a G a L O B A L S l l T A T U c c S R E P O R T o O o N A L C O H O h L h A N D H E A o L o T H l l 2 0 1 4 Global status report EXIT THE MAZE OF HARMFUL SUBSTANCE USE on alcohol and health FOR BETTER GLOBAL HEALTH 2014 Contact ISBN 978 92 4 156475 5 Management of Substance Abuse Department of Mental Health and Substance Abuse 20, Avenue Appia 1211 Geneva 27 Switzerland Tel: + 41 22 791 21 11 Email: [email protected] www.who.int/substance_abuse Global status report on alcohol and health 2014 WHO Library Cataloguing-in-Publication Data Global status report on alcohol and health – 2014 ed. 1.Alcoholism - epidemiology. 2.Alcohol drinking - adverse effects. 3.Social control, Formal - methods. 4.Cost of illness. 5.Public policy. I.World Health Organization. ISBN 978 92 4 156475 5 (Print) (NLM classification: WM 274) ISBN 978 92 4 069276 3 (PDF) © World Health Organization 2014 All rights reserved. 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Printed in Luxembourg. contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 1 Alcohol and public health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Alcohol consumption in its historical context . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2 Pathways of alcohol-related harm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.1 Volume of alcohol consumed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.2 Pattern of drinking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.3 Quality of alcohol consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.3 Mechanisms of harm in an individual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4 Abstention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.5 Factors affecting alcohol consumption and alcohol-related harm . . . . . . . . 7 1.5.1 Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.5.2 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5.3 Familial risk factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5.4 Socioeconomic status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5.5 Economic development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.5.6 Culture and context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.5.7 Alcohol control and regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6 Alcohol-related harms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6.1 Health consequences for drinkers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6.2 Socioeconomic consequences for drinkers. . . . . . . . . . . . . . . . . . . . . 13 1.6.3 Harms to other individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.6.4 Harm to society at large. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.7 Action to reduce harmful use of alcoho.l . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.7.1 Evidence of effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.7.2 Global action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.7.3 Regional action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.7.4 National policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.8 Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 2 Alcohol consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.1 Levels of consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.1.1 Total per capita consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 2.1.2 Unrecorded alcohol consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2.1.3 Most consumed alcoholic beverages. . . . . . . . . . . . . . . . . . . . . . . . . . 31 2.2 Patterns of drinking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2.2.1 Abstention rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2.2.2 Heavy episodic drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 2.2.3 Patterns of drinking score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 2.2.4 Factors impacting on alcohol consumption . . . . . . . . . . . . . . . . . . . . . 36 v Global status report on alcohol and health 2014 2.3 Trends and projections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 2.3.1 Five-year change in alcohol consumption . . . . . . . . . . . . . . . . . . . . . . 41 2.3.2 Projections up to 2025. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 3 Health consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 3.1 Aggregate health effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.1.1 Alcohol-attributable mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 3.1.2 Alcohol-attributable burden of disease and injury . . . . . . . . . . . . . . . . 50 3.1.3 Factors impacting on health consequences. . . . . . . . . . . . . . . . . . . . . 52 3.2 Trends and projections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 4 Alcohol policy and interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.1 Leadership, awareness and commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.1.1 Written national alcohol policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.1.2 Nationwide awareness-raising activities . . . . . . . . . . . . . . . . . . . . . . . 63 4.2 Health services’ response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 4.3 Community action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 4.4 Drink–driving countermeasures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 4.4.1 BAC limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 4.4.2 Methods used to ascertain driver BACs . . . . . . . . . . . . . . . . . . . . . . . 69 4.5 Regulating availability of alcoho.l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 4.5.1 National control of production and sale of alcohol. . . . . . . . . . . . . . . . 71 4.5.2 Restrictions on on-/off-premise sales of alcoholic beverages. . . . . . . 72 4.5.3 National minimum purchase or consumption age. . . . . . . . . . . . . . . . 74 4.5.4 Restrictions on drinking in public. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.5.5 Restrictions on purchase of alcohol at petrol stations. . . . . . . . . . . . . 75 4.6 Marketing restrictions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 4.6.1 Regulations on alcohol advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 4.6.2 Regulation on alcohol product placement . . . . . . . . . . . . . . . . . . . . . . 78 4.6.3 Regulation on alcohol sales promotions. . . . . . . . . . . . . . . . . . . . . . . . 80 4.6.4 Methods of detecting marketing infringements . . . . . . . . . . . . . . . . . 80 4.7 Pricing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 4.7.1 Excise tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 4.8 Reducing negative consequences of drinking. . . . . . . . . . . . . . . . . . . . . . . 81 4.8.1 Responsible beverage services training. . . . . . . . . . . . . . . . . . . . . . . . 81 4.8.2 Labels on alcohol containers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 4.9 Addressing illicit and informal production. . . . . . . . . . . . . . . . . . . . . . . . . . 82 4.9.1 Inclusion of informal or illicit production in national alcohol policies. . 83 4.9.2 Methods used to track illicit or informal alcohol . . . . . . . . . . . . . . . . . 84 4.10 Monitoring and surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 4.10.1 National surveys on alcohol consumption. . . . . . . . . . . . . . . . . . . . . . 84 4.10.2 Legal definition of an alcoholic beverage. . . . . . . . . . . . . . . . . . . . . . . 84 4.10.3 National monitoring systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 4.11 Trends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Country profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Appendix I – Alcohol consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Appendix II – Health consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Appendix III – Indicators related to alcohol policy and interventions. . . . . . . 321 Appendix IV – Data sources and methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 vi Foreword I am pleased to present the World Health Organization’s Global status report on alcohol and health 2014. WHO has published several reports in the past on this topic with the last one being published in 2011, but this report of 2014 has some unique features. First, it describes some progress made in alcohol policy development in WHO Member States after endorsement of the Global strategy to reduce the harmful use of alcohol in 2010. Second, this report provides a wealth of information on alcohol-related indicators for the comprehensive global monitoring framework for the prevention and control of non-communicable diseases (NCDs) adopted by the 66th World Health Assembly. The global monitoring framework was developed to fulfil the mandate given by the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (NCDs) and includes the voluntary target of a 10% relative reduction in harmful use of alcohol by 2025 measured against a 2010 baseline. Thirdly, this report presents an overview of some of the mechanisms and pathways which underlie the impact of the harmful use of alcohol on public health. The report highlights some progress achieved in WHO Member States in the development and implementation of alcohol policies according to the ten areas of action at the national level recommended by the Global strategy. This progress is uneven and there is no room for complacency given the enormous public health burden attributable to alcohol consumption. Globally, harmful use of alcohol causes approximately 3.3 million deaths every year (or 5.9% of all deaths), and 5.1% of the global burden of disease is attributable to alcohol consumption. We now have an extended knowledge of the causal relationship between alcohol consumption and more than 200 health conditions, including the new data on causal relationships between the harmful use of alcohol and the incidence and clinical outcomes of infectious diseases such as tuberculosis, HIV/AIDS and pneumonia. Considering that beyond health consequences, the harmful use of alcohol inflicts significant social and economic losses on individuals and society at large, the harmful use of alcohol continues to be a factor that has to be addressed to ensure sustained social and economic development throughout the world. In the light of a growing population worldwide and the predicted increase in alcohol consumption in the world, the alcohol- attributable disease burden as well as the social and economic burden may increase further unless effective prevention policies and measures based on the best available evidence are implemented worldwide. And, importantly, we know that in countries with lower economic wealth the morbidity and mortality risks are higher per litre of pure alcohol consumed than in the higher income countries. Following the endorsement of the Global strategy to reduce the harmful use of alcohol WHO has strengthened its actions and activities to prevent and reduce alcohol-related harm at all levels. Several regions have developed and adopted regional strategies focusing on the target areas recommended in the global strategy. At the global level the WHO Secretariat has facilitated establishment of a global network of WHO national counterparts as well as a coordinating council to ensure effective collaboration with and between Member States. At the same time all the efforts and resources available at all levels are clearly not adequate to confront the enormous public health burden caused by the harmful use of alcohol, and further progress is needed at all levels and by all relevant actors to vii Global status report on alcohol and health 2014 achieve the objectives of the Global alcohol strategy and the voluntary global target of at least a 10% relative reduction in the harmful use of alcohol by 2025. WHO is prepared and committed to continue to monitor, report and disseminate the best available knowledge on alcohol consumption, alcohol-related harm and policy responses at all levels, which is key to monitoring progress in implementing the Global strategy and regional action plans. Accurate and up-to-date information is vital for alcohol policy development, and I hope that you will find this report, which is largely based on the information submitted from Member States, useful in contributing to the public health objectives articulated in the Global strategy to reduce the harmful use of alcohol. Oleg Chestnov Assistant Director-General Noncommunicable Diseases and Mental Health viii acknowledGements t he report was produced by the Management of Substance Abuse Unit (MSB) in the Department of Mental Health and Substance Abuse (MSD) of the World Health Organization (WHO), Geneva, Switzerland. The report was developed within the framework of WHO activities on global monitoring of alcohol consumption, alcohol-related harm and policy responses, and is linked to WHO’s work on the Global Information System on Alcohol and Health (GISAH). Executive editors: Vladimir Poznyak and Dag Rekve. Within the WHO Secretariat, Oleg Chestnov, Assistant Director-General, Noncommunicable Diseases and Mental Health, and Shekhar Saxena, Director, Department of Mental Health and Substance Abuse, provided vision, guidance, support and valuable contributions to this project. The WHO staff involved in development and production of this report are: Alexandra Fleischmann, Vladimir Poznyak, Dag Rekve and Maria Renström of the WHO MSD/MSB unit at WHO Headquarters in Geneva. The report benefited from technical inputs from Nicolas Clark of WHO MSD/MSB. Linda Laatikainen provided a significant contribution to the production of the report during its final stages in her capacity as a consultant. Gretchen Stevens and Colin Mathers from the Department of Health Statistics and Information Systems, contributed to the estimates of alcohol-attributable disease burden and provided technical input at all stages of the report’s development. Margie Peden from the Department of Violence and Injury Prevention provided technical input to the report at different stages of its development. Leanne Riley, Regina Guthold and Melanie Cowan from the Department of Prevention of Noncommunicable Diseases provided data from the WHO-supported surveys and technical input to the report. Florence Rusciano from the Department of Health Statistics and Information Systems created the maps used in the report. Preparation of this report is a collaborative effort of the WHO Department of Mental Health and Substance Abuse, Management of Substance Abuse, with the Centre for Addiction and Mental Health (CAMH), Toronto, Canada. The contributions from Jürgen Rehm, Kevin Shield, Margaret Rylett (CAMH, Canada) as well as from Gerhard Gmel and Florian Labhart (Addiction Info, Switzerland) and David Jernigan and Marissa Esser (Johns Hopkins Bloomberg School of Public Health, USA) have been critical for development of this report. The collection of data in the framework of the WHO Global Survey on Alcohol and Health and the development of this report were undertaken in collaboration with the six WHO regional offices and WHO country offices. Key contributors to the report in the WHO regional offices are: WHO African Region: Carina Ferreira-Borges, Davison Munodawafa and Hudson Kubwalo WHO Region of the Americas: Maristela Monteiro, Jorge J. Rodriguez and Blake Andrea Smith ix Global status report on alcohol and health 2014 WHO Eastern Mediterranean Region: Khalid Saeed WHO European Region: Lars Møller and Nina Blinkenberg WHO South-East Asia Region: Vijay Chandra and Nazneen Anwar WHO Western Pacific Region: Xiangdong Wang and Maribel Villanueva. For their contributions to individual chapters and annexes we acknowledge the following: Executive summary: Linda Laatikainen and Maria Renström. Chapter 1: Linda Laatikainen, Alexandra Fleischmann, Gerhard Gmel, David Jernigan, Vladimir Poznyak, Jürgen Rehm, Dag Rekve, Maria Renström, Margaret Rylett. Chapter 2: Gerhard Gmel, Florian Labhart, Jürgen Rehm, Margaret Rylett, Kevin Shield. Chapter 3: Jürgen Rehm, Kevin Shield, Gretchen Stevens. Chapter 4: David Jernigan and Marissa Esser with contributions from Baigalmaa Dangaa (Mongolia), Melvyn Freeman (South Africa), Ivan Konorazov (Belarus), John Mayeya (Zambia) and Margaret Rylett. Country Profiles: Alexandra Fleischmann and Margaret Rylett with contributions from Gerhard Gmel, David Jernigan, Vladimir Poznyak, Jürgen Rehm and Dag Rekve. Appendices 1–3: Margaret Rylett and Alexandra Fleischmann with contribution from Gretchen Stevens. Appendix 4: Margaret Rylett with contributions from Alexandra Fleischmann, Jürgen Rehm and Gretchen Stevens. This report would not have been possible without contributions of the WHO national counterparts for implementation of the Global strategy to reduce the harmful use of alcohol in WHO Member States who provided country level data and other relevant information regarding alcohol consumption, alcohol-related harm and policy responses. The report benefited from the input provided by the following peer reviewers: Chapter 1: Steve Allsop (Australia), Thomas Babor (USA), Maria Elena Medina-Mora (Mexico), Neo Morojele (South Africa), Esa Österberg (Finland). Chapters 2 and 3: Guilherme Borges (Mexico), Wei Hao (China), Ralph Hingson (USA), Pia Mäkelä (Finland), Ingeborg Rossow (Norway). Chapter 4: Bernt Bull (Norway), Maris Jesse (Estonia), Isidore S. Obot (Nigeria), Esa Österberg (Finland), Charles Parry (South Africa). Susan Kaplan (Switzerland) edited the report. L’IV Com Sàrl (Switzerland) developed the graphic design and layout. Administrative support was provided by Divina Maramba and Mary Dillon. WHO interns who contributed to the report include: Fredrik Ansker, Sally Cruse, Michael Dean, Nina Elberich, Elise Gehring, Wenjing Huang, Angelos Kassianos, Dan Liu, Celine Miyazaki, Even Myrtroen, Eugenie Ng, Ifeoma Onyeka, Derrick Ssewanya, Karin Strodel, Helen Tam-Tham and Christina von Versen. Finally, WHO gratefully acknowledges the financial support of the Government of Norway for the development and production of this report. x