Global patterns and problems, and building a concerted response Robin Room School of Population Health, University of Melbourne Turning Point Alcohol &

Global patterns and problems, and building a concerted response

Robin RoomSchool of Population Health, University of MelbourneTurning Point Alcohol & Drug Centre, Fitzroy, Victoria

Centre for Social Research on Alcohol & Drugs, Stockholm University

[email protected]

Presented at Alcohol Policy 15, Washington, DC 5 Dec. 2010

Global patterns and problems (Alcohol: No Ordinary Commodity, 2nd ed. and

beyond)

Alcohol in the Global Burden of Disease – work on the GBD for 2005 (led by Jürgen Rehm

with myself as coleader) With the help of many others: Core group: G. Borges (Mexico), G.

Gmel (Switzerland), K. Graham (Canada), B. Grant (US, NIAAA), C. Parry (South Africa), V. Poznyak (Belarus, WHO) and T. Vos as guidance from steering committee

Exposure: M. Rylett, A. Fleischmann, G. Gmel, T. Kehoe Risk Relations:

Causality: Meeting in Cape Town (CDC, WHO, MRC South Africa) Meta-analyses: D. Baliunas, H. Irving, N. Joharchi, S. Mohapatra, J.

Patra, M. Roerecke, A. Samokhvalov, P. Shuper, B. Taylor Systematic reviews: P. Anderson, C. Cherpitel, T. Greenfield, K.

Lönnroth, M. Neuman

Alcohol consumption

Volume Patterns Quality

Health outcomes

Incidencechronic conditionsincluding AUDs

Incidence acuteconditions

Mortality bycause

Societal Factors

Drinking culture

Alcohol Policy

Drinking environment

Health care system

Population group

Gender

Age

Poverty Marginalization

(individual)

Currently used model for alcohol Comparative Risk Analysis 2005

Rates of abstention, 2006

Prevalence of abstention in World 2005

0.00 - 0.20

0.20 - 0.40

0.40 - 0.60

0.60 - 0.80

0.80 - 1.00

Lighter and greener = more abstainersGlobally, there are more abstainers than drinkers among adultsPer-drinker consumption varies much less than abstainer rates

Total consumption in litres pure alcohol 2005

0 - 3

3 - 6

6 - 9

9 - 12

12 - 15

15 - 21

Total consumption, recorded & unrecorded, 2005

Darker = higherHighest in Russia & Europe, high in Latin America, growing in middle-income countries

1: Least hazardous; Regular drinking, often with meals and without heavy drinking bouts

4: Most hazardous: Infrequent but heavy drinking

Least hazardous in southern Europe, Japan; more hazardous in Russia and much of developing world

More and less hazardous patterns of drinking

Chronic and infectious disease:Infectious disease: TB, pneumonia, HIV/AIDSHIV incidence still under review!Cancer: Mouth & oropharyngeal cancer, esophageal cancer, liver cancer, colorectal cancer, female breast cancerNeuropsychiatric diseases: Alcohol use disorders, unipolar major depression, primary epilepsyDiabetesCardiovascular diseases: Hypertensive diseases, ischemic heart disease, ischemic stroke, hemorrhagic stroke, atrial fibrillationGastrointestinal diseases: Liver cirrhosis, pancreatitisConditions arising during perinatal period: Low birth weight, FAS

Injury:Most unintentional and intentional injury

Alcohol-attributable disease and injury 2005 (green mainly protective)

New developments with respect to causality: inclusion of alcohol-attributable disease categories

Colorectal cancer included (IARC; Baan et al., 2007) Tuberculosis/pneumonia incidence and worsening the

disease course included HIV incidence discussed but not included; enough

evidence for alcohol worsening the disease course Pancreatitis and conduction disorders (cardiac

dysrhythmias) included (new disease categories in GBD) Diverse new GBD injury categories (most injury categories

have been causally linked to alcohol consumption) Revision of determination of risk relationship between

alcohol consumption and primary epilepsy (excluding “alcohol withdrawal seizures” – in collaboration with epilepsy experts in GBD)

Rate of alcohol-attributable infectious disease, 2004

(in DALYs per 100,000 adult population)0 - 50

50 - 150

150 - 300

300 - 700

700 - 1100

Green = low; Dark brown = highProblems particularly in much of the developing world and Russia

Alcohol-attributableInfectious diseases

Alcohol-attributable disease and injury 2005 (green mainly protective)

Chronic and infectious disease:Infectious disease: TB, pneumonia, HIV/AIDSHIV incidence still under review!Cancer: Mouth & oropharyngeal cancer, esophageal cancer, liver cancer, colorectal cancer, female breast cancerNeuropsychiatric diseases: Alcohol use disorders, unipolar major depression, primary epilepsyDiabetesCardiovascular diseases: Hypertensive diseases, ischemic heart disease, ischemic stroke, hemorrhagic stroke, atrial fibrillationGastrointestinal diseases: Liver cirrhosis, pancreatitisConditions arising during perinatal period: Low birth weight, FAS

Injury:Most unintentional and intentional injury

Adding in another dimension: alcohol’s harm to others

Global burden of disease estimates are essentially concerned with harm to the drinker

Alcohol also harms others, both individually and collectively

Cost of alcohol studies (in the cost-of-illness tradition) count in some costs to others – from crime, drunk driving – and to society

Other harms and costs to others not measured In our recent Australian study, adding in costs to

specific others doubled the costs

Why so little and late an emphasis for alcohol? (e.g., compared to tobacco) The effects are not confined to health – brings in

other professions and institutions; effects are often immediate rather than delayed Heavily moralised territory (e.g., violence against women,

child abuse) focus on individual responsibility and away from environmental/population perspectives

The long shadow of the temperance era 2+ generations of reaction against Prohibition Particularly in public health, since PH and temperance

paradigms were so close The challenge: counting harm to others in the

policy rationale while pointing to population-level solutions rather than punitive individualistic policies

Building a concerted response, based on evidence

• Parallel tracks -- local, national, global• Develop the evidence of the extent and nature of

particular alcohol-related problems• Plan and implement policies/interventions to reduce

rates of problems• Evaluate the effects of a policy change

– Planned experiments – usually “quasi-experiments” with controls

– “Natural experiments” (= no research input on the design)

• Build provision (and funding) for evaluation into any policy change

• Adjust policy/intervention in view of the evaluations

Example 1: reducing tobacco deaths (the Australian experience)

– High taxes

– Advertising bans and controls

– Smoking bans: workplaces; restaurants and pubs, etc.

– Graphic warnings, media campaign

– Enforcement of age limits; regulations of sales outlets

– Nicotine replacement products

– Brief interventions by health professionals

– Countering tobacco industry influences

– International Framework Convention on Tobacco Control

28 million cigarettes in 1980; 20 million in 1997

(Yet Australian efforts were critiqued by California program leaders: “a monumental paucity of funds and political will”, MJA 178:313-4, 2003.)

Example 2: driving down traffic casualties in Victoria, Australia• Compulsory seatbelts 1970• Random breath-testing 1976• Cameras for red lights 1983; speed 1986• “Speed kills” campaign; bike helmets

mandatory 1990• Mobile radars 1996• Lowered speed limit in residential areas;

anti-speed measures 2001-2002 Deaths in 1970: 1061; in 2003: 330

Characterizing success

• Clear goals: reducing the harm to a minimum– Consensus that the existing burden is

unacceptable• Professionals as advocates• A long-term perspective– in terms of decades• Cross-sector collaboration

– e.g. for transport safety: Transport Industry Safety Group: coroner, road & transport industry, community and regulatory bodies

• Initiatives in terms of what is possible at the time, cumulating over time

• Sometimes the unthinkable becomes possible– e.g., a smoking ban in pubs

Joining the policy dialogue – roles for professionals and researchers

• The limits of technocracy• Experience-based policy advocacy

– Alcohol and drug counselors– Emergency service & other doctors and nurses– Mental health clinicians– Police and community response staff– Social workers, family counselors, clergy

• at community levels:– Licensing decisions about on- and off-licenses– Community planning to minimize alcohol-related harms

• at regional and national levels:– Supporting preventive legislation– Encouraging enforcement or laws and regulations; supporting funding

for it• at the international level:

– Pushing for exclusion of alcohol from free trade agreements– Supporting a strong leading role for WHO in reducing alcohol problems