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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 REFERENCE LIST 1. 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