Alcohol and related health issues in China: action needed

On Nov 28, 2014, the Chinese Government introduced its first national tobacco control guideline, which prohibits smoking in all indoor and many outdoor public places, and shows a new commitment by the Government to reduce the health problems caused by smoking.1The LancetA step change for tobacco control in China?.Lancet. 2014; 384: 2000Scopus (1) Google Scholar However, the social and health issues related to alcohol use and misuse, such as liver and cardiovascular diseases, mental disorders, cancers, violence, and transport and unintentional injuries, have been largely neglected. In the past three decades, along with rapid economic growth in China, there has been a striking increase in alcohol consumption, greater than in most other parts of the world (figure). Although the population drinking level in China used to be far lower than in many high-income and middle-income countries, per capita alcohol consumption has risen from 2·5 L in 1978 to 6·7 L in 2010.2WHOGlobal status report on alcohol and health. World Health Organization, Geneva2014Google Scholar However, more than half of the Chinese population aged 15 years and older are alcohol abstainers—42% of men and 71% of women in 2010.2WHOGlobal status report on alcohol and health. World Health Organization, Geneva2014Google Scholar So the alcohol consumption level of those who actually drink was 15·1 L in 2010, which is higher than the equivalent figure in the UK, the USA, Sweden, Germany, Australia, New Zealand, and many other countries.2WHOGlobal status report on alcohol and health. World Health Organization, Geneva2014Google Scholar Furthermore, there is a great disparity in alcohol consumption and rates of dependence between the sexes: the rates of alcohol use disorder are 9·3% among men and 0·2% among women, with the male-to-female ratio of 47:1 being substantially higher than in most other countries in the world.2WHOGlobal status report on alcohol and health. World Health Organization, Geneva2014Google Scholar, 5Tang Y-L Xiang X-J Wang X-Y Cubells JF Babor TF Hao W Alcohol and alcohol-related harm in China: policy changes needed.Bull World Health Organ. 2013; 91: 270-276Crossref PubMed Scopus (109) Google Scholar The Global Burden of Disease study 2010 revealed that alcohol use was ranked as the sixth greatest risk factor for men in China in terms of attributable disability-adjusted life-years (DALYs) lost, contributing to more than 310 000 deaths and 13·8 million DALYs among men each year.3Institute for Health Metrics and EvaluationChina Global Burden of Disease Study 2010 (GBD 2010) Results 1990–2010.http://ghdx.healthdata.org/record/china-global-burden-disease-study-2010-gbd-2010-results-1990-2010Google Scholar Drinking alcohol has been widely accepted as an important aspect of the culture in China for thousands of years; it has been seen as a symbol of happiness and celebration of special events or festivals, and one of the most effective ways of building links within families, relatives, friends, and business relationships.5Tang Y-L Xiang X-J Wang X-Y Cubells JF Babor TF Hao W Alcohol and alcohol-related harm in China: policy changes needed.Bull World Health Organ. 2013; 91: 270-276Crossref PubMed Scopus (109) Google Scholar Today, drinking with clients and colleagues is seen as vital to career advancement. Some job advertisements highlight “good drinking capacity” as a potential requirement for their candidates.6AnonThe spirit level: the Chinese are drinking more.Economist. Aug 9, 2014; (accessed Feb 26, 2015).http://www.economist.com/news/china/21611118-chinese-are-drinking-more-spirit-levelGoogle Scholar There are many news reports that heavy drinking has become a part of official duties for some civil servants and officials, and, in one study, a fifth of Government employees in a Chinese city were found to have fatty liver disease due to heavy drinking.5Tang Y-L Xiang X-J Wang X-Y Cubells JF Babor TF Hao W Alcohol and alcohol-related harm in China: policy changes needed.Bull World Health Organ. 2013; 91: 270-276Crossref PubMed Scopus (109) Google Scholar, 7He M Liao G Zhong R Fan Y Zhong X The prevalence of fatty liver and its risk factors in civil servants of a certain city.J Chongqing Med University. 2009; 34 (in Chinese).: 788-791Google Scholar An anti-corruption campaign led by the central Government since last year has diminished the sales of cognac and other luxury products, but it does not seem to have affected overall drinking; China's largest wine importer insists that “the Chinese are still drinking…just not splurging”.5Tang Y-L Xiang X-J Wang X-Y Cubells JF Babor TF Hao W Alcohol and alcohol-related harm in China: policy changes needed.Bull World Health Organ. 2013; 91: 270-276Crossref PubMed Scopus (109) Google Scholar, 8Chow J Cognac makers are feeling the hangover from China's corruption crackdown.Wall Street J China. Aug 21, 2014; (accessed Feb 26, 2015).http://blogs.wsj.com/chinarealtime/2014/08/21/cognac-makers-are-feeling-the-hangover-from-chinas-corruption-crackdown/Google Scholar Given the dramatic increase in alcohol consumption and alcohol-related social and health problems in China, both policy attention and policy and cultural changes are needed. Although there had been Government monopolisation of alcohol in ancient China and in modern times since 1915, this ended during the 1980s, allowing uncontrolled expansion of production, without substantial attention to limiting adverse effects on public health. Re-establishment of a monopoly is one potential instrument for public health purposes, as is done for instance in several Nordic countries and Canada. An alternative is to establish public-health-oriented systems of licensing and regulation to limit and channel the availability of alcohol. Compared with many other countries, there is almost no alcohol control policy in China—such provisions as licensing controls for selling alcohol, restrictions on trading hours for alcohol sales or service, and legally binding regulations on alcohol sponsorship and sales promotion are lacking. The main exceptions are limited excise taxes on alcohol products and modest restrictions on alcohol advertising.2WHOGlobal status report on alcohol and health. World Health Organization, Geneva2014Google Scholar In 2006, the Chinese Government introduced a regulation to prohibit selling alcohol to minors, but the penalties for violations were not specified. Thus, a more effective minimum legal drinking age law is needed. Although European-style beer and wine have gained footholds, China is primarily a spirits-drinking country. The main form of spirits, known as Baijiu, is generally 40–60% alcohol by volume. The Chinese Government decreased the spirits tax from a range of 40–50% to 15–25% of the value in 1994, in connection with changes required for its entry into the World Trade Organization. The drafting of this policy in 1992 was followed by an increase in alcohol consumption (figure). In 2001, a volumetric tariff of ¥0·5 per 500 g or 500 mL was added onto the existing alcohol tax as a means of raising government revenues, leading to a dramatic decrease in alcohol production and consumption after the tariff's initial announcement in 2000 (figure). In 2006, the central Government lowered the tax again on spirits, introducing a unified tax rate of 20% of the value.9Ministry of Finance of the People's Republic of ChinaNotice of Ministry of Finance and State Administration of Taxation on adjusting and perfecting consumption tax policies (no. 33). Ministry of Finance, Beijing2006Google Scholar This resulted in a steep rise in alcohol consumption again. There is thus evidence that changes in alcohol taxation have significant effects on the level of alcohol consumption in China, and also on levels of alcohol-related mortality.10Chung RY Kim JH Yip BH et al.Alcohol tax policy and related mortality: an age-period-cohort analysis of a rapidly developed Chinese population, 1981–2010.PLoS ONE. 2014; 9: e99906Crossref PubMed Scopus (10) Google Scholar Therefore, taxation or price policy could be considered as an effective means to reduce rates of alcohol-related health and social harms. A first step forward would be to establish a public-health-oriented commission or agency charged specifically with developing controls over the alcohol market and a strategy for reducing levels of alcohol consumption and problems, drawing on the strategies agreed on in the WHO Global Strategy for Reducing Harmful Use of Alcohol.11WHOGlobal strategy to reduce the harmful use of alcohol. World Health Organization, Geneva2010Google Scholar Additionally, a national monitoring and surveillance system is urgently needed to inform alcohol policy at a time when Chinese alcohol consumption has rapidly grown, with a resulting toll of death and disease. We declare no competing interests.

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