Alcohol Abuse
High-risk alcohol use7 is a serious public health problem.8 It directly harms the health of those who drink excessively and contributes to risky behaviors that cause injury and impairment to themselves and others. Alcohol consumption is linked to long-term health and social consequences through three intermediate mechanisms: intoxication, dependence, and direct biological effects (figure 5.4).
[Figure
5.4]
"Alcohol-related diseases account for about 4 percent of global DALYs each year . . . from a low of 0.5 percent in the Middle East and North Africa . . . to . . . 10.7 percent in Eastern Europe and Central Asia."
Alcohol-related diseases account for about 4 percent of global DALYs each year and range from a low of 0.5 percent in the Middle East and North Africa, where alcohol consumption is low, to between 1.5 and 2.0 percent in South Asia and Sub-Saharan Africa, 4.3 percent in East Asia and the Pacific, 8.8 percent in Latin America and the Caribbean, and 10.7 percent in Eastern Europe and Central Asia. About 75 percent of this disease burden is manifested in chronic illnesses such as alcohol dependence, vascular disease, cirrhosis of the liver, and cancer, with unintentional and intentional injuries (particularly road traffic accidents) accounting for the remaining 25 percent.
". . . a 10 percent increase in the price of alcohol reduces consumption of beer by about 3 percent, wine by 10 percent, and distilled spirits by as much as 15 percent."
High-risk drinking is particularly problematic in Europe and Central Asia, where as many as 1 in 5 men and 1 in 10 women between the ages of 15 and 29 engage in high-risk drinking. Even though high-risk drinking in Europe and Central Asia is only marginally more prevalent than in high-income countries, it accounts for double the disease burden because more of that drinking is in the hazardous, higher volume part of the high-risk range.
Interventions may be designed to prevent high-risk drinking or to mitigate its effects. Some of these interventions operate at the population level, such as legislative measures and taxes, improved law enforcement, and mass media campaigns. Other measures aim specifically at high-risk drinkers to encourage behavior modifications.
As in the case of tobacco, public policy can have a substantial effect on alcohol abuse. Taxing alcohol raises the price and thereby reduces consumption. Estimates indicate that a 10 percent increase in the price of alcohol reduces consumption of beer by about 3 percent, wine by 10 percent, and distilled spirits by as much as 15 percent. Restricting sales to a limited number of licensed retail outlets or restricting the hours when alcohol can be sold can make obtaining alcohol more difficult. Strict drunk driving laws also discourage excessive consumption, prevent traffic accidents, and can reduce traffic fatalities by 7 percent. When enforcement through random breath testing is included, fatalities and nonfatal injuries from accidents may fall an additional 15 percent. Making these kinds of public policy measures effective requires enforcing regulations and laws, whether by means of additional policing to reduce smuggling and tax evasion or by mounting random breath testing of drivers to discourage drunk driving (box 5.2).
[Box 5.2]
When they are effective, bans or restrictions on advertising alcoholic products remove cues that encourage alcohol consumption; however, manufacturers often substitute other methods of marketing, such as sponsoring sporting events. Consequently, restricting advertising may only reduce high-risk drinking by 1 to 3 percent.
Many countries engage in mass media campaigns and school-based education about the risks of drinking. Studies show that such efforts do increase knowledge about and attitudes toward alcohol and its risks to health, but they have not shown sustained reductions in the rate of alcohol consumption or reductions in alcohol-related harm.
"Strict drunk driving laws . . . can reduce traffic fatalities by 7 percent."
Brief interventions to reduce high-risk drinking at the personal level through educational sessions and psychosocial counseling in primary health care settings reduce alcohol consumption among high-risk drinkers by 13 to 34 percent, but poor adherence and low coverage can offset these gains substantially.
In the three regions where high-risk alcohol use is found among more than 5 percent of the population—Europe and Central Asia, Latin America and the Caribbean, and Sub-Saharan Africa—the most effective interventions are taxation and brief interventions, averting more than 500 DALYs per 1 million total population per year. The remaining control strategies, random breath testing, reduced hours of sale at the weekend, and a comprehensive advertising ban, produced effects in the range of 200 to 400 DALYs averted per 1 million population per year. In the two remaining regions with lower rates of high-risk drinking, particularly among the female population, the burden that is avertable via taxation is significantly reduced: 10 to 100 DALYs averted per 1 million population per year. In South Asia, the most effective intervention appears to be enforcement of drinking and driving laws given the combination of the higher prevalence of traffic-related injuries and lower levels of high-risk drinking.
". . . where high-risk alcohol use is found among more than 5 percent of the population . . . . the most effective interventions are taxation and brief interventions . . ."
The cost-effectiveness of interventions also varies substantially between regions. Whereas taxation, limitations on retail sales, and advertising bans are the most cost-effective interventions in the three regions with a higher prevalence of high-risk drinking, these same interventions are among the least cost-effective in the other two developing regions.
In Europe and Central Asia, Latin America and the Caribbean, and Sub-Saharan Africa, raising excise taxes by 25 percent costs between US$100 and US$200 per DALY averted, reducing access to retail outlets costs between US$152 and US$340 per DALY averted, and enforcing advertising bans cost between US$134 and US$380 per DALY averted. Random breath testing of drivers is much more costly, ranging from US$973 per DALY averted in Sub-Saharan Africa to US$1,856 per DALY averted in Europe and Central Asia. By contrast, in South Asia, the cost-effectiveness ranking of these interventions is inverted: enforcing a 25 percent increase in taxes on alcoholic beverages costs US$3,654 per DALY averted, whereas random breath testing of drivers costs US$531 per DALY averted.
In general, countries with a high prevalence of high-risk drinking should begin with taxation because in such contexts it appears to have the largest effect for the fewest resources. In places where high-risk drinking is less of a public health burden, other intervention strategies that restrict the supply or promotion of alcoholic beverages appear to be promising and relatively cost-effective.
"High-risk alcohol use, along with tobacco use . . . demonstrate[s] that . . . public policy measures can be substantially more cost-effective than individualized medical treatment."
High-risk alcohol use, along with tobacco use, accounts for a sizable and growing portion of the disease burden in low- and middle-income countries. They both demonstrate that for some risk factors and conditions public policy measures can be substantially more cost-effective than individualized medical treatment. They also show that good health policies may also be good tax policies. The value of such multisectoral interventions is a common theme in DCP2 chapters dealing with addictions and recurs in discussion of interventions to reduce CVD, diabetes, and road traffic injuries.
