues of social development and alcohol’s
role in communicable and non-communicable disease is needed to establish priorities and guide
action.Such goals and priorities should be based on epidemiological evidence, while the choice of
strategies and interventions should be evidence-based.Targets make policy objectives more specific,
allowing progress to be monitored and often inspiring partners to support policy initiatives.
ACCOUNTABILITY
Accountability for the health and development impact of alcohol actions and programmes rests with all
sectors of society, as well as the government officials who prepare action plans, allocate resources and
initiate legislation.Mechanisms such as alcohol policy audits and publicly accessible health impact
assessments can ensure that both the public sector and private industry are held accountable for the
health effects of their actions relating to alcohol.Accountability can be achieved through mechanisms to
coordinate, monitor and evaluate progress in implementing action plans, through procedures for
reporting to elected bodies and through use of the mass media.
POLICY COHERENCE
The responsibility of the national government for developing and implementing an action plan on
alcohol is usually split among several governmental departments and levels.The departments involved
can include those devoted to industry and trade, agriculture, employment, finance and health.The
interests and priorities of these different sectors are often in conflict on alcohol policy, and they may
also wield power unequally.Thus, policy coherence is crucial. Coordination is needed to ensure that all
levels of government and all affected sectors and stakeholders are considered in making alcohol policy
decisions that impact on reducing alcohol-related communicable and non-communicable and in
promoting social and economic development. A coordinating body, such as a national alcohol council,
should include senior representatives from the ministries and partners involved.
MONITORING AND SURVEILLANCE
Monitoring and surveillance data comprise an important basis for each step in policy development and
implementation, for example in setting priorities. Alcohol monitoring and surveillance systems are
necessary to identify and publicize information about current and future trends, the effectiveness of
policy actions, risk factors for alcohol-related harm, vulnerable groups, organizational and institutional
challenges in implementing policies, governance, key contextual factors, the role and motivation of key
actors, user and consumer preferences, opportunities for and constraints on change, and events and
reforms in other sectors that have implications for alcohol policy. Information systems are a critical
22
element in disseminating knowledge on alcohol and must be accessible to a wide range of actors,
including researchers, health professionals, decision-makers and policy advocates.
THE PROFESSIONAL WORKFORCE
The professional workforce engaged in communicable diseases and alcohol policy includes public health
practitioners, health care providers, policy advocates and researchers. Policy and programme work in
these areas requires an appropriately trained workforce with a wide variety of knowledge and skills.
Effective action can be hampered by a poor understanding and lack of information about modern
epidemiology, public health, health promotion, evidence-based medicine and the application of social
science research, due in part to a lack of public health education and training opportunities. In addition,
to negotiate effectively with the alcohol industry, other stakeholders need to understand it better and
develop media and policy advocacy skills.
FINANCING ACTION
Finally, effective alcohol policies cannot be developed and implemented without sufficient funds, which
are critical to all aspects of alcohol policy. Funding sources can include governmental budgets, donations
from charitable organizations and earmarked taxes.
ALCOHOL POLICY OPTIONS
An extensive evidence base, largely from high income countries, but also from middle and low income
countries find a range of policies that reduce alcohol consumption, heavy drinking and alcohol related
harm [74].Whilst very few policies have been evaluated for their impact in reducing infectious diseases,
policies that reduce consumption and especially heavy drinking are likely to impact on the incidence and
progression of alcohol-specific infectious diseases.In addition, effective policies will mitigate the harm
done by alcohol consequent to social and economic development, and, in turn, contribute to social and
economic development.Effective policies that will impact on communicable diseases are those that
regulate the availability, price and marketing of alcohol.Brief interventions for hazardous and harmful
alcohol use and treatment for alcohol use disorders are effective in reducing alcohol-related harm,
although there is no research to say whether or not such programmes will improve treatment
compliance for infectious diseases such as TB and HIV/AIDS.In contrast, as discussed below, in general,
educational approaches are not found to influence behaviour itself [76]; nevertheless, they do have a
role in informing the public and in mobilizing support for effective policy measures, facilitated by
community action [77].
23
URBAN HEALTH AND REGULATION OF ALCOHOL OUTLETS
As the Commission on Social Determinants of Health noted, urban settings can be risk factors for
harmful alcohol use and harmful patterns of drinking, particularly in areas of low social capital [78].This
is especially true with respect to the risk of infectious diseases, where crowding and unsanitary
conditions in the poorest parts of urban agglomerations potentiate the effect of alcohol.An increased
density of alcohol outlets is associated with increased levels of alcohol consumption amongst young
people, with increased levels of assault, and with other harms such as homicide, child abuse and
neglect, and self-inflicted injury [74].
A study in Los Angeles, focusing on rates of gonorrhoea as a measure of risky sexual behaviour,
presented evidence from a natural experiment on the effects of a reduction in alcohol outlets [79].After
the 1992 civil unrest in Los Angeles, in which many liquor stores were burned, 270 alcohol outlets
surrendered their licences in the wake of a community campaign to prevent damaged outlets from
reopening.The study attempted to differentiate between alcohol outlets as a causal factor (through
alcohol consumption and risky behaviour) and as a marker of poor neighbourhoods.The results of this
study showed a marked impact of alcohol outlets on rates of gonorrhoea, suggesting that outlets play a
significant role in the spread of gonorrhoea even when poor neighbourhoods were controlled for. A unit
decrease in the number of alcohol outlets per mile of roadway was associated with 21 fewer gonorrhea
cases per 100,000 (p<.01) in areas affected by the unrest compared to those not affected
There is also evidence that restricting days and hours of sale reduces problems [74].For example,
homicide is a leading cause of death in Brazil, with one of the highest murder rates occurring in the city
of Diadema.To respond to this situation, local policy measures were introduced which included a new
licensing law in 2002 prohibiting on-premises alcohol sales after 23:00 [80].To evaluate the effect on
restricting alcohol availability through limiting opening hours on homicides and violence, data from the
local police archives on homicides and assaults were analysed. Models were adjusted for contextual
conditions, municipal efforts and law enforcement interventions that took place before and after the
closing-time law was adopted.The introduction of a limit on opening hours resulted in a significant 44%
decline in the number of murders.
Implementation of laws which set a minimum age for the purchase of alcohol show clear reductions in
alcohol-related harms [74] the most effective means of enforcement is on sellers, who have a vested
interest in retaining the right to sell alcohol.
Strict restrictions on availability can create an opportunity for a parallel illicit market; but, in the absence
of substantial home or illicit production, in most circumstances this can be managed with enforcement.
Where a large illicit market exists, license-enforced restrictions may increase the competitiveness of the
alternate market, and this will need to be taken into account in policy-making.
PRICE AND TAX COLLECTION
24
Drinkers respond to changes in the price of alcohol as they do to changes in the price of other consumer
products. When other factors are held constant, such as income and the price of other goods, a rise in
alcohol prices leads to less alcohol consumption and less alcohol-related harm and vice versa in both
high and low income countries [74]. Demand for alcohol is relatively inelastic to price, such that an
increase in price results in a drop in consumption that is relatively smaller than the price increase; thus,
increasing alcohol taxes not only reduces alcohol consumption and related harm, but increases
government revenue at the same time, which can be used to fund alcohol policies and programmes and
contribute to social development programmes. In general, alcohol taxes are well below their maximum
revenue-producing potential, and the revenue collected is usually well below the social costs of alcohol.
The existence of a substantial illicit market for alcohol complicates policy considerations on alcohol
taxes; in such circumstances, tax changes require efforts to bring the illicit market under effective
government control, for example through taxation policies that increase the attractiveness of lower
alcohol content forms of culturally preferred beverages such as lower rates of taxation on lower
strength beer. In addition, there should be much stronger enforcement, including the closure of illegal
factories and after hours production, and the use of tax stamps to record that duty has been paid on
informal products.
Beverage elasticities are generally lower for the preferred beverage (beer, spirits or wine) in a particular
market than for the less-preferred beverages, and tend to decrease with higher levels of consumption. If
prices are raised, consumers reduce overall consumption and tend to shift to cheaper beverages, with
heavier drinkers tending to buy the cheaper products within their preferred beverage category.
Policies that increase alcohol prices delay initiation of drinking, slow young people’s progression towards
drinking larger amounts, and reduce young people’s heavy drinking and the volume per occasion of
drinking. Price increases reduce the harms caused by alcohol, as well as alcohol dependence. Increases
in alcohol prices also reduce death rates from cirrhosis, intentional and unintentional injuries, workplace
injuries and sexually transmitted disease rates [81].Setting a minimum price per unit gram of alcohol has
been modelled as reducing consumption and alcohol-related harm [82], and is under active
consideration in a number of countries.Both price increases and setting a minimum price are estimated
to have a much greater impact on heavier rather than lighter drinkers, with modest or only minimal
extra financial cost to lighter drinkers.
In setting alcohol taxes, trade-offs between price increases and the potential impact on family poverty
need to be considered.When a bottle of beer can cost the weekly income of some poor people, even if
this person uses the cheaper alternative of unrecorded alcohol, there can still be spill-over effects on
family income, increasing the risk of undernutrition.Measures to compensate for these effects can be
financed with the increased revenues from alcohol tax increases.
COMMERCIAL COMMUNICATIONS
25
Alcohol is marketed through increasingly sophisticated advertising in mainstream media, as well as
through linking alcohol brands to sports and cultural activities, through sponsorships and product
placements, and through direct marketing such as the Internet, podcasting and mobile telephones.
Marketing contributes to the uptake and spread of alcohol use, and the consequent spread of harm
[74].The effects of exposure seem cumulative and, in markets with greater availability of alcohol
advertising, young people are more likely to continue to increase their drinking as they move into their
mid-twenties, while drinking declines at an earlier age in those who are less exposed. Regulation and
restriction of all marketing should be a core component of alcohol policy, rather than leaving industries
to make voluntary agreements, which tend to be under interpreted, under enforced, and unstable
[70].Legislation can be written to ensure that all forms of marketing are not allowed unless specified, as
is the case with present French law. This legislation needs to cover sponsorship and all branding of
events, which are powerful forms of marketing.The nature of marketing, which increasingly uses global
technologies and strongly interacts with a global youth culture, means that an international response,
covering the internet and satellite broadcast, is needed in addition to the national response.
INFORMATION AND EDUCATIONAL PROGRAMMES
Many national alcohol strategies and initiatives underscore the need to inform and educate the
public.There are many reasons for placing an emphasis on education and information. Sometimes it
expresses a simple moral conviction, that a population should know about and understand alcohol and
its health risks.But sometimes this emphasis reflects the view that information and education can solve
alcohol-related problems, a view that is contradicted by the evidence. It can also indicate a desire to
avoid discussing and implementing other, more effective approaches to reducing the harm done by
alcohol, for instance by regulating the availability of alcohol or increasing alcohol taxes.
Moreover, alcohol education rarely goes beyond providing information about the risks of alcohol, rather
than aiming, for instance, to promote the availability of help for hazardous and harmful consumption, or
to mobilize public opinion and support for effective alcohol policies.Often, alcohol education
programmes centre around informing people about what levels of alcohol consumption are risky or
harmful, and how to calculate the content of alcohol in a typical drink.While such information may seem
useful, there is in fact very little evidence showing the effectiveness of such campaigns in changing
behaviours, and often the consumption levels described are based on an outdated understanding of risk
[74].
Nevertheless, even though the evidence base indicates that the impact of alcohol education
programmes is small, that does not mean they should be abandoned.Rather, they should be improved,
first by using surveys of public beliefs and knowledge in order to target such efforts better and second
by orienting the programmes to building support for implementing more effective alcohol policies.The,
the use of educational programmes funded by the alcohol industry should be resisted.The limited
evidence available suggests that such initiatives are likely to backfire, resulting if anything in more
positive views about alcohol and the alcohol industry [83;84] – an outcome comparable to what has
26
been more clearly demonstrated by a larger evidence base for tobacco education funded by the tobacco
industry [85;86].
Educational programmes can be supported by community action to encourage communities and
mobilize public opinion to address local determinants of increased alcohol consumption and problems.
Examples of ways that communities may address such determinants include counteracting the
attractiveness of the image of alcohol and drinking, reducing unfair privileges attached to alcohol use,
improving recognition by everybody of the nature and magnitude of health and social consequences of
harmful use of alcohol, recognizing and counteracting the influences that encourage increased alcohol
consumption, encouraging quitting or reduction of use or change in patterns of consumption, as
appropriate, and encouraging the implementation of effective policies, locally and beyond [87].
ALCOHOL TREATMENT AS PART OF INFECTIOUS DISEASE TREATMENT
Brief advice heads the list of effective evidence-based treatment methods [88].I do not know the cited
literature and surely brief interventions are the most cost-effective treatment option, but I seriously
doubt, that it is the most effective.The Cochrane series would suggest otherwise. There is extensive
evidence from a variety of health-care settings in different countries for the effectiveness of early
identification and brief advice for persons with hazardous and harmful alcohol use in the absence of
severe dependence, with evidence that more intensive brief interventions are no more effective than
less intensive interventions.Such evidence-based technologies are being implemented and evaluated in
demonstration programmes in both high-and low-income countries, with an increasing evidence base
for effective implementation strategies.
For individuals with severe alcohol dependence and related problems, a wide variety of specialized
treatment approaches have been evaluated, with evidence of effect for reducing the harm of alcohol
withdrawal, cognitive-behavioural therapies and pharmacological therapies including glutamate
inhibitors and opiate antagonists [74].There is evidence that matching individuals with alcohol use
disorders to specified treatments does not substantially improve outcomes.
Two randomized clinical trials have been conducted of the impact of a social cognitive model of health
behaviour change on risk-reduction skills for HIV/AIDS, one trial undertaken in sexually transmitted
disease clinics [89], and one in the community [90].The interventions showed mixed results, with more
behavioural changes at 3 month follow-up than at six month follow-up. In the community based trial,
heavier drinkers did not respond to the interventions as well as lighter drinkers.
Further research is needed to test the impact of integrated brief interventions and treatment for
hazardous and harmful alcohol consumption and treatment for TB and HIV/AIDS. Opportunities must be
created within the health care system to provide every TB and HIV/AIDS patient who consumes alcohol
in a hazardous or harmful way to reduce their consumption. Treatment for TB and HIV/AIDS is mostly
undertaken in settings, where formal interventions for alcohol use disorders can take place. Further,
since not all people with TB and HIV/AIDS currently get treated, the treatment coverage rate should also
27
be increased.It is hoped that through the identification and treatment of alcohol use disorders among
TB and HIV/AIDS patients, higher levels of lasting treatment success will be achieved. In the case of TB,
this can also be combined with smoking cessation programmes.
GOVERNANCE OF ALCOHOL POLICIES
Global, regional, and national policies that accelerate free trade in goods, services, and financial
investments facilitate the expansion of alcohol businesses in emerging markets, contributing to
increased availability, affordability, and marketing of alcohol.Trade agreements, structural adjustment
programmes, and World Trade Organization (WTO) dispute settlements have often failed to recognise
alcohol as a health-damaging commodity [91].Attention to trade treaties is an important part of policy
development for alcohol control, because membership of the WTO, and involvement with regional,
multilateral, and bilateral trade agreements, directly and indirectly can affect the success of alcohol
policies.
Alcohol producers are well organised and effective lobbyists for industry-friendly policies both
internationally and nationally. A major focus of industry lobbying is to campaign against effective
strategies and to campaign for ineffective strategies.Public-relations interests are also met by an
increased focus on corporate activities, such as disaster relief and support for global governance activity
[Casswell & Thamarangsi 2009].An indication of the organisation of the industry is their network of
social aspects organisations (SAOs), which are industry-funded groups established to manage issues
detrimental to the industry’s interests.SAOs have been established in countries with emerging alcohol
markets, and have taken an active role in shaping alcohol policy in low income countries, with results
that are regarded as industry-friendly and unsupportive of public health [70].
The WHO Expert Committee on Problems Related to Alcohol Consumption recommended that that
WHO continue its practice of no collaboration with the various sectors of the alcohol industry [71].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 roles as producers, distributors and
marketers of alcohol, and not in terms of alcohol policy development or health promotion.There are no
signs as yet that alcohol businesses recognise the need to support international and national regulation
to protect their own and societies’ interests [70].
Major development of activity both nationally and internationally will need increased resources to
enable advocacy from well-informed voices that are independent of commercial interests. The tobacco
experience shows that investment in the NGO sector can catalyse and support national action. However,
in the alcohol policy arena, NGO engagement is severely constrained by a lack of resources [70].Global
donor contributions to address the tobacco epidemic have not been matched for alcohol.Nor has
alcohol advocacy had the benefit of funding from charitable foundations, such as cancer societies and
heart foundations, which have been supportive of antitobacco activity.Alcohol’s role in infectious
diseases could change this.
Given that globalization has internationalized country-based alcohol policy, with market forces and
trade agreements imposing limits on actions to counter and contain problems, and, given the need for
international action to support social and economic development, mitigating against alcohol-related
28
harm consequent to economic development, coordinated action at the global level is required to
empower and back up actions at national and local levels [70].In 2008, WHO member states called for
the development of a global alcohol strategy.The World Bank, which once facilitated the establishment
of breweries as part of economic development, now takes public health issues and social policy concerns
into account when considering investments in production of alcohol beverages.Furthermore, World
Bank statements have called for countries to strengthen their alcohol policies, especially for tax,
availability control, and advertising bans [92].Additionally, development agencies have provided some
small-scale assistance to address alcohol issues in low-income and middle-income countries.
In view of the comparability between tobacco and alcohol, plus the precedent established by the
Framework Convention on Tobacco Control, calls have been made for a Framework Convention on
Alcohol Control [70;93]. These calls come from a range of sectors, including professional, academic, and
NGO sectors.Furthermore, the WHO Expert Committee on Problems Related to Alcohol Consumption
recommended that WHO should analyse the feasibility of international mechanisms, including legally
binding agreements [71], and the WHO Commission on the Social Determinants of Health stated that
alcohol is a prime candidate for stronger global, regional, and national regulatory controls [75].
Alcohol’s role as a risk factor in the incidence and progression of certain infectious diseases, and its
contribution to increasing alcohol’s contribution to the global burden of diseases make the need for a
framework convention on alcohol all the more important.
Table 12:
Step-wise approach to alcohol policy that will reduce alcohol-specific infectious
diseases (adapted from [70]
Affordability
CORE
EXPANDED
Availability
Regulation of
Marketing
Excise tax
reflecting volume
of ethanol
Regulation of all
production, and
sale
Regulation of all
marketing
including
sponsorship
Taxes inflation
adjusted
Licensing of
places for sale
and consumption
Content restricted
with no lifestyle
ads
Licensing of days
and hours of sale
Bans on
sponsorship
Minimum
purchase age
Placementrestrict
ed by volume and
media (eg no
electronic media)
Bans of sales and
drinking in public
places
No pricing
promotions or
discounts
Treatment
Brief intervention
as part of TB and
HIV/AIDS
treatments
Education
Mass media
campaigns on
relationship
between alcohol
and infectious
diseases
29
Enforced laws on
service (to
intoxication and
to minors)
No promotions
using
competitions,
gifts
Different
availabilityreflecti
ng volume of
alcohol
OPTIMAL
Minimum price
Restrictions on
packaging and
product design
Cognitive/Behavio
ural therapies for
alcohol use
disorders
Ban advertising of
corporate
philanthropy
Pharmacological
Treatments for
alcohol use
disorders
Mass media
campaigns
supporting
effective policy
Ban on all forms
of product
marketing
GOVERNANCE STEPS NEEDED TO REDUCE ALCOHOL-RELATED INFECTIOUS DISEASES.
ADAPTED FROM [70]
•
•
•
•
•
•
National and local governments to create joined up actions between communicable diseases
programmes and alcohol policy programmes to formulate and implement policies on the basis of
evidence of cost-effectiveness
Non-governmental organisations and civil society to enhance the position of alcohol on economic
and social policy agendas, and improve understanding of and support for effective policies
Academics to work independently of commercial interests, researching and assessing control
policies, particularly those relevant to alcohol-related infectious diseases and low-income and
middle-income countries
Request development of international health policy in the form of a Framework Convention for
Alcohol Control
International agencies, including development agencies and philanthropic foundations, to provide
technical support and aid capacity building— particularly in low-income and middle-income
countries—to develop, implement, and assess alcohol-control policies and joined up work between
communicable diseases and actions on alcohol
Alcohol industry to withdraw efforts to influence effective policy development, health promotion
efforts, and research agendas, and to focus instead on reducing harm in their capacity as producers,
distributors and marketers of alcohol.
30
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