Epidemiology of heavy drinking and heavy episodic drinking in Brazil

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1 Epidemiology of heavy drinking and heavy episodic drinking in Brazil Laura Helena S. G. Andrade Camila Magalhães Silveira Silvia S. Martins Carla L. Storr Yuan-Pang Wang Maria Carmen Viana INTRODUCTION Recent population-based studies completed in Latin America and the Caribbean (LAC) countries, such as Mexico, 1 Chile, 2,3 and Brazil, 4,5 have shown a growing burden of mental illness, including alcohol consumption, in the region 6. Murray and Lopez 7 anticipated in 1996 that by the year 2020, the proportion of disability-adjusted life years (DALY) attributable to neuropsychiatric conditions was expected to be 20.6% in LAC. Alcohol is one of the most pertinent risk factors for the Global Burden of Disease (GBD), particularly in Latin America and the Caribbean region, where 10% of death and disability are attributable to alcohol 8. In the World Health Organization s (WHO)-designed region B of the Americas, in which there are low childhood and adult mortalities, and Brazil is located, alcohol is the leading risk

2 Alcohol and its consequences: dealing with multiple concepts factor for disease burden, accounting for 11.4% DALY for estimates made in the year The number is higher for men (17.3%) than for women (4.1%). 9 Most of the available evidence on patterns of alcohol use is provided from research undertaken in developed countries, and little is known about developing countries, where the majority of the world s population resides 10. Alcohol use is responsible for considerable mortality and morbidity 11, but in the most recent WHO Global Burden of Disease estimates, the authors unanimously asserted that better epidemiological data on alcohol use were needed, particularly in low and middle-income countries The average prevalence for alcohol disorders (abuse/dependence) based on 14 studies, most of them conducted in the United States, was 5.9% 16. The estimated cost for alcohol or other drug use according to an important study funded by the U.S. government 17 was more than 200 billion dollars per year. These estimates are based on direct and indirect costs, with the direct costs being mostly treatment costs. Brazil, a high-middle-income country and the largest in Latin America has a current population of almost 190 million inhabitants 18. Brazil has undergone a number of changes in the last decade, including an increase in urbanization, education and life expectancy, and a reduction in poverty levels, fertility rates and infant mortality rates. 18 As a result, Brazil is undergoing an epidemiological transition, with changing patterns in morbidity and mortality. Epidemiologic research can contribute greatly to the understanding of patterns of alcohol use in developing countries such as Brazil as well as contribute to the future development of preventive strategies that target a decrease in alcohol and related problems. Epidemiologic studies such as the Epidemiologic Catchment Area - São Paulo (SP-ECA study), with data collected between 1994 and 1995, and the São Paulo Megacity study (SP-Megacity study) with data collected between 2005 and 2007 constitute a unique opportunity to examine whether changes in patterns of alcohol use and alcohol abuse/dependence occurred in the past decade in the general population of São Paulo. 100

3 Epidemiology of heavy drinking and heavy episodic drinking in Brazil Alcohol consumption in Brazil and the importance of studying drinking patterns In Brazil, the 2004 annual per capita consumption of alcohol, including unrecorded consumption, was estimated at 8.32 L of pure alcohol per adult, far above the world average of 5.8 L 19. Recently, the average volume of alcohol consumption has been recognized as an incomplete predictor of risky drinking, and more attention has been given to drinking patterns 20. Brazil has a score of 3 in the criteria created for the Comparative Risk Assessment (CRA) module of the GBD, designed to capture changes in population health resulting from exposure to hazardous drinking. The criteria comprises of several indicators of heavy drinking episodes, including drinking in public settings and the frequency of drinking during meals, 21 with the score of 1 designating the least detrimental pattern and 4 the most detrimental. 9 In addition to that, about 50% of psychiatric hospitalizations in male Brazilians are related to alcohol use and abuse/dependence. 22 Some local studies suggested a worrisome scenario. In a survey of 24 cities of the state of São Paulo, the point prevalence of alcohol dependence increased from 6.6% to 9.4% in a 2 year period. 23 In Porto Alegre (Southern Brazil) Moreira et al. found that 9.3% of their sample was alcohol dependent, 15.5% were heavy drinkers, 12.3% drank daily, and 12.3% were abstainers. 24 In two surveys carried out among college students at the University of São Paulo in 1996 and 2001, a significant increase in lifetime and past-year use of alcohol was observed. 25 In 1990 Carlini et al., found alcohol use among students to be at 9.2% and in 1997 it increased to 15%. In Brazil, alcohol-related problems are still reported in the extreme case of alcohol dependency. However, studies have shown that there are larger and just as serious alcohol-related problems across the spectrum of drinking behaviors 27 : heavy drinkers are more likely to be diagnosed with psychiatric disorders than moderate drinkers;

4 Alcohol and its consequences: dealing with multiple concepts psychiatric disorders may be more related to quantity and frequency of consumption than to symptoms caused by consumption as defined in alcohol use disorder criteria; 28,29 increasing attention is being paid to the association between risk drinking and social harm as well as its association with disease; 29 risk drinking, in a long term, may be a precursor of alcohol use disorders and may develop into abuse or dependence; 29 history of heavy drinking (HD) is a risk factor for alcohol related aggression. 30 Drinking patterns among adults in Brazil The most comprehensive epidemiological studies on alcohol use in the general population were those performed by CEBRID the Brazilian Information Center on Psychotropic Drugs.23,26 The prevalence of alcohol was estimated for the first time in the Brazilian general population in This specific household survey study encompassed 107 Brazilian cities with more than 200,000 inhabitants, corresponding to 47,045,907 inhabitants, i.e. 27.7% of the total population. The sample was comprised of 8,589 respondents, and the lifetime use of alcohol in the total population was 68.7%. This proportion remains relatively stable in the different age ranges, as almost 50.0% of adolescents between 12 and 17 years old had already used alcoholic beverages. Prevalence of alcohol dependence was 11.2% to 17.1% for males and 5.7% for females. The prevalence of dependence was higher on the North and Northeast regions of the country (16%). Of greater concern is the fact that, in Brazil, 5.2% of the adolescents were alcohol-dependent. In the North and Northeast these percentages were close to 9%. The lifetime use of alcohol in this study of major cities of the country was 68.7%, which was close to numbers observed for Chile at 70.8% and the United States at 81%. A crucial distinction that has been made in the literature pertaining to heavy episodic drinking (HED) involves one s average quantity (e.g., drinks per occasion) and frequency (e.g., drinks per week). Although there has been much 102

5 Epidemiology of heavy drinking and heavy episodic drinking in Brazil debate, and little consensus regarding a precise definition of this construct, most scientists concur that HED requires the consumption of at least four to five drinks per drinking occasion. 31 Adverse health effects specifically associated with binge drinking include unintentional injuries (e.g., motor vehicle accidents, falls, drowning, hypothermia and burns), suicide, sudden infant death syndrome, alcohol poisoning, hypertension, acute myocardial infarction, gastritis, pancreatitis, sexually transmitted diseases, meningitis and poor control of diabetes. Many consequences of binge drinking have especially high social and economic costs, including interpersonal violence (e.g., homicide, assault, domestic violence, rape and child abuse), fetal alcohol syndrome, unwanted pregnancy, child neglect, and lost of productivity. Reducing HED among adults is one of the leading health indicators in Healthy People Motor vehicle accidents were the most frequent cause of death for binge drinkers. Among men, the other common causes of death were homicide, suicide, alcohol poisoning and drowning. For women, homicide, hemorrhagic stroke, alcohol poisoning and suicide. Almeida-Filho et al. 33 analyzed hazardous alcohol use by gender in a Northeast city of Brazil. They defined hazardous drinking as daily or weekly binge drinking plus episodes of drunkenness or frequent drunkenness (at least once a week). They found that 56% of respondents admitted to drinking. The overall 12-month prevalence of highrisk drinking was 7%, and was six times more prevalent in males than females (about 13% compared to 2.4%). Using data from the SP-ECA study, Silveira et al. 34 have shown that past-year prevalence of heavy drinking was 10.7%, with 15.4% of the men and 7.2% of the women reporting heavy drinking. Regarding the elderly, Castro-Costa et al. described the pattern of alcohol consumption for the first time, among respondents aged 60 years and older using data from the first Brazilian National Alcohol Survey (BNAS). Among the 400 older adult respondents 12% reported heavy drinking behavior while 10.4% and 2.9% were binge drinkers and alcohol dependent respectively. 35 Epidemiological research over the past two decades has shown that even in early adulthood alcohol use disorders (abuse and dependence) according to DSM- IV criteria are more frequent than previously thought. In developed countries, 103

6 Alcohol and its consequences: dealing with multiple concepts prevalence estimates for dependence on alcohol are considerable, in some studies up to 10% and above Thus, it is important to examine the issue of the temporal evolution of substance use regular substance use and substance use disorders (SUD). Despite evidence for substantial gender differences in the prevalence of substance use and disorders between males and females, 41,42 it is not as clear, whether there are gender differences in transition patterns. Gender convergence Hypotheses regarding gender differences in alcohol use stem primarily from the biological and socio-cultural aspects. 43 Biologically, the same amount of alcohol consumed by a man and a woman of the same weight will produce a higher blood alcohol concentration in the woman. There are several reasons for this, including women s lower body water content, differences in alcohol dehydrogenase, metabolism and hormone levels. 44 Interacting with these biological factors are socio-cultural influences in drinking behavior that have recently received considerable attention in the literature. Areas of interest, other than cross-cultural genders differences in alcohol use patterns, include abstinence, intoxication and related sexual behaviors. 43 According to Wilsnack and Wilsnack, 45 gender differences in alcohol consumption are based on the ways each culture considers male and female roles. Consequently, gender differences in drinking vary according to cultural differences in social roles. In recent decades there has been increased concern about drinking behavior as an aspect of gender roles, because in some societies gender differences in drinking behavior have grown smaller. A common hypothesis about such convergence in drinking patterns is that increased opportunities for women to perform traditionally male roles (particularly in the workforce) have also enabled and encouraged women to increase their drinking, though with more adverse consequences. 46 Consistent with this hypothesis, where convergence has occurred, it has usually been most evident among adolescents or young adults

7 Epidemiology of heavy drinking and heavy episodic drinking in Brazil Males consistently report more alcohol use as young adults, and college students in particular, 31,48 although there is some evidence of gender convergence in drinking behaviors. For example, among younger college students, there is evidence of similarities in coping as a motivation for drinking among men and women. 49,50 However, male college students have also been found to report a significantly greater motivation to drink for social reasons and are more likely to drink to get high compared to female college students. 51 Problematic alcohol use has been consistently related to coping and negative emotion regulation in both general and college populations; 52,53 thus, it is important to understand the relevance of gender with respect to these dimensions. Alcohol-related disorders among women have become progressively more prevalent since the World War II, 54 with estimates that vary from 4% to 8%. 55,56 Data indicate that the initiation of alcohol use among women is occurring at progressively younger ages, therefore increasing the risk of developing alcohol dependence. Concern is greater because women are posited to be more vulnerable than men to the medical consequences of alcohol use. 57 Few studies about Brazilian female substance users have been reported. 58 In Latin America, Andrade et al. 5 reported variable male-to-female ratios (MFR) of the prevalence of alcohol abuse/dependence from 5 to 10:1. In Campinas, Brazil, a household survey study of 515 subjects has shown an alcohol dependence of 6.6% (MFR=4.4:1). This MFR varies according to age, being smaller in the youngest cohort (2.1:1 to 6.8:1). Also, a recent study using data from two different community samples from a southeast Brazilian town found gender differences in drinking patterns related to sociocultural characteristics. 59 One community (Botucatu) had an older, predominantly Catholic, educated, Caucasian population, with more women in the labor force. The other community (Rubião Junior) had a socioeconomic-educational level far below Botucatu. Data from Botucatu showed that women and men had similar patterns of drinking which is further evidence that as women s roles become more similar to men s, their drinking patterns also become similar. Rubião Junior had much 105

8 Alcohol and its consequences: dealing with multiple concepts higher use of alcohol among men, and almost 22% of those under 49 years old were binge drinkers. Access, smoking, income and having a partner who is a heavy drinker are important risk factors for women s drinking. Further studies to understand gender differences in alcohol use may prevent costly biases in how societies attempt to control or reduce alcohol related problems. Demographic factors associated with alcohol use in Brazil While in developed countries studies have shown that a high socio-economic status (SES) is associated with alcohol use and frequent alcohol use, low SES is associated with heavy drinking and alcohol dependence. 60,61,62 In Brazil, a study has found that high SES is associated with higher alcohol consumption, HED, and alcohol dependence among men. 63 Similar findings were also obtained when analyzing data from men and women in Southeastern Brazil as part of the Gender, Culture and Alcohol problems (GENACS) 60 a multinational study and for HED and alcohol dependents among older adults in a national study. 35 However, studies conducted in Brazil s southernmost state have shown that heavy drinking is associated with low SES and low education levels. 24 In an epidemiologic study of 568 high school students between 14 and 20 years old in São Carlos (a city in the state of São Paulo) adolescents with higher SES had higher lifetime prevalence of alcohol when compared to their low SES counterparts. 64 In the United States, low educational levels were highlighted as a factor related to higher alcohol consumption in men; however, this was found to have an opposite effect in women. 65 In Brazil, data shows that men consumed more alcohol than women, 77.3% and 60.6% respectively, during their lives. 26 Among those older than 25 years old, men consumed about 5 times more alcohol than women. Men also had dependency rates 3 times higher than that of women. The highest number of dependents was found among those with aged between 18 to 24 years old, and the least among those aged 12 to 17 years old. Men had 106

9 Epidemiology of heavy drinking and heavy episodic drinking in Brazil a higher prevalence for exposure to situations of physical risk under the influence of alcohol or afterwards, from drink-related personal problems, and from loss of controlling alcohol (more frequent use or larger quantities than intended). 26 In Brazil, the alcohol consumption rate between men and women varies from 3:1 to 11:1. 33 Despite variations in research design and case identification procedures, most studies that included social variables confirmed alcoholism as negatively associated with SES, education, occupation, and income. There is also empirical evidence suggesting that in Brazil alcoholism starts at an earlier age among males and individuals from lower SES as compared to higher SES, and that the known pattern of a middle-age prevalence decline occurs earlier. There are two recent studies on HED in Brazil. Laranjeira et al. 66 conducted a national survey that found that 28% of the Brazilians, 40% males and 18% females, mainly young (18 to 24 years old), reported heavy drinking in the past year and 50% reported it at least once over a 12 month period. Silveira et al. 34 using data from the SP-ECA study found that the past-year prevalence of HED was 10.7% for men and 7.2% for women. Higher percentages of HED were found among single women aged 18 to 44 years old and men aged 18 to 24 years old when compared to other age groups. It should be noted that this public health problem has been recognized as the main burden of disease in Brazil. 67 Almeida-Filho et al. 33 have also shown that heavy drinking was 6 times higher among men than women. The socio-psychological explanations have been compared to justify this prevalence. Men can be exposed to more drinking opportunities, both from drinking more and from family or social influences, such as stress at work, which are different for each gender. Curiously, despite the fact that Brazil is a racially diverse country, there is very little data on the association of alcohol use/abuse/dependence with race/ ethnicity in Brazil. Almeida-Filho et al. 33 investigated the association between race/ ethnicity and alcohol use and abuse in Bahia, Brazil, a research setting characterized by racial/ethnic diversity. No relationship was found between ethnicity and alcohol 107

10 Alcohol and its consequences: dealing with multiple concepts use or abuse. Kerr-Corrêa at al. 44 conducted a study in an urban center, using a representative sample of 740 subjects. At the low drinking levels, women and men had very similar drinking patterns. Women demonstrated changes in their socio-cultural roles in that they were frequently working outside the home, had good incomes, and more access to alcohol. As their roles became more similar to men s, so did their drinking patterns. Caucasians who are highly educated and with higher incomes, were less likely to be abstainers. As expected for a Latin American country, religious affiliation (Catholics and Evangelical/Protestants) seemed an important reason for abstinence in this region. For women, the only risk factor for heavy drinking was drinking alone. For men, smoking and being between the ages of 35 and 49 were associated with HED. Data on the association between SES and alcohol use and abuse/dependence is still controversial in Brazil; epidemiologic studies on gender and education level differences in alcohol use and abuse/dependence in Brazil are virtually nonexistent. Alcohol associations with medical problems There are few studies that document alcohol-related medical problems in Brazil. Mott et al. 68 found that 93.6% of chronic pancreatitis patients in São Paulo city exhibited heavy alcohol use. Alcoholism was the main cause of chronic pancreatitis 69 and cirrhosis of the liver. 70 Lolio 71 found a significant association between high arterial hypertension and heavy alcohol use in the urban population of Araraquara (a city in the state of São Paulo). In another study, Nappo 72 reported that alcohol was the most common substance used in drug-related non-natural deaths in São Paulo city. In a household survey in the state of São Paulo, Noto et al. 73 evaluated the cases of household interpersonal violence and the consumption of alcohol and other drugs. They found that when violence was reported, 52% of perpetrators were intoxicated by alcohol. 108

11 Epidemiology of heavy drinking and heavy episodic drinking in Brazil Alcohol associations with psychiatric comorbidity The event of an additional illness may change the symptomatology and interfer in the diagnosis, treatment and prognosis of either. Regarding mental disorders, alcohol use often coexists with other psychiatric illnesses. In general, the use of even small doses of alcohol may have more serious consequences than those seen in patients without comorbidity. 74,75 The incidence of these disorders seems to be increasing in the last few decades. These findings may be related to the priority given to community-based mental health care, alcohol availability and the closing of psychiatric hospitals to give way to outpatient treatment, and the increase in the availability of alcohol community-based mental health services. 76 It is believed that about 50% of patients with severe mental disorders will develop alcohol use related problems at some period in their lives. 77 Studies show that patients with comorbidity, especially those with severe psychiatric disorders have higher rates of aggressiveness, suicide, relapse, imprisonment, costs of treatment, repeat hospitalization, homelessness, and use of medical services. These patients show low social evolution and cause negative impacts on family income and healthy. 78 Many psychiatric disorders are related to alcohol abuse/dependence. 38,79 In general, psychiatric comorbidities are more prevalent in women than men Also, psychiatric disorders precede alcohol use more frequently in women than in men In general, internalizing disorders (depression and anxiety) are associated to alcohol use in women 79,81 and externalizing disorders (e.g. anti-social personality disorder and dependency on other drugs) are most common in men. Using data from seven international sites (including data from the SP-ECA study) Kessler et al. 88 have shown that conduct disorders, antisocial personality disorders, and mood and anxiety disorders are associated with alcohol use problems and alcohol dependence. In Brazil, Almeida-Filho et al. 89 examined the co-occurrence of anxiety and depressive symptoms with alcohol abuse in a sample of 2,302 adults in Bahia. Comorbidity between alcohol abuse and depressive and or anxious symptoms was low (around 1% of the sample), which might be due to the fact that the study 109

12 Alcohol and its consequences: dealing with multiple concepts did not use either DSM-IV or ICD-10 diagnostic criteria measures. Menezes and Ratto 90 investigated the prevalence of substance use among 192 respondents treated for severe mental illness (non-affective psychosis, bipolar disorder or major depression with psychotic symptoms) in São Paulo; 7.3% fulfilled criteria for alcohol abuse or dependence. Public policy for alcohol use in Brazil Policies seeking to reduce alcohol consumption have been implemented by different countries at different times in history, always aiming to minimize alcohols adverse effects on health, safety and social well-being of the population. Only recently, however, such strategies and interventions have been approached by scientific scrutiny. Public policies for alcohol use should, idealistically, be guided by scientific evidence, prove to be cost-effective, show consistency in actions with clear objectives, obtain community approval and support, and address the population s most relevant problems, allowing the development of strategies that can benefit the whole population. In Brazil, alcohol related problems are greater than drug related problems. 26 There are substantial regional differences in economic status, access to healthcare, education, and cultural backgrounds within the country. The First Consensus on Alcohol Public Policies elaborated in a joint effort by researchers and politicians was completed in 2007, taking into account local and international scientific evidence of effectiveness in reducing social costs, morbidity and mortality. 66 Although the required minimum age for purchasing alcohol is 18 years old, the access to alcohol is relatively easy, as shown in a study conducted in the city of Sao Paulo. 91 There are no laws that control operating hours of bars, licensing to sell alcoholic beverages or manage the density of bars per geographical region. 84 The state of São Paulo limited the supply of alcohol in the driving environment by banning sales in commercial facilities on or near state highways, 92 and despite almost no enforcement, there was a significant reduction in car accidents causing injuries. 110

13 Epidemiology of heavy drinking and heavy episodic drinking in Brazil On June 19, 2008, Brazil approved a zero tolerance law for drivers with any measurable concentration of alcohol in their blood. Law cancels the previous law, which only determined penalties for people with greater than 0.6 grams of alcohol per liter of blood (blood alcohol concentration BAC). Valid all over Brazil, the law also forbids the sale of alcoholic beverages along rural stretches of federal roads. Traffic accidents caused by drunk drivers are a relevant problem in Brazil. A study conducted by Duailibi et al. 93 in a city of southeastern Brazil revealed that 23.7% of the drivers had some level of alcohol air and in 19.4% of cases, the alcohol level was equal to or higher than the previous legal limit of 0.6 grams of alcohol per liter of blood. Another study in Salvador (northeastern Brazil) showed that 37% of drivers involved in traffic accidents were under the influence of alcohol 94. Law , commonly referred to as Lei Seca (Dry Law), determines that drivers caught with a blood alcohol concentration of 0.2 grams of alcohol per liter of blood (or.02% BAC level) must pay a fine and have their right to drive suspended for a year. Drivers caught with over 0.6 grams of alcohol per liter of blood (0.06% BAC level) will be arrested and may serve terms of 6 months to 3 years. All of these factors are reflected in the patterns of alcohol consumption. Specific public policies to face the problem and more national studies are needed. Looking to the future The monitoring of heavy episodic drinking and alcohol abuse/dependence through epidemiologic data is extremely important not only for the development of prevention strategies but also for the development of public policies that aim to decrease alcohol abuse and addiction. As the SP-Megacity Study also covered the same area where SP-ECA was carried out 10 years before, the data available from both studies represent an exclusive opportunity to track temporal changes of alcohol use in this specific area. Furthermore, the impact and the burden of alcohol use on the household population in this area can constitute the ground to enable planning actions for policy makers, by proposing testable interventions, or formulating local programs. 111

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