Heterogeneity in trends of alcohol use around the world: Do policies make a difference?

In this issue of Drug and Alcohol Review, in a section entitled ‘Alcohol trends and policies in the wider world – beyond a Eurocentric view’, four overview papers are presented [1-4], which describe regional trends in alcohol use, attributable harm and policy. These papers are part of an effort to expand the base of epidemiological data and policy experience beyond the high-income countries so that other areas of the world are represented. The review articles were commissioned for the third edition of Alcohol: No Ordinary Commodity [5], a multi-authored volume written by an international group of alcohol researchers to provide a comprehensive review of the scientific literature relevant to alcohol policy at the local, national and international levels. This editorial summarises common themes and lessons learned from these papers, together with a similar paper on Southeast Asian countries [6], and some insights from analyses of alcohol use in China that, while not represented in this journal, provides an illustrative example. A related set of commissioned papers, dealing with theoretical [7], epidemiological [8] and alcohol marketing issues [9], is being published simultaneously in another journal. What are the commonalities and differences between countries and regions in their experiences with respect to alcohol use and attributable harm? And how can we explain some of these phenomena? A classic theory on alcohol use and attributable harm, based on economics, predicts that, as a non-essential good, more alcohol would be purchased and consumed once there was enough wealth for a population to afford to do so. Thus, when countries transition from low-income to lower-middle income and upper-middle income status, the level of alcohol use is expected to increase [10, 11]. Figure 1 gives an overview of regional and national wealth trends over the past 30 years as measured by gross domestic product (GDP) purchasing power parity per capita in current prices (international $) [12] for six key areas of the world, which include few high-income countries. In terms of increasing wealth as measured in GDP per capita, all six regions/countries started at below the global average (the International Monetary Fund does not present GDP purchasing power parity per capita, so this comparison is based on values that are not adjusted for purchasing power); in the cases of India and China, both countries started at less than one-tenth of the global average [12]. Latin America and the Caribbean already surpassed the global average 10 years ago. Note: ASEAN-5 consists of Indonesia, Malaysia, Philippines, Thailand and Vietnam. ASEAN, Association of Southeast Asian Nations. [source: 10]. So far, we have restricted ourselves to discussing general consumption trends in regions and large countries. However, there were large differences within regions or within many countries. Let us give a few examples: Gururaj and colleagues [2] report on three regions in India where less than 2.5% of the population are drinkers but also on two regions in which more than every third person consumes alcohol (Chhattisgarh, Tripura). Similarly, in Latin America and Africa, we find countries where very little alcohol is consumed and countries in which consumption is more than 50% above the global average [3, 4]. Even in a region that is relatively homogenous economically, such as Southeast Asia (all middle-income countries), per capita consumption varied between less than 2 L of absolute alcohol (Malaysia) and greater than 10 L (Laos [6]). This indicates that a complex interplay of factors other than the economy, crucially including religion, plays a role in determining the level of alcohol use (and alcohol-attributable harm). When the level of drinking increases with economic growth, this does not automatically translate into higher age-standardised disease and mortality rates [see also 14]. Trends in alcohol-attributable rates depend as much on the overall trends in disease and mortality as they depend on trends in alcohol use. Somewhat paradoxically, as increases in wealth are usually accompanied by improved living conditions, health-care systems and life expectancy [15], some increases in alcohol use may be accompanied by decreases in alcohol-attributable disease and mortality rates. However, the proportions of disability-adjusted life years and deaths, which are caused by alcohol use (i.e. the so-called alcohol-attributable fraction [e.g. 16]), are generally found to be increasing in areas where wealth is increasing. Alcohol-attributable harm depends not only on the overall level of use but also on patterns of drinking, especially on the frequency and extent of heavy-drinking occasions. In this respect, most countries covered by the review articles can be characterised as having large proportions of abstainers, yet the average level of drinking per drinker and heavy-drinking occasions are higher than in high-income countries. Consider Sub-Saharan Africa as one example: while in most African regions, the majority of the population are lifetime abstainers, the alcohol consumed per drinker is higher than, for instance, in Europe, leading to very high alcohol-attributable disability-adjusted life years and mortality rates [4]. A similar situation is reported for India, where both indicators are even more extreme (i.e. much higher abstention rates and alcohol use per drinker [2]). Can these differences in the level of use and harm be explained by alcohol control policy, or in other words, can alcohol policies impact over and above economic factors? The clearest case in this respect can be made for Eastern Europe, Russia and other former Soviet Union countries [1, 17]. In this region, alcohol control policies in the last decade markedly changed use levels, thus decreasing attributable health and social harm and clearly contributing to a significantly increased life expectancy [17, 18]. How was such remarkable progress achieved? First, this was achieved by implementing the so-called ‘best buys’ [19, 20] in the manner originally intended by the World Health Organization and other public health advocates. An example related to one of these ‘best buys’—increases in price—in the original World Health Organization publications assumed price increases of 10% or 15% for alcoholic beverages [21], a level that would more than cover inflation and salary increases. In other words, affordability of alcohol would be reduced by the implementation of tax increases of this magnitude. Indeed, unlike many small increases in excise taxation in other countries, in exemplary countries in Eastern Europe, Russia [18] and Lithuania [22], alcohol excise taxation increased substantially so that it actually resulted in reduced affordability of alcohol after the implementation [for the concept of affordability, see 23]. In general, former Soviet Union countries also implemented strategies to reduce alcohol availability that were known to be effective, such as reduced hours of sale and an increase in the minimum legal drinking age that resulted in marked reductions in availability [for the concepts, see 24, 25]. Finally, bans on advertising and marketing were implemented to start changing the overall drinking culture. Despite warnings from the alcohol industry about potential increases of unrecorded use once prices were increased or availability reduced [8], most of these policies were not accompanied by increases of illegal or other unrecorded alcohol. The example of Lithuania showed that such policy changes and resultant effects are possible in a relatively high-income European country. What about the other regions? In India, except for some changes during the COVID-19 pandemic, which seem to be mainly driven by revenue generation purposes rather than public health considerations [2], regulatory policies and alcohol control programs have not been effective in slowing down the trend of increasing use across the country [but note the large variations across states/territories detailed above; 2]. Gururaj and his co-authors also state that policies are needed to address the aggressive and innovative marketing strategies of the alcohol industry in India [2]. There are marked differences between Indian states (the key level of government for alcohol control), partly based on the implementation of different policies between the states. In states where prohibition is in effect, use remains low. In China, centralised control of the alcohol market through a national alcohol monopoly was abolished in the 1980s and was succeeded by limited controls on the market overseen by a variety of ministries and levels of government, each with vested market interests resisting controls [26]. Per capita alcohol use more than doubled from 2.5 L per capita in 1978 to 6.7 in 2010, although abstention rates remained high, particularly among women, so the per-drinker use level was higher in 2010 than in many high-income countries [27]. The lagged effect of the rise in use was seen in a sharp rise in alcoholic liver disease rates in the 2000s [28]. Tax policy changes, both increases and decreases, driven primarily by considerations other than public health [26, 29], affected levels of use in the 1990s and 2000s. It has been argued that, in the interest of public health, China needs to adopt measures that ‘will have a significant impact on the frequency of alcohol-related problems’, including the best buys mentioned above [30]. Examples of successful alcohol control policies in Southeast Asia include policies by Muslim-majority countries, including Brunei, which bans alcohol entirely; these countries clearly see less drinking and fewer alcohol-attributable problems. In addition to this, alcohol excise taxation seems to have made a small contribution to reducing, or at least not increasing, harm [6]. And the flattened development of alcohol use per capita in Thailand after implementation of alcohol control policies, such as marketing and availability restrictions [31], seems to indicate that the overall upward trends associated with economic growth can at least be slowed down [32]. In Africa, alcohol policies are diverse. Again, Muslim-majority countries maintained bans on alcohol use, with some success in controlling use and attributable harm [4]. In other countries, various attempts were made to implement stricter alcohol control policies—often drawing vehement opposition from the alcohol industry [4]. For example, the case study of Botswana in the review article by Morojele and co-authors illustrates some of the problems encountered in trying to implement strong alcohol control policies, including facing opposition from the media, from the alcohol industry and, in part, from the population. The authors [see Case Study 2] partly attribute this to poor implementation practices. In South America, various alcohol control policies [3] were reported to be successful at the country level, corroborating the impact of taxation increases and some success with measures restricting availability in reducing violence—a major problem in the region. In addition, drink-driving countermeasures were found to reduce alcohol-attributable traffic injury if implemented with a sufficient degree of enforcement. Both types of policies have already accumulated a solid evidence base [e.g. 25], and the findings from South America corroborate past findings. On the other hand, implementation of screening and brief interventions yielded mixed results and could not be shown to impact the population level [3]. This corroborates earlier research [29] suggesting that the impact of alcohol screening and brief intervention programs have yet to be demonstrated at the population level despite considerable research demonstrating efficacy in controlled clinical trials [e.g. 33] and statistical models showing the potential impact based on these trials [e.g. 19, 34]. In the context of increasing wealth and economic prosperity in the rapidly developing regions of the world where the large majority of the world's population lives, several conclusions can be drawn from these commissioned policy overviews [1-4, 6]. First, alcohol use in large parts of the world continues to be a major risk factor for disease and mortality [see also 35, 36]. Second, there are examples which demonstrate that alcohol control policies—if properly implemented in low- and middle-income countries, even in the context of increasing wealth—can reduce alcohol use and attributable harm effectively. And, third, the implementation of potentially effective alcohol control policies has often been successfully contested by the alcohol industry and other interests. Thus, there is a large potential, which is currently untapped, for improving quality of life and life expectancy while saving resources. It is hoped that the reviews in this special section will contribute to better policy implementation and reduced harms in the future.

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