Harmful use of alcohol - a public health problem
History Beer 10,000 years ago accident from grain? 1100 AD guild formed devoted to brewing 1722 a nourishing drink for potters and laborers created called Potter Wine 8,000 years ago 5,000 years ago the vineyards 2,000 BC -Hammurabi ruler of Babylon sets rules for the sale and purchase of wine 1,500 BC Greek god of wine Dionysus / Bacchus
Historical Perspective T is not the drinking that is to be blamed, but the excess. John Selden (1584 1654)
Current Views Alcohol is the number one drug of choice among our Nation s youth. Yet the seriousness of this issue does not register with the general public or policymakers. Enoch Gordis, M.D. Director, National Institute on Alcohol Abuse and Alcoholism.
Alcohol consumption-overview Worldwide consumption in 2010 was equal to 6.2 liters of pure alcohol consumed per person aged 15 years or older, which translates into 13.5 grams of pure alcohol per day. A quarter of this consumption (24.8%) was unrecorded, i.e., homemade alcohol, illegally produced or sold outside normal government controls. Of total recorded alcohol consumed worldwide, 50.1% was consumed in the form of spirits. Worldwide 61.7% of the population aged 15 years or older (15+) had not drunk alcohol in the past 12 months. In all WHO regions, females are more often lifetime abstainers than males. There is a considerable variation in prevalence of abstention across WHO regions. Worldwide about 16.0% of drinkers aged 15 years or older engage in heavy episodic drinking. In general, the greater the economic wealth of a country, the more alcohol is consumed and the smaller the number of abstainers. High-income countries have the highest alcohol per capita consumption (APC) and the highest prevalence of heavy episodic drinking among drinkers.
Epidemiology Pure alcohol consumption per capita in EU member countries WHO HFA, 2010 KSH, 2011
Unit of alcohol I. Standard unit (ethanol grams) Country 8 UK 9.9 NL 10 AU, FR, HU, IE, NZ,PL, SP 11 SF 12 DK, IT 13.6 CA A standard drink is a notional drink that contains a specified amount of pure alcohol (ethanol). 14 PT, US Drinks at home, bars or restaurants are usually NON-STANDARD drinks, larger than that..
Unit of alcohol II. On deciliter beer (1 dl = 100 ml), if the strength is 3%, contains 3 ml etil-alcohol. Concentraion ot etilalcohol is 0,8 g/cm3, so the total mass is 2,4 g (3 x 0,8=2,4). One glass of beer is 330 ml, 3% of it (3 x 330 / 100= 9,9 ml), equals to (9,9 x 0,8= 7,9 g) alcohol. Drink Quantity % by volume Alcohol content (ml) Alcohol content (g) Beer 0,5 l = 500 ml 4 V/V% 20 16 Wine Spirits Martini Whisky vodka Champagne elsosegely.hu 2 dl = 200 ml 0,5 dl = 50 ml 1 dl = 100 ml 1 dl = 100 ml 1 dl = 100 ml 1 dl = 100 ml 8 V/V% 16 12,87 40 V/V% 20 16 16 V/V% 16 13 50 V/V% 50 40 38 V/V% 38 30,4 11,5 V/V% 11,5 9,2
The Nature of Alcohol Ethyl Alcohol only alcohol that can be consumed Beer: 3-6% alcohol by volume Malt Liquors (not lower than 5%): 6-8% alcohol by volume Table wines: 9-14% alcohol by volume Fortified wines: 20% alcohol by volume Hard liquors: 35-50% (or more) alcohol by volume
Low risk drinking levels 1. 2 standard drinks or less in any 1 day (for healthy men and women, aged 18 and over)with two days break in 7 days 2. No more than 4 standard drinks per occasion(for reduced risk of injury) 3. For people <18 years of age: safest not to drink Under 15: Especially important not to drink Between 15-17: Delay drinking initiation for as long as possible 4. Pregnant (or planning a pregnancy) or breastfeeding: Not drinking is safest option * Different organizations may define different recommendations. Also new scientific evidence may overwrite present recommendations.
Hungarian epidemiology and definition of terms Heavy drinker: Women: more than 7 drinks / week Men: more than 14 drinks / week Binge drinker : more than 5 or 6 drinks on one ocasion Moderate drinker: weekly consumption but not heavy drinker Occasional drinker: less than weekly consumption Alcohol consumption habits EHIS, 2009
Alcohol induced health problems
Acute Effects CNS Depressant Depression of inhibitory control Vasodilation, warm, flushed, reddish skin Emotional outbursts Decreased memory & concentration Poor judgment Decreased reflexes Decreased sexual response
Acute Alcohol induced health problems Low concentrations (0.03%-0.05%): light-headedness, relaxation, release of inhibitions High concentrations (0.1%-0.2%): motor coordination, verbal performance and intellectual functions impaired Acute intoxication (drunk) 2,5 / 1000 BAC (0.25%) Clear evidence of recent use of a psychoactive substance (or substances) at sufficiently high dose levels to be consistent with intoxication. Symptoms or signs of intoxication compatible with the known actions of the particular substance (or substances), and of sufficient severity to produce disturbances in the level ofconsciousness, cognition, perception, affect or behaviour which are of clinical importance. Not accounted for by a medical disorder unrelated to substance use, and not better accounted for by anothermental or behavioural disorder. F1x.00 Uncomplicated F1x.01 With trauma or other bodily injury. F1x.02 With other medical complications. Examples are haematemesis, inhalation of vomit. F1x.03 With delirium. F1x.04 With perceptual distortions. F1x.05 With coma. F1x.06 With convulsions. F1x.07 Pathological intoxication (applies only to alcohol). Blood alcohol content is usually expressed as a percentage of ethanol in the blood in units of mass of alcohol per volume of blood or mass of alcohol per mass of blood, depending on the country. http://www.rupissed.com/ Coma usually occurs at 0.35% and higher concentrations can be fatal
Alcohol Dependence Craving: A strong need, or compulsion, to drink. Loss of control: The inability to limit one s drinking on any given occasion. Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, occur when alcohol use is stopped after a period of heavy drinking. Tolerance: The need to drink greater amounts of alcohol in order to get high.
Alcohol Abuse and Dependence Alcohol abuseis recurrent use that has negative consequences Alcohol dependence oralcoholismincludes more extensive problems like tolerance and withdrawal Warning signs of alcohol abuse Drinking alone Using deliberately and repeatedly Feeling uncomfortable on occasions when not drinking Escalating consumption Getting drunk regularly Drinking in the morning or unusual times 22
Alcohol abuse (chronic overuse) (DSM-IV) A maladaptive pattern of alcohol abuse leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period: Recurrent alcohol use resulting in failure to fulfil major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; or neglect of children or household). Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine). Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct). Continued alcohol use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the alcohol (e.g., arguments with spouse about consequences of intoxication or physical fights).
Alcohol dependence (DSM-IV) A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three or more of the following seven criteria, occurring at any time in the same 12-month period: Tolerance, as defined by either of the following: A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. Markedly diminished effect with continued use of the same amount of alcohol. Withdrawal, as defined by either of the following: The characteristic withdrawal syndrome for alcohol (refer to DSM-IV for further details). Alcohol is taken to relieve or avoid withdrawal symptoms. Alcohol is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or there are unsuccessful efforts to cut down or control alcohol use. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
Risk Factors for Alcoholism GENETIC Specific genes G X E Interaction ENVIRONMENTAL Family, Peers Workplace Comorbidity Early onset
Alcohol Withdrawal Effects Tremor Nausea Irritability Agitation Tachycardia Hypertension Seizers Hallucinations
Possible Health Benefits of Alcohol Moderate doses may reduce the risk of HD Moderate drinking = one drink per day for women and two drinks per day for men Raises blood levels of HDL May lower risk of diabetes, arterial blockages, and Alzheimer s On average, light to moderate drinkers live longer than both abstainers and heavy users 28
The Effects of Chronic Use Digestive system Alters liver function Liver cell damage and destruction (cirrhosis) Cirrhosis causes drinker to lose capacity to tolerate alcohol Acute Pancreatitis Cardiovascular system Higher doses elevates BP, and may weaken heart muscle (cardiac myopathy) Cancer Mouth, throat, larynx, liver, breast, & esophagus Brain Damage Cognitive impairments Memory loss, dementia, and compromised problem-solving Mortality Alcoholics average life expectancy is about 15 years less than non-alcoholics
The Effects of Alcohol Use During Pregnancy Effects are dose-related Fetal Alcohol Syndrome (FAS) Full-blown FAS occurs in up to 15 out of every 10,000 live births in the U.S. Small head, abnormal facial structures, heart defects, and other physical abnormalities Slowed physical and mental growth, with many mentally impaired Alcohol-related neurodevelopment disorder (ARND) Appear physically normal but often have learning and behavioral disorders; more likely to develop substance abuse
Health consequences ingeneral In 2012, about 3.3 million net deaths, or 5.9% of all global deaths, were attributable to alcohol consumption. There are significant sex differences in the proportion of global deaths attributable to alcohol, for example, in 2012 7.6% of deaths among males and 4% of deaths among females were attributable to alcohol. In 2012 139 million net DALYs (disability-adjusted life years), or 5.1% of the global burden of disease and injury, were attributable to alcohol consumption. There is also wide geographical variation in the proportion of alcohol-attributable deaths and DALYs, with the highest alcoholattributable fractions reported in the WHO European Region.
Harm done by alcohol consumption in Europe 10800 deaths per year due to road traffic accidents (1 in 3 of road traffic fatalities) 2000 homicides (4 in 10 of all murders) 10000 suicides (1 in 6 of all suicides) 45000 deaths from liver cirrhosis 50000 cancer deaths, of which 11,000 are female breast cancer 17000 deaths due to neuropsychiatric conditions Some 5 million children are born with birth defects and developmental disorders because of their mother drinking during pregnancy Anderson & Baumberg, 2006
Prevention of alcohol abuse Primary prevention: Decrease availability Health education on the adverse consequences of alcohol abuse Secondary prevention: Early detection of individuals with alcohol-related problems (high levels or dangerous patterns binge drinking - of alcohol consumption) Early initiation of treatment measures Tertiary prevention: Pharmacotherapy (i.e.: carbamazepines, SSRIs) Psychotherapy Socio-therapy, work therapy Alcoholics anonymous (AA) group participation Gradual reintegration into society
Alcohol Use Disorder Identification Test (AUDIT) Source: Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG.. AUDIT. WHO, 2001. Available: http://www.who.int/substance_abuse/.
The patient was assessed - so what next? Source: Babor TF, Higgins-Biddle JC. Brief Intervention for Hazardous and Harmful Drinking. WHO, 2001. Available: http://www.who.int/substance_abuse/publications/alcohol/en/index.html.
Frequently asked questions (FAQ) Source: Babor TF, Higgins-Biddle JC. Brief Intervention for Hazardous and Harmful Drinking. WHO, 2001. Available: http://www.who.int/substance_abuse/publications/alcohol/en/index.html.
Patternsof drinking and harm Binge drinking The consequences of getting drunk: Violence, accidents STD s, sexual mishaps Regular drinking the consequences of repeated heavy exposure Cirrhosis Other physical damage Psychosocial harms But note that these patterns are not mutually exclusive
Patterns of drinking and harm Binge drinking The consequences of getting drunk: Violence, accidents STD s, sexual mishaps Regular drinking The consequences of repeated heavy exposure: Cirrhosis Other physical damage Psychosocial harms
Drinking Behavior and Responsibility Examine your drinking behavior CAGE screening test: Feel the need to CUT down, ANNOYED by criticism, feel GUILTY about drinking, use alcohol as an EYE-OPENER Drink moderately and responsibly Drink slowly Space your drinks Eat before and while drinking Know your limits and your drinks 44
Treatment Programs No one program works for everyone AA 12-step program Employee assistance programs Inpatient hospital rehabilitation Pharmacological treatments Antabuse Inhibits the metabolic breakdown Naltrexone Reduces the craving for alcohol and decreases its pleasant effects 46
Industryand publichealthparadigm Alcohol is normal Problems arise when a minority of people misuse it ( spoil it for the rest of us) Therefore the solution is to change the behaviour of the minority ( target other people ) through education and culture change Alcohol is not an ordinary product The problem is not with the individual but the product Therefore the solution is to make the environment less pro-alcohol and reduce the population consumption The maximum health gain is through shifting the consumption curve left ( everyone s problem )
Policiesand interventions Alcohol policies are developed with the aim of reducing harmful use of alcohol and the alcohol-attributable health and social burden in a population and in society. Such policies can be formulated at the global, regional, multinational, national and subnational level. Delegations from all 193 Member States of WHO reached consensus at the World Health Assembly in 2010 on a WHO Global stratgyto reduce the harmful use of alcohol. Many WHO Member States have demonstrated increased leadership and commitment to reducing harmful use of alcohol over the past years. A significantly higher percentage of the reporting countries indicated having written national alcohol policies and imposing stricter blood alcohol concentration limits in 2012 than in 2008.
Pricing: impactof a 50pminimum unit price Research into the effect of a 50p minimum price per unit shows for every year (England): 3,393 fewer deaths 97,900 fewer hospital admissions 45,800 fewer crimes 296,900 fewer sick days And a total saving of 15 billion over ten years (health, crime, social care.) Source: Chief Medical Officers Report 2008, Meier 2009
Government Warning The Alcoholic Beverage Labeling Act of 1988 requires that the following health warning statement appear on the labels of all containers of alcohol beverages offered for sale or distribution in the United States: According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects. Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery, and may cause health problems. http://www.icap.org/table/alcoholbeveragelabeling
Summary Those who do drink consume on average 17 liters of pure alcohol annually. On average every person in the world aged 15 years or older drinks 6.2 liters of pure alcohol per year. Less than half the population (38.3%) actually drinks alcohol. The harmful use of alcohol results in 3.3 million deaths each year.
Summary Alcohol use is legal and firmly embedded in our society and will remain so. The cardiovascular benefits, if real, are seen at very low consumption levels, affect only the middle aged + and are not a reason for non-drinkers to drink Health and other harms are a major societal issue and are not confined to those who obviously misuse alcohol. We need to better understand the links to low socio-economic status
Summary While the relationship between population consumption and harm are not perfect, the maximum health improvements will be seen through shifting the whole consumption curve downwards Individuals may choose to live with different levels of risk associated with their pattern and volume of consumption, but must be provided with good information on those risks. This is not currently possible Within those who choose to drink at higher levels there will willbe many with a degree of dependence on alcohol who are not exercising free will, and we need to get better at identifying and helping them.