Impacte del consum d’alcohol en la
nostra societat i les estratègies més
efectives per reduir-ne els danys
Jürgen Rehm, Director de la Social and
Epidemiological Research (SER) Department. CAMH
Impact of alcohol consumption in our
society and the most effective
strategies to reduce damage
Jürgen Rehm, Ph.D.
Social and Epidemiological Research (SER) Department, CAMH
Dalla Lana School of Public Health, University of Toronto (UofT), Canada
Dept. of Psychiatry, Faculty of Medicine, UofT, Canada
Head, PAHO/WHO Collaborating Centre for Mental Health & Addiction
Head, Epidemiological Research Unit, Technische Universität Dresden,
Klinische Psychologie & Psychotherapie, Dresden
The impact of alcohol
Alcohol is one of the most important risk factors
Risk factor for what?
• Burden of disease and injury -> alcohol consumption
has causal impact on more than 200 three digit ICD
codes; alcohol is part of more than 30 disease names;
diseases and injuries which would be completely
unknown without alcohol consumption
• Harm to others -> alcohol consumption does not only
hurt the drinkers themselves but also others (e.g.,
pregnant mothers’ drinking the fetus; driving under the
influence other traffic participants; heavy drinking
induced violence)
• Social consequences of alcohol
Alcohol-attributable disease burden
Three examples given
Example 1: Alcohol is one of the four major
risk factors for non-communicable diseases
(NCD)
Contribute to the
WHO goal to reduce
the mortality burden
of NCDs by 2025 by
reducing the harmful
use of alcohol and
lowering the
prevalence of
hypertension
1. WHO Global Action Plan for the prevention and control of NCDs 2013-20, May 2013. Link.
6
Example 2:
possible impacts on the drinkers
themselves
Alcohol can harm the drinker
by its:
Intoxicating effects
Immunosuppressant effects
Carcinogenic effects
Neurotoxic effects
Dependence producing
properties
It seems to have some
beneficial effects.
Carcinogenic effects
Alone based on it carcinogenic
effect alcohol would be forbidden
as a food, if it was discovered
today!
Example 3:
years of life lost in the EU 2013
• In 2013, the latest year with available data, alcohol
consumption in the EU was responsible for 8.3% of all years
of life lost due to premature mortality and for 5.5% of all
disease burden (disease burden is a composite measure
summing up years of life lost due to premature mortality
and years of life lost due to disability).
• Put in other words: every 10th year of life lost due to
premature mortality for men, and every 20th year of life lost
in women was attributable to alcohol, meaning they would
not have occurred if no alcohol was consumed in Europe.
Source: own calculations based on Global Burden of Disease
and Injuries Study 2013
Harm to others
The effect of alcohol on others is relatively larger than the
effect of second hand smoke!
Impact on people other than the drinker
Alcohol can harm other than the drinker by:
Its teratogenic effects
Physical injuries, violence and crime
Psychological violence
Using up a relative or colleagues’ time and
resources
Using up taxes, private wealth and other
resources in society
A recent study in Australia found, that the economic
societal costs of harm to others were larger than the
costs of drinking to the drinker!
Harm to society at large
Social cost in Europe 2010 in billion €
17,6
18.8
11,3
Crime - Police
Crime - Defensive
Crime - Damage
15,1
Traffic Accidents Damage
Health
Treatment/Prevention
7,5
12,6
Mortality
Absenteeism
Unemployment
45,2
21,4
6,3
Own calculations for 2010, based on Anderson & Baumberg, Alcohol in Europe 2006: total
tangible costs to the EU € billion 155.8, equivalent of 1.3% (0.9% - 2.4%) of GDP
Most effective strategies to reduce
alcohol attributable burden
Best buys and beyond
Introducing interventions to tackle NCD risk
factors: identifying 'best buys'
For harmful use of alcohol:
- Raise taxes on alcohol
- Restrict access to retailed alcohol
- Enforce bans on alcohol advertising
Very cost-effective: US $ per DALY prevented < GDP per person
Implementation costs: very low (< US $ 0.50 per capita)
Feasibility: high
The rationale of taxation for
alcoholic beverages
Taxation: a means by which governments finance their
expenditure by imposing charges on citizens and corporate
entities.
A Pigouvian tax is a tax applied to a market activity that is
generating negative externalities (costs for somebody else).
The tax is intended to correct an inefficient market
outcome, and does so by being set equal to the negative
externalities. In the presence of negative externalities, the
social cost of a market activity is not covered by the private
cost of the activity. In such a case, the market outcome is
not efficient and may lead to over-consumption of the
product.
Given the social costs of alcohol, a Pigouvian tax is
clearly justified!
Taxation may be a best buy, and justified
by economic reasons, but it is not
popular….
• Even though it gives the government additional
revenue and decreases the harm
Sometimes, a minimum price may be more acceptable
in such situations (but may run into legal problems….)
A simulation on different taxation systems for the
UK
(all lead to a reduction of mortality by 4.3% ; Meier et al., Lancet)
Current (UK) Tax Increase (CT) Raise current alcohol taxes1
(comprising excise duty + VAT) for all beverage categories by
16%.
Sales Tax (ST)2 Introduce an additional 4% alcohol-specific sales
tax on product value (after excise duty is applied but before VAT)
Volumetric Tax (VT) Replace current excise duty with a duty of
£0.22 per unit for all beverage types (UK unit = 10ml ethanol).
Minimum Unit Price (MUP) Introduce a floor price of £0.50 per
unit within the current tax system
1 In
the UK, duty rates for wine and cider are charged per hectolitre of product
(not linked to alcoholic strength); beer, spirits and spirits-based drinks are
taxed by ethanol volume. A general sales tax of 20% VAT is applied to alcohol
prices including excise duty.
2 For a product currently sold at £1.20, £1 is the price after duty and £0.20 is
existing value added tax (VAT) . In this policy, a 4% sales tax is applied to the
£1 price giving £1.04, and then 20% VAT is applied to give a revised price of
£1.25.
Differential effects of different taxation
strategies on all drinkers by SES
Current
situation
CT: Current ST: alcohol
system
sales tax
taxation rise rise
VT:
Volumetric
tax rise
MUP:
Minimum
unit price
And another good strategy to reduce burden is via the
primary health care system, e.g., via screening of all incident
people with hypertension for alcoholimary care patients
HD
AUD
HBP
HD: Heavy drinking
AUD: Alcohol Use
Disorders
HBP: Hypertension
(High Blood Pressure)
data on file
Interventions for heavy drinking alcohol
Low risk
drinking
Hazardous
drinking
Harmful
drinking
Severe disorder
Specialized Tx
No
intervention
Brief
intervention
Treatment in
primary c.
Adopted from: Raistrick D, Heather N, Godfrey C (2006). Review
of the effectiveness of treatment for alcohol problems. London:
National Treatment Agency for Substance Misuse.
Higher consumption of alcohol
What could happen in Spain?
(shifts for systolic BP only)
People with hypertension (aged 40-64):
30% of women, 42%of men
Unaware of their
condition
(undetected)
100%
Intervention for
hypertension (shift
from 150mm Hg to
144 mm Hg
17% M
15% W
Brief
intervention
(BI)
14% M
5% W
Treatment
for AUD
(TxAUD)
data on file
Detected but not
controlled
17% M
15% W
BI
14% M
5% W
TxAUD
Controlled
17% M
15% W
BI
Shifts: HDI: -2.4% mm Hg
TxAD: - 4.1% mm Hg
14% M
5% W
TxAUD
Cases of people with high BP lowered beyond the
threshold > more than 400 deaths avoided in 1
year!
Women 40-64 years of age
Mean
%
Increase
systolic controlled in control
BP
among Ht.
delta%
Systolic
BP ≥ 140
mmHg in
population
Men 40-64 years of age
Mean
%
Systolic
Increase
systolic controlled in control
BP
among Ht.
delta%
BP ≥ 140
mmHg in
population
Before
146.0
40.4
-
17.8 146.8
38.8
-
25.7
After
increasing
awareness
(50%)
144.8
43.0
2.6
17.0 145.3
42.2
3.5
24.2
+ alcohol
interventions
(50%)
144.1
44.8
4.4
16.5 144.5
44.1
5.3
23.5
data on file
Need for interventions
• Burden is high, so action is
needed
• WHO “best buys” for
cost-effective prevention ->
• Taxation
• Reduction of availability
• Marketing ban
• Let us not forget interventions
for heavy drinking including
brief advice and treatment