A public health approach to alcohol use and its related harms in Iran

In Iran, alcohol consumption, production, and trade are criminalised for Muslim citizens (ie, about 99% of the population);1Lankarani KB Afshari R Alcohol consumption in Iran.Lancet. 2014; 384: 1927-1928Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar however, bootleg alcohol is common and alcohol consumption is associated with a number of harms (eg, violence, injuries).2Shadloo B Motevalian A Rahimi-Movaghar V et al.Psychiatric disorders are associated with an increased risk of injuries: data from the Iranian Mental Health Survey (IranMHS).Iran J Public Health. 2016; 45: 623-635PubMed Google Scholar, 3Amin-Esmaeili M Rahimi-Movaghar A Sharifi V et al.Alcohol use disorders in Iran: prevalence, symptoms, correlates, and comorbidity.Drug Alcohol Depend. 2017; 176: 48-54Crossref PubMed Scopus (39) Google Scholar A nation-wide household mental health survey suggested that 5·7% of the adult population had consumed alcohol in the previous year,3Amin-Esmaeili M Rahimi-Movaghar A Sharifi V et al.Alcohol use disorders in Iran: prevalence, symptoms, correlates, and comorbidity.Drug Alcohol Depend. 2017; 176: 48-54Crossref PubMed Scopus (39) Google Scholar with a higher prevalence among men, young adults, single adults, urban areas, and some geographical regions.3Amin-Esmaeili M Rahimi-Movaghar A Sharifi V et al.Alcohol use disorders in Iran: prevalence, symptoms, correlates, and comorbidity.Drug Alcohol Depend. 2017; 176: 48-54Crossref PubMed Scopus (39) Google Scholar, 4Nikfarjam A Hajimaghsoudi S Rastegari A et al.The frequency of alcohol use in Iranian urban population: the results of a national network scale up survey.Int J Health Policy Manag. 2016; 6: 97-102Crossref PubMed Scopus (22) Google Scholar Moreover, alcohol poisoning outbreaks due to the consumption of substandard alcoholic drinks are frequent and contribute to alcohol poisoning deaths and hospitalisations across the country.5Hassanian-Moghaddam H Nikfarjam A Mirafzal A et al.Methanol mass poisoning in Iran: role of case finding in outbreak management.J Public Health. 2015; 37: 354-359Crossref Scopus (67) Google Scholar For example, 768 cases of hospitalisation due to methanol poisoning were reported in eight provinces in Iran over the course of 4 weeks in late 2018; among these patients, 170 had dialysis, 16 were blinded, and 96 died.6The Islamic Republic News AgencyAlcohol poisoning cases will not be criminalized. 2018 (in Persian).http://www.irna.ir/fa/News/83069192Date accessed: January 28, 2019Google Scholar The surge in alcohol poisonings might be partly explained by the collapse in the value of Iranian currency—the Rial—in the past few years, which could have induced people to buy cheap homemade alcohol rather than expensive, illegally imported foreign products. While the prevalence, amount, and health consequences of alcohol consumption in Iran are lower than in non-Muslim majority settings—because of Islam's promotion of alcohol abstinence and Iran's prohibition policies—the burden of alcohol-related harms is substantial and should no longer be overlooked. Indeed, the Iranian Ministry of Health has acknowledged this issue by establishing a joint multi-sectoral initiative to develop a national programme that aims to reduce alcohol consumption by 10% between 2015 and 2025 through three main action steps: first, integration of alcohol screening, brief intervention, and referral to treatment in primary health care, aimed at detecting problematic drinking practices early and providing appropriate treatment and care; second, primary prevention, aimed at providing non-drug-specific primary prevention programmes for substance use disorders (eg, parental interventions) in community health centres; and third, treatment programmes, aimed at improving access to alcohol treatment services.7Iranian National Committee for NCDs Prevention and ControlNational action plan for prevention and control of non-communicable diseases and the related risk factors in the Islamic Republic of Iran, 2015–2025. 2015 (in Persian).https://ncdrc.info/publications/books/item/404-incd-national-action-plan-for-prevention-and-control-of-non-communicable-diseases-and-the-related-risk-factors-in-the-islamic-republic-of-iran,-2015-2025Date accessed: January 28, 2019Google Scholar Although the development of such policies is an important step towards tackling alcohol-related problems in Iran, they have not been fully and successfully implemented into the primary health-care system, which is already understaffed and overburdened. Moreover, not including first-line medical and legal settings, in which people with alcohol use disorders are often over-represented, in the early detection programmes is a missed opportunity. Furthermore, despite the initial plan to institute several outpatient and inpatient alcohol treatment programmes, few programmes have actually been established and are functioning. Iran's current alcohol use policies have, therefore, failed to consider comprehensive primary prevention strategies such as provision of educational programmes to the public, age-specific school-based prevention programmes, and targeted prevention programmes for individuals at risk. For example, there are no interventions aimed at preventing alcohol-related harms through the introduction of guidelines for low-risk drinking for people who would not be able to comply with complete abstinence, or through public education initiatives regarding limits for alcohol blood levels for driving. Absence of such policies is incompatible with the Islamic principles and education regarding the importance of implementing evidence-informed interventions in order to preserve and protect the health and life of individuals and of the society at large.8Kamarulzaman A Saifuddeen SM Islam and harm reduction.Int J Drug Policy. 2010; 21: 115-118Crossref PubMed Scopus (35) Google Scholar While Iran's religious-driven zero-tolerance alcohol policy might help keep alcohol consumption at a low level, it is insufficient and fails to reduce alcohol-related harms, particularly among those who either are at risk or already are problematic drinkers.1Lankarani KB Afshari R Alcohol consumption in Iran.Lancet. 2014; 384: 1927-1928Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar Indeed, Iran could learn from its successful experience of revisiting the country's drug policy. Despite the illegality of recreational drugs, harm-reduction policies—including opioid maintenance treatments and needle and syringe programmes—were adopted in the early 2000s.9Razzaghi E Nassirimanesh B Afshar P Ohiri K Claeson M Power R HIV/AIDS harm reduction in Iran.Lancet. 2006; 368: 434-435Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar Although supply and demand reduction policies were still prominent, the policy shift towards adopting a harm-reduction approach enabled Iran to control HIV epidemics among people who inject drugs.10Rahimi-Movaghar A Amin-Esmaeili M Haghdoost AA Sadeghirad B Mohraz M HIV prevalence amongst injecting drug users in Iran: a systematic review of studies conducted during the decade 1998–2007.Int J Drug Policy. 2012; 23: 271-278Crossref PubMed Scopus (68) Google Scholar The lessons learned from this experience can be used to provide a more efficient response to alcohol-related problems. In the absence of specific alcohol-control guidelines and recommendations for countries where alcohol production, distribution, and use are already prohibited,11World Health OrganizationGlobal status report on alcohol and health 2018. WHO, Geneva2018Google Scholar we believe it is time for Iran to identify and develop culturally acceptable best-practice models to improve how it addresses alcohol consumption and its related harms among its population. Establishing a consistent and effective dialogue between religious or political authorities and the scientific and public health communities is an essential first step; the pragmatic flexibility granted to revising drug policy and applying harm-reduction approaches should be considered for tackling alcohol misuse and its related harms in Iran. We declare no competing interests.

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