|Year : 2017 | Volume
| Issue : 3 | Page : 205-207
Awakening to the alcohol epidemic - need of the hour
Dharav Sunil Shah
Consultant Psychiatrist, Parivartan Trust, Satara, Maharashtra; National Consultant, Alcohol and Drug Information Centre, Thiruvananthapuram, Kerala, India
|Date of Web Publication||15-Sep-2017|
Dharav Sunil Shah
602, Sai Krishna Kunj, D. N. Nagar, Andheri West, Mumbai - 400 053, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Globally, alcohol has become the most common risk factor for death and disability in the young age group of 15–49 years. Its use has been rapidly increasing in developing countries. It is a critical time wherein if effective preventive measures are not undertaken urgently, damage done will be difficult to reverse. However, health professionals are not responding to the alcohol epidemic in the manner that they responded to the tobacco epidemic. The article discusses two beliefs which are making us accept the use of alcohol as normal. Recent evidence indicates that it is not advisable to drink alcohol even in moderation. Furthermore, social drinking has failed to decrease alcohol-related harm in western countries. Because of its addictive nature, many people end up drinking excessively though they do not intend to. Hence, we need to shift our focus from only “reducing harmful use of alcohol” to “reducing use of alcohol” in general.
Keywords: Addictive behavior, alcohol addiction, culture of abstinence, social drinking
|How to cite this article:|
Shah DS. Awakening to the alcohol epidemic - need of the hour. Indian J Public Health 2017;61:205-7
| Introduction|| |
Alcohol killed 3,300,000 people in 2012; 1 death every 10 s. The UK study which analyzed multiple factors found that out of all the substances of abuse, the combined harm done to drug users and others in the society was maximum for alcohol. However, its consumption continues to be popular in most parts of the world. In developing countries like India and China especially, the consumption of alcohol has been rapidly increasing. A study done in Kerala revealed that the percentage of drinking population under 21 years has increased from 2% to 20%; age of initiation has decreased from 19 to 13.5 years, from 1986 to 2014. This trend of decreasing age of initiation is particularly worrisome because the still-developing brains of teenagers are more sensitive to the damaging effects of alcohol, and their risk of developing alcohol dependence is higher. The National Family Health Survey-3 indicates that around 32% men in India use alcohol. National Mental Health Survey of India 2015–2016, found that prevalence of alcohol use disorders (dependence and harmful use) in males was 9% and in females was 0.5%. It was the third most common mental disorder after tobacco use disorder and depression. Globally, alcohol has become the most common risk factor for death and disability in the young age group of 15–49 years.
| And Yet this Epidemic Fails to Alarm Us|| |
The enthusiasm being shown by influential members of society regarding the prevention of tobacco use is lacking with regard to alcohol. Why this contradiction? It is because of the high social acceptability enjoyed by alcohol, lack of adequate awareness about the magnitude of harm it is causing in our society, existence of many misconceptions surrounding its use, and industry propaganda to normalize its use. Alcohol industry facilitates formation of advocacy organizations such as “International Center for Alcohol Policies,” so that they can influence public opinions and public health policy. A key goal of industry propaganda is to shift the responsibility of alcohol-related problems from alcohol to the alcohol user. Moreover, they seem to have been extremely successful at that. Most of us have developed a belief that so far as a well-educated person chooses to drink responsibly, taking alcohol is relatively harmless. Two myths which are keeping us away from working on preventing alcohol use are discussed below.
| Myth 1: It is Advisable to Start Drinking Alcohol in Moderation to Protect the Heart|| |
Yes, there are many studies which have found that alcohol in moderation reduces adverse cardiovascular outcomes. Such studies receive large-scale publicity and influence our perception of alcohol. To the extent that some doctors even go ahead with recommending people to start drinking, “but in control.” Some alcohol-dependent people I have treated had taken their first alcohol drink not because their friends forced them but because their doctor had advised them to start drinking to improve their health!
We need to consider following issues before regarding moderate drinking to be desirable:
Some researchers have raised doubts about the “protective effect” hypothesis
It has been pointed out that based on current evidence, we cannot definitely conclude whether the improved outcomes seen in some studies are due to moderate alcohol consumption or due to other differences between those who drink moderately and those who do not, e.g., differences in their exercise patterns and socioeconomic stressors.,, Second, a misclassification error has been found to be present in most studies, which evaluate the association of alcohol with coronary heart disease (CHD) mortality or all-cause mortality, i.e., “past alcohol users” were included in control group rather than taking only “lifetime abstainers.” Studies where “past alcohol users” category was analyzed separately have shown that their risk for CHD is more than current drinkers. This is because alcohol users typically stop drinking after alcohol has already impaired their health significantly. Hence, including “past alcohol users” in “abstainer” category is bound to give erroneous results. A meta-analysis which kept strict operational definitions found that out of 89 studies on this topic, only nine studies did not have this misclassification error. In all these nine studies, abstainers did not have a higher risk of mortality compared to moderate drinkers.
Even if “protective hypothesis” is considered to be true, the various potential dangers of taking alcohol far outweigh the claimed benefits
American Heart Association states, “…it's not possible to predict in which people alcoholism will become a problem. Given these and other risks, American Heart Association cautions people not to start drinking… if they do not already drink alcohol.”
There is now strong evidence that this claim does not hold true for Indians at least
In a multicentric Indian study having a large sample size (11,898 men), it was seen that the risk for CHD increased with even light or occasional alcohol intake.
If one really wants to prevent coronary heart disease, there are many well-proven methods
If one really wants to prevent coronary heart disease, there are many well-proven methods like regular exercise, low-fat diet, etc. One does not need to consume an addictive substance for that. In fact, for those who end up drinking heavily, it actually increases the risk of CHD. In 2012, due to the cardiovascular diseases and diabetes caused by alcohol consumption, there were 1,098,000 deaths.
There is now evidence that certain cancers are caused by even light alcohol consumption
In a meta-analysis of 222 studies, it was estimated that in 2004, worldwide, 34,000 cancer deaths were attributable to light drinking.
| Myth 2: Western Societies With a “Social-Drinking Culture” Do not Have Much of Alcohol-Related Problems|| |
During awareness talks on alcohol, when I ask the question, “which country is harmed more by alcohol - India or USA?” the answer is always a unanimous “India.” However, consider this data  given in [Table 1].
|Table 1: Co-relation of prevalence of alcohol use disorders with proportion of lifetime abstainers (in 15 yrs+ males), 2010|
Click here to view
Yes, in societies with a wet culture, a huge proportion of the population is used to drink in control in social contexts. However, a significant proportion of the population gets addicted or binges as well. Withdrawal, tolerance, craving, etc., are physiological properties of addictive substances such as alcohol. They can develop in anyone irrespective of his/her intentions or culture. In countries with wet culture, because the number of people experimenting with alcohol is so large, a larger proportion of the total population ends up drinking excessively.
| Promoting a Culture of Abstinence|| |
The above data indicate that promoting a culture of abstinence can prove to be a very effective way to decrease alcohol-related harm substantially. We did not find it impractical to recommend youth to abstain from tobacco completely although tobacco use had become a part of the culture. Then, why are we being soft with this other popular addictive poison? When youngsters hear from the medical community “guidelines for healthy/responsible drinking,” would it not contribute toward normalizing alcohol use and make them think that it is safe to drink, so far as one intends to drink responsibly? Yes, culture of abstinence does not uproot the problem completely. However, neither does social drinking. A culture of abstinence definitely decreases the magnitude of harm in a very big way.
Few things which can be done to promote a culture of abstinence are:
- Taking adequate awareness to youngsters before the age of 1st contact and empowering them with refusal skills to deal with peer pressure
- Helping youngsters develop a perspective toward surrogate advertisements and alcohol's glamorization in media so that they do not start regarding it to be a way to success, fame, courage, female empowerment, etc.,
- Actively recommending people around us to stay away from alcohol; thereby shaping peer pressure around us in healthy direction
- Leading by example: the opinion and behavior of medical community influence public perception of tobacco or alcohol in a big way. Hence, there are some associations of doctors which have taken a firm stand on this issue and have prohibited alcohol in their gatherings
- Denormalizing its use by removing it from our celebrations and promoting healthy ways of recreation and socializing. The huge emphasis given on denormalization in tobacco control programs is evident from this statement by Dr. Zsuzsanna Jakab, WHO Regional Director for Europe, “Governments must… define a common goal: a Europe where tobacco is not a social norm”
- Advocating for legislative measures such as ban on advertisements and restricting hours of sale.
| It is a Critical Period for Countries like India|| |
Countries such as France and Scotland have started realizing the damaging consequences of their drinking culture and have started making efforts to change it. For example, the Scottish Government released a booklet in 2009, “Changing Scotland's Relationship with Alcohol: A Framework for Action.” Due to such efforts, the consumption in many European countries has started to decrease. However, still, the problem is far from being solved. The firmly established alcohol industry over there is trying hard to oppose policies that have the potential to effectively reduce alcohol use and alcohol-related harm.
Countries such as India and China were protected till now by their culture of abstinence. However, now with aggressive marketing, the social acceptability of alcohol is rapidly increasing. If doctors and other influential citizens of these countries do not undertake urgent measures to maintain their dry culture, alcohol-related harm will continue to rise rapidly and the damage done will be difficult to reverse. Furthermore, example of Thailand has shown that a large proportion of benefits of development get squandered if a developing country allows alcohol consumption to rise.
| Concluding Remarks|| |
We need to take cognizance of the magnitude of harm that alcohol is causing in our society and commit ourselves to respond to the situation. Social acceptability of alcohol use is a huge determinant of the magnitude of alcohol-related problems in that society. “Social drinking” has failed to decrease alcohol-related harm in western countries. Like with tobacco, we need to encourage people to abstain completely from alcohol as well. Because of its addictive nature, many people end up drinking excessively though they do not intend to. Just trying to reduce “harmful use of alcohol” is bound to fail. It is important to make people aware that it is not advisable to drink even in moderation. Promoting a culture of abstinence would go a long way in decreasing alcohol-related harm substantially.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
WHO. Global Status Report on Alcohol and Health 2014. Geneva: World Health Organisation; 2014.
Nutt DJ, King LA, Phillips LD, Independent Scientific Committee on Drugs. Drug harms in the UK: A multicriteria decision analysis. Lancet 2010;376:1558-65.
Edayaranmula JJ. Alcohol Atlas of Kerala. Kerala (India): Alcohol and Drug Information Centre; 2014.
Indian Institute of Population Sciences and Macro International. National Family Health Survey-3. Mumbai: IIPS; 2007.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK; NMHS Collaborators Group, et al
. National Mental Health Survey of India, 2015-16: Summary. NIMHANS Publication No. 128. Bengaluru: National Institute of Mental Health and Neuro Sciences; 2016.
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al.
Acomparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224-60.
Rutherford D. Beware of the alcohol industry bearing gifts. Globe 2013;3:3-7.
Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: A systematic review and meta-analysis. BMJ 2011;342:d671.
Chikritzhs T, Fillmore K, Stockwell T. A healthy dose of scepticism: Four good reasons to think again about protective effects of alcohol on coronary heart disease. Drug Alcohol Rev 2009;28:441-4.
Knott CS, Coombs N, Stamatakis E, Biddulph JP. All cause mortality and the case for age specific alcohol consumption guidelines: Pooled analyses of up to 10 population based cohorts. BMJ 2015;350:h384.
Naimi TS, Brown DW, Brewer RD, Giles WH, Mensah G, Serdula MK, et al.
Cardiovascular risk factors and confounders among nondrinking and moderate-drinking U.S. adults. Am J Prev Med 2005;28:369-73.
Roy A, Prabhakaran D, Jeemon P, Thankappan KR, Mohan V, Ramakrishnan L, et al.
Impact of alcohol on coronary heart disease in Indian men. Atherosclerosis 2010;210:531-5.
Cryer PC, Saunders J, Jenkins LM, Neale H, Cook AC, Peters TJ. Clusters within a general adult population of alcohol abstainers. Int J Epidemiol 2001;30:756-65.
Fillmore KM, Stockwell T, Chikritzhs T, Bostrom A, Kerr W. Moderate alcohol use and reduced mortality risk: Systematic error in prospective studies and new hypotheses. Ann Epidemiol 2007;175 Suppl:S16-23.
Bagnardi V, Rota M, Botteri E, Tramacere I, Islami F, Fedirko V, et al.
Light alcohol drinking and cancer: A meta-analysis. Ann Oncol 2013;24:301-8.
Thamarangsi T. Thailand: Alcohol today. Addiction 2006;101:783-7.