Transcript Robin Room will address the international level

Global patterns and problems, and
building a concerted response
Robin Room
School of Population Health, University of Melbourne
Turning 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
Currently used model for alcohol
Comparative Risk Analysis 2005
Population
group
Societal Factors
Drinking culture
Alcohol Policy
Drinking
environment
(individual)
Gender
Alcohol consumption
Volume
Patterns
Incidence
chronic
conditions
including AUDs
Health care
system
Quality
Incidence
acute
conditions
Health outcomes
Mortality by
cause
Age
Poverty
Marginalization
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 abstainers
Globally, there are more abstainers than drinkers among adults
Per-drinker consumption varies much less than abstainer rates
Total consumption, recorded &
unrecorded, 2005
Total consumption in litres
pure alcohol 2005
0-3
3-6
6-9
9 - 12
12 - 15
15 - 21
Darker = higher
Highest in Russia & Europe, high in Latin
America, growing in middle-income countries
More and less hazardous patterns of
drinking
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
Alcohol-attributable disease and injury
2005 (green mainly protective)
Chronic and infectious disease:
Infectious disease: TB, pneumonia, HIV/AIDS
HIV incidence still under review!
Cancer: Mouth & oropharyngeal cancer, esophageal cancer, liver cancer,
colorectal cancer, female breast cancer
Neuropsychiatric diseases: Alcohol use disorders, unipolar major
depression, primary epilepsy
Diabetes
Cardiovascular diseases: Hypertensive diseases, ischemic heart disease,
ischemic stroke, hemorrhagic stroke, atrial fibrillation
Gastrointestinal diseases: Liver cirrhosis, pancreatitis
Conditions arising during perinatal period: Low birth weight, FAS
Injury:
Most unintentional and intentional injury
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)
Alcohol-attributable
Infectious diseases
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 = high
Problems particularly
in much of the
developing world and
Russia
Alcohol-attributable disease and injury
2005 (green mainly protective)
Chronic and infectious disease:
Infectious disease: TB, pneumonia, HIV/AIDS
HIV incidence still under review!
Cancer: Mouth & oropharyngeal cancer, esophageal cancer, liver cancer,
colorectal cancer, female breast cancer
Neuropsychiatric diseases: Alcohol use disorders, unipolar major
depression, primary epilepsy
Diabetes
Cardiovascular diseases: Hypertensive diseases, ischemic heart disease,
ischemic stroke, hemorrhagic stroke, atrial fibrillation
Gastrointestinal diseases: Liver cirrhosis, pancreatitis
Conditions 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


The long shadow of the temperance era



Heavily moralised territory (e.g., violence against women, child abuse)
 focus on individual responsibility and away from
environmental/population perspectives
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
–
•
•
•
Professionals as advocates
A long-term perspective– in terms of decades
Cross-sector collaboration
–
•
•
Consensus that the existing burden is unacceptable
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
–
–
–
–
–
•
at community levels:
–
–
•
Licensing decisions about on- and off-licenses
Community planning to minimize alcohol-related harms
at regional and national levels:
–
–
•
Alcohol and drug counselors
Emergency service & other doctors and nurses
Mental health clinicians
Police and community response staff
Social workers, family counselors, clergy
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