Global burden of disease from alcohol, illicit drugs and tobacco

The use of alcohol, tobacco and illicit drugs entails considerable burden of disease: in 2000, about 4% of the global burden as measured in disability adjusted life years was attributable to each alcohol and tobacco, and 0.8% to illicit drugs. The burden of alcohol in the above statistic was calculated as net burden, i.e. incorporating the protective health effects. Tobacco use was found to be the most important of 25 risk factors for developed countries in the comparative risk assessment underlying the data. It had the highest mortality risk of all the substance use categories, especially for the elderly. Alcohol use was also important in developed countries, but constituted the most important of all risk factors in emerging economies. Alcohol use affected younger people than tobacco, both in terms of disability and mortality. The burden of disease attributable to the use of legal substances clearly outweighed the use of illegal drugs. A large part of the substance-attributable burden would be avoidable if known effective interventions were implemented. [Rehm J, Taylor B, Room R. Global burden of disease from alcohol, illicit drugs and tobacco. Drug Alcohol Rev 2006;25:503 - 513]     

Health impact and economic burden of alcohol consumption in India

BackgroundThe health and economic consequences of alcohol consumption have been assessed mainly in developed countries. This study aims to estimate health impact and economic burden attributable to alcohol use in India.MethodsA combination of decision tree and mathematical markov model was parameterized to assess the health effects and economic cost attributable to alcohol consumption. Health effect of alcohol was modelled for a time period of 2011 to 2050 on three sets of conditions – liver disease, cancers and road traffic accidents. Estimates of illness, death, life years lost and quality adjusted life years (QALYs) gained were estimated as a result of alcohol consumption. Both direct and indirect costs were estimated to determine economic burden. Future costs and consequences were discounted at 3% for time preferences of cost and utility. Uncertainties in parameters were assessed using probabilistic sensitivity analysis.ResultsBetween 2011 and 2050, alcohol attributable deaths would lead to a loss of 258 million life years. In contrast, 552 million QALYs would be gained by eliminating alcohol consumption. Treatment of these conditions will impose an economic burden of INR 3127 billion (US$ 48.11 billion) on the health system. Societal burden of alcohol, inclusive of health system cost, out of pocket expenditure and productivity losses will be INR 121,364 billion (US$ 1867 billion). Even after adjusting for tax receipts from sale of alcohol, alcohol poses a net economic loss of INR 97,895 billion (US$ 1506 billion). This amounts to an average loss of 1.45% of the gross domestic product (GDP) per year to the Indian economy.ConclusionAlcohol causes significant negative health impact and economic burden on Indian society and evidence informed policy interventions are needed to control alcohol attributable harm.     

Alcohol policy in Iran: Policy content analysis

BackgroundMuslim majority countries (MMCs) typically have limited alcohol policy development due to Islamic prohibition of alcohol consumption. In response to recent increases in alcohol consumption and related harms, MMCs have introduced civil alcohol policies, ranging from total prohibition to European-style regulations. Using Iran as a case study, we describe how alcohol prohibition is translated into policy in the face of influences from globalisation.MethodsWe collected information from publicly available literature and policy documents, because of the sensitivity of the topic of alcohol in Iran. The search was conducted in English and Persian. We verified information through consultations with policy actors. We also reviewed newspapers over periods just before the 1979 Islamic revolution, and before and after the 2011 alcohol policy (2008–2010; 2014–2016) was introduced. We analysed policy content based on WHO policy recommendations and used the Walt & Gilson health framework to identify policy content, context, actors and process.ResultsDespite its broad approach of civil prohibition with concessions for the non-Muslim population, Iran has developed approaches to reduce the harmful impacts of alcohol and adopted nine of ten policy interventions recommended by WHO. Pricing policy was the only intervention not used. We identified contextual challenges, such as resources, stigma and cultural offence that influence policy development.ConclusionMMCs face challenges in creating civil alcohol policies. Iran has taken steps, including a national alcohol strategy, to reduce alcohol-related harms. The socio-cultural, governance and historical context have shaped Iran’s adaptation of policy interventions recommended by WHO.     

Alcohol supply,demand, and harm reduction: What is the strongest cocktail?

The concept of harm reduction emerged from the drug field in the 1980s in response to the urgent need to reduce the risk and spread of blood-borne viruses in people who continued to inject illicit drugs. The concept has since become increasingly influential in the alcohol and even tobacco fields. While there are many different applications of the term today, the distinction used by the International Harm Reduction Association (IHRA) between strategies relying on ‘use reduction’ and those that primarily strive for harm reduction without necessarily requiring reduction in consumption is used here. The evidence base for the effectiveness of harm reduction strategies on the one hand, and efforts that require a degree of use reduction via demand or supply reduction on the other hand, is summarised based on a comprehensive review funded by the Australian government. In the alcohol field, the concept of harm reduction has sometimes been proposed as an alternative to the view that alcohol-related harm will only be reduced via a reduction of the total population consumption of alcohol. This paper will present evidence to suggest that, in order to be most effective, a comprehensive policy to reduce alcohol-related harm needs also to include interventions to reduce the quantity of alcohol consumed per occasion. Furthermore, it is highly unlikely in most modern drinking societies that significant reductions in alcohol-related harm can occur without also a significant drop in total population consumption. Nonetheless, harm reduction is an important and influential principle in alcohol policy that can be incorporated alongside such effective strategies as controls on the physical and economic availability of alcohol and the routine delivery of brief interventions in primary health care settings.     

How the alcohol industry relies on harmful use of alcohol and works to protect its profits

The alcohol industry have attempted to position themselves as collaborators in alcohol policy making as a way of influencing policies away from a focus on the drivers of the harmful use of alcohol (marketing, over availability and affordability). Their framings of alcohol consumption and harms allow them to argue for ineffective measures, largely targeting heavier consumers, and against population wide measures as the latter will affect moderate drinkers. The goal of their public relations organisations is to ‘promote responsible drinking’. However, analysis of data collected in the International Alcohol Control study and used to estimate how much heavier drinking occasions contribute to the alcohol market in five different countries shows the alcohol industry's reliance on the harmful use of alcohol. In higher income countries heavier drinking occasions make up approximately 50% of sales and in middle income countries it is closer to two‐thirds. It is this reliance on the harmful use of alcohol which underpins the conflicting interests between the transnational alcohol corporations and public health and which militates against their involvement in the alcohol policy arena. [Caswell S, Callinan S, Chaiyasong S, Cuong PV, Kazantseva E, Bayandorj T, Huckle T, Parker K, Railton R, Wall M. How the alcohol industry relies on harmful use of alcohol and works to protect its profits. Drug Alcohol Rev 2016;35:661–664]     

An Analysis of Family Dynamics on High School Adolescent Risky Behaviors in Ghana

This study examined the relationship between family dynamics and student engagement in consumption of alcohol, smoking of cigarettes, and use of illicit drugs in Ghana, West Africa. Adolescents who reported that their parents consumed alcohol were more likely to do likewise. Parental consumption of alcohol increased the adolescent probability of doing the same irrespective of the gender. Adolescence is a formative period during which health risk behaviors may be learned and solidified. Policies and subsequent interventions to address health risk behaviors should not be limited to school setting. Parental engagement and monitoring outside of school significantly mediates the extent to which students engage in health risk behaviors.     

The feasibility of providing community pharmacy‐based services for alcohol misuse: A literature review

Objectives Excessive consumption of alcohol is a major public health concern. The use of community pharmacies and pharmacists as sources of public health information and services is gaining greater recognition. The objective of this review was to provide an overview of the evidence on the feasibility, effectiveness and acceptability of providing community pharmacy‐based services to address the excessive consumption of alcohol. Methods Electronic databases were searched for the period 1996–2007 to identify relevant evidence. Searches were also conducted of relevant pharmacy and addiction journals. Information was sought from key contacts in pharmacy and alcohol research. Studies were included if they were conducted in a community pharmacy setting. Key findings The review comprised three feasibility studies which included 14 pharmacies and 500 customers. Non‐significant reductions in alcohol consumption were reported with two studies following brief interventions by pharmacists. Between 30% and 53% of pharmacy customers were identified as having hazardous or harmful drinking behaviour. Customer opinion of the pharmacy‐based alcohol services was not reported. Conclusions There has been little empirical evaluation of the effectiveness of community pharmacy‐based services for alcohol misuse. The evidence presented in this review suggests that community pharmacy‐based screening is feasible. Organisations and individuals involved with tackling excessive alcohol consumption should consider the inclusion of community pharmacies and pharmacists as part of their strategies to address this problem. Large‐scale studies are needed to evaluate the short‐ and long‐term effects and cost‐effectiveness of community pharmacy‐based interventions to reduce excessive alcohol consumption, as well as to explore the acceptability of the service to users.     

High alcohol use and misuse among a national sample of school adolescents in Benin in 2016

Abstract

The study aimed to investigate the prevalence and correlates of alcohol use and misuse among adolescents in the 2016 Benin ‘Global School-Based Student Health Survey (GSHS)’. In all, 2536 adolescents with a median age of 17?years (interquartile range = 3) from Benin responded to the 2015 cross-sectional GSHS. A nationally representative sample of students between the ages of 13 and 17?years was selected based on a two-stage (schools and classes) cluster sample design. Students responded to questions on sociodemographic factors, substance use, psychological distress, other health risk behaviour and protective factors. Almost half (44.1%) of the adolescents reported past-month alcohol use, 25.3% ever been drunk, and 15.0% past-month heavy alcohol use (≥two more drinks/day). In adjusted Poisson regression analysis, among both boys and/or girls, current tobacco use, multiple sexual partners, ‘ever cannabis use’, ‘ever amphetamine use’, school truancy, bullying victimization, soft drink consumption and lack of parental support were associated with alcohol use and/or misuse. A high prevalence of alcohol use and misuse was found and strategies to prevent alcohol misuse, including a number of risk behaviours, are needed.     

Australian drinkers’ perceptions of alcohol-related risk by consumption status

Background: This study investigated Australian drinkers’ alcohol-related beliefs according to their alcohol risk status. The primary aims were to assess drinkers’ awareness of the association between alcohol consumption and a range of health consequences and their understanding of the degree of risk represented by their own alcohol consumption.

Method: An online survey was administered to 2168 drinkers who consume alcohol at least twice per month. Respondents reported their alcohol intake levels and their beliefs relating to the relationship between alcohol and shorter-term (proximal) risks (e.g., drink-driving) and longer-term (distal) risks (e.g., stroke and cancer).

Results: Just over half (52%) of those drinking at high or very high risk levels did not perceive their drinking to be harmful. A large majority (85%) of the sample was aware of various short-term risks of excessive alcohol consumption, but only half appeared aware of the association between alcohol consumption and more distal health conditions.

Conclusions: The relatively low levels of awareness of the alcohol–disease link and the weak relationship between perceived risk and alcohol consumption levels suggest that attempts to reduce current high levels of alcohol-related harm could include public education campaigns designed to (i) improve drinkers’ understanding of the prevalence of alcohol-related harms upon which current alcohol guidelines are based, (ii) prompt drinkers to review their intake levels in the light of the guidelines to assess their potential risk of harm, and (iii) make alcohol-related risks more salient to every-day consumption decisions.     

Assessing modified risk tobacco and nicotine products: Description of the scientific framework and assessment of a closed modular electronic cigarette

Cigarette smoking causes many human diseases including cardiovascular disease, lung disease and cancer. Novel tobacco products with reduced yields of toxicants compared to cigarettes, such as tobacco-heating products, snus and electronic cigarettes, hold great potential for reducing the harms associated with tobacco use. In the UK several public health agencies have advocated a potential role for novel products in tobacco harm reduction. Public Health England has stated that “The current best estimate is that e-cigarettes are around 95% less harmful than smoking” and the Royal College of Physicians has urged public health to “Promote e-cigarettes widely as substitute for smoking”.Health related claims on novel products such as ‘reduced exposure’ and ‘reduced risk’ should be substantiated using a weight of evidence approach based on a comprehensive scientific assessment. The US FDA, has provided draft guidance outlining a framework to assess novel products as Modified Risk Tobacco Products (MRTP). Based on this, we now propose a framework comprising pre-clinical, clinical, and population studies to assess the risk profile of novel tobacco products.Additionally, the utility of this framework is assessed through the pre-clinical and part of the clinical comparison of a commercial e-cigarette (Vype ePen) with a scientific reference cigarette (3R4F) and the results of these studies suggest that ePen has the potential to be a reduced risk product.     

Evidence-based care for alcohol use disorders is affordable

OBJECTIVE: Despite efficacious treatment, alcohol use disorders contribute significantly to the disability burden. Although wider dissemination of evidence-based health care may impact on the population burden, the affordability of this strategy is unknown. This article compares the cost-effectiveness of current treatment for alcohol use disorders with the cost-effectiveness of optimal treatment, a hypothetical treatment scenario that has been informed by evidence-based practice to determine the affordability of such an approach. METHOD: This study calculated the cost-effectiveness in the Australian population of evidence-based health care for alcohol harmful use and alcohol dependence, as defined by the International Classification of Diseases, Injuries, and Causes of Death, 10th Revision. Outcome was calculated as years lived with disability (YLD) averted. Data from the Australian National Survey of Mental Health and Wellbeing, in conjunction with published meta-analyses and expert reviews, were used to estimate 1-year costs (1997-98 Australian dollars) and YLD averted by current health care services as well as costs and outcomes for an optimal strategy of evidence-based health care. RESULTS: Of those currently seeking treatment, approximately 45% of those with alcohol harmful use and 58% of those with alcohol dependence receive an evidence-based intervention. The cost of this care was estimated at 73 million dollars, resulting in a cost per YLD averted of 96,813 dollars for harmful use of alcohol and 98,095 dollars for alcohol dependence. Under optimal care for harmful use, costs declined and health gains doubled, substantially reducing the cost per YLD averted to 8861 dollars. For dependence, costs doubled, but optimal treatment resulted in increased health gains, reducing the cost per YLD to 57,542 dollars. CONCLUSIONS: Evidence-based care for alcohol use disorders would produce greater population health gain at an increased cost for alcohol dependence but at a reduced cost for harmful use of alcohol. For both disorders, there are substantial increases in cost-effectiveness.     

Heightened hypocrisy: a critical analysis of how the alcohol industry-sponsored ‘‘Nigerian Beer Symposium’’ jeopardises public health

This paper analyses how an alcohol industry-sponsored ‘Nigerian Beer Symposium’ (NBS) could endanger public health. The NBS, an annual one-day symposium, sponsored by Heineken-Nigerian Breweries, was recently introduced to create awareness of the ‘health and nutritional benefits of beer consumption’. Amongst other resource persons, Heineken-Nigerian Breweries contracts professors, medical doctors, nutritionists, advertisers, and celebrities from Africa and Europe to discuss the health and nutritional benefits of beer consumption. While all of the speakers strategically focused on the health and nutritional benefits of beer consumption, a few, in passing, mentioned drinking in moderation. In particular, male speakers focused on how beer prevents cancer, reduces the incidence of kidney stones, enhances vitality and cardiovascular health, and facilitates longevity and cognition among the aged. The female speakers encouraged women to consume beer because it enhances vitality and improves skin/physical beauty. Overall, none of the speakers specifically mentioned the consequences of alcohol (mis)use. This paper argues that the NBS is strategically organised to encourage beer initiation and/or high consumption, which will increase the sponsor’s profit. By providing biased information about the purported health and nutritional benefits of beer, the NBS will mislead the public, leading to more alcohol-related problems in Nigeria. Therefore, NBS should be regulated by implementing WHO-recommended alcohol policies in Nigeria.     

Prevention of deaths from harmful drinking in the United States: the potential effects of tax increases and advertising bans on young drinkers

OBJECTIVE: Harmful alcohol consumption is a leading cause of death in the United States. The majority of people who die from alcohol use begin drinking in their youth. In this study, we estimate the impact of interventions to reduce the prevalence of drinking among youth on subsequent drinking patterns and alcohol-attributable mortality. METHOD: We first estimated the effect of public health interventions to decrease harmful drinking among youth from literature reviews and used life table methods to estimate alcohol-attributable years of life lost by age 80 years among the cohort of approximately 4 million U.S. residents aged 20 in the year 2000. Then, from national survey data on transitions in drinking habits by age, we modeled the impact of interventions on alcohol-attributable mortality. RESULTS: A tax increase and an advertising ban were the most effective interventions identified. In the absence of intervention, there would be 55,259 alcohol-attributable deaths over the lifetime of the cohort. A tax-based 17% increase in the price of alcohol of dollar 1 per six pack of beer could reduce deaths from harmful drinking by 1,490, equivalent to 31,130 discounted years of potential life saved or 3.3% of current alcohol-attributable mortality. A complete ban on alcohol advertising would reduce deaths from harmful drinking by 7,609 and result in a 16.4% decrease in alcohol-related life-years lost. A partial advertising ban would result in a 4% reduction in alcohol-related life-years lost. CONCLUSIONS: Interventions to prevent harmful drinking by youth can result in reductions in adult mortality. Among interventions shown to be successful in reducing youthful drinking prevalence, advertising bans appear to have the greatest potential for premature mortality reduction.     

Alcohol and tobacco use patterns among heterosexually and homosexually experienced California women

BACKGROUND: Mounting evidence suggests that lesbians and bisexual women may be at especially elevated risk for the harmful health effects of alcohol and tobacco use. METHODS: We report findings from the California Women's Health Survey (1998-2000), a large, annual statewide health surveillance survey of California women that in 1998 began to include questions assessing same-gender sexual behavior. RESULTS: Overall, homosexually experienced women are more likely than exclusively heterosexually experienced women to currently smoke and to evidence higher levels of alcohol consumption, both in frequency and quantity. Focusing on age cohorts, the greatest sexual orientation disparity in alcohol use patterns appears clustered among women in the 26-35-year-old group. We also find that recently bisexually active women report higher and riskier alcohol use than women who are exclusively heterosexually active. By contrast, among homosexually experienced women, those who are recently exclusively homosexually active do not show consistent evidence of at-risk patterns of alcohol consumption. DISCUSSION: Findings underscore the importance of considering within-group differences among homosexually experienced women in risk for tobacco and dysfunctional alcohol use.     

Pills and pints: risky drinking and alcohol-related harms among regular ecstasy users in Australia

Introduction and Aims. A significant proportion of young Australians engage in risky alcohol consumption, and an increasing minority are regular ecstasy (3,4‐methylenedioxymethamphetamine) users. Risky alcohol use, alone or in combination with ecstasy, is associated with a range of acute and chronic health risks. The aim of this study was to document the incidence and some health‐related correlates of alcohol use, and concurrent alcohol and ecstasy use, among a large, national sample of regular ecstasy users (REU) in Australia. Design and Methods. National, cross‐sectional surveys of REU in Australia 2003–2008. Among REU in 2008 (n = 678) usual alcohol use, psychological distress and health‐related quality of life were measured using the Alcohol Use Disorders Identification Test, Kessler Psychological Distress Scale and Short Form‐8 Survey respectively. Results. Among REU in 2008, 36% reported high‐risk patterns of usual alcohol consumption, 62% reported usually consuming more than five standard drinks with ecstasy, and 24% reported currently experiencing high or very high levels of psychological distress. Controlling for age and education, high‐risk drinking among REU was associated with higher levels of psychological distress and poorer health‐related functioning; however, the associations between concurrent alcohol and ecstasy use, and health outcomes, were not significant (P > 0.05). Discussion and Conclusions. A large and increasing proportion of REU in Australia engage in high‐risk patterns of alcohol consumption, including in combination with ecstasy. High‐risk alcohol consumption among this group is associated with adverse health‐related outcomes. Prevention and harm reduction interventions for REU should incorporate messages about the risks associated with alcohol use. There is an ongoing need for youth‐specific, coordinated alcohol and other drug and mental health services.[Kinner SA, George J, Johnston J, Dunn M, Degenhardt L. Pills and pints: Risky drinking and alcohol‐related harms among regular ecstasy users in Australia. Drug Alcohol Rev 2012;31:273–280]     

Alcohol and drug prevention in nightlife settings: a review of experimental studies

This study examines the evidence regarding the effectiveness of interventions aimed at the prevention of harmful alcohol and drug use in nightlife settings. A literature search was conducted in 2009. Of 161 studies, 17 experimental studies were included in the review, 15 alcohol-related and two drug-related studies. The results show that preventive substance abuse interventions in nightlife settings can effectively reduce high-risk alcohol consumption, alcohol-related injury, violent crimes, access to alcohol by underage youth, and alcohol service to intoxicated people. A combination of approaches such as enforcement activities seem to be facilitating factors. However, results should be considered cautiously as more gold standard (cost-) effectiveness research is required, in particular directed at drug prevention and educational interventions in nightlife settings.     

Modeling the impact of alcohol dependence on mortality burden and the effect of available treatment interventions in the European Union

Alcohol consumption is a major risk factor for the burden of disease, and Alcohol Dependence (AD) is the most important disorder attributable to this behavior. The objective of this study was to quantify mortality associated with AD and the potential impact of treatment. For the EU countries, for the age group 15–64 years, mortality attributable to alcohol consumption in general, to heavy drinking, and to AD were estimated based on the latest data on exposure and mortality. Potential effects of AD treatment were modeled based on Cochrane and other systematic reviews of the effectiveness of the best known and most effective interventions. In the EU 88.9% of men and 82.1% of women aged 15–64 years were current drinkers; and 15.3% of men and 3.4% of women in this age group were heavy drinkers. AD affected 5.4% of men and 1.5% of women. The net burden caused by alcohol consumption was 1 in 7 deaths in men and 1 in 13 deaths in women. The majority of this burden was due to heavy drinking (77%), and 71% of this burden was due to AD. Increasing treatment coverage for the most effective treatments to 40% of all people with AD was estimated to reduce alcohol-attributable mortality by 13% for men and 9% for women (annually 10,000 male and 1700 female deaths avoided). Increasing treatment rates for AD was identified as an important issue for future public health strategies to reduce alcohol-attributable harm and to complement the current focus of alcohol policy.     

Moderate alcohol use and reduced mortality risk: Systematic error in prospective studies

The majority of prospective studies on alcohol use and mortality risk indicates that abstainers are at increased risk of mortality from both all causes and coronary heart disease (CHD). This meta-analysis of 54 published studies tested the extent to which a systematic misclassification error was committed by including as ‘abstainers’ many people who had reduced or stopped drinking, a phenomenon associated with ageing and ill health. The studies judged to be error free found no significant all-cause or cardiac protection, suggesting that the cardiac protection afforded by alcohol may have been over-estimated. Estimates of mortality from heavier drinking may also be higher than previously estimated.