Alcohol in Europe and Brief Intervention. Dr Lars Møller Programme Manager World Health Organization Regional Office for Europe

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1 Alcohol in Europe and Brief Intervention Dr Lars Møller Programme Manager World Health Organization Regional Office for Europe

2 Global risk factors ranked by attributable burden of disease 2010 (GBD, Lancet, 2012) 1 High blood pressure 2 Tobacco smoking 3 Alcohol use 4 Household air pollution 5 Diet low in fruits 6 High body-mass index 7 High fasting plasma glucose 8 Childhood underweight 9 Ambient particulate matter pollution 10 Physical inactivity and low physical activity

3 Western Europe risk factors ranked by attributable burden of disease 2010 (GBD, Lancet, 2012) 1 Tobacco smoking 2 High blood pressure 3 High body-mass index 4 Alcohol use 5 Physical inactivity and low physical activity 6 High fasting plasma glucose 7 Diet low in fruits 8 High total cholesterol 9 Diet low in nuts and seeds 10 Diet high in sodium

4 Central Europe risk factors ranked by attributable burden of disease 2010 (GBD, Lancet, 2012) 1 High blood pressure 2 Alcohol use 3 Tobacco smoking 4 High body-mass index 5 Diet low in fruits 6 Physical inactivity and low physical activity 7 High fasting plasma glucose 8 Diet low in nuts and seeds 9 Diet high in sodium 10 High total cholesterol

5 Eastern Europe risk factors ranked by attributable burden of disease 2010 (GBD, Lancet, 2012) 1 Alcohol use 2 High blood pressure 3 Tobacco smoking 4 High body-mass index 5 Diet low in fruits 6 High total cholesterol 7 Physical inactivity and low physical activity 8 Diet low in nuts and seeds 9 Diet high in sodium 10 High fasting plasma glucose

6 Central Asia risk factors ranked by attributable burden of disease 2010 (GBD, Lancet, 2012) 1 High blood pressure 2 Alcohol use 3 Tobacco smoking 4 High body-mass index 5 Diet low in fruits 6 Diet high in sodium 7 High fasting plasma glucose 8 Diet low in nuts and seeds 9 Physical inactivity and low physical activity 10 Ambient particulate matter polution

7 Alcohol ranked by attributable burden of disease 2010 (GBD, Lancet, 2012) Globally 3 Western Europe 4 Central Europe 2 Eastern Europe 1 Central Asia 2

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9 Per capita alcohol consumption

10 Recorded alcohol consumption in the EU (in litres pure alcohol per capita 15+) stable but high (more than twice the world average) Total Beer Wine Spirtis Other

11 But big differences between countries Total consumption 2009 (including unrecorded) Austria 13.0 Latvia - Belgium 11.8 Lithuania 13.2 Bulgaria 11.5 Luxembourg 12.3 Cyprus 9.5 Malta 8.0 Czech Republic 16.6 Netherlands 9.7 Denmark 12.9 Poland 13.6 Estonia 14.0 Portugal 13.2 Finland 12.2 Romania 16.3 France 12.7 Slovakia 14.6 Germany 12.9 Slovenia 15.3 Greece 10.5 Spain 13.1 Hungary 13.5 Sweden 9.1 Ireland 12.9 United Kingdom 12.1 Italy 9.6 EU average: l (world: 6.13)

12 Regional differences in alcohol consumption

13 THE 2011 ESPAD REPORT Substance Use Among Students in 36 European Countries

14 Alcohol use during the past 30 days, boys (2011)

15 Alcohol use during the past 30 days, girls (2011)

16 Being drunk during the past 30 days, boys (2011)

17 Being drunk during the past 30 days, girls (2011)

18 The Pareto principle 1/5 of consumers consume 4/5 of any product In the EU among the 20% highest consumers we estimate that 100% 90% % men and 70% 60% Moderate drinkers alcohol. 50% Hazardous drinkers 40% Harmful drinkers 30% 20% We estimate that 10% 5.4% of 0% men and % population % alcohol consumed Three-quarters of the alcohol sold is drunk by hazardous/harmful drinkers women deaths are attributable to 1.5 % of all women are alcohol dependent

19 High exposure, high burden of mortality and disease For men between ages of 15 and 64, 1 in 7 deaths in 2004 were caused by alcohol (clearly premature deaths given the life expectancy in Europe) For women of the same age category, 1 in 13 deaths in 2004 were caused by alcohol

20 Proportion of deaths for major disease categories attributable to alcohol

21 Social costs of alcohol 1.3% of GDP (EU) EUR billion in ( 20 billion, UK)

22 European Alcohol Action Plans from 1992

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26 European action plan to reduce the harmful use of alcohol (EAAP) action areas Leadership, awareness and commitment, as sustainable intersectoral action requires strong leadership and a solid base of awareness and political will Health services response, as these services are central to tackling health conditions in individuals caused by harmful alcohol use Community action, as governments and other stakeholders can support and empower communities in adopting effective approaches to prevent and reduce harmful alcohol use Policies and countermeasures on drink driving, as it is extremely dangerous to drivers, passengers and other people using the roads Availability of alcohol, as public health policies to regulate commercial or public availability have proved to be very effective in reducing the general level of harmful use and drinking among minors

27 EAAP action areas Marketing of alcoholic beverages, as systems are needed to protect people, particularly children and young people, from advanced advertising and promotion techniques Pricing policies, as most consumers, particularly heavy drinkers and young people, are sensitive to changes in the prices of alcohol products Reducing the negative consequences of drinking and alcohol intoxication, in order to minimize violence, intoxication and harm to intoxicated people Reducing the public health impact of illicit and informally produced alcohol, as its consumption could have additional negative health consequences due to its higher ethanol content and potential contamination with toxic substances Monitoring and surveillance, as relevant data create the basis for the appropriate delivery and success of responses

28 Health service response evidence-based strategies Implementation of early identification and brief advice in primary care social welfare settings accidents an emergency departments Offering brief advice programmes at the workplace educational environments

29 Health service response - strategies Governmental support by Producing clinical guidelines Provide training in primary care and material Reimburse for such interventions Support primary care with specialist services Move away from inpatient treatment to outpatient and community-based treatment Compulsory treatment is not recommended except for recidivist drink-drivers All pregnant women should be informed about alcohol and pregnancy

30 No. of countries offering brief intervention by the health services (EU + candidate countries) Services Brief intervention programmes 21 Training of health professionals in BI 14 Clinical guidelines for BI by professional body 18 Counselling of pregnant women with alcohol problems 21 Prenatal care services to pregnant women with alcohol problems Counselling for children in families with alcohol problems 22 No of countries 15

31 Experience from a Danish study on BI (Beich et al. BMJ 2002; 325: 870-2) Of 7691 eligible patients 6897 (aged 1864 years) were screened by completing the AUDIT questionnaire (the other 794 patients refused to participate) Screening showed that 1087 patients (15.8%) drank excessively Alcohol dependency was suspected in 181 patients (2.6%) Of the patients shown by screening to drink excessively (mean consumption 13 units a week), 906 (607 men) were randomised to a brief intervention group or to a control group 554 patients (61%) responded to follow up 12 months later

32 Experience from a Danish study on BI (Beich et al. BMJ 2002; 325: 870-2) General practitioners who have tried a screening and brief intervention programme in their practice find the extra workload onerous and have problems in establishing rapport with excessive drinkers located by screening The programme disrupts normal patterns of work and cooperation in the general practice setting while failing to detect and deal with some problem drinkers

33 Experience from a Danish study on BI (Beich et al. BMJ 2002; 325: 870-2) Three arguments prevailed: the screening and brief intervention programme was seen as awkward to implement in the normal flow of a consultation. It disturbed the agenda, and patients seemed to be distracted from the subject that made them seek health care in the first place doctors could not work in their usual patient centred way because of the agenda setting imposed by the screening the extra workload was too high, taking resources from other functions of general practice and in general disrupting the pattern of working together in the practice.

34 Discussion Brief intervention show impressive results in lowering alcohol consumption The political will is important how to influence politicians to add focus/funds into BI? Who should develop the guiding material, be responsible for training and pay for the service? How should it be implemented in general practice and other settings to avoid the Danish study? Good examples from countries?