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Changing drinking patterns: a sobering thought

2010; Elsevier BV; Volume: 376; Issue: 9736 Linguagem: Inglês

10.1016/s0140-6736(10)61095-1

1474-547X

Talha Burki,

Alcohol Consumption and Health Effects

As aclohol consumption stabilises in developed countries, manufacturers are increasingly targeting untapped and unregulated markets in developing countries. Talha Burki reports. This year's session of the World Health Assembly (WHA) concluded with a resolution undertaking to “reduce the harmful use of alcohol”. According to WHO estimates, about 2·5 million people worldwide are killed by alcohol every year. Many die from injuries incurred after they or someone else has had too much to drink: car accidents, or instances of violence and suicide, for example. Others die from the dozens of physical disorders alcohol causes; such as cardiovascular disease, cancers of the mouth and oesophagus, and cirrhosis of the liver. Experts agree that global misuse of alcohol is a worsening problem. They cite the creeping rise in the proportion of worldwide deaths caused by alcohol, currently at about 4%. Countries such as Uganda, where 5–10% of the population is estimated to be alcohol-dependent, and the UK, where rates of cirrhosis roughly trebled between 1970 and 1998, also give cause for serious concern. There are three key indicators for gauging the extent of a nation's alcohol problem. The first is yearly consumption, measured in litres of pure alcohol, per person. Alcohol-associated health problems have unsurprisingly been shown to rise and fall with per person consumption: sharp falls in alcohol consumption in France in the second half of the 20th century, for example, led to sharp falls in chronic liver disease. But it does not tell the full story. Worldwide, per person consumption is roughly 6·2 L; however, considering that more than half the world's adult population does not drink, this figure is meaningless. A glance at where each nation stands in per person consumption throws up some surprises. Uganda tops the list with 19·5 L, but in second place is Luxembourg (17·5 L), traditionally thought to be a rather temperate place. Citizens of the UK, a country with a reputation for drinking, consume an average of 10·4 L of pure alcohol per year, putting them behind the French, Spanish, and Swiss. All of which leads to the second indicator: the number of abstainers in each country. Only 2·5% of Luxembourgers forego alcohol, so consumption is scattered across most of the population. 12% of UK citizens are teetotal, concentrating drinking into a smaller section of society. Which is not to say drinking populations imbibe uniformly; on the contrary, in many nations—Germany is one example—10% of drinkers are responsible for 50% of consumption. Needless to say, these are the individuals at risk of chronic illness. Still, this does not explain why the weekend sees UK town centres strewn with the debris of drunken nights out. Heavy episodic—or binge—drinking is behind most of the injuries that comprise a third of the disease and disability burden attributable to alcohol, as well as the social cost. Usually associated with youngsters, binge drinking is an important component of the third, and most difficult to quantify, indicator: drinking patterns. The subject is bound up in issues of cultural identity, gender and generational differences, and economics. “The usual argument is why can't we in the UK drink beautifully like the French and never get drunk?”, explains Griffith Edwards (King's College London, UK). “It's not true—the French do get drunk—but you can't pin a Latin culture on an Anglo-Saxon culture”. Historically, the wine-growing nations of the Mediterranean have tended to drink greater quantities, but as an accompaniment to meals; the countries of northern Europe drank less overall, but were more disposed to hard drinking sessions (Roman historian Tacitus suggested it might be easier to conquer the Germans with beer than with arms). But old habits are changing. Broadly speaking, alcohol consumption is increasing in developing countries, and stabilising or falling in developed countries. Western Europe is seeing a rough homogenisation of drinking habits, with decreasing per person consumption and a shift from wine to beer. The taboo against binge drinking in places such as Italy, France, and Spain seems to be eroding, at least among younger generations. Nordic and eastern European countries continue to have a high prevalence of binge drinking, as does Russia, which combines hefty overall consumption, with destructive drinking patterns. Thomas Babor (University of Connecticut, Farmington, CI, USA) talks of the natural experiments of the past 50 years. “We've learned a lot from observing countries which have attempted alcohol controls, or relaxed laws”. Take the UK, which has not seen the falls in consumption that characterise other parts of Western Europe. “A lot of traditional measures that were effective in limiting alcohol consumption up until the 1970s—pub licensing hours, and restrictions on the number and density of outlets—were abolished or relaxed”, explains Babor. The alcohol industry began intensively directing marketing campaigns towards young adults. Also, and most crucially, alcohol became more affordable. “There's a scary correlation between per capita consumption and the affordability of alcohol”, Sir Ian Gilmore, President of the Royal College of Physicians, told The Lancet. A report by the British Medical Association noted that between 1980–2006, the affordability of alcohol in the UK rose by 65%. The same period saw an increase in per person consumption of 1·5 L. Over the past decade, the UK has overtaken France, Spain, and Italy in rates of chronic liver disease and cirrhosis. All of which serves as a warning to the developing world. Consumption tends to rise with prosperity. Hence the sizeable markets, as yet largely untapped, of Brazil, China, and India are particularly attractive to the alcohol industry. Take Brazil, where beer is scarcely thought of as an alcoholic beverage. Alcohol taxes are low, as are prices; minimum age requirements and advertising restrictions are barely enforced. There are no restrictions on drinking hours and retail sales, nor does the country operate a licensing system for vendors. Meanwhile, the industry is consolidating into a smaller number of multinational corporations. “It means economies of scale can be reinvested in aggressive marketing in developing countries at a time when alcohol control policies are weak or non-existent” explains Babor. “It adds up to a perfect storm for an alcohol epidemic along the lines of what you've seen in the UK”, he concluded. The picture is complicated by illicit and informally produced alcohol; the former implies home production of spirits—which is illegal in most countries—the latter implies home production of wine or beer, which most states permit. WHO estimates 27% of worldwide alcohol consumption is unrecorded. The currently available statistics for alcohol use are not wholly satisfactory as it is, but unrecorded alcohol makes them even trickier to interpret. It is thought to account for half the consumption in Africa—as much as 90% in eastern parts of the continent—two-thirds the consumption in the Indian subcontinent, and a third of the consumption in eastern Europe and Russia. The average Ukrainian, for example, is reckoned to consume 8 L of unrecorded alcohol every year. In 2000, 140 Kenyans were reported to have died after imbibing an illegally produced liquor. A 2007 WHO report stated that contaminants found within illicit alcohol included methanol, car battery acid, and formalin. Informally produced alcohol is safer. It tends to entail small operations, particularly in rural Africa, producing unbranded beers and traditional beverages for the local community. Usually run by women, it is important economically, and it is not in the vendors' interest to kill their customers. Still, there is no monitoring of the safety of these products, and there is a risk of contaminants, including water-borne diseases. WHO does not expect any rapid changes in oversight; after all, “it took a century for France to bring home distillation by farmers under state control”, notes the 2007 report. In sections of UK society, binge drinking is a longstanding tradition. In the corner of William Hogarth's print Gin Lane (1750) lies a tavern, above which are etched the words “drunk for a penny, dead drunk for tuppence”. Heavy drinkers (and youngsters) gravitate towards the cheapest alcohol. Experts agree that raising prices is the best way to change the UK's drinking habits. “All serious epidemiologists think there is a causal relationship between price and consumption”, says Gilmore. He has pressed for a minimum unit price for alcohol, a recommendation that was echoed by the former Chief Medical Officer, the Health Select Committee on Alcohol, and the National Institute for Health and Clinical Excellence. But politicians are afraid of alienating moderate drinkers. And of course, the industry fights any moves that strike at its profits: UK households spend about £40 billion on alcohol every year; alcohol-related harm, incidentally, is estimated to cost the country roughly £20 billion per year. A policy document issued by the UK's new coalition Government promises to ban outlets from selling alcohol below cost price. The document guarantees a review of alcohol taxation and pricing but emphasises the government's desire not to “unfairly penalise responsible drinkers, pubs and important local industries”, a desire which drove its decision to reverse the previous administration's planned 10% tax rise on cider. Meanwhile, the WHA resolution endorsed WHO's Global Strategy on alcohol, and urged member states to implement its recommendations. “It recommends methods which have been shown to work”, says Babor. The Global Strategy emphasises taxation, availability controls, marketing, and drink driving laws. “If member states take these measures seriously they can realise major benefits in terms of healthcare costs, healthier populations and smaller social costs”, said Babor.