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WHO Global Status Report on Alcohol 2004

Foreword

This volume is the culmination of three years of dedicated collaborative work of the WHO
Department of Mental Health and Substance Abuse and a WHO Collaborating Centre, the
Swiss Institute for the Prevention of Alcohol and Drug Problems in Lausanne, Switzerland. It
is an overview of the available data on alcohol consumption and drinking patterns worldwide.

WHO has been actively involved in documenting the global, regional and national dimensions
of alcohol consumption since the start of the Global Alcohol Database in 1996. Out of the
earlier work came the

Global Status Report on Alcohol (1999)

, the

Global Status Report on

Alcohol and Young People (2001)

and the recently published

Global Status Report: Alcohol

Policy (2004)

. This publication follows the same tradition of the first Global Status Report

five years ago, but it represents a complete update of the information. It gives valuable new
perspectives on the recent status of health and social consequences of alcohol use and levels
and patterns of alcohol consumption worldwide.

A clear focus of this publication has been on developing countries, those long-neglected areas
where alcohol problems are likely to increase at an alarming rate in the future. It tries through
objective analysis to provide in a comprehensive and readily accessible way all the
accumulated scientific information and knowledge on issues pertinent to alcohol consumption
at global, regional and national levels.

However, it is clear that many gaps remain to be filled for a comprehensive picture of the
global situation with alcohol use and its health consequences. For example, for many
countries the data is very limited, and the alcohol per capita consumption estimates are clearly
of varying quality. I hope that recognition of the limitations of available data will encourage
WHO Member States and international organizations to work closely with WHO in
improving data collection and reporting.

I sincerely recommend this as a reference source for a wide audience of policy-makers,
teachers, students, scientists and all those interested in alcohol issues.

Catherine Le Galès-Camus

Assistant Director-General

Noncommunicable Diseases and Mental Health

WHO Global Status Report on Alcohol 2004

Introduction

The World Health Organization (WHO) estimates that there are about 2 billion people
worldwide who consume alcoholic beverages and 76.3 million with diagnosable alcohol use
disorders. From a public health perspective, the global burden related to alcohol consumption,
both in terms of morbidity and mortality, is considerable in most parts of the world. Alcohol
consumption has health and social consequences via intoxication (drunkenness), alcohol
dependence, and other biochemical effects of alcohol. In addition to chronic diseases that may
affect drinkers after many years of heavy use, alcohol contributes to traumatic outcomes that
kill or disable at a relatively young age, resulting in the loss of many years of life due to death
or disability. There is increasing evidence that besides volume of alcohol, the pattern of the
drinking is relevant for the health outcomes. Overall there is a causal relationship between
alcohol consumption and more than 60 types of disease and injury. Alcohol is estimated to
cause about 20–30% of oesophageal cancer, liver cancer, cirrhosis of the liver, homicide,
epileptic seizures, and motor vehicle accidents worldwide (WHO, 2002).

Alcohol causes 1.8 million deaths (3.2% of total) and a loss of 58.3 million (4% of total) of
Disability-Adjusted Life Years (DALY) (WHO, 2002). Unintentional injuries alone account
for about one third of the 1.8 million deaths, while neuro-psychiatric conditions account for
close to 40% of the 58.3 million DALYs. The burden is not equally distributed among the
countries. Alcohol consumption is the leading risk factor for disease burden in low mortality
developing countries and the third largest risk factor in developed countries. In Europe alone,
alcohol consumption was responsible for over 55 000 deaths among young people aged 15–29
years in 1999 (Rehm & Eschmann, 2002).

Given alcohol’s significance in world health, WHO has, since 1996, been developing a
database, the Global Alcohol Database, to provide a standardized reference source of
information for global epidemiological surveillance of alcohol use and its related problems.
The database is the world’s largest single source that documents global patterns of alcohol
use, health consequences and national policy responses, by country. This monitoring system
and database enables WHO to disseminate data and information on trends in alcohol
consumption, drinking patterns and alcohol-related mortality, including details of policy
responses in countries. The aim of the project is to provide up-to-date and comparative data
regarding the status of alcohol consumption and alcohol problems.

WHO has been undertaking a major exercise in passive epidemiological surveillance,
gathering published and unpublished data and information about key aspects of the alcohol
situation in WHO Member States. Given that this was a pioneering effort to document a
highly diverse and complex issue, the findings clearly reveal the shortcomings of global
alcohol epidemiology. The data presented in this report can be found in the Global Alcohol
Database and most of it is also available on the web site of the database (WHO, 2004a). Two
earlier reports that were published by WHO using data from this database were the first

Global Status Report on Alcohol

(WHO, 1999) and the

Global Status Report: Alcohol and

Young People

(2001a).

This new edition provides an update on the global picture of the status of alcohol as a factor in
world health and contains data that is not found in the earlier edition. The

Global Status

Report on Alcohol 2004

seeks to document what is known about alcohol consumption and

drinking patterns among various population groups as well as alcohol’s impact on health
worldwide. This information will hopefully spur further research and action to prevent and

WHO Global Status Report on Alcohol 2004

Data sources and methods

General

The country profiles, presented in Part II of the report (in CD-ROM), attempt to give an
overview of the current situation regarding alcohol in 189 WHO Member States. This was
achieved on the basis of a select number of indicators chosen by a group of experts for which
as much data as possible was collected. The indicators were: adult per capita consumption,
drinking patterns (abstainers, high risk drinking and heavy episodic drinking, both for the
general population and for young people separately), rates of alcohol dependence, traditional
or local alcoholic beverages, unrecorded alcohol consumption, alcohol-related mortality (four
chronic and four acute consequences), alcohol-related morbidity, health and social problems
(including social and economic costs), and finally some country background information.
Based on the different data searches, first drafts of the country profiles were prepared. These
drafts were then sent to the countries requesting for changes or additions. Only a small
number of countries returned comments or suggestions. The overview section is based mainly
on the data from the existing profiles and summarizes some of the main features on a global
level. In the preparation every attempt was made to include accurate and up-to-date
information available as at April 2004. All the sources used are referenced under each country
separately.

In the following sections the indicators mentioned above are explained in more detail.

Recorded adult (15+) per capita

(APC) alcohol consumption

WHO often uses adult (people 15 years and older) per capita to measure alcohol consumption,
instead of the also widely used per capita for the whole population. This is to balance the fact
that population distributions in developing countries are quite different from developed
countries, i.e. they have a much larger proportion of children and young people. Using per
capita would mean that countries with many young people will underestimate the
consumption among adults, if it is assumed that most young people below 15 do not consume
significant quantities of alcohol.

Where available, the graph of the adult per capita consumption is shown as time series from
1961 until 2001 for all beverages, and for beer, wine and spirits separately, in litres of pure
alcohol per adult per year in that particular country. The data is for recorded alcohol, i.e.
unrecorded alcohol is not included, such as alcohol from cross-border shopping, smuggling,
homemade (legal or not), and tourist consumption. For some countries estimates of the
unrecorded alcohol is presented in a separate section.

The APC estimates are based on either FAO (Food and Agriculture Organization of the
United Nations) or WDT (World Drink Trends) data, except for a few countries in Europe
where the data comes directly from governments. Where both FAO and WDT data exist, a
choice has been made in favour of the more accurate and reliable data. In the European
Region WDT is used for 25 countries, FAO for 19 and government data for four countries.
Outside Europe the overlap between FAO and WDT concerns 24 countries, from which 17
use FAO data and 7 WDT. The rest of the countries of the world use FAO, as no other source
could be found. When using WDT data the per capita is recalculated into adult per capita
consumption. The FAO data consists of estimates of production and trade in metric tonnes for

WHO Global Status Report on Alcohol 2004

the following beverages: wine, vermouth, must of grape, fermented beverages, spirits,
sorghum beer, millet beer, maize beer, barley beer, wheat fermented and rice fermented. All
the beverages are converted into pure alcohol and then combined into the categories of beer,
wine and spirits so that all beers make up the beer category, and all other beverages, besides
spirits, belong to the wine category. FAO collects the data from the countries through a
questionnaire to the Ministries of Agriculture and Trade once a year. It should be noted that a
change took place in method of calculation for the group of wine, which does not influence
the total alcohol consumption but which for some countries will show a sudden increase in
wine consumption from 1996.

The data is clearly only as reliable as the original data from the sources used. For some
countries large and sudden changes from one year to another can be seen, which unless there
is a major natural or man-made disaster or conflict is in reality rare. For more precise data on
the adult per capita please refer to the webpage of the Global Alcohol Database (WHO,
2004b), where the actual numbers are presented for each year and each country.

Drinking patterns

The adult per capita gives some idea about the level of alcohol consumption in a country, but
survey data is much needed to understand better the picture of who drinks, how much they
drink, etc. In the context of this report drinking pattern refers to the frequency, quantity and
circumstances surrounding alcohol consumption. Besides looking at gender differences, it
would also be useful to examine differences in age groups with regard to drinking patterns, as
this is useful trying to target risk groups for certain behaviours. However, due to space
constraints, this report has concentrated on drinking patterns in the total population and
among young people only. Compared to supply surveys (i.e. data on production and trade
such as FAO and WDT), these consumer surveys assessing people’s own alcohol
consumption usually show overall consumption figures which are much lower, quite often
around 40% to 60% of supply-based estimates (WHO, 2000a). This would indicate that
people are underestimating their own consumption and that these surveys do not reach the
people with the highest consumption.

Table 1:

Geographic coverage of the survey data

WHO Region

Countries with survey data/total number of countries

% population covered

AFR

28 / 46

76.72

AMR

32 / 35

99.96

SEAR

7 / 11

98.38

EMR

12 / 21

90.33

EUR

49 / 52

99.99

WPR

20 / 27

99.94

Total

148 / 192

96.22

Note

: Survey data was also found for Puerto Rico and Tokelau (both Associate Members of WHO). The data for

Puerto Rico is presented under the Region of the Americas and for Tokelau under the Western Pacific Region.

The data for drinking patterns were obtained from surveys and other studies conducted in the
respective countries, mainly from published peer-reviewed journal articles and official
reports, and in some cases grey literature such as conference papers and reports found on the
Internet. Priority was always given to published sources in peer-reviewed journals, and
secondly to official government reports. Most of the data are referring to the total population

WHO Global Status Report on Alcohol 2004

(unless otherwise specified), with data for males and females shown separately whenever
available. Besides youths, which has been the main subgroup used in the report, sometimes
data for other subgroups are also presented. This may include the incarcerated population,
people attending health care facilities or treatment, occupational categories, demographic
subgroups defined by race or ethnicity, religious subgroups, or subgroups defined by income
or geographical place of residence. Within the drinking patterns section four indicators were
chosen for the country profiles.

Rates of abstainers in the population, i.e. people who have not consumed any alcohol in

the last 12 months (if other definition of abstainer it has been separately noted).

Problem drinkers, heavy drinkers or high risk drinkers, as defined in the corresponding

source, people drinking regularly at a level where there is a high risk of chronic or
acute consequences.

Heavy episodic or binge drinkers, as defined in the corresponding source, people

drinking occasionally at a level where there is a high risk of intoxication and acute
consequences.

Rates of alcohol dependence, either in the general population or some sub-population

using some internationally validated instruments such as AUDIT and CAGE, and
diagnostic criteria such as those found in the ICD-10 or DSM-IV.

If available, data were also presented for young people for all the categories above stemming
from surveys conducted in schools or universities.

The data are presented as two graphs where possible: one showing the overall rate as
percentages and the other showing data by gender. Please note that the graphs representing
data by gender are merely for graphical purposes and are not to proportion. An example for
Bangladesh (lifetime abstainers) is shown below:

Figure 1:

Lifetime abstainers in Bangladesh

Total

94%

87.

99.

Ustun TB et al. The World Health Surveys. In: Murray CJL, Evans DB, eds.

Health Systems Performance

Assessment: Debates, Methods and Empiricism

. Geneva, World Health Organization, 2003.

For example, the total lifetime abstainers in Bangladesh as measured by the 2003 World
Health Survey is estimated to be 94% of the total population. The second graph shows the
male to female proportion from the overall, e.g. 87.4% of male Bangladeshis are abstainers,
and likewise, 99.7% of female Bangladeshis are abstainers (Ustun et al., 2003). Next to the
graphs is a text box containing information about the kind of survey used, sample size and age
group of the population sampled, the definition of the drinking pattern measured, and a

Data from the 2003 World Health
Survey. Total sample size

5508; males

= 2567 and females

= 2941. Sample population aged

18 years and above.

Note: These

are preliminary, early-release,
unpublished data from the World
Health Survey made available
exclusively for this report. Some
estimates may change in the final
analyses of the World Health
Survey.

WHO Global Status Report on Alcohol 2004

reference to the original source. When no national data were found, regional surveys or
surveys of certain cities have been used, in which case this is clearly mentioned.

Traditional alcoholic beverages

This section gives examples of different local or traditional alcoholic beverages, with short
descriptions of their alcohol by volume content, process of production, etc. Many of these
beverages would not show up in the recorded APC figures used in the beginning of the
profiles because they are locally produced in the villages, homes, etc. They are often outside
the western beer, wine and spirits categories, and also outside the control of the local
governments. The source of data is almost exclusively grey literature on the Internet, i.e.
sources which often could not be corroborated by other independent sources. This is because
there exists very little published materials about these kinds of beverages and is a fact which
should be taken into account when considering the reliability of the data.

Unrecorded alcohol consumption

This section gives an estimate of the amount of alcohol which is unrecorded in a country, i.e.
does not show up in the official APC data. Much of the unrecorded alcohol consists of the
traditionally brewed beverages described above, but there is also unrecorded alcohol derived
from means such as cross border trade and smuggling. However, only a few countries have
estimates on unrecorded alcohol consumption. This is because very little published material
exists about these kinds of beverages, which should be taken into account when considering
the reliability of the data.

Alcohol-related mortality

The data for alcohol-related mortality are shown in two graphs, one for chronic and one for
acute consequences, with time series since 1961 for each cause of death where available. It
should be noted that chronic diseases are measured on two axes. The data clearly shows gaps
in coverage, both in terms of the number of countries where no data exists and of the scarcity
of data for some specific causes. The mortality rates are from the WHO mortality database
where countries report their mortality each year using the (International Statistical
Classification of Diseases and Related Health Problems (ICD) coding system. Those crude
numbers of deaths have been converted into age standardized death rates per 1000 population
for each country using the WHO standard population. Data is only shown if there is a time
series of at least five years. One should be cautious about making any comparisons because
reliability of these figures depends on the registration of deaths at the national level.
Furthermore, death registration coverage and cross-national differences in coding practices,
particularly in the use of codes for ill-defined and unknown causes, must be taken into
account to validly compare mortality rates for specific causes across countries. Additionally,
where coverage is less than 100%, the cause of death distribution for the uncovered
population may differ from that of the covered population.

In total, eight causes of death were included here (ICD-10 codes used shown in Table 2): four
causes which were assigned as showing consequences related to high level, long time chronic
drinking (liver cirrhosis and liver disease; lip, oral cavity and pharynx cancers; alcohol
dependence and ischaemic heart disease was added to this group, although depending on the
drinking pattern, alcohol can have a protective effect for some subgroups of populations in

WHO Global Status Report on Alcohol 2004

some, mainly developed countries). The other four causes show more acute consequences
related to intoxication, i.e. motor vehicle traffic accidents, homicide and unintentional or
intentional injury, falls, and poisonings.

Table 2:

ICD codes used for causes where alcohol is one of the underlying risk factors

Cause of death

ICD-9 4-digit

ICD-9 3-digit

ICD-10 4-digit

ICD-10 3-digit

Mouth and oropharynx
cancers

140-149

C00-C14

Alcohol use disorders

291, 303,
305.0

291, 303

F10

Ischaemic heart disease

410-414

I20-I25

Cirrhosis of the liver

571

K70, K74

Road traffic accidents

E810-819,
E826-829,
E929.0

E810-819,
E826-829

V01-V04, V06,
V09-V80, V87,
V89, V99

Poisonings

E850-869

X40-X49

Falls

E880-888

W00-W19

Intentional injuries

E950-978,
990-999

X60-Y09, Y35-
Y36, Y870,
Y871

X60-Y09, Y35-
Y36, Y87

V01.1-V01.9, V02.1-V02.9, V03.1-V03.9, V04.1-V04.9, V06.1-V06.9, V09.2, V09.3, V10.4-V10.9, V11.4-

V11.9, V112.3-V12.9, V13.3-V13.9, V14.3-V14.9, V15.4-V15.9, V16.4-V16.9, V17.4-V17.9. V18.4-V18.9,
V19.4-V19.6, V20.3-V20.9, V21.3-V21.9, V22.3-V22.9, V23.3-V23.9, V24.3-V24.9, V25.3-V25.9, V26.3-
V26.9, V27.3-V27.9, V28.3-V28.9, V29.4-V29.9, V30.4-V30.9, V31.4-V31.9, V32.4-V32.9, V33.4-V33.9,
V34.4-V34.9, V35.4-V35.9, V36.4-V36.9, V37.4-V37.9, V38.4-V38.9, V39.4-V39.9, V40.4-V40.9, V41.4-
V41.9, V42.4-V42.9, V43.4-V43.9, V44.4-V44.9, V45.4-V45.9, V46.4-V46.9, V47.4-V47.9, V48.4-V48.9,
V49.4-V49.9, V50.4-V50.9, V51.4-V51.9, V52.4-V52.9, V53.4-V53.9, V54.4-V54.9, V55.4-V55.9, V56.4-
V56.9, V57.4-V57.9, V58.4-V58.9, V59.4-V59.9, V60.4-V60.9, V61.4-V61.9, V62.4-V62.9, V63.4-V63.9,
V64.4-V64.9, V65.4-V65.9, V66.4-V66.9, V67.4-V67.9, V68.4-V68.9, V69.4-V69.9, V70.4-V70.9, V71.4-
V71.9, V72.4-V72.9, V73.4-V73.9, V74.4-V74.9, V75.4-V75.9, V76.4-V76.9, V77.4-V77.9, V78.4-V78.9,
V79.4-V79.9, V80.3-V80.5, V81.1, V82.1, V83.0-V83.3, V84.0-V84.3, V85.0-V85.3, V86.0-V86.3, V87.0-
V87.8, V89.2, V89.9, V99, Y850.

Morbidity, health and social problems from alcohol use

This section is not a comprehensive overview of all the health and social problems related to
alcohol consumption, which are numerous. Rather it is a brief insight into some of the
consequences alcohol causes for particular societies. The section presents in a qualitative
manner some results from national studies on different issues such as traffic accidents,
suicide, violence, work absenteeism, and public drunkenness. The briefs are based primarily
on published scientific literature and reports from governments or national agencies.

WHO Global Status Report on Alcohol 2004

Figure 3: Population weighted means of the recorded adult per capita consumption in the

WHO Regions 1961-1999

Year

litres of pure alcohol

SEARO

WPRO

EURO

EMRO

AMRO

AFRO

The regional data indicates that for the WHO Regions other than EMR (mostly countries with
majority Muslim populations) there is a certain trend towards harmonization of the
consumption levels. On a regional level, those with the highest consumption are decreasing,
while those with the lowest are increasing their consumption. This also falls within the
explanatory model that many developing countries are increasing their alcohol consumption
with an increasing level of economic development. On a more general level the link between
economic prosperity and rising alcohol consumption can also be seen e.g. for the Nordic
countries and Ireland. Of course the regional level also hides large differences within
countries, as again increases and decreases may cancel each other out.

Data at the country level as regards adult per capita consumption can be found in each country
profile. For an overview of all the countries with the most recent data, Table 3 shows the
recorded adult per capita consumption for all available countries for the year 2000 or 2001,
arranged from the lowest recorded consumption to the highest.

WHO Global Status Report on Alcohol 2004

Table 3:

Total recorded alcohol per capita consumption (15+), in litres of pure alcohol

Country Total

Iran

0.00

Brunei Darussalam

0.49

Kiribati

1.66

Jamaica

3.37

Kuwait

0.00

Bhutan

0.57

Mozambique

1.67

Bolivia

3.43

Libyan Arab Jamahiriya (the)

0.00

Syrian Arab Republic (the)

0.62

Fiji

1.69

El Salvador

3.45

Saudi Arabia

0.00

Micronesia (Federated States of)

0.64

Côte d'Ivoire

1.71

Seychelles

3.61

Somalia

0.00

Tunisia

0.65

Maldives

1.72

Cuba

3.65

Bangladesh

0.00

Turkmenistan

0.77

Kenya

1.74

Cameroon

3.66

Mauritania

0.01

India

0.82

Lesotho

1.83

Cape Verde

3.72

Pakistan

0.02

Solomon Islands

0.86

Mongolia

1.96

Philippines (the)

3.75

Algeria

0.03

Equatorial Guinea

0.90

Israel

1.99

Ukraine

4.04

Nepal

0.08

Ethiopia

0.91

Ecuador

1.99

The form. Yugoslav Rep. of Mac.

4.12

Comoros

0.08

Togo

0.95

Dem. Republic of the Congo

2.01

Lebanon

4.13

Yemen

0.08

Papua New Guinea

1.01

Gambia (the)

2.27

Antigua and Barbuda

4.24

Indonesia

0.10

Malaysia

1.06

Honduras

2.28

Burkina Faso

4.38

Egypt

0.10

Djibouti

1.08

Congo

2.36

China

4.45

Niger (the)

0.11

Vanuatu

1.11

Namibia

2.39

Belize

4.50

Jordan

0.11

Benin

1.22

Georgia

2.41

Guam

4.50

Guinea

0.14

Armenia

1.23

Albania

2.51

Mexico

4.62

Sri Lanka

0.18

Oman

1.32

Nicaragua

2.53

Peru

4.68

Iraq

0.20

Viet Nam

1.35

Bahrain

2.63

Zimbabwe

5.08

Chad

0.23

Madagascar

1.38

Singapore

2.73

United Republic of Tanzania

5.29

Sudan (the)

0.27

Samoa

1.42

United Arab Emirates (the)

2.75

Brazil

5.32

Cambodia

0.36

Malawi

1.44

Guinea-Bissau

2.76

Botswana

5.38

Myanmar

0.36

Turkey

1.48

Kazakhstan

2.89

Costa Rica

5.45

Morocco

0.41

Uzbekistan

1.52

Angola

2.91

Kyrgyzstan

5.50

Tajikistan

0.41

Eritrea

1.54

Zambia

3.02

Dem. People's Republic of Korea

5.68

Qatar

0.44

Ghana

1.54

Liberia

3.12

Iceland

5.74

Senegal

0.48

Guatemala

1.64

Mauritius

3.16

Norway

5.81

Mali

0.49

Central African Republic (the)

1.66

Trinidad and Tobago

3.22

Suriname

5.82

WHO Global Status Report on Alcohol 2004

Country Total

Guyana

5.84

Gabon

7.97

Hungary

11.92

Colombia

5.92

Belarus

8.12

Denmark

11.93

Chile

6.02

Canada

8.26

Spain

12.25

Panama

6.04

Thailand

8.47

Lithuania

12.32

Sao Tome and Principe

6.07

United States of America (the)

8.51

Slovakia

12.41

Dominican Republic (the)

6.11

Argentina

8.55

Portugal

12.49

Haiti

6.51

Bosnia and Herzegovina

8.62

Austria

12.58

Slovenia

6.55

Poland

8.68

Croatia

12.66

Saint Vincent and Grenadines

6.58

Venezuela

8.78

Germany

12.89

Sierra Leone

6.64

Italy

9.14

Bermuda

12.92

Paraguay

6.66

Australia

9.19

Reunion

13.39

Cyprus

6.67

Dominica

9.19

France

13.54

Barbados

6.70

Bahamas (the)

9.21

Republic of Moldova (the)

13.88

Lao People's Democratic Republic (the)

6.72

Greece

9.30

Ireland

14.45

Malta

6.74

Latvia

9.31

Czech Republic (the)

16.21

Rwanda

6.80

Burundi

9.33

Luxembourg

17.54

Sweden

6.86

Swaziland

9.51

Uganda

19.47

Azerbaijan

6.94

Netherlands (the)

9.74

Uruguay

6.96

New Zealand

9.79

Bulgaria

7.13

Estonia

9.85

Japan

7.38

Netherlands Antilles

9.94

Grenada

7.39

Nigeria

10.04

Saint Kitts and Nevis

7.62

Belgium

10.06

Romania

7.63

United Kingdom (the)

10.39

French Polynesia

7.68

Finland

10.43

Republic of Korea (the)

7.71

Saint Lucia

10.45

South Africa

7.81

Russian Federation (the)

10.58

New Caledonia

7.83

Switzerland

11.53

Sources

: FAO (Food and Agriculture Organization of the United Nations), World Drink Trends 2003

Note:

Several African countries (Burundi, Nigeria, Swaziland and Uganda) appear in the list in the top 30 positions of adult per capita consumption. This is because the

calculations were based on FAO data which included fermented beverages and estimates of beer produced locally from sorghum, millet and other agricultural products.

WHO Global Status Report on Alcohol 2004

Beverage preferences

Looking a bit further into beverage preferences shows that countries often can be categorized
as mainly beer, wine or spirits countries. Table 4 gives an example of beverage preferences
among the different countries. It shows the top 20 countries with the highest consumption for
each beverage category, using simply the recorded adult per capita (APC) in litres of pure
alcohol for that specific beverage type. Among the mainly beer drinking countries are mostly
European countries, and a few African. The largest wine drinkers are the wine producing
countries of Europe. Most of the large spirits consuming countries are found in Eastern
Europe, Asia and some island states.

Table 4:

Top 20 countries with highest beverage-specific adult per capita consumption

Beer Wine*

Spirits

Country APC

Country

APC

Country

APC

Czech Republic (the)

9.43

Luxembourg

9.43

Republic of Moldova (the)

10.94

Ireland 9.24

France

8.38

Reunion

8.67

Swaziland

7.49

Portugal

7.16

Russian Federation (the)

7.64

Germany 7.26

Italy

6.99

Saint

Lucia

7.27

Austria 6.42

Croatia

6.42

Dominica

7.20

Luxembourg 6.16

Switzerland

6.23

Thailand

7.13

Uganda 6.14

Argentina 5.63

Bahamas

(the)

7.05

Denmark 6.02

Spain 5.07

Latvia

6.62

The United Kingdom

5.97

Bermuda

4.95

Haiti

6.46

Belgium 5.90

Greece

4.78

Belarus

6.34

Venezuela

5.69

Denmark

4.57

Lao People's Democratic Republic

6.09

Lithuania 5.53

Austria

4.47

Bosnia and Herzegovina

6.03

Slovakia 5.34

Hungary

4.47

Saint Vincent and Grenadines

5.98

Australia

5.20

Uruguay

4.35

Dem. People's Republic of Korea

5.48

Croatia 5.16

Germany

3.38

Slovakia

5.44

Netherlands Antilles

4.96

Romania

3.37

Grenada

5.06

Netherlands (the)

4.91

Chile

3.25

Lithuania

4.92

Finland 4.89

French

Polynesia

3.10

Azerbaijan 4.66

United Republic of Tanzania

4.85

Bulgaria

3.05

Kyrgyzstan

4.61

Gabon

4.77

Republic of Korea (the)

2.99

Czech Republic (the)

4.41

*Throughout the report, fermented beverages are included in the wine category. However, for this table only
average wine has been used to present the countries with the highest adult per capita wine consumption. If the
fermented beverages were included, countries such as Uganda, Nigeria, Burundi, Sierra Leone, Rwanda and
Sao Tome and Principe would appear to be among the top 'wine' drinking countries.

Changes in beverage preferences can be illustrated with the case of Europe where
consumption of beer is increasing, consumption of wine is decreasing and consumption of
spirits is rather stable as in Europe non-wine producing countries are opening up to wine,
while wine-producing countries are opening up to other alcoholic beverages.

An example of a typology of wine consumption in Europe:

1. Wine producers with a high level of production, a high level of consumption, and
decreasing consumption continually (France, Greece, Italy, Portugal and Spain).

WHO Global Status Report on Alcohol 2004

Unrecorded alcohol consumption

Total alcohol consumption is either derived from official records on consumption or
representative population surveys on consumption. As mentioned in the data sources and
methods section official statistics on alcohol consumption, sales or trade are usually only
based on the recorded figures. In many countries there is alcohol available which lies outside
of the recorded sphere. This is often called unrecorded alcohol. This alcohol mainly stems
from the following sources:

home production, in many countries licit for wine and beer, while illicit for spirits;

travellers' imports and cross-border shopping;

smuggling, either organized criminal activity or travellers importing amounts which

exceed the legal allowance;

surrogate alcohol intended for industrial, technical or medical purposes;

tourist consumption i.e. alcoholic beverages consumed during visits to other countries;

beverages with alcohol content below the legal definition of alcohol.

Relatively few countries have conducted studies on estimating the level of unrecorded alcohol
consumption, thus, for the majority of countries, no official estimate of unrecorded alcohol
could be found. Recently, a group of alcohol experts have attempted to estimate the level of
unrecorded alcohol consumption in a number of countries (Rehm & Gmel, 2001). These
estimates were derived from a variety of sources, including the first Global Status Report on
Alcohol, specialized surveys that asked about unrecorded alcohol in particular countries, and
through focal point reports or replies to questionnaires sent to individual countries. Table 5
shows estimates of unrecorded alcohol for a select number of countries (for complete table
see Rehm & Gmel, 2001).

Some countries have an estimated unrecorded alcohol consumption level of zero or even
negative. For instance, in the case of Luxembourg (-1.0 litres per adult capita), it is estimated
that visitors or tourists account for a sizable portion of the alcohol consumed which could
explain why the overall consumption level for the actual Luxembourg population may have
been over-recorded. At the other end can be found countries where most of the alcohol is
unrecorded, e.g. in East Africa where over 90% of alcohol consumed according to some
estimates is unrecorded. Countries in Africa with a relatively high level of estimated
unrecorded alcohol include Burundi (4.7 litres), Kenya (5.0 litres), Rwanda (4.3 litres),
Seychelles (5.2 litres), Swaziland (4.1 litres), Uganda (10.7 litres) and Zimbabwe (9.0 litres).
Also, certain countries in Eastern Europe and some of the former Soviet Union republics have
a sizeable estimated unrecorded alcohol consumption e.g. Belarus (4.9 litres), Croatia (4.5
litres), Estonia (5.0 litres), Kazakhstan (4.9 litres), Latvia (7.0 litres), Republic of Moldova
(12.0 litres), Russian Federation (4.9 litres), Slovakia (7.0 litres), and Ukraine (8.0 litres).
Other countries with very high estimated unrecorded alcohol consumption include Mauritius
(11.0 litres) and the Republic of Korea (7.0 litres). On a regional basis, unrecorded alcohol
consumption is estimated to be at least two thirds of all alcohol consumption in the Indian
subcontinent, about half of consumption in Africa, and about one third in Eastern Europe and
Latin America (Rehm et al., 2003b).

WHO Global Status Report on Alcohol 2004

Table 5:

Estimated volume of unrecorded consumption in litres of pure alcohol per capita
for population older than 15 for the years after 1995

Country

Unrecorded

consumption

Country

Unrecorded

consumption

Country

Unrecorded

consumption

Albania 3.0

Fiji

1.0

Republic of Korea (the)

7.0

Algeria 0.3

Georgia

2.0

Republic of Moldova (the)

12.0

Argentina 1.0

Guatemala 2.0

Romania

4.0

Armenia 1.9

Guyana 2.0

Russian Federation (the)

4.9

Australia 0.0

Haiti

0.0

Rwanda

4.3

Austria 1.0

Honduras

2.0 Saudi

Arabia

0.6

Azerbaijan 1.9

Hungary 4.0

Senegal

0.8

Barbados -0.5

Iceland 1.0

Seychelles

5.2

Belarus 4.9

India

1.7 Slovakia

7.0

Belgium 0.5

Iraq

1.0

Slovenia

1.3

Belize 2.0

Jamaica

1.0 South

Africa

2.2

Bolivia

3.0 Japan

2.0 Spain

1.0

Botswana 3.0

Kazakhstan

4.9

Sri

Lanka

0.5

Brazil 3.0

Kenya

5.0

Sudan

1.0

Bulgaria

3.0 Kyrgyzstan

2.0 Suriname

0.0

Burkina Faso

3.3

Latvia

7.0

Swaziland

4.1

Burundi

4.7

Lithuania

4.9

Syrian Arab Republic (the)

0.4

Cameroon

2.6 Luxembourg

-1.0 Tajikistan

4.0

Chile 2.0

Malaysia

3.4

TFYR

Macedonia

2.9

China

1.0

Mauritius

11.0

Thailand

2.0

Colombia

2.0

Mexico

3.0

Trinidad and Tobago

0.0

Costa Rica

2.0

Mongolia

2.0

Tunisia

0.5

Croatia 4.5

Myanmar

0.4

Turkey

2.7

Cuba 2.0

Nicaragua

0.5 Turkmenistan

1.0

Czech Republic (the)

1.0 Nigeria

3.5 Uganda

10.7

El Salvador

2.0

Paraguay

1.5

Ukraine

8.0

Eritrea 1.0

Peru 1.0 Uzbekistan

1.9

Estonia 5.0

Philippines

(the) 3.0

Venezuela

2.0

Ethiopia 1.0

Poland

3.0 Zimbabwe

9.0

Source

: Rehm & Gmel (2001)

One study that attempts to document the extent of unrecorded alcohol within the European
Union (EU) is the ECAS project (European Comparative Alcohol Studies) which involved 13
EU member states (Greece and Luxembourg excluded) and Norway. According to this study,
the approximate level of unrecorded alcohol consumption (litres of pure alcohol per inhabitant
aged 15 or over) in the study countries ranged from about 0.5 litres (Netherlands and
Belgium), around 1 litre (Austria, France, Germany, Ireland, Portugal and Spain), between 1
and 2 litres (Italy) and approximately 2 litres (Norway, Finland, Sweden, Denmark and the
United Kingdom) (Leifman, 2001). The concern over the level of unrecorded alcohol has been
the highest in the Nordic countries and in Norway and Sweden in particular. For example, in
Norway, according to the Norwegian Institute for Alcohol and Drug Research (SIRUS), a
notable amount of unrecorded alcohol is consumed in the country, mostly originating from
legal (wine) or illegal home production, smuggling and travel imports. The proportion of the
unrecorded alcohol is estimated at 25 to 30% of the total consumption (SIRUS, 2003).
Estimates are even higher for other countries - in Lithuania for instance, it has been estimated
that up to 65% of alcohol consumed in 1994 was illegally produced or imported (Logminiene

WHO Global Status Report on Alcohol 2004

et al., 2004). According to the

1999 Lithuanian Human Development Report

published by the

United Nations Development Program, consumption of alcohol is higher among the rural
population. Traditions of drinking heavily became stronger when home brew alcohol became
more widespread and accessible. The rural population in Lithuania remains the principal
market for illegal alcohol (Subata, 1999).

In most cases, adult per capita (APC) alcohol consumption is useful for looking at population
level trends in alcohol consumption, but they do not include unrecorded alcohol consumption,
which in some countries is actually the majority of the alcohol available. In Nepal, for
instance, unlicensed home-brewing accounts for a major part of alcohol production. In fact,
the Liquor Control Act of Nepal allows for the production of homemade forms of alcohol for
domestic use, although much homemade alcohol is produced for the market. Such activity
takes place mostly in rural settings but also occurs in urban areas. The poor are quite often
dependent on home-brewing for their livelihood (Jhingan et al., 2003). Variations may also
exist within a country. In China for example, a 2001 survey of community residents in five
areas of China found that 7.1% of respondents reported having consumed unrecorded
alcoholic beverages in the three months prior to the interview (most frequently rice wine and
paddy wine); the amount of unrecorded alcoholic beverage (in pure alcohol terms) accounted
for 14.9% of overall alcohol consumption in the five areas studied. The amount of unrecorded
alcohol consumption varied, e.g., in Shandong Province, 24.1% of respondents had consumed
unrecorded alcoholic beverages in the past three months and the proportion of these beverages
was 29.9% of the overall alcohol consumption (Hao et al., 2004). In most cases for APC, the
national or local level data is more reliable than international data. When thinking about the
impact on the overall level of alcohol consumption of issues like smuggling, tourism,
overseas consumption, stockpiling, duty-free purchases, home- or informally produced
alcohol, it is recommended that questions about sources of unrecorded alcohol should be
added to national or regional drinking surveys.

The official sales statistics in a country do not, for various reasons, represent the actual
consumption of alcoholic beverages among the inhabitants. Part of the unrecorded alcohol
stems from consumption of alcohol when inhabitants are abroad and also from tax-free
purchases. The first one is to a large extent included in the official statistics, but not in the
country where the consumer lives. A European study looking at potential corrections for
consumption abroad and tax-free purchases found that among the 15 countries of the study,
the correction in the official sales was between +11.4% and -1.5%; on an aggregated level this
corresponds to 2–3% of the official sales in the area (Trolldal, 2001).

It is not only for reasons of statistical accuracy that improved knowledge of unrecorded
alcohol is needed. More important is the fact that variations in unrecorded alcohol
consumption, both between and within countries over time, may indicate differences and
changes in per capita consumption and in drinking patterns not otherwise revealed by changes
in recorded consumption. Documentation of unrecorded alcohol is therefore of importance in
alcohol policy studies, and especially in studying the links between alcohol policy, alcohol
consumption and alcohol-related problems (Leifman, 2001).

WHO Global Status Report on Alcohol 2004

Traditional or local alcoholic beverages

In many countries there are beverages which either fall outside of the usual beer, wine and
spirits categories or which are traditionally produced at the local level, for example in villages
and in homes. This kind of production seems especially common in many African countries,
where a wide variety of different beverages can be found. Many of these are produced by
fermentation of seeds, grains, fruit, vegetables or from palm trees, which is a rather simple
procedure. Through fermentation the alcohol content does not rise very high and often the
beverages have a very short shelf life before they are spoilt. Distillation is a more complex
procedure requiring more equipment and time, but then the result is both more potent and has
a longer shelf life date.

Even with the limited data available about prices, it seems that there is ground for the
expectation that at least some home or locally made beverages are cheaper than mass or
factory produced “branded” beverages. In some cases the price difference is quite significant.
This means that it is mostly the poorer segments of the society which consume these local
beverages, except in the case of some culturally important beverages which might have
ceremonial value. In Nigeria for example, the alcoholic beverage called

burukutu

is popular in

rural areas and in poor urban neighbourhoods because it is more affordable than commercially
produced beer (Obot, 2000). Likewise, in the United Republic of Tanzania, domestically
produced “homemade” or “informal-sector” drinks continue to dominate the market and local
drinking habits (Green, 1999). In the case of Seychelles, although home brew is consumed
only by a minority of the population (mainly of low socioeconomic status), home brew
drinkers consumed particularly high amounts of alcohol derived from these homemade
beverages. The much lower cost per alcohol unit of home brews compared to beer or spirits is
likely to be an important factor to maintain home brew drinking in segments of the population
(Bovet, 2001). Furthermore, in some countries (e.g. Namibia), the production of home-
brewed beverages is the dominant channel for alcohol availability. Control was practically
non-existent and cheap home-brewed beer found an easy market among the low-income or
no-income consumers. Production of home-brewed beverages is closely connected to food
production in both the urban and rural areas. The producers are a heterogenous group, but
many of them are women, particularly widows or divorced older women. Especially for older
women it is largely a question of improving their economic livelihoods (Mustonen, Beukes &
Du Preez, 2001).

These traditional forms of alcohol are usually poorly monitored for quality and strength, and
in most countries it is possible to find examples of health consequences related to harmful
impurities and adulterants. Extreme cases might even result in death as was the case in Kenya
in November 2000 where 140 people reportedly died, many went blind and hundreds were
hospitalized after consuming an illegally brewed and poisonous liquor called

kumi kumi

in the

poor neighbourhoods of Mukuru Kwa Njenga and Mukuru Kaiyaba. Made from sorghum,
maize or millet, the alcoholic drink is common among Kenyans living in the country's low-
income urban and rural areas who can ill-afford conventional legal beer.

Kumi kumi

contains

methanol and other dangerous additives such as car battery acid and formalin (Mureithi,
2002). In Zimbabwe, it has been noted that in addition to home-brewed beer, alcohol industry
representatives and government officials agree that there is a strong enough market for

kachasu

, a name given to home-distilled products with 10% to 70% alcohol content, to

warrant it as a major problem. Occasional newspaper reports of alcohol poisonings from

kachasu

point not only to the high alcohol content, but also the continued use of lethal

additives to speed drinkers to their desired high (Riley & Marshall, 1999). Similar cases have

WHO Global Status Report on Alcohol 2004

also been reported in Bangladesh, India and Somalia (see country profiles for details). When
viewed from a public health and welfare perspective, it is important for the state to gain
effective control and oversight over informal alcohol production and distribution. Licensing
and inspection of production, whether it be a matter of cottage, of small factory or of full-
scale industrial production, is an important means of eliminating adulterants (Rehm et al.,
2003b).

Although more expensive, there is indication that industrially produced beverages,
particularly lager-style beer, are gaining popularity in many developing countries, due
perhaps to issues of prestige attached to international brands and increasing marketing efforts
by multinational alcohol beverage companies (Babor et al., 2003).

It would seem that there may be health benefits from replacing cottage-produced with
industrially-produced alcohol in terms of the purity of the product. However, these benefits
should also be empirically verified, since they can easily be overstated (Room et al., 2002).
On the other hand, it could be speculated that traditionally produced alcoholic beverages may
potentially carry the benefits of having a lower alcohol content, providing local employment
opportunities and preserving values of the local culture (which may or may not promote lower
levels of alcohol consumption).

The following case examples present some information regarding local and traditional
alcoholic beverages in selected countries. As mentioned earlier, there exists a wide range of
beverages - what is interesting to note here is the social context in which these beverages are
produced and consumed in different parts of the world.

Case example 1: India

Country liquor is a distilled alcoholic beverage made from locally available cheap raw material such as sugar-
cane, rice, palm, coconut and cheap grains, with an alcohol content between 25% and 45%. Common varieties of
country liquor are

arrack

(from paddy or wheat),

desi sharab

and

tari

. Illicit liquor is mostly produced

clandestinely in small production units with raw materials similar to that used for country liquor. With no legal
quality control checks on them, alcohol concentration of illicit liquor varies (up to 56%). Adulteration is quite
frequent, industrial methylated spirit being a common adulterant, which occasionally causes incidents like mass
poisoning with consumers losing their lives or suffering irreversible damage to the eyes. Cheaper than licensed
country liquor, illicit liquor is popular among the poorer sections of the population. In many parts of India, illicit
production of liquor and its marketing is a cottage industry with each village having one or two units operating
illegally.

Source

: Mohan et al. (2001)

Case example 2: Venezuela

Corn liquor is consumed by an indigenous tribe in Venezuela. Several times each year, especially during the corn
harvest season, the trunk of a large tree would be hollowed out and filled with corn mash by an individual
specially chosen by the community. The corn mash would be allowed to ferment to create an alcoholic beverage
with a high enough alcohol content to cause intoxication after consumption of only two glasses or gourdfuls.
When the corn liquor is ready, a village festival would be held in which all adults would drink to the point of
falling down. Men would typically bring their bows and arrows and fight to settle grudges. Festivals would end
after two or three days, when the corn liquor ran out. There were rarely individuals who consumed alcoholic
beverages at times other than festival celebrations.

Source

: Seale et al. (2002)

WHO Global Status Report on Alcohol 2004

Case example 3: Malaysia

In the East Malaysian states of Sabah and Sarawak on the island of Borneo, indigenous people traditionally drink
a homemade rice wine called

tuak

tapai

in conjunction with harvest celebrations and social or communal

gatherings. This rice wine is reportedly very potent. At such important functions, especially the harvest festival,
which is of much significance for these agrarian folk, almost all are required to drink. Refusal by guests to
partake of these drinks is a breach of etiquette. Such drinking is an integral part of the culture of these tribes.

Source

: Arokiasamy (1995)

Case example 4: Uganda

Tonto

is a traditional brew produced from juice obtained from special varieties of bananas. The common local

banana varieties used in making

tonto

are

kisubi

ndizi

musa

kivuru

kabula

and

mbidde

. Another common

name used for the brew in central Uganda is

mwenge bigere

. It is mostly consumed in central and western

Uganda, where banana growing is a major agricultural activity, and in urban areas all around the country at
social gatherings and in bars. In various parts of the country, it is a source of income for many families. The
production of

tonto

is as follows: Green bananas are ripened for 3–5 days in a covered, previously warmed, pit

lined with banana leaves to ensure uniform temperature. The juice is extracted from the ripe banana by
squeezing, by a group of men using their feet after mixing with spear grass. The juice is then filtered through
grass held in a calabash funnel and diluted with water in known ratios. Roasted and ground sorghum is added to
the diluted banana juice in a canoe-shaped wood container. The fermentation broth is then covered with banana
leaves and split banana stems in a warmed pit and incubated for 2–4 days. The alcohol content in

tonto

ranges

between 6 and 11% v/v and is consumed from small gourds using straws.

Source

: Mwesigye & Okurut (1995)

Case example 5: Botswana

Bojalwa

(sorghum beer)

and

khadi

are both home-brewed beer-like drinks that vary greatly in terms of taste,

consistency and alcohol content depending on availability of ingredients and methods of fermentation. Indeed

khadi

could almost be described as a ‘designer alcohol’ often brewed to the consumer’s needs and tastes. It is

made from a base or ‘mash’ that can consist of a combination of any of the following ingredients: wild berries,
wild pumpkins, wild roots, oranges, sorghum and maize. Yeast, black tobacco or other unspecified substances
are sometimes added to this base to give it ‘strength’, and there have been rumours around Ghanzi of car battery
acid also being added.

Source

: Molamu & Macdonald (1996)

Case example 6: Ethiopia

Talla

is an Ethiopian home-brewed beer which differs from the others in some respects. First it is brewed with

barley or wheat, hops, or spices. Secondly, it has a smoky flavour due to the addition of bread darkened by
baking and use of a fermentation vessel which has been smoked by inversion over smoldering wood.

Talla

is not

processed under government regulations hence the alcohol content varies but is usually around 2% to 4%.
Filtered

tella

has a higher alcohol content ranging from 5% to 6%.

Source

: Selinus (2004)

WHO Global Status Report on Alcohol 2004

Case example 7: Egypt

Bouza

(traditional beer) is a fermented alcoholic beverage produced from wheat in Egypt, and has been known

by the Egyptians since the days of the Pharaohs. It is a thick, pasty yellow beverage and produces a sensation of
heat when consumed. Like other opaque beers,

bouza

has a very short shelf life and is expected to be consumed

within a day. It has an alcoholic content of between 3.8% and 4.2%.

Source

: Haard (1999)

Case example 8: Ghana

Pito

(local brew made from millet) is widely consumed in Ghana. The brewing of

pito

is traditionally associated

with the people in the northern part of the country, but migration has led to its production throughout the
country. The industry is mostly controlled by women between the ages of 18 and 67 years old.

Pito

is golden

yellow to dark brown in colour with taste varying from slightly sweet to very sour. It contains lactic acid, sugars,
amino acids, 2% to 3% alcohol and some vitamins and proteins. There are four types of

pito

in Ghana –

nandom

kokmba

togo

and

dagarti

. The peculiar characteristics of each lies in the differences in their wort

extraction and fermentation methods.

Source

: Akyeampong (1995); Sefa-Dedeh (1999)

Case example 9: Kenya

Muratina

is an alcoholic drink made from sugar-cane and muratina fruit in Kenya. The fruit is cut in half, sun-

dried and boiled in water. The water is removed and the fruit sun-dried again. The fruit is added to a small
amount of sugar-cane juice and incubated in a warm place. The fruit is removed from the juice after 24 hours and
sun-dried. The fruit is now added to a barrel of sugar-cane juice which is allowed to ferment for between one and
four days. The final product has a sour alcoholic taste.

Source

: The Schumacher Centre for Technology & Development (2004)

Case example 10: United Republic of Tanzania

A study that collected and analysed 15 homemade but commercially available alcoholic beverages in Dar es
Salaam found that ethanol concentrations of the brewed samples ranged from 2.2 to 8.5% w/v whilst the two
distilled samples contained 24.2% and 29.3% ethanol w/v. Aflatoxin B1 was found in nine brewed beverages,
suggesting the use of contaminated grains or fruit for their production. The amount of zinc in four samples was
double the World Health Organization recommended maximum for drinking water (5 mg/litre). One brewed
beverage contained toxic amounts of manganese (12.8 mg/litre). Both distilled spirits were rich in fusel alcohols
and one was fortified by caffeine. The results suggested that impurities and contaminants possibly associated
with severe health risks, including carcinogens, are often found in traditional alcoholic beverages. Continuous
daily drinking of these beverages is certain to increase health risks.

Source

: Nikander et al. (1991)

WHO Global Status Report on Alcohol 2004

Drinking patterns

The consumption of alcoholic beverages can be studied from a number of viewpoints, ranging
from the viewpoint of an economist to that of a cultural anthropologist. When viewed from a
public health perspective, alcoholic beverages can potentially be an agent of illness and
mortality. Depending on the consumption pattern, use of alcoholic beverages can elevate the
drinker’s risk of health problems (traffic and other accidents, chronic illness such as cirrhosis
and cancer, and mental disorders such as alcohol dependence) as well as social problems
(inability to cope with work, family and other roles, and harm to those in the drinker's
surrounding environment). Against this burden, there is some evidence that small amounts of
alcohol may play a protective role in heart disease (Midanik & Room, 1992; Corrao et al.,
2000).

The distribution of drinking patterns in the population at large is of interest from all these
perspectives, although different perspectives tend to emphasize different aspects of drinking.
A public health analysis should take into account environmental factors, because they put
drinking in its socioeconomic context and can provide important information on potential
means of harm reduction. However, a public health analysis should also take into account the
amount of alcohol consumed, because the alcohol content of beverages is a key risk factor for
its various adverse consequences – as a biochemical agent in the development of chronic
health problems, as an intoxicant involved in accidents and other acute problems, and as a
dependence-causing substance in chronic problems (Midanik & Room, 1992).

Alcohol consumption in the population can be measured in two main ways: by analysing
production and distribution statistics for alcoholic beverages as market commodities and by
asking samples of the population questions about their drinking behaviour (Midanik & Room,
1992).

Survey data offer important advantages. In the first place, it is one way to measure, however
imperfectly, the alcohol consumption, which is not recorded in official statistics – which in
many countries constitutes the greater share of total alcohol consumption. Second, survey data
can give a picture of the social location of drinking in a society, and also allows a direct focus
on charting the distribution and correlates in the population of the patterns of drinking most
likely to be associated with harm – intoxication episodes, and long-term heavy drinking.
Third, a survey offers a way to measure directly alcohol-related problems, which do not show
up in police or health statistics: problems in family life, for instance, or in work performance.
Fourth, analyses of survey data can explore directly the relationship between patterns and
contexts of drinking and the occurrence of social and health problems. Fifth, when surveys are
repeated over time, they can be used to monitor the situation in the society and to evaluate
policy initiatives (WHO, 2001b).

However, the most important advantage of survey data over consumption statistics is that
each respondent’s patterns are recorded separately. A person’s drinking pattern can thus be
related to other personal characteristics and behaviours. Drinking patterns can be surveyed for
all kinds of population subgroups, whereas consumption statistics can be broken down only
geographically.

A further advantage of survey data is that they allow a detailed examination of different facets
of drinking behaviour. Many drinkers have quite complex patterns of drinking. Consider an
example of a week’s drinking by a relatively heavy-drinking respondent (adapted from
Midanik & Room, 1992):

WHO Global Status Report on Alcohol 2004

one drink after work on Monday with a work client

two drinks with family dinner on Monday, Tuesday and Thursday

no drinks on Wednesday

eight drinks at a party on Friday night

two drinks on a Saturday afternoon while relaxing in the backyard

four drinks out at dinner with friends on Saturday evening

no drinks on Sunday

The respondent’s pattern can be summarized in a number of ways. In terms of

volume

drinking, here the respondent drinks, on average, three drinks a day. In terms of

frequency

drinking, the respondent drinks nearly every day – 5 days out of 7. But neither of these
summaries provides a sense of

variability

in the drinking pattern – that the respondent drinks

relatively moderate amounts on most days, but sometimes drinks much larger amounts. This
aspect of drinking can be covered by a measure of dispersion (like the standard deviation), or
with a summary of how often the respondent drinks more than a certain amount. For example,
this respondent probably falls into the category of heavy episodic drinking – consuming five
or more drinks on one occasion at least once a week (Midanik & Room, 1992).

The aspect of drinking pattern that should be emphasized during data collection and analysis
depends in part on the purpose of the research. When viewed as a risk factor for many long-
term physical consequences of drinking – such as cirrhosis of the liver – the overall volume of
drinking is probably the most important aspect. But as a risk factor for accidents or social
disruptions, it is the individual episodes of heavy drinking that are of interest, in combination
with the drinking context. The greatest immediate risk associated with the above sample
respondent’s drinking week, for instance, would probably be if he or she attempted to drive
home on Friday or Saturday night. For studies attuned to such consequences, the average
number of drinks per day is less important than the frequency of drinking large amounts of
alcohol. Someone who drinks one drink at lunch and two with dinner every day, for example,
would be at less risk for problems associated with intoxication than the sample respondent,
although the overall volume of drinking would be the same (Midanik & Room, 1992).

The modern tradition of survey research on drinking patterns and problems in the general
population is a rather recent development. Some countries (mainly developed ones) have
established in about the last 30 years or so a tradition of repeated surveys, allowing trends and
developments to be monitored in the whole society and in subgroups of the population.
Survey research on drinking patterns and problems in developing societies is much less
common (although some exceptions such as in Costa Rica, India and Mexico can be found).
Such surveys have contributed important information on the demography of drinking – where
different patterns on drinking (or abstention) are distributed by subgroups of the population
formed by differentiations such as gender, age, socioeconomic status and region of residence.
They might have become a way of gathering information on alcohol consumption not
recorded in official statistics. As a society builds up a tradition of such surveys, they also
become tools for monitoring trends in different social groups, and sometimes for evaluating
the effects of policy interventions in the society. They thus become an important tool for
alcohol policymaking in a public health perspective (WHO, 2001b).

WHO Global Status Report on Alcohol 2004

This report looked at rates of alcohol abstainers, some measure of heavy and hazardous
drinking, high risk drinking or problem drinking, heavy episodic drinking or binge drinking
and alcohol dependence.

Who are the abstainers?

As can be seen in Table 6, the rates of abstainers vary considerably across countries. The
proportion of last year abstainers among the total adult population reported across countries
ranged from a low of 2.5% in Luxembourg to a high of 99.5% in Egypt. In relation to lifetime
abstainers (have never tried alcohol) among the total adult population, the rates range from
9.4% in Latvia to 98.4% in the Comoros (see country profiles for more information). Care
must be taken when interpreting this table as the cut-off age for different countries varies
(from 12 years and above to 18 years and above). Given the role of alcohol in different
societies, these differences may be quite easily explained. The one consistency that appears to
transcend cultures is the difference in abstention rates between males and females. A higher
proportion of women abstain from alcohol than men. A second common finding is the role of
religion in shaping drinking habits. For instance, countries with Islam as the official religion
almost always have higher rates of abstinence. However, in each case, one must keep in mind
that patterns of abstinence, like drinking patterns, may vary within specific subpopulations
and across different regions of a particular country. This is especially true for multicultural
and multiethnic societies, in which different groups may represent quite diverse traditions
with respect to alcohol.

Table 6:

Rate of last year abstainers among the adult population

Country

Year

Total (%)

Male (%)

Female (%)

Albania 1995

24.0

12.0

36.0

Algeria 1995

89.0

80.0

98.0

Argentina

2003

16.2

7.5

23.2

Armenia 1995

24.0

12.0

36.0

Australia 2001

17.5

14.1

20.8

Austria 1993

11.0

5.8

16.1

Azerbaijan 1995

24.0

12.0

36.0

Barbados 1995

49.5

29.0

70.0

Belarus 1995

3.0

2.0

4.0

Belgium 2001

18.9

11.5

25.8

Belize 1995

34.0

24.0

44.0

Benin

a,b

1998 N.A. 16.8 14.3

Bolivia 1995

34.5

24.0

45.0

Botswana 1995

53.5

37.0

70.0

Brazil

2001–2002 51.5

40.0

60.5

Bulgaria 1997

N.A.

32.1

65.1

Cambodia 1995

85.0

74.0

Canada

1998–1999 22.1

17.8

26.1

Chile 2002

25.3

22.0

28.6

China

2000–2001

48.6

27.5

73.1

Colombia 2000–2001

15.1

4.9

20.7

Costa Rica

1995

60.0

45.0

75.0

Cuba 1995

49.5

29.0

70.0

Cyprus 1995

8.0

1.0

15.0

Czech Republic (the) 2002

14.6

9.1

20.0

WHO Global Status Report on Alcohol 2004

Country

Year

Total (%)

Male (%)

Female (%)

Denmark

1997–1998

3.0

2.0

4.0

Egypt 2000–2001

99.5

99.0

100.0

El Salvador

1995

23.5

9.0

38.0

Fiji

1993

88.7

78.8

97.9

Finland 2000

7.4

7.1

7.7

France 1999

6.7

4.3

8.9

Georgia 2000–2001

22.9

8.7

33.5

Germany 2000

5.1

4.3

5.9

Greece 1995

8.0

1.0

15.0

Guatemala 1995

53.5 45.0 62.0

Guyana 1995

30.0

20.0

40.0

Haiti 1995

60.0

58.0

62.0

Honduras 1995

23.5

9.0

38.0

Hungary 2001

17.5

9.2

25.5

Iceland 2003

11.8

11.4

12.2

India

2000–2001 79.1

67.1

89.3

Indonesia 2000–2001

94.8

89.8

98.9

Iraq 1995

89.0

80.0

98.0

Ireland

2002 22.0 17.0 26.0

Israel 2001

35.5

25.7

45.4

Italy 2000

25.0

36.4

12.8

Jamaica 2001

57.6

43.8

69.4

Japan 2001

13.5

7.4

19.7

Jordan 1995

86.0

74.0

98.0

Kenya 1995

55.0

45.0

65.0

Kiribati

1981 73.1 51.4 92.9

Kyrgyzstan 1995

70.0

60.0

80.0

Lebanon 2000–2001

77.4

67.4

86.7

Lesotho

a,b

N.A. 74.0 47.0 81.0

Lithuania 1999

20.0

10.0

28.0

Luxembourg 1995

2.5

1.0

4.0

Malaysia 1995

49.5

35.0

64.0

Marshall Islands (the)

N.A. 66.3 80.6 95.5

Mexico 1998

41.6

22.4

55.0

Micronesia (Federated States of)

N.A.

67.6 45.1 90.9

Mongolia 1995

41.5

20.0

63.0

Myanmar 1995

69.5

45.0

94.0

Namibia 1998

N.A.

39.0

53.0

Netherlands (the)

2001 15.8 9.4 21.8

New Zealand

2000 15.0 12.0 17.0

Nicaragua 1995

23.5

9.0

38.0

Nigeria

2000–2001 75.6

51.3

89.6

Norway 1999

6.0

5.8

6.2

Pakistan 1995

94.5

90.0

99.0

Palau 1990–1991

N.A.

23.1

64.2

Papua New Guinea

1995

54.5

22.0

87.0

Paraguay 1995

28.0

18.0

38.0

Peru 2002

24.9

20.2

29.0

Philippines (the)

1995

40.0

10.0

70.0

Poland 1995

19.0

12.0

26.0

Portugal 1995

15.5

7.0

24.0

WHO Global Status Report on Alcohol 2004

Country

Year

Total (%)

Male (%)

Female (%)

Republic of Korea (the)

2001 27.1 12.4 38.9

Republic of Moldova (the) 1995

13.5

9.0

18.0

Romania 1995

38.0

23.0

53.0

Russian Federation (the) 1996

23.1

9.0

35.0

Saudi Arabia

1995

97.0

95.0

99.0

Seychelles 1995

27.5

10.0

45.0

Singapore 2000–2001

74.5

66.6

82.3

Slovakia 2000–2001

7.7

3.6

10.4

Slovenia 1995

24.0

12.0

36.0

South Africa

1995 69.0 55.0 83.0

Spain

2003 37.7 26.9 48.7

Sri Lanka

2002

67.6

41.4

92.9

Suriname 1995

42.5

30.0

55.0

Sweden 2002

11.3

8.0

14.7

Switzerland 2002

22.5

14.2

30.4

Syrian Arab Republic (the) 2000–2001

95.7

92.4

98.8

Tajikistan 1995

70.0 60.0 80.0

Thailand

2001 67.4 44.1 90.2

TFYR Macedonia

1995 24.0 12.0 36.0

Tokelau

1976 N.A. 50.0 92.0

Trinidad and Tobago

1995

49.5

29.0

70.0

Tunisia 1995

82.5

70.0

95.0

Turkey 2000–2001

80.4

77.5

82.5

Turkmenistan 1995

45.0

35.0

55.0

Uganda

2003

54.3

48.2

60.3

The United Kingdom

2000

12.0

9.0

14.0

United States of America (the)

2002

33.9

29.3

38.2

Uzbekistan 1995

70.0

60.0

80.0

Venezuela 1995

42.5

30.0

55.0

a Regional survey

b No definition of abstainers given.
c Last month abstainers
d The former Yugoslav Republic of Macedonia

e Current abstainers

Note

Please refer to individual country profiles for details of references/sources used.

Who are the heavy drinkers?

Heavy drinking is a pattern of drinking that exceeds some standard of moderate drinking or –
more equivocally – social drinking. Heavy drinking is often defined in terms of exceeding a
certain daily volume (e.g. three drinks a day) or quantity per occasion (e.g. five drinks on an
occasion, at least once a week), or daily drinking. Such persistent patterns of drinking may
incur acute or chronic health and social consequences on the drinker in question. Table 7
presents some data for selected countries with data on heavy drinkers. Note that this table is
not comparable as different surveys have varying definitions of heavy drinking and samples
cover different age ranges. However, the majority of the data below are for the adult
population of 18 years and above.

WHO Global Status Report on Alcohol 2004

Table 7:

Heavy drinkers among the adult population

Country

Year

Total (%)

Male (%)

Female (%)

Argentina

a,b,c

2003 N.A. 11.5 2.0

Australia

2001 7.0 6.7 7.2

Austria

b,c

1993 N.A. 17.3 7.0

Brazil

b,c

2001–2002 N.A.

17.8

18.2

Bulgaria

1997 N.A. 18.2 0.8

Burkina Faso

2003 11.6 10.0 13.2

Chad

2003 11.0 12.8 9.5

Colombia

c,f

2001–2002 31.8

52.4

21.0

Costa Rica

b,c

2003 N.A. 5.0 3.0

Czech Republic (the)

b,c

2002 N.A. 25.7 12.5

Dominican Republic (the)

2003 2.1 1.1 3.1

Ecuador

2003 4.1 7.3 1.7

Estonia

1997 N.A. 9.3 0.5

Ethiopia

2003 9.3 8.1 10.6

Finland

b,c

2000 N.A. 5.8 3.4

France

b,c

1999 N.A. 16.6 7.8

Georgia

c,f

2001–2002 27.8

50.1

10.6

Germany

b,c

2000 N.A. 11.2 11.3

Ghana

2003 1.9 2.1 1.7

Hungary

2003 12.4 16.9 9.3

India

2003 1.4 2.4 0.4

Israel

b,c

2001 N.A. 5.9 4.7

Italy

2000 5.8 9.8 2.0

Japan

b,c

2001 N.A. 22.7 4.9

Lao People’s Dem. Rep.

2003 2.7 3.8 1.8

Mexico

c,f

2000–2001 14.2

18.1

11.6

Namibia

2003 4.1 3.1 4.9

Nepal

2003 3.5 3.0 4.0

Netherlands (the)

b,c

1999 N.A. 10.4 11.1

Nigeria

b,c

2003 N.A. 27.8 36.1

Norway

b,c

1999 N.A. 3.0 5.2

Paraguay

2003 3.1 5.6 1.0

Russian Federation (the)

2003 2.4 3.7 1.6

Slovakia

2003 7.0 5.2 7.9

South Africa

c,f

1998 7.6 7.0 8.8

Switzerland

b,c

1997 N.A. 8.6 6.1

Turkey

c,f

2000–2001 1.7

1.3

2.5

Uganda

b,c

2003 N.A. 40.1 20.3

The United Kingdom

c,f

2000 N.A. 39.0 42.0

United States of America (the)

b,c

1996 N.A. 6.4 5.0

Viet Nam

2003

2.9

5.7

0.6

Zimbabwe 2003

2.7

5.8

1.0

Regional survey

Consumption of 40 g or more pure alcohol/day for men and 20 g or more pure alcohol/day for women.

Among drinkers only

Consumption of more than 40 g pure alcohol/day for men and more than 20 g pure alcohol/day for women.

Consumption of 560 g of ethanol a week or more (80 g a day or more).

Consumption of five or more standard drinks for males and three or more standard drinks for females on a

typical drinking day.

Consumption of more than 0.5 litres of wine daily.

Note

Please refer to individual country profiles for details of references/sources used.

WHO Global Status Report on Alcohol 2004

Who are the heavy episodic drinkers?

The term “binge drinking” or “heavy episodic drinking”, as used in this report, has been
rather ambivalently used in the literature. Gmel, Rehm and Kuntsche (2003) identified two
main definitions: (a) a drinking occasion leading to intoxication, often measured as having
more than

number of drinks on one occasion, and (b) a pattern of heavy drinking that occurs

over an extended period of time set aside for this purpose, and linked to more clinical
definitions of harmful use or dependence. This report uses the former definition of bingeing
as a risky single drinking occasion. Data for some countries show continued trends of binge or
heavy episodic drinking among those who drink. In Ireland, for example, results of a recent
survey suggest that among those consuming alcohol, binge drinking is the norm among men
and occurs in about a third of the drinking occasions of women (Ramstedt & Hope, 2003). A
national survey conducted in New Zealand in 2000 found that 19% of male drinkers and 9%
of female drinkers engaged in heavy episodic drinking at least weekly (Habgood et al., 2001).
A more recent national survey conducted in the Republic of Korea found that 63.4% of
drinkers (66.3% of male drinkers and 57.8% of female drinkers) had engaged in heavy
episodic drinking (Ministry of Health and Social Affairs, 2002).

Table 8 presents data for a selected number of countries on rates of heavy episodic drinking
among the total adult population. Again, caution must be taken when interpreting this table as
the cut-off age for different countries varies (from 14 years and above to 18 years and above).

Table 8:

Heavy episodic drinkers among the adult population

Country

Year

Total (%)

Male (%)

Female (%)

Australia

2001 13.4 15.3 11.6

Belgium

2001 20.1 32.6 8.4

Bosnia and Herzegovina

2003 1.2 2.9 0.0

Brazil

2003 9.9 17.2 4.1

Burkina Faso

2003 10.9 13.9 7.7

Canada

c,f

2001–2002 20.1

28.3

11.2

Chad

2003 12.3 17.2 7.9

China

2003 3.8 7.5 0.3

Colombia

2001–2002 5.2

11.6

1.9

Comoros (the)

2003 0.2 0.4 0.0

Congo

2003 5.2 8.3 2.5

Costa Rica

c,d

2003 N.A. 22.1 8.2

Côte d’Ivoire

2003

4.1

6.5

0.9

Czech Republic (the)

c,d

2002 N.A. 28.8 9.9

Dominican Republic (the)

2003 9.1 15.7 3.5

Ecuador

2003 4.7 9.3 1.2

Estonia

2003 6.9 15.2 2.3

Ethiopia

2003 4.1 7.7 0.4

Finland

c,h

2000 N.A. 49.1 14.1

France

c,h

2000 N.A. 27.9 9.7

Georgia

2003 10.8 22.3 1.2

Germany

c.d

2000 N.A. 42.1 12.7

Ghana

2003 1.4 2.5 0.4

Guatemala

2003 1.3 3.4 0.2

Hungary

2003 9.1 18.9 1.9

Iceland

c,d

2001 N.A. 42.7 20.0

India

2003 1.4 2.9 0.1

WHO Global Status Report on Alcohol 2004

Country

Year

Total (%)

Male (%)

Female (%)

Italy

b,c

2001–2002 N.A.

12.8

11.5

Japan

c,h

2001 N.A. 38.3 10.7

Kazakhstan 2003

4.4

8.8

2.0

Lao People’s Dem. Republic (the)

2003 12.3 20.9 4.8

Mexico

c,d

1998 N.A. 46.9 5.8

Namibia

2003 6.2 9.5 4.0

Netherlands (the)

c,h

1999 N.A. 36.6 11.6

Nigeria

c,d

2003 N.A. 52.0 39.6

Paraguay

2003 14.3 27.4 3.4

Philippines (the)

2003 7.0 13.2 1.6

Russian Federation (the)

2003 8.2 15.1 3.6

Slovakia

2003 6.8 13.9 2.8

Spain

2003 4.6 8.5 1.6

Sri Lanka

2003 2.4 4.9 0.1

Ukraine

2003 9.6 19.5 3.7

Uganda

c,d

2003 N.A. 46.0 17.6

The United Kingdom

2000 17.0 24.0 9.0

Viet Nam

2003 4.7 10.2 0.3

Zimbabwe

2003 4.0 10.1 0.9

a Consumption of seven or more standard drinks for males (five or more for females) on any one drinking
occasion at least monthly.
b At least once a month six or more drinks on the same day.
c Among drinkers only

d Consumption of five or more drinks on one occasion at least once a month in the last year.

e At least once a week consumption of five or more standard drinks in one sitting.

f Consumption of five or more drinks on one occasion, 12 or more times in the last year.

g Consumption of six or more drinks on one occasion weekly or more.
h Consumption of six or more drinks on one occasion at least once a month in the last year.

Note

: Countries in bold indicate that surveys were not national but regional. Please refer to individual country

profiles for details of references/sources used.

Alcohol dependence

The Tenth Revision of the International Classification of Diseases and Health Problems (ICD-
10) defines alcohol dependence syndrome as being a cluster of physiological, behavioural,
and cognitive phenomena in which the use of alcohol takes on a much higher priority for a
given individual than other behaviours that once had greater value. A central descriptive
characteristic of the dependence syndrome is the desire (often strong, sometimes
overpowering) or sense of compulsion to take alcohol. It is worth noting here that reporting
rates of alcohol dependence in different countries is complicated by the fact that there exists
important differences in the diagnostic instruments and tools based on the Diagnostic and
Statistical Manual of Mental Disorders, Third Edition,
Revised (DSM-III-R) or the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) and ICD-10; as well as if the prevalence rates measured refer to lifetime or
last year alcohol dependence. Table 9 shows the rate of alcohol dependence among the
national adult population in some selected countries. Again, caution must be taken when
interpreting this table as the cut-off age and diagnostic measures used differed between
countries.

WHO Global Status Report on Alcohol 2004

Table 9:

Alcohol dependence among adult population

Country

Year

Total (%)

Male (%)

Female (%)

Measure

Argentina

1999 4.31 6.67 1.74

ICD-10

Australia

1997 3.5 5.2 1.8

ICD-10

Austria

1996 2.2 N.A. N.A.

CAGE

Belgium

2001 7.0 9.5 3.6 N.A.

Brazil

2001 11.2 17.1 5.7 N.A.

Canada

2002 9.3 14.0 4.5 mixed

Chile

N.A. 6.4 11.0 2.1

DSM-III-R

China

2001 3.8 6.6 0.2

DSM-III-R

Colombia

2000–2001 4.8

9.8

2.2 ICD-10

Costa Rica

b,e

2000–2001

7.0 10.8 2.4 mixed

Egypt

2000–2001 0.2

0.4

0.0 ICD-10

Ethiopia

1994 1.0 1.9 0.1

CAGE/CIDI

Finland

2000 4.0 6.5 1.5

DSM-IV

France

2000 N.A. 13.3 4.1 DETA

Georgia

2000–2001 3.2

7.3

0.2 ICD-10

Germany

2000 3.8 6.0 1.5

DSM-IV

India

2000–2001 3.6

6.8

0.7 ICD-10

Indonesia

2000–2001 1.0

1.7

0.3 ICD-10

Iran

N.A. 7.3 11.9 2.7

DSM-IV

Japan

1997–1999 4.1

8.4 0.7

DSM-III-R

Mexico

2000–2001 1.8

4.2

0.2 ICD-10

Netherlands (the)

1996 5.5 9.0 1.9

DSM-III-R

Nigeria

2001–2002 0.7

1.9

0.0 ICD-10

Peru

2002 10.6 17.8 4.3 ICD-10

Poland

1999 12.2 23.3 4.1 CAGE

Republic of Korea (the)

2003 4.3 6.9 1.7 CIDI

Singapore

2001–2002 0.6

1.1

0.2 ICD-10

Slovakia

2001–2002 4.8

9.4

1.1 ICD-10

South Africa

1998 N.A. 27.6 9.9 CAGE

Syrian Arab Republic (the)

2001–2002 0.2

0.5

0.0 ICD-10

Turkey

2001–2002 1.3

1.7

0.7 ICD-10

The United Kingdom

N.A. 4.7 7.5 2.1

ICD-10

United States of America (the)

2002 7.7 10.8 4.8

DSM-IV

Uruguay

2001 5.0 8.5 1.3

DSM-IV

Last year alcohol dependence

No definition of alcohol dependence given.

Alcohol dependence classification was based on a set of questions which examined aspects of alcohol tolerance

(for e.g. needing more to have an effect), withdrawal, loss of control, and social or physical problems related to
alcohol use in daily life.

Lifetime alcohol dependence

Alcohol dependency/alcoholic was defined as an individual that presents/displays the inability to abstain from

the consumption of spirits or is unable to stop when consuming spirits as well as symptoms of greater
deprivation (e.g. tremors).

Diminuer entourage trop alcohol (Reduce alcohol-based surroundings) test

Alcohol dependence or abuse

Note

: Countries in bold indicate that surveys were not national. Please refer to individual country profiles for

details of references/sources used.

WHO Global Status Report on Alcohol 2004

Youth drinking

With the large exception of Europe and North America, there is little uniformity in the means
and scales used to monitor alcohol consumption among young people. Although it is more
common for countries to survey their young populations regarding alcohol use than to
conduct national population surveys, the range of ages being surveyed and of definitions of
categories of consumption used render cross-national comparisons difficult in most regions.

In Europe, two large-scale international studies have been carried out in an attempt to collect
comparable data on alcohol use among young people. The European School Survey Project
on Alcohol and other Drugs (ESPAD) was conducted for the first time in 1995 and
subsequently in 1999 and 2003. This study examined drinking (also smoking and illicit drug
use) among representative samples of 15–16-year-old school students in Europe. The second
ESPAD study carried out in 1999 involved more than 90 000 students from a total of 30
countries. This is probably the largest international study of the social and behavioural aspects
of alcohol epidemiology ever attempted (Plant & Miller, 2001). The Health Behaviour in
School Children (HBSC) study, established in 1982, is conducted by an international network
of research teams in collaboration with the WHO Regional Office for Europe. It aims to gain
new insight into and to increase understanding of young people’s health, well-being, health
behaviour and social context. There have since been several rounds of the HSBC surveys
being conducted every four years involving young people aged 11 to 15 years. The most
recent surveys were in 2001/2002 whereby 35 countries and regions participated (WHO,
2004d).

Other examples of large-scale studies on youth and alcohol include the Monitoring the Future
Survey (MTF) – an annual survey among 8

, 10

, and 12

graders in the United States, the

Youth Risk Behavior Survey conducted among students in grades 9 to 12 in the United States,
and the Harvard School of Public Health College Alcohol Study, and the recently initiated
Health Behaviour and Lifestyle of Pacific Youth (HBLPY) survey conducted in the Federated
States of Micronesia, Tonga and Vanuatu. Such initiatives should be strongly encouraged as a
means to obtain reliable, useful and comparable data on monitoring alcohol consumption
among youths.

In line with this, WHO has launched the Global school-based student health survey (GSHS) –
an international collaborative surveillance project designed to help countries measure and
assess the behavioural risk factors and protective factors in ten key areas (alcohol use being
one of them) among young people aged 13 to 15. The GSHS is a relatively low-cost school-
based survey which uses a self-administered questionnaire to obtain data on young people's
health behaviour and protective factors related to the leading causes of morbidity and
mortality among children and adults worldwide. Among the countries participating in this
study are the Bahamas, Botswana, Chile, China, Guatemala, Guyana, Jordan, Kenya,
Mozambique, the Philippines, Swaziland, Trinidad and Tobago, Uganda, Venezuela, Zambia
and Zimbabwe (to access more information on the GSHS, please see WHO, 2004b).

There is widespread agreement that the health and well-being of many young people today are
seriously being threatened by the use of alcohol. Worries have arisen as emerging trends in
consumption are starting to permeate youth culture, showing increasing signs of transcending
national boundaries. There appears to be an international pattern towards a more hedonistic
attitude to drinking, consciously using alcohol for its pleasurable psychological effects.
Associated with this is a trend of increased drinking to intoxication. Increased binge drinking
and intoxication in young people – the pattern of consumption associated with Northern

WHO Global Status Report on Alcohol 2004

Table 10: Heavy episodic drinkers among youths

Country

Year

Total (%)

Male (%)

Female (%)

Age group

Australia

2001 10.7 9.6

11.8

14–19

Bulgaria

1999 11.0 15.0

6.0

15–16

Canada

2000–2001

15.3 26.3 5.2

15–19

China

2000–2001

1.3 2.5 0.0 15–19

Colombia

2000–2001

7.8 14.5 4.1

15–19

Cyprus

1999 12.0 18.0

6.0

15–16

Denmark

2002 N.A. 62.0

54.0

11–15

Finland

1999 18.0 21.0

15.0

15–16

France

1999 12.0 16.0

7.0

15–16

Georgia

2000–2001

2.7 4.4 1.3 15–19

Greece

1999 9.0 13.0

5.0

15–16

Hungary

2003 27.5 39.2

22.2

15–16

Iceland

1999 17.0 18.0

15.0

15–16

Ireland

1999 31.0 32.0

32.0

15–16

India

2000–2001

0.5 1.2 0.0 15–19

Indonesia

2000–2001

1.1 1.1 1.1 15–19

Lithuania

1999 9.0 12.0 18.0

15–16

Malta

1999 22.0 25.0

23.0

15–16

Mexico

2000–2001

2.5 0.8 1.5 15–19

Nigeria

2000–2001

1.2 1.0 1.3 15–19

Norway

2003 15.0 17.0

14.0

15–16

Poland

1999 31.0 41.0

23.0

15–16

Sweden

1999 17.0 22.0

13.0

15–16

Syrian Arab Republic (the)

2000–2001

0.4 0.0 0.2 15–19

Turkey

2000–2001

1.4 0.5 1.1 15–19

The United Kingdom

1999 30.0 33.0

27.0

15–16

United States of America (the)

2002 10.7 11.4

9.9

12–17

Consumption of seven or more standard drinks on any one drinking occasion for males and five or more

standard drinks on any one drinking occasion for females (at least weekly).

Consumption of five or more drinks in a row three times or more in the last 30 days.

Consumption of five or more drinks on one occasion, twelve or more times in the last year (among drinkers

only).

At least once a week consumption of six or more standard drinks in one sitting.

Consumption of five or more standard drinks in one day at least once in the last month.

Consumption of five or more drinks on one occasion at least once in the past month.

Note

: Countries in bold indicate that surveys were not national. Please refer to individual country profiles for

details of references/sources used.

WHO Global Status Report on Alcohol 2004

Table 11: Heavy episodic drinkers among young adults aged 18–24 years old

Country

Year

Total (%)

Male (%)

Female (%)

Bosnia and Herzegovina

2003 0.8

1.8

0.0

Brazil

2003 15.3 26.3

5.2

Burkina Faso

2003 6.4

8.4

5.1

Chad

2003 9.3 13.7

5.6

China

2000–2001 2.1

3.9

0.3

Colombia

2000–2001 7.8

14.5

4.1

Comoros

2003 0.3

0.6

0.0

Congo (the)

2003 3.9

6.4

2.2

Côte d’Ivoire

2003 3.9

6.9

0.3

Croatia

2003 4.6

9.6

0.0

Czech Republic (the) 2003

20.1

32.7

9.0

Dominican Republic

2003 12.0 17.9

7.4

Ecuador

2003 5.1 11.2

0.5

Estonia

2003 6.0 10.4

3.5

Ethiopia

2003 2.0

4.2

0.2

Georgia

2003 10.1 19.6

2.1

Ghana

2003 0.6

1.0

0.3

Guatemala

2003 1.7

4.8

0.0

Hungary

2003 12.2 20.8

3.5

India

2000–2001 0.7

1.6

0.0

Indonesia

2000–2001 0.8

1.3

0.3

Kazakhstan

2003 3.1

6.8

1.1

Lao People’s Democratic Republic (the)

2003 11.5 19.2

5.3

Latvia

2003 14.4 27.3

4.3

Lebanon

2000–2001 0.2

0.4

0.0

Malawi

2003 1.9

4.5

0.2

Malaysia

2003 0.2

0.5

0.0

Mali

2003 0.3

0.6

0.0

Mauritius

2003 2.8

5.2

0.0

Mexico

2003 3.1

6.3

0.8

Morocco

2003 0.6

1.2

0.2

Namibia

2003 5.4 10.6

2.0

Nepal

2003 0.6

1.3

0.2

Nigeria

2000–2001 1.0

1.7

0.6

Paraguay

2003 16.1 29.2

4.4

Philippines (the)

2003 7.3 13.6

0.9

Russian Federation (the)

2003 5.7

6.9

4.6

Slovakia

2003 17.8 28.4

9.0

Spain

2003 8.6 15.1

3.2

Sri Lanka

2003

0.8

1.5

0.0

Tunisia

2003

3.3

6.3

0.0

Turkey

2003 0.8

2.1

0.0

Ukraine

2003 8.5 13.4

4.9

Uruguay

2003 8.4 13.5

2.8

Viet Nam

2003 3.7

8.1

0.0

Zimbabwe

2003 2.8

6.6

0.3

At least once a week consumption of five or more standard drinks in one sitting.

At least once a week consumption of six or more drinks in one sitting.

Note:

Countries in bold indicate that surveys were not national. Please refer to individual country profiles for

details of references/sources used.

WHO Global Status Report on Alcohol 2004

Health effects and global burden of disease

Alcohol use is related to wide range of physical, mental and social harms

. Most health

professionals agree that alcohol affects practically every organ in the human body. Alcohol
consumption was linked to more than 60 disease conditions in a series of recent meta-analyses
(English et al., 1995; Gutjahr, Gmel & Rehm, 2001; Ridolfo & Stevenson, 2001; Single et al.,
1999). The present chapter mainly draws on the work of Gutjahr and Gmel (2001) and Rehm
et al. (in press).

The link between alcohol consumption and consequences depends a) on the two main
dimensions of alcohol consumption: average volume of consumption and patterns of drinking;
and b) on the mediating mechanisms: biochemical effects, intoxication, and dependence (see
Figure 4 for the main paths).

Figure 4: Model of alcohol consumption, mediating variables, and short-term and long-

term consequences

* Independent of intoxication or dependence

Source

: Rehm et al. (2003c)

Direct biochemical effects

of alcohol may influence chronic disease either in a beneficial

(e.g., protection against blood clot formation of moderate consumption (Zakhari, 1997),
which is protective for coronary heart disease) or harmful way (e.g., toxic effects on acinar
cells triggering pancreatic damage (Apte, Wilson & Korsten, 1997).

Intoxication

is a

Social outcomes of alcohol are defined as changes that affect the social behaviour of individuals, or their interaction with

partners and other family members, or their circumstances (Klingemann & Gmel, 2001). Social outcomes would include
family problems, public disorder, or workplace problems. Social outcomes or consequences will not be addressed as part of
this chapter unless they are part of the International Statistical Classification of Diseases and Related Health Problems (ICD).
The majority of these problems are not covered by the ICD classification, even though health by WHO is defined in a broad
way to include well-being. However, the quantification of such outcomes is difficult to derive and fraught by methodological
difficulties. It is nevertheless important to note that social harm has a major impact on wellbeing, which may even exceed
that from “quantifiable” diseases. For overviews see e.g. Klingeman and Gmel (2001) or Gmel and Rehm (2003).

Chronic
disease

Accidents/Injuries

(acute disease)

Acute social
consequences

Chronic

social

Intoxication

Toxic

and

benefical biochemical

effects

Dependence

Patterns of drinking

Average volume

WHO Global Status Report on Alcohol 2004

powerful mediator mainly for acute outcomes, such as accidents, or intentional injuries or
deaths, domestic conflict and violence (Klingemann & Gmel, 2001; Gmel & Rehm, 2003).

Alcohol dependence

is a powerful mechanism sustaining alcohol consumption and thus

impacting on both chronic and acute consequences of alcohol (see Drummond, 1990), though
it is also a consequence of drinking itself.

Total consumption or average volume of consumption has been historically the usual measure
of exposure linking alcohol to disease (Bruun et al., 1975). Average volume of consumption
as a risk factor is mainly linked to long-term consequences (WHO, 2000a). Acute effects of
alcohol related to injury and death are much better predicted by

patterns of drinking

(Rehm et

al., 1996; Bondy, 1996; Puddey et al., 1999), although there is also an association with
volume of drinking. For example, the same overall average volume of alcohol can be
consumed in small quantities regularly with meals (e.g. two drinks a day with meals) or in
large quantities on few occasions (e.g. two bottles of wine on a single occasion every Friday).
In other words, the impact of an average volume of consumption on mortality or morbidity is
partly moderated by the way alcohol is consumed by the individual, which in turn is
influenced by the social context (Room & Mäkelä, 2000). It should be noted that patterns of
drinking have not only been linked to acute health outcomes such as injuries (Greenfield,
2001; Rossow, Pernanen & Rehm, 2001), but also to chronic diseases such as coronary heart
disease (CHD) and especially sudden cardiac death (Britton & McKee, 2000; Chadwick &
Goode, 1998; Puddey et al., 1999; Trevisan et al., 2001a; Trevisan et al., 2001b).

Thus, the variation of disease burden due to alcohol consumption across countries depends at
least on two factors. First, it depends on the overall amount consumed in a country for which
an indicator is

per capita

consumption.

Per capita

consumption of course is also influenced

by the percentages of drinkers (or abstainers) in a country. Second, it depends on the way
alcohol is consumed, e.g. regularly in moderate amounts with meals versus irregular in heavy
drinking occasions often outside meals. Similarly, the distribution of alcohol related burden
across diseases may vary widely across countries. At the risk of oversimplifying, chronic
alcohol-related diseases predominantly depend on volume of drinking and should thus have a
bigger share of the total burden in countries in which total

per capita

consumption is high, but

the prevailing drinking pattern is a regular drinking pattern, whereas the share of acute
consequences on the total burden should be higher in countries, where alcohol is commonly
used more infrequently but often in high amounts when alcohol consumption takes place.

“Alcohol relatedness” varies across diseases. This is commonly expressed in alcohol
attributable fractions (AAF). Some diseases or consequences are fully attributable to alcohol
(e.g. the alcohol dependence syndrome), other consequences have a high alcohol attribution
such as liver cirrhosis, for some consequences there are many other factors which may cause a
disease, among which alcohol often plays one role, and thus the alcohol attributable part may
be low. Low, however does not mean negligible. If 10% of all cases may be attributable to
alcohol, for some highly prevalent diseases (e.g. breast cancer for women) the alcohol-related
share may clearly outnumber diseases that are fully attributable to alcohol, but commonly
rare. There are different ways to determine AAFs of diseases (for details see English et al.,
1995). One is the indirect way, where relative risk estimates derived from meta-analyses are
combined with country-specific disease prevalences to yield country-specific AAFs. The
second is to use directly estimated AAFs, e.g. the percentage of traffic accidents where an
involved person was tested positive for a blood alcohol concentration (BAC) exceeding a
certain amount (e.g. 0.5 per mille). For most chronic diseases the indirect method is used.
Behind this calculation stands the assumption that the mechanism for the development of a
disease depend mainly on the consumed amount of alcohol and is therefore cross-culturally

WHO Global Status Report on Alcohol 2004

stable. Therefore, Relative Risks (RR) can be derived by meta-analytical pooling of
epidemiologic studies across different countries and regions all over the world. Differences in
AAFs across countries then depend mainly on the prevalence of consumption distribution,
e.g. the prevalence of chronic heavy drinking.

For most acute diseases, however, AAFs should be derived directly, because they depend on
the way alcohol is consumed, e.g. a drinking pattern of frequent drinking to intoxication. An
example for consequences for which the AAF are commonly directly derived are road
accidents for which an alcohol attributable fraction is based on whether the accident-
responsible driver tested positive for alcohol and to what degree (e.g. at blood alcohol
concentration BAC >0.05%).

Harmful effects of alcohol consumption excluding depression and coronary
heart disease

Wholly alcohol-attributable diseases

A number of diseases are by definition fully attributable to alcohol (AAF = 1 or 100%). These
are listed in Table 12

Table 12: Disease conditions which are by definition alcohol-related (attributable fraction

of 1)

ICD-9 Disease

291 Alcoholic

psychoses

303 Alcohol-dependence

syndrome

305.0 Alcohol

abuse

357.5 Alcoholic

polyneuropathy

425.5 Alcoholic

cardiomyopathy

535.3 Alcoholic

gastritis

571.0–571.3 Alcoholic

liver

cirrhosis

790.3 Excess

blood

alcohol

980.0, 980.1

Ethanol and methanol toxicity

Source: Rehm et al. (2003c)

Diseases with a contributory role

Cancer

Oropharyngeal, oesophageal and liver cancers

Alcohol has consistently been related to the

risk of cancer of the mouth (lip, tongue), pharynx, larynx, hypopharynx, oesophagus and liver
(Corrao et al., 1999; English et al., 1995; Gurr, 1996; Single et al., 1999; US Department of
Health and Human Services, 2000; WHO, 2000a). The relationship between average volume
of alcohol consumption and cancer is usually characterized as almost monotonically
increasing relative risks with increasing volume of drinking (Bagnardi et al., 2001).

Female breast cancer

: Much research has been conducted over the last decade on breast

cancer. Prior to 1995, it has most often been concluded that evidence of a causal relationship
with alcohol was insufficient (English et al., 1995; Rosenberg, Metzger & Palmer, 1993;

WHO Global Status Report on Alcohol 2004

Schatzkin & Longnecker, 1994). However, recent studies and reviews have shown that not
only hazardous or harmful drinking, but also even moderate alcohol consumption, can cause
female breast cancer (Single et al., 1999). A meta-analysis by Smith-Warner et al. (1998)
found a clear linear relationship over the whole continuum of consumption. Other original
studies supported this finding (Bowlin et al., 1997; Corrao et al., 1999; Nasca et al., 1994;
Royo-Bordonada et al., 1997; Swanson et al., 1997; van den Brandt, Goldbohm & van 't Veer,
1995; Wingo et al., 1997).

Cancers of the stomach, pancreas, colon, rectum, prostate, salivary glands, ovarium,
endometrium, bladder:

Many recent research projects have investigated whether these cancers

are alcohol-related. Overall, evidence for a causal relationship between alcohol and cancer of
the stomach, pancreas, colon, rectum, if any was found, was weak and inconclusive (Bode &
Bode, 1997; Boutron et al., 1995; De Stefani et al., 1998; Gapstur, Potter & Folsom, 1994;
Harnack et al., 1997; Ji et al., 1996 ; Longnecker & Enger, 1996; Lundberg & Passik, 1997;
Piette, Barnett & Moos, 1998; Sarles, Bernard & Johnson, 1996; Seitz, Poschl & Simanowski,
1998; Seitz et al., 1998; Soler et al., 1998). A recent meta-analysis assessing the link between
alcohol and various types of cancer showed that statistically significant increases in risk
existed for cancers of the stomach, colon, rectum and ovaries (Bagnardi et al., 2001).

On prostate cancer, again most studies did not report observing an increased risk (Breslow &
Weed, 1998; Ellison et al., 1998; Hiatt et al., 1994; Tavani et al., 1994), whereas two cohort
studies (Ajani et al., 1998; Putnam et al., 1998) and one case–control study (Hayes et al.,
1996) reported a small increased risk in men who consume even moderate amounts of
alcohol.

It has been hypothesized that alcohol might constitute a risk factor for cancer of the major
salivary glands (Horn-Ross, Ljung & Morrow, 1997; Muscat & Wynder, 1998), ovarium,
endometrium (Bradley et al., 1998; Longnecker & Enger, 1996; Newcomb, Trentham-Dietz
& Storer, 1997; Parazzini et al., 1995), and the bladder (Bruemmer et al., 1997; Donato et al.,
1997; Longnecker & Enger, 1996; Yu et al., 1997). For each of these sites, results were either
scarce or heterogeneous, or the effects, if any were found, not statistically significant. In sum,
evidence for a causal relationship between alcohol and cancers of these sites so far has not
produced consistent results, especially with regard to physiological pathways.

Overall, the risk relationship between alcohol and alcohol-related cancers can be
characterized by an almost linear dose–response relationship between volume of drinking and
the relative risk of outcome. Although there have been speculations about the impact of
patterns of drinking

especially for breast cancer (Kohlmeier & Mendez, 1997), the current

state of knowledge does not suggest that patterns of drinking play an important role in the
etiology of cancer.

Cardiovascular disease

There is increasing research in the past decades about the role of alcohol as both a risk and
protective factor for cardiovascular disease.

Coronary heart disease

and the protective role of

alcohol has been the focus of most research and will be discussed in a separate point below.
Most studies suggest that low-level consumption equally offers some protection against

ischaemic stroke

Part of this lack of an influence on patterns of cancer risk may be due to methodological reasons. Most epidemiological

studies only measure volume of consumption and only model monotonically increasing trends and thus could not detect any
influence of patterns of drinking even it were present.

WHO Global Status Report on Alcohol 2004

In contrast,

hypertension

and other cardiovascular disorders such as

cardiac arrhythmias

heart failure

are adversely affected by alcohol (see Friedman, 1998; Klatsky, 1995; Puddey et

al., 1999; Rosenqvist, 1998; US Department of Health and Human Services, 1997; Wood et
al., 1998). There are some indications that hypertension may be related to the pattern of heavy
drinking occasions (Murray et al., 2002; Puddey et al., 1999; Wannamethee & Shaper, 1991).

For

haemorrhagic stroke

the weight of evidence suggests an increase in risk for males even

at low levels of consumption (Berger et al., 1999; Jackson, 1994; Sacco et al., 1999; You et
al., 1997). For females the most recent meta-analyses of Ridolfo and Stevenson (2001)
suggested a protective effect for drinking below 40 g pure ethanol per day, but an 8-fold
increased risk for drinking above these limits. Patterns of drinking

not only play a role in any

protective effects of alcohol on CHD, drinking patterns are also relevant to risks of stroke
(Hillbom, Juvela & Karttunen, 1998) and for sudden cardiovascular death or cardiovascular
death in general (Kauhanen et al., 1997a; Kauhanen et al., 1997b; Kozarevic et al., 1982;
Poikolainen, 1983; Wannamethee & Shaper, 1992) with heavy drinking occasions and
intoxication resulting in increased risk.

Liver cirrhosis

Alcohol has been estimated as the leading cause of liver cirrhosis in established market
economies (Corrao et al., 1997; Corrao et al., 1998; English et al., 1995). There is some
debate whether alcohol’s contributory role should be restricted to alcoholic liver cirrhosis
alone or be extended to unspecified liver cirrhosis. Several authors contend that, empirically,
it is extremely difficult to separate alcoholic from unspecified liver cirrhosis, and that the term
“unspecified liver cirrhosis” is applied when no specific etiological factor is reported or
identified (English et al., 1995). Research in the United States and in Central and South
American countries indicated that an appreciable proportion of cirrhosis deaths without
mention of alcohol was in fact attributable to alcohol (Haberman & Weinbaum, 1990; Puffer
& Griffith, 1967; Room, 1972).

On the other hand, applying RRs of liver cirrhosis derived in established market economies to
other countries can be extremely misleading. In many countries (e.g. China or India), liver
cirrhosis is mainly caused by other factors such as viral infections. The corresponding AAFs
have been shown to vary between less than 10% (China) and 90 % (Finland) (WHO, 2000a).

The relationship between alcohol consumption and liver cirrhosis seems to be mainly
dependent on volume of drinking and independent of patterns of drinking (Lelbach, 1975;
Lelbach, 1976). However, some research also indicates a potential effect of occasions of
heavy drinking (Rhodés, Salaspuro & Sorensen, 1993).

Effects of prenatal alcohol exposure

Alcohol consumption during pregnancy is related to various risks to the fetus, which include
gross congenital anomalies and Fetal Alcohol Spectrum Disorders (FASD), which include
conditions such as fetal alcohol syndrome (Alvear, Andreani & Cortes, 1998; Church et al.,
1997; Faden, Graubard & Dufour, 1997; Habbick et al., 1997; Larkby & Day, 1997; Larroque
& Kaminski, 1996; Mattson et al., 1997; Passaro & Little, 1997; Passaro et al., 1996;
Polygenis et al., 1998; Roebuck, Mattson & Riley, 1998; Shu et al., 1995; Windham et al.,
1995). FASD ranges from individual anomalies at one end and serious neurobiological
dysfunctions, including mental retardation, on the other (Connor & Streissguth, 1996). The
prenatal teratogenic effects of alcohol also include lethal consequences. They comprise
spontaneous abortion, low birth weight, fetal damage, prematurity, and intrauterine growth
retardation (Abel, 1997; Bradley et al., 1998; Windham et al., 1997).

WHO Global Status Report on Alcohol 2004

Mental conditions

The co-morbidity of alcohol dependence with other mental conditions is high, both in clinical
and in general population samples (e.g. Grant & Harford, 1995; Merikangas et al., 1998). The
crucial question in this respect is about causation. Sufficient evidence for a causal role of
alcohol consumption at this point of research appears to exist mainly for depression. Since
this relationship is controversial it will be discussed below in a separate section.

Other chronic conditions

Other risks of alcohol consumption currently discussed in the literature include

epilepsy

(see

e.g. Jallon et al., 1998; Leone et al., 1997; Martín et al., 1995),

acute and chronic pancreatitis

(Ammann, Heitz & Klöppel, 1996; Skinazi, Lévy & Bernades, 1995; Damström Thakker,
1998; Robles-Diaz & Gorelick, 1997) and

psoriasis

(English et al., 1995).

Beneficial health effects of alcohol consumption excluding CHD

Ischaemic stroke

Cerebrovascular disease (stroke)

consists of several subtypes, the most common subtypes

being ischaemic stroke and haemorrhagic stroke, which are affected differently by alcohol.
For ischaemic stroke, the predominant type of stroke, the weight of evidence including
biological mechanisms, suggests effects similar to those for CHD, namely that low to
moderate consumption may offer some protection (Beilin, Puddey & Burke, 1996; Hillbom,
1998; Keil et al., 1997; Kitamura et al., 1998; Knuiman & Vu, 1996; Sacco et al., 1999; Thun
et al., 1997; Yuan et al., 1997; Wannamethee & Shaper, 1996). Alcohol consumption has
detrimental effects on haemorrhagic stroke.

Other beneficial health effects of alcohol consumption

Alcohol may offer some protection against

diabetes

and cholelithiasis (gallstones) (English et

al., 1995; see also Ashley et al., 2000, for a recent overview on beneficial effects of alcohol).
Findings from a cohort of more than 40 000 male health professionals showed that moderate
alcohol consumption may decrease the risk of diabetes, perhaps through the effects of alcohol
on insulin sensitivity (Rimm et al., 1995). The protective effect was further substantiated,
mainly in studies in established market economies (Perry et al., 1995; Ajani et al., 1999),
however there may be differential effects on men and women, and even detrimental effects at
higher levels of intake (Wei et al., 2000; Kao et al., 1998). Plausible biological mechanisms
were seen to exist in mediating effects of moderate alcohol intake on glucose tolerance and
insulin resistance (Facchini, Chen & Reaven, 1994; Kiechl et al., 1996; Lazarus, Sparrow &
Weiss, 1997; Flanagan et al., 2000).

With regard to

cholelithiasis

(gallstones) there is some evidence that alcohol may offer some

protection against gallstones (English et al., 1995; Holman et al., 1996). These findings have
been substantiated by recent large-scale cohort and case-control studies, which reported an
inverse relationship (Attili et al., 1998; Caroli-Bosc et al., 1998; Chen et al., 1999; Leitzmann
et al., 1998).

WHO Global Status Report on Alcohol 2004

Table 13 gives an overview of diseases on which alcohol potentially has beneficial effects.

Table 13: Relative risks for beneficial alcohol-related health effects for different drinking

categories (compared to abstainers)

Disease ICD-9

Drinking category I

Drinking category II

Drinking category III

F M F M F M

Diabetes

250

0.92 0.99 0.87 0.57 1.13 0.73

Ischaemic

stroke

433-435 0.52 0.94 0.64 1.33 1.06 1.65

Cholelithiasis 574

0.82 0.82 0.68 0.68 0.50 0.50

Source

Gutjahr, Gmel & Rehm (2001), Ridolfo & Stevenson (2001); Rehm et al. (in press).

Definition of drinking categories

category I

for females not exceeding on average 0 to 19.99 g pure alcohol

per day; for males not exceeding on average 0 to 39.99 g pure alcohol per day;

category II

: for females not

exceeding on average 20 to 39.99 g pure alcohol per day; for males not exceeding on average 40 to 59.99 g pure
alcohol per day;

category III

: for females on average 40 g pure alcohol and above per day; for males on

average 60 g pure alcohol and above per day. For comparison: a 75 cl. bottle of wine contains about 70 g of
pure alcohol.

CHD as a chronic condition where alcohol has harmful and beneficial consequences

Coronary heart disease

is one of the leading causes of death in the world (Murray & Lopez,

1996a). The most important health benefits of alcohol have been found in the area of coronary
heart disease at low to moderate levels of average volume of alcohol consumption
(Beaglehole & Jackson, 1992; Doll, 1998; Edwards et al., 1994; Fuchs et al., 1995; Goldberg,
Hahn & Parkes, 1995; Hillbom, 1998; Holman et al., 1996; Jackson, 1994; Rehm et al., 1997;
Single et al., 1999; Svärdsudd, 1998). Only a few individual-level studies have failed to
substantiate this association in men (Hart et al., 1999) or women (Fillmore et al., 1998;
Maskarinec, Meng & Kolonel, 1998).

While some studies have found that alcohol may offer protection against CHD not only at low
to moderate average intake, but across the continuum of alcohol consumption (Camargo et al.,
1997; Doll et al., 1994; Keil et al., 1997), they nevertheless show that most of the protective
effect is gained at low levels of consumption such as one drink every other day. The common
assumption nowadays is that – at least in established market economies - average volume of
drinking and CHD shows a J-shape relationship (Corrao et al., 2000), with detrimental effects
compared with abstainers at higher levels of alcohol intake. The epidemiological evidence
that light to moderate average alcohol consumption protects against CHD is strengthened by
substantial evidence concerning the biological mechanisms by which a protective effect could
be mediated:

Favourable lipid profiles, especially an increase in high-density lipoproteins (HDL)

(Baraona & Lieber, 1998). It has been estimated that as much as 40%–50% of the
protective effect may be attributable to this mechanism (Criqui et al., 1987; Criqui &
Ringek, 1994; Shu et al., 1992).

Favourable effects on coagulation profiles, in particular, through its effects on platelet

aggregation (McKenzie & Eisenberg, 1996; Rubin, 1999) and fibrinolysis (Reeder et
al., 1996).

CHD is used here for denoting all diseases with ICD 9 rubrics 410–414 (ICD 10: I20–I25). The same categories have also

been labelled ischaemic heart disease (IHD).

WHO Global Status Report on Alcohol 2004

Favourable effects on insulin resistance (Kiechl et al., 1996; Lazarus, Sparrow &

Weiss, 1997; Rankin, 1994).

Favourable effects on hormonal profiles, in particular, its estrogen effects (Svärdsudd,

1998).

Alcohol metabolite acetate has been postulated to protect against CHD by promoting

vasodilation (US Department of Health and Human Services, 1997).

Alcohol may affect inflammation (Imhof et al., 2001; Jacques et al., 2001; Morrow &

Ridker, 2000; Ridker, 2001).

Finally, it is possible that some of the protective effects are mediated through the anti-
oxidative constituents of alcohol beverages, especially wine (Reinke & McKay, 1996).
However, most of the protective effect appears to be linked to ethanol, per se. In sum, the
relationship between average volume of drinking and CHD seems to be J-shaped. Light to
moderate drinking is associated with a lower CHD risk than abstaining or heavy drinking.
However, the studies on average volume of consumption and CHD are heterogeneous,
indicating that factors other than the ones included in the study co-determine the relationship.
One of the main factors is pattern of drinking (i.e. the way in which the same average amount
of alcohol is consumed). In this respect two patterns deserve mentioning: irregular heavy
drinking occasions and drinking with meals.

As regards

heavy drinking occasions

, several studies showed that for the same volume

consumed (i.e. adjusting for volume in multiple regression models) heavy drinking occasions
(e.g. eight drinks in one sitting) have detrimental effects on CHD (McElduff & Dobson, 1997;
Murray et al., 2002; Trevisan et al., 2001a).

In addition to the effect on CHD, there appears to be a relationship between irregular heavy
drinking occasions and other forms of cardiovascular death, especially sudden cardiac death
(Kauhanen et al., 1997b; Wannamethee & Shaper, 1992; Wood et al., 1998). This is
consistent with the physiological mechanisms of increased clotting and reducing the threshold
for ventricular fibrillation after heavy drinking occasions, which have been reviewed by
McKee and Britton (1998). Specifically, heavy drinking occasions have been shown to
increase low-density lipoproteins, which in turn have been linked to negative cardiovascular
outcomes. Contrary to low or moderate steady drinking, heavy irregular drinking occasions
are not associated with an increase of high-density lipoproteins, which themselves have been
linked to favourable cardiovascular outcomes. In addition, irregular drinking is associated
with increased risk of thrombosis, occurring after cessation of drinking (Renaud & Ruf,
1996). Finally, irregular heavy drinking seems to predispose to histological changes in the
myocardium and conducting system, as well as to a reduction in the threshold for ventricular
fibrillation. In sum, irregular heavy drinking occasions are mainly associated with
physiological mechanisms increasing the risk of sudden cardiac death and other
cardiovascular outcomes, in contrast to the physiological mechanisms triggered by steady low
to moderate consumption and linked to favourable cardiac outcomes.

With respect to

drinking with meals,

Trevisan and colleagues (2001a; 2001b) reported more

protective effects of alcohol consumption when it was predominately consumed with meals
compared to alcohol consumption outside meals.

The potential mechanisms linking consumption of alcoholic beverages with meals to a lower
CHD risk, remain to be fully clarified. Mechanisms may be the reduced postprandial blood
pressure (Foppa et al., 1999), positive effects on fibrinolysis (Hendriks et al., 1994) and lipids

WHO Global Status Report on Alcohol 2004

(Veenstra et al., 1990), and an increased alcohol elimination rate or a reduced alcohol
absorption rate with food in the gastrointestinal tract (Gentry, 2000; Ramchandani, Kwo & Li,
2001). Several studies - mainly conducted at the aggregate level - showed that cultural
drinking patterns are related to differential effects of volume on CHD mortality and
morbidity. Most of them were either related to drastic changes in alcohol consumption and
CHD mortality connected with the anti-alcohol campaign of the last years of the Soviet Union
(Shkolnikov & Nemtsov, 1997; Bobak & Marmot, 1999; Britton & McKee, 2000; Leon et al.,
1997; McKee, Shkolnikov & Leon, 2001; Notzon et al., 1998; Shkolnikov, McKee & Leon,
2001). Another indirect line of research on the effect of heavy drinking on CHD shows that
countries with a tradition of heavier or binge-drinking occasions on weekends show
proportionately high CHD or cardiovascular disease morality on or immediately after the
weekend [Germany: CHD, (Willich et al., 1994); Moscow, Russian Federation:
cardiovascular disease events, (Chenet et al., 1998); Lithuania: CHD events, (Chenet et al.,
2001); Scotland: CHD events (cf. Evans et al., 2000)]. Finally, in the Global Burden of
Disease (GBD) 2000 study, the moderating effect of drinking patterns on CHD could be
demonstrated (Gmel, Rehm & Frick, 2003; Rehm et al., in press).

Depression

Alcohol is implicated in a variety of mental disorders which are not alcohol-specific.
However, before the GBD 2000 study no major overview on alcohol-attributable burden of
disease has included these conditions (English et al., 1995; Gutjahr, Gmel & Rehm, 2001;
Rehm & Gmel, 2001; Ridolfo & Stevenson, 2001; Single et al., 1999). While the causality of
the relation is hard to define, sufficient evidence now exists to assume alcohol’s causal role in
depression, a common mental disorder.

In the general population, alcohol dependence and major depression co-occur over-
proportionally, on both a 12-month and a lifetime basis (Kessler et al., 1996; Kessler et al.,
1997; Lynskey, 1998). Among alcohol consumers in the general population, higher volume of
consumption is associated with more symptoms of depression (Graham & Schmidt, 1999;
Mehrabian, 2001; Rodgers et al., 2000). Among patients in treatment for alcohol abuse and
dependence, the prevalence of major depression is higher than in the general population
(Lynskey, 1998; Schuckit et al., 1997). Higher prevalence of alcohol use disorders has been
documented for patients in treatment for depression (Alpert et al., 1999; Blixen, McDougall &
Suen, 1997).

This suggests that alcohol use disorders are linked to depressive symptoms, and that alcohol
dependence and depressive disorders co-occur to a larger degree than expected by chance.
However, it is not clear in the individual case whether the depression caused alcohol
problems, whether the alcohol consumption or alcohol problems caused depression, or
whether both could be attributed to a third cause (Vaillant, 1993). The pathway from
depression to harmful alcohol use and alcohol dependence has long been discussed under the
heading of self-medication (i.e. the use of alcohol to alleviate depressive symptoms). In
addition, a shared third cause could be certain neurobiological mechanisms (see Markou,
Kosten & Koob, 1998) or genetic predisposition. To be a causal factor, one condition is that
alcohol use disorders must precede depression, i.e. only that fraction of depression can
logically be caused by alcohol dependence where the onset of dependence preceded the onset
of depression. Such fractions can be found in many countries (see data of the International
Consortium in Psychiatric Epidemiology (ICPE), Merikangas et al., 1998). Commonly,
proportions of depressive disorders, which are preceded by alcohol dependence, were higher

WHO Global Status Report on Alcohol 2004

Table 14: Relative risk for major chronic disease categories by sex and average drinking

category

F M

Disease

ICD-9
4digit

ICD-10

4digit

Drinking

cat.I

Drinking

cat.II

Drinking

cat.III

Drinking

cat.I

Drinking

cat.II

Drinking

cat.III

Conditions arising during the
perinatal period

760–779

minus 771.3

P00-P96

Low birth weight

764–765

P05-P07 1.00 1.40 1.40 1.00 1.40 1.40

Malignant neoplasms

140–208

C00-C97

Mouth and oropharynx cancers

140–149

C00-C14 1.45 1.85 5.39 1.45 1.85 5.39

Oesophagus cancer

150

C15

1.80 2.38 4.36 1.80 2.38 4.36

Liver cancer

155

C22

1.45 3.03 3.60 1.45 3.03 3.6

Breast cancer*

1.14 1.41 1.59 n.a. n.a. n.a.

Under 45 years of age*

1.15

1.41

1.46

n.a.

45 years and over*

174

C50

1.14 1.38 1.62 n.a. n.a. n.a.

Other neoplasms

210–239 D00-D48 1.10 1.30 1.70 1.10 1.30 1.70

Diabetes mellitus

250

E10-E14

0.92

0.87

1.13

1.00

0.57

0.73

Neuro-psychiatric conditions

290–319,

324–359

F01-F99,

G06-G98

Unipolar major depression

300.4

F32-F33

AAF were directly assessed using dependence rates, but
varied widely across regions and sex. For details see Rehm
et al. (in press).

Epilepsy

345

G40-G41 1.34 7.22 7.52 1.23 7.52 6.83

Alcohol-use disorders

291, 303,

305.0

F10

AAF

100%

AAF

100%

AAF

100%

AAF

100%

AAF

100%

AAF

100%

Cardiovascular diseases

390–459

I00-I99

Hypertensive disease

401–405

I10-I13 1.40 2.00 2.00 1.40 2.00 4.10

0.82 0.83 1.12 0.82 0.83 1.00

Coronary heart disease

410–414

I20-I25

AAFs need modelling of drinking patterns and thus widely
vary across regions and sex. For details see Rehm et al. (in
press).

Cerebrovascular disease

430–438

I60-I69

Ischaemic stroke*

433-435

0.52 0.64 1.06 0.94 1.33 1.65

Haemorrhagic stroke*

430-432

0.59 0.65 7.98 1.27 2.19 2.38

Digestive diseases

530–579

K20-K92

Cirrhosis of the liver

571

K70,

K74 1.30 9.50 13.00 1.30 9.50 13.00

Sources

Gutjahr & Gmel (2001), Ridolfo & Stevenson (2001); if indicated by *; the category III estimates for

CHD were based on Corrao et al. (2000) and Rehm et al. (in press).

Definition of drinking categories

category I

for females not exceeding on average 0 to 19.99 g pure alcohol

per day; for males not exceeding on average 0 to 39.99 g pure alcohol per day;

category II

: for females not

exceeding on average 20 to 39.99 g pure alcohol per day; for males not exceeding on average 40 to 59.99 g pure
alcohol per day;

category III

: for females on average 40 g pure alcohol and above per day; for males on

average 60 g pure alcohol and above per day. For comparison: a 75 cl. bottle of wine contains about 70 g of
pure alcohol.

WHO Global Status Report on Alcohol 2004

Acute adverse health consequences: accidental injury and poisoning,
suicide, interpersonal violence and assaults

Alcohol use has been associated with increased risk of injury in a wide variety of settings
including road traffic accident (vehicles, bicycles, pedestrians), falls, fires, injuries related to
sports and recreational activities, self-inflicted injuries or injuries resulting from interpersonal
violence (Cherpitel, 1992; Freedland, McMicken & D'Onofrio, 1993; Hingson & Howland,
1987; Hingson & Howland, 1993; Hurst, Harte & Firth, 1994; Martin, 1992; Martin &
Bachman, 1997; US Department of Health and Human Services, 1997; US Department of
Health and Human Services, 2000). There is also some evidence that the presence of alcohol
in the body at the time of injury may be associated with greater severity of injury and less
positive outcomes (Fuller, 1995; Li et al., 1997).

Unintentional injuries

Alcohol consumption produces effects that are often perceived as positive, as evidenced by
the widespread popularity of drinking. But it also leads to actions that result in unintentional
injury and death. This section highlights research findings on causality of alcohol
involvement and findings relevant to establishing dose–response relationships and drinking
patterns. It focuses on traffic injuries, as most of the research has been conducted in this area,
and traffic accidents are the most important component of unintentional injuries (Rehm et al.,
2003a).

Studies relating average volume of drinking to risk of injury have found the risk of injury to
be positively related to increasing average intake levels of alcohol, with the risk increasing at
relatively low volumes of intake (Cherpitel et al., 1995). Several patterns of drinking have
been related to injury risk. Frequent heavy drinking and frequent subjective drunkenness are
both associated with injury, particularly injury resulting from violence (Cherpitel, 1996).
Often, the greatest risk was found in individuals who consume relatively large amounts on
some occasions, and whose highest amounts are markedly greater than their average amount
per occasion (Gruenewald & Nephew, 1994; Gruenewald, Mitchell & Treno, 1996;
Gruenewald, Treno & Mitchell, 1996; Treno, Gruenewald & Ponicki, 1997; Treno & Holder,
1997). This was also confirmed in a statistically adequate re-analysis of the Grand Rapids
study, that indicates that though all levels of BAC are associated with an increased risk of
crashes, relative to a BAC of zero, the risk slope was accelerated for less frequent drinkers
(Hurst, Harte & Firth, 1994).

There are clear biological mechanisms why alcohol is related to injury. Moderate doses of
alcohol have been demonstrated in controlled experimental studies to have cognitive and
psychomotor effects that are relevant to the risk of injury, such as reaction time, cognitive
processing, coordination and vigilance (Eckhardt et al., 1998; Krüger et al., 1993; Moskowitz
& Robinson, 1988; US Department of Health and Human Services, 1997). The
comprehensive recent review by Eckardt and colleagues (1998) concluded that the threshold
dose for negative effects on psychomotor tasks is generally found at around 40 to 50 mg%
(equivalent to 0.04%–0.05%).

In summary, the evidence indicates that the amount consumed per occasion, and more
specifically blood alcohol content, is the critical feature in determining risk of injury. Table
15 gives the attributable fractions for alcohol for different kinds of injuries in four recent
reviews. The reviews based their estimates on meta-analyses or other summaries of the

WHO Global Status Report on Alcohol 2004

relations found in published studies. It should be recognized that, while there are many such
studies, they are mostly from a relatively small range of countries, mostly from established
market economies. Hence, such estimates cannot necessarily be projected to other countries
with different patterns of drinking and different average volumes of drinking.

Intentional injuries

Alcohol is strongly associated with violent crime (Graham & West, 2001), although this
association varies considerably across settings (Murdoch, Pihl & Ross, 1990; Room &
Rossow (2001), Rossow, Pernanen & Rehm, 2001). Studies on violence have repeatedly
shown that alcohol consumption precedes violent events, and that the amount of drinking is
related to severity of subsequent violence. Based on meta-analyses of experimental studies
there appears to be a small effect size of about 0.22 (Bushman, 1997) in the overall
relationship between alcohol consumption and aggression. However, experimental research
was not able to attribute effects on aggression to pharmacological effects only. Specific
expectations of consumers as regards the effects of alcohol must accompany alcohol
consumption to result in aggression (Gmel & Rehm, 2003). The general conclusion is that
expectations form part of the “psycho-pharmacological” effects of alcohol (Bushman, 1997;
Graham et al., 1998), and should not be separated in attempting to understand the effects of
alcohol.

There are a number of different effects of alcohol contributing to increased likelihood of
aggressive behaviour. Alcohol may have an effect on the serotonin (5HT) and GABA brain
receptors that may reduce fear and anxiety about social, physical or legal consequences of
one’s actions. Alcohol also affects cognitive functioning (Peterson et al., 1990), leading to
impaired problem solving in conflict situations (Sayette, Wilson & Elias, 1993) and overly
emotional responses or emotional ability (Pihl, Peterson & Lau, 1993). Other behavioural and
attitudinal effects of alcohol related to aggression have been identified, although at this point
not necessarily linked to particular pharmacological effects on the brain. These include a
narrow and tenacious focus on the present (Graham, West & Wells, 2000; Washburne, 1956),
also described as “alcohol myopia” (Steele & Josephs, 1990), and increased concerns with
demonstrating personal power, at least for men (Graham, West & Wells, 2000; McClelland et
al., 1972; Tomsen, 1997).

Estimating the proportion of alcohol induced intentional injuries is problematic and needs
assessment from different sources, such as time-series analyses, natural experiments, case–
control studies, emergency-room studies, general population surveys, and experimental
designs (Pernanen, 2001). For details of a potential approach, using volume of drinking and
drinking patterns in a cross-cultural approach see Rehm et al. (in press).

WHO Global Status Report on Alcohol 2004

Table 15: Attributable fractions of acute alcohol-related health effects in the adult general

population

USA

Stinson et al.

(1993)

AUSTRALIA

English et al.

(1995)

CANADA

Single et al.

(1996)

AUSTRALIA

Ridolfo & Stevenson

(2001)

Injury ICD-9

F M F M F M

Motor vehicle
traffic accidents

E810–E819 0.42 0.42 0.18 0.37 0.43 0.43

Motor vehicle
nontraffic accidents

E820–E825 0.42 0.42 0.18 0.37 0.43 0.43

Bicycle accident
injuries

E826

0.20 0.20 0.18 0.37 0.20 0.20

Other road vehicle
accident injuries

E829 0.20

0.20

0.18

0.37

0.2

0.20

0.11 for

deaths (d)

and hospitali-

zations (h);

pedestrians

0.17 (d); 0.06

(h)

0.33 (d);

024 (h);

pedestrians

0.40 (d); 0.37

(h)

Water transport
accident injuries

E830–E839

0.20

No data No data

0.20

No data

Air-space transport
accident injuries

E840–E845

0.16

No data No data

0.16

No data

Accidental ethanol
and methanol
poisoning

E860.0–
E860.2

1.00 1.00 1.00 1.00 1.00 1.00

1.00

Accidental fall
injuries

E880–E888 0.35 0.35 0.34 0.34

0.13-

0.34

0.20-

0.34

0.14 for age

<65;

0.04> = 65

0.22 for age

<65;

0.12> = 65

Arson

injuries E890–E899 0.45 0.45 0.44 0.44 0.38 0.38

0.44

Accidental
excessive cold

E901

0.25

No data No data

0.25

No data

Accidental
drowning

E910 0.38

0.38

0.34

0.31–

0.50

0.31–

0.50

0.34 0.34

Accidental
aspiration

E911 0.25

0.25

1.0

1.00

0.25

1.00

Striking against /
struck by objects

E917

0.25

No data No data

0.07

No data

Caught in /
between objects

E918

0.25

No data No data

0.07

No data

Occupational and
machine injuries

E919–E920 0.25 0.25 0.07 0.07 0.07 0.07

0.07

Accidental firearm
missile injuries

E922

0.25

No data No data

0.25

No data

Suicide, self-
inflicted injuries

E950–E959 0.28 0.28 0.08 0.12

0.11–

0.19

0.23–

0.31

0.29 0.32

Victim, fight, brawl,
rape

E960

0.46 0.46 0.47 0.47 0.27 0.27

0.47

Victim assault
firearms

E965

0.46 0.46 0.47 0.47 0.27 0.27

0.47

Victim assault
cutting instrument

E966

0.46 0.46 0.47 0.47 0.27 0.27

0.47

Victim child
battering

E967

0.46 0.46 0.16 0.16 0.16 0.16

0.16

Victim assault
other

E968

0.46 0.46 0.47 0.47 0.27 0.27

0.47

Late effects of
injuries by another

E969

0.46 0.46 0.47 0.47 0.27 0.27

0.47

Remarks

:Ranges refer to age-specific attributable fractions; minimum (>0) and maximum estimates are shown.

Source

: Rehm et al. (in press)

WHO Global Status Report on Alcohol 2004

To sum up, in some countries there would be even more alcohol-related “prevented” death
than caused deaths, mainly owing to the beneficial effect of low and moderate alcohol
consumption on cardiovascular disease in some populations, like women of advanced age.
This, however applies mainly to countries with established market economies, where life
expectancy is high and the country’s prevailing drinking pattern is a regular drinking pattern
of moderate amounts, preferably consumed with meals. If one considers, however, life years
lost instead of counting deaths only, a different picture emerges. There are more life years lost
due to alcohol consumption than deaths “prevented”. This can be explained by the fact that
the years gained from alcohol consumption’s beneficial effect on CHD are usually gained at
higher ages and comprise only few years compared to the many years lost in deaths at early
ages, e.g. in alcohol-related traffic-casualties. The balance would even bend down more
stronger to the detrimental side, if in addition to life years lost also years spent in disability
were included in estimates, such as in the burden of disease measure of disability adjusted life
years lost (for details see next paragraph). Figures 5 and 6 demonstrate the difference in
counting death versus other measures of life years lost for alcohol use disorders.

Figure 5: Global disease burden (in DALYs) in 2001 from alcohol use disorders, by age

group and sex

0-4

5-14

15-29

30-44

45-59

60-69

70-79

80+

illio

Male Female

WHO Global Status Report on Alcohol 2004

Table 16: Global burden of disease in 2000 attributable to alcohol according to major

disease categories (DALYs in 000s)

Disease or Injury

Female

Male

Total

% of all alcohol-

attributable DALYs

Conditions arising during the
perinatal period

55 68

123 0%

Malignant

neoplasm

1021 3180 4201

Neuro-psychiatric conditions

3814

18 090

21 904

38%

Cardiovascular

diseases

-428 4411 3983

Other noncommunicable diseases
(diabetes, liver cirrhosis)

860 3695 4555

Unintentional injuries

2487

14 008

16 495

28%

Intentional

injuries

1117 5945 7062

12%

Alcohol-related disease burden all
causes (DALYs)

8926 49

397 58

323

100%

All DALYs

693 911

761 562

1 455 473

% of all DALYs that can be
attributable to alcohol

1.3%

6.5%

4.0%

In comparison: estimate
for 1990: 3.5%

Source

: Rehm et al. (2003d)

What are the most striking differences between regions? Clearly alcohol-related burden is
most detrimental in the developed world. Here 9.2% of all the disease burden is attributable
to alcohol, only exceeded by the burden attributable to tobacco and blood pressure (see Table
17 and WHO, 2002). Here also the ratio of males to females is lowest. However, as Table 17
indicates, alcohol also places a toll on health in the developing world with relatively low
mortality patterns. Here the disease burden attributable to alcohol is the highest of all 26 risk
factors examined in the CRA of the GBD 2000 study (Ezzati et al., 2002). In the developing
world with high mortality patterns like Africa and parts of South-East Asia, alcohol is not yet
one of the major risk factors. Here, the most important risk factors are being underweight,
unsafe sex, unsafe water sanitation and hygiene and other environmental factors. However, if
seems to be predictable that alcohol–attributable burden will increase in these regions as well
with economic development (Rehm et al., in press).

Table 17: Burden of disease in 2000 attributable to tobacco, alcohol and drugs by

developing status and sex

High mortality developing

Low mortality developing

Developed

(AFR-D, AFR-E, AMR-D,

EMR-D, SEAR-D)

(AMR-B, EMR-B,

SEAR-B, WPR-B)

(AMR-A, EUR-A, EUR-B,

EUR-C, WPR-A)

Male

Female

Total

Male

Female

Total

Male

Female Total

Total DALYs (000s)

420 711 412 052 832 763 223 181 185 316 408 497 117 670 96 543 214 213

Smoking and oral tobacco (%)

3.4

0.6

2.0

6.2

1.3

4.0

17.1

6.2

12.2

Alcohol (%)

2.6

0.5

1.6

9.8

2.0

6.2

14.0

3.3

9.2

Illicit drugs (%)

0.8

0.2

0.5

1.2

0.3

0.8

2.3

1.2

1.8

Source

: Rehm et al. (in press).

WHO Global Status Report on Alcohol 2004

As stated above, the impact of alcohol consumption on diseases and the distribution of
alcohol-related diseases should vary according to two factors: the volume and the drinking
pattern.

Table 18 gives an overview of differences in alcohol consumption across WHO regions. The
regional subgroupings have been defined by WHO (2000b) on the basis of high, medium or
low levels of adult and of infant mortality. 'A' stands for very low child and very low adult
mortality, 'B' stands for low child and low adult mortality, 'C' for low child and high adult
mortality, 'D' for high child and high adult mortality, and 'E' for very high child and very high
adult mortality (WHO, 2000b). From this it can be seen that in the developed low mortality
countries (EUR-A, AMR-A, WPR-A) alcohol consumption of drinkers is usually high but
alcohol is commonly consumed in a less detrimental way (e.g. regularly with meals; for
details as regards the average drinking pattern, see Rehm et al., in press), and thus one would
expect a larger share of chronic diseases including alcohol abuse and dependence, and a lower
share of acute consequences such as injury. In developing countries with low mortality
(AMR-B, EMR-B, SEAR-B, WPR-B) volume of drinking is high but drinking patterns are
more detrimental. Thus, there should be a larger share of acute consequences. The same is
true for high mortality developing countries (AFR-D, AFR-E, AMR-D, EMR-D, SEAR-D),
for which however volume of drinking is usually low and thus the total alcohol-related burden
should also be lower compared to the developing countries with low mortality. The greatest
burden from alcohol consumption should be expected in the EUR-B and EUR-C regions
where both volume of drinking is high and alcohol is consumed mostly in a detrimental
pattern, and thus there should again be a high share of acute consequences again.

As Table 19 shows, empirically the aforementioned predictions could be confirmed, with the
highest alcohol-related burden in the former socialist countries and the lowest burden in
regions with low volume of drinking. Burden from acute consequences are highest in those
regions, where regular drinking is rare, but alcohol is often consumed in large amounts when
drinking takes place.

Table 20 shows the average attributable alcohol fractions (AAF) which were derived from
calculations described in Babor, Rehm and Room (in press), for the categories of disorders for
which alcohol was considered to be causal. The average AAFs are shown for men and
women separately and together, for the world as a whole and for the three categories of high-
mortality developing countries, low-mortality developing countries, and developed countries.
Looking at the table, there are obvious gender differences to be found, with males having
higher AAFs than females globally and in all regions. Also, the AAFs for developed countries
are considerably higher than those of developing countries.

Table 21 gives an overview of standardized death rates for the chronic and acute diseases used
in the current report (data shown is for most recent year available). It should be noted that
these are not purely alcohol-related deaths. Traffic injuries, for example, also depend on the
development of the transport system in a country, traffic or car densities, or road safety issues.
Similarly, liver cirrhosis in many countries do not have a high alcohol involvement, but are
related to poor sanitary conditions (poor drinking water quality causing high levels of
hepatitis infections and liver diseases). Also, the numbers here do not imply that alcohol is
responsible for all deaths from say cirrhosis of the liver or mouth and oropharynx cancer -
with the exception of alcohol use disorders, the standardized mortality rates shown here are
derived from the total number of deaths from the eight causes chosen irrespective of whether
alcohol was a direct or indirect contributor to the deaths.

WHO Global Status Report on Alcohol 2004

Table 18: Characteristics of adult alcohol consumption in different regions of the world 2000 (population weighted averages)

WHO Region
(Definition see below)

Beverage type mostly consumed

Total

consumption

unrecorded

of total

% heavy

drinkers

among

males

drinkers

among

females

Consumption

per drinker

Average
drinking

pattern

Africa D (e.g. Nigeria, Algeria)

Mainly other fermented beverages

4.9

5.3

13.3

2.5

Africa E (e.g. Ethiopia, South Africa)

Mainly other fermented beverages and
beer

7.1

46 10.3 55 30 16.6 3.1

Americas A (Canada, Cuba, the United
States)

> 50% of consumption is beer, about
25% spirits

9.3

11 11.2 73 58 14.3 2.0

Americas B (e.g. Brazil, Mexico)

Beer, followed by spirits

9.0

9.1

14.1

3.1

Americas D (e.g. Bolivia, Peru)

Spirits, followed by beer

5.1

2.7

7.6

3.1

Eastern Mediterranean B (e.g. the Islamic
Republic of Iran, Saudi Arabia)

Spirits and beer, but scarce data

1.3

1.5

11.0

2.0

Eastern Mediterranean D (e.g.
Afghanistan, Pakistan)

Spirits and beer, but scarce data

0.6

0.1

6.0

2.4

Europe A (e.g. Germany, France, the
United Kingdom)

Wine and beer

12.9

15.7

15.1

1.3

Europe B (e.g. Bulgaria, Poland, Turkey)

Spirits

8.3

8.8

13.4

2.9

Europe C (e.g. the Russian Federation,
Ukraine)

Spirits

13.9

38 18.6 89 81 16.5 3.6

South-East Asia B (e.g. Indonesia,
Thailand)

Spirits

3.1

27 1.2 35 9 13.7

2.5

South-East Asia D (e.g. Bangladesh,
India)

Spirits

2.0

79 0.9 26 4 12.9

3.0

Western Pacific A (e.g. Australia, Japan)

Beer and spirits

8.5

4.2

10.4

1.2

Western Pacific B (e.g. China, the
Philippines, Viet Nam)

Spirits

5.0

26 4.1 84

30 8.8 2.2

1 Estimated total alcohol consumption per resident aged 15 and older in litres of absolute alcohol (recorded and unrecorded)

2 Percentage of total adult per capita consumption (= column 3) which is estimated to be unrecorded

3 Estimated % rate of heavy drinking (males

≥

40 g and females

≥

20 g) among those aged 15+

4 Estimated total alcohol consumption (in litres of absolute alcohol) per adult drinker
5 Estimated average pattern of drinking (1-4 with 4 being the most detrimental pattern i.e. based on many heavy drinking occasions, drinking outside meals, high level of
fiesta drinking and drinking in public places, etc. and 1 being the least detrimental pattern i.e. least heavy drinking occasions, drinking with meals, no fiesta drinking, elast
drinking in public places, etc. )

Source

: Rehm et al. (2003b)

WHO Global Status Report on Alcohol 2004

Table 19: Alcohol-related harm in different regions of the world (population weighted averages), DALYs (000s)

Developing countries

Developed countries

World

very high or high

mortality

low mortality

very low mortality

only burden

Former Socialist:

low mortality

AFR-D, AFR-E, AMR-D,

EMR-D, SEAR-D

AMR-B, EMR-B,

SEAR-B, WPR-B

AMR A, EUR A,

WPR A

Eur B, C

DALYs % DALYs % DALYs % DALYs % DALYs %

Neuro-psychiatric conditions* and other NCD**

4369 33.2 12

006 47.0 6484 68.7 3601 30.7 26460 44.2

Alcohol use disorders

3885 29.5 5715 22.4 6318 65.8 2550 21.7 18469 31.7

Unintentional injuries

5033 38.2 5961 23.4 1571 16.4 3929 33.5 16494 28.3

Intentional injuries

1689 12.8 2940 11.5 558 5.8 1874 16.0 7061 12.1

Total alcohol related burden in DALYs

13 165

100.0

25 519

100.0

9445

100.0 11742 100.0 58323 100.0

Total burden of disease in DALYs

845

628 411268 115246 100250 1472392

% of total disease burden which is alcohol related

1.6 6.2 8.3 11.7 4.0

*dominated by alcohol use disorders (plus epilepsy and depression)
** other noncommunicable diseases, dominated by liver cirrhosis (plus diabetes)

# before reduction of – 1548 DALYs due to protective effects of vascular diseases

Source

: Rehm et al. (2003d); WHO (2001c, p. 150) (also available www.who.int/whr2001/2001/main/en/annex/Annex3-en-WEB.xls); own calculations

WHO Global Status Report on Alcohol 2004

Table 20: Selected population alcohol-attributable fractions, by disease category, sex and level of development (% DALYs for each cause) in

2000

High mortality

developing

Low mortality

developing

Developed

World

(AFR-D, AFR-E, AMR-D,

EMR-D, SEAR-D)

(AMR-B, EMR-B, SEAR-

B, WPR-B)

(AMR-A, EUR-A, EUR-B,

EUR-C, WPR-A)

GBD disease categories

Males Females Both

Males Females Males Females Males Females

Mouth

and

oropharynx

cancers

22 9 19 11 4 28 10 41 28

Oesophagus

cancer

37 15 29 17 6 42 16 46 36

Liver

cancer

30 13 25 23 10 32 11 36 28

Other

neoplasms

6 3 4 2 1 5 2

11 8

Unipolar

depressive

disorders

3 1 2 2 0 3 0 7 2

Epilepsy

23 12 18 14 7 27 13 45 36

Alcohol

use

disorders

100 100 100 100 100 100 100 100 100

Ischaemic

heart

disease

4 -1 2 7 0 5 0 2 -3

Haemorrhagic

stroke

18 1

10 7 2

21 2

26 0

Ischaemic

stroke

3 -6 -1 1 0 3 0 5

-16

Cirrhosis

the

Liver

39 18 32 19 7 45 13 63 49

Motor

vehicle

accidents

25 8 20 19 5 25 8 45 18

Drownings

12 6

10 8 4

10 6

Falls

9 3 7 5 1 8 3

21 8

Poisonings

23 9

18 7 3

11 7

Other

unintentional

injuries

15 5 11 10 4 15 6 32 16

Self-inflicted

injuries

15 5

11 8 2

10 5

Homicide

26 16 24 18 12 28 16 41 32

Other

Intentional

injuries

13 7 12 7 3 20 11 32 19

Source

: Babor, Rehm & Room (in press)

WHO Global Status Report on Alcohol 2004

Table 21: Standardized mortality rates (per 100 000) for acute and chronic disease and injury, by WHO regional subgroupings (data shown is

for most recent year available)

Country

Falls

Intentional

injuries

Traffic

casualties

Accidental

poisoning

Alcohol

use

disorders

Liver

cirrhosis

Mouth

and

oropharynx

cancer

Ischaemic

heart

disease

Mauritius 2.77

14.44

15.91

N.A.

2.04

15.78

3.85

173.51

AFR-D

AMR-D

Ecuador

3.42 22.16 11.95 1.96 2.97 15.45 0.97 31.32

EMR-D Egypt

0.93 0.51

6.65 0.15 0.00 35.89 0.57 27.05

AMR-B

Argentina

0.79 15.51 9.56 0.45 1.83 6.39 2.14

49.38

Bahamas

(the)

a,b

0.45 26.02 20.04 0.30 3.98 16.91 2.49 85.79

Brazil

3.53 29.63 16.63 0.17 3.28 11.31 3.87 72.26

Chile

0.83 10.26 10.69 0.27 1.47 20.49 1.35 62.42

Colombia

3.34 69.15 17.71 0.29 0.03 6.25 1.72

89.80

Costa

Rica

2.35 11.78 17.83 0.27 0.93 7.81 2.22

93.08

Salvador

3.92 50.62 33.51 0.22 19.50 12.41 1.05 77.84

Mexico

3.14 15.00 11.64 1.05 5.82 36.15 1.33 75.78

Panama

3.69 15.88 15.25 0.41 1.03 7.91 2.83

59.02

Paraguay

0.74 16.38 10.42 0.43 1.42 6.26 2.05

51.31

Trinidad

and

Tobago

2.48

16.74

11.87

3.33

0.67

9.55

3.87

170.91

Uruguay

1.43

15.18

10.05

4.02

1.45

5.95

3.27

60.10

Venezuela

3.19

19.39

23.20

2.24

0.84

11.21

1.81

119.36

EMR-B Kuwait

2.20

3.93

19.01

0.65

0.05

4.01

0.97

79.10

WPR-B Philippines

(the)

2.35 19.80 8.60 0.30 0.71

10.00

4.67

86.22

Republic of Korea (the)

6.59 16.00 20.00 0.92 2.48 20.02 1.69 27.01

WHO Global Status Report on Alcohol 2004

Country

Falls

Intentional

injuries

Traffic

casualties

Accidental

poisoning

Alcohol

use

disorders

Liver

cirrhosis

Mouth

and

oropharynx

cancer

Ischaemic

heart

disease

AMR-A

Canada

3.08 12.09 8.45 2.73 1.61 5.24 2.06

82.97

Cuba

12.26 18.22 12.19 0.32 2.31 7.61 3.82

108.52

United States of America (the)

6.78

20.21

15.00

0.58

1.90

7.47

2.00

112.40

EUR-A

Austria

6.76 15.38 9.84 1.11 2.98

14.95

3.96

100.03

Croatia

8.33

17.32

11.27

1.72

3.18

20.90

5.27

127.98

Czech Republic (the)

12.18

14.31

8.65

2.76

0.76

12.36

4.04

141.13

Denmark

12.20 13.00

9.57 2.96 6.90 11.70 3.17 90.91

Finland

10.84

23.20

7.77

9.12

3.63

9.60

1.82

122.98

France

8.69 15.01 13.06 0.79 3.37 11.45 5.85 39.12

Germany

4.40 11.15 8.05 1.14 4.01

13.36

3.77

95.74

Greece

3.20

4.06

18.88

2.57

0.05

3.83

1.22

63.65

Iceland

2.81 11.42 6.16 0.57 2.29 2.58 1.60

108.20

Ireland

7.00

11.97

10.14

1.04

1.98

3.94

3.04

133.70

Israel

1.46

8.26

5.57

0.26

0.93

3.85

1.20

77.33

Italy

7.48 6.38

11.76 0.37 0.22 10.73 2.90 57.20

Luxembourg

5.25 16.77 17.36 5.22 4.17 12.19 4.28 59.33

Malta

8.70 9.55 4.49 1.30

0.37

5.46

4.64

144.63

Netherlands

(the)

2.66

9.54

6.59

0.74

1.39

4.44

2.47

70.17

Norway

8.05 12.16 6.05 1.99 3.44 3.10 2.47

81.19

Portugal

3.38 4.82

12.50 0.64 0.32 13.08 4.06 50.51

Spain

2.31

7.49

13.98

2.03

0.52

8.45

3.75

49.94

Sweden

18.45

21.10

5.84

1.49

2.47

3.97

1.69

89.28

Switzerland

2.88 14.65 6.50 3.85 2.31 5.79 3.33

70.55

United

Kingdom

(the)

14.80

14.62

5.62

1.91

0.87

7.36

2.15

112.41

WPR-A

Australia

2.27 13.63 8.91 3.05 0.99 3.77 2.69

85.46

Japan

2.78 18.80 7.38 0.38 0.24 6.15 2.23

27.29

New

Zealand

4.17

13.23

11.57

0.83

0.46

2.40

2.65

102.50

Singapore

3.09 9.47 4.96 0.09

N.A.

2.84

5.83

91.24

WHO Global Status Report on Alcohol 2004

Country

Falls

Intentional

injuries

Traffic

casualties

Accidental

poisoning

Alcohol

use

disorders

Liver

cirrhosis

Mouth

and

oropharynx

cancer

Ischaemic

heart

disease

EUR-B Albania

1.22 11.52 7.83 2.97 0.39 N.A. 1.88

77.81

Armenia

0.72

3.62

5.43

1.32

N.A.

13.07

2.16

261.22

Azerbaijan

0.30 6.80 5.15 1.14

N.A.

34.02

1.23

284.62

Bulgaria

3.06

14.95

10.92

2.18

0.77

12.74

3.12

144.31

Kyrgyzstan

3.39 21.81 11.36

13.61

1.98

38.36

2.98

240.83

Poland

7.87

15.04

13.21

3.72

2.91

10.67

3.61

102.65

Romania

5.80

13.75

11.23

5.10

3.38

37.09

5.72

175.06

Slovenia

11.82 24.24 13.42 1.57 4.90 26.29 6.34 78.62

TFYR

Macedonia

0.99 19.09 5.12 0.97 0.80 5.70 2.51

84.17

Turkmenistan

4.01 28.40 8.60 19.04

N.A.

42.35

3.63

319.76

Uzbekistan

11.25 14.68 8.89 1.31 N.A. 39.05 2.59

316.50

EUR-C Belarus

5.14

38.92

13.97

29.09

N.A.

12.76

4.37

331.23

Estonia

7.99

38.35

14.35

25.65

3.63

17.39

6.18

274.79

Hungary

18.67 25.96 11.69 1.40 2.87 45.79

12.64

179.07

Kazakhstan

2.41 42.20 12.02

44.47

1.90

23.20

3.54

269.93

Latvia

13.25

37.26

22.78

13.60

8.15

12.10

3.99

250.55

Lithuania

10.22

45.94

18.16

16.20

1.10

14.36

5.58

250.20

Republic of Moldova (the)

3.33 22.37 11.69 8.60 1.58

65.03

4.72

311.58

Russian Federation (the)

8.42

61.42

25.82

36.62

N.A.

4.49

285.38

Ukraine

9.30

8.72

10.56

1.85

N.A.

20.72

5.21

368.11

Caution should be exercised when interpreting the results as death registration level is incomplete.

As countries with very small population size are likely to have spurious trends, care should be exercised when making inter-country comparisons.

WHO Global Status Report on Alcohol 2004

Social problems associated with alcohol use

Alcohol consumption is linked to many harmful consequences for the individual drinker, the
drinker’s immediate environment and society as a whole. Such social consequences as traffic
accidents, workplace-related problems, family and domestic problems, and interpersonal
violence have been receiving more public or research attention in recent years, indicating a
growing interest in a broader concept of alcohol-related consequences (Klingemann & Gmel,
2001). On the other hand, however, social consequences affect individuals other than the
drinker e.g. passengers involved in traffic casualties, or family members affected by failure to
fulfill social role obligations, or incidences of violence in the family. Ultimately, however,
these events have an impact on society as a whole insofar as they affect economic
productivity or require the attention and resources of the criminal justice or health care
system, or of other social institutions (Gmel & Rehm, 2003). Due to space constraints, this
section will only highlight some issues and data involving the following selected social
problems: alcohol consumption and workplace problems, alcohol consumption and family
problems, poverty, and domestic violence.

Alcohol consumption and the workplace

Heavy drinking at the workplace may potentially lower productivity. Sickness absence
associated with harmful use of alcohol and alcohol dependence entails a substantial cost to
employees and social security systems. There is ample evidence that people with alcohol
dependence and problem drinkers have higher rates of sickness absence than other employees
(Klingemann & Gmel, 2001).

Klingemann & Gmel (2001) note that a number of studies have demonstrated an association
between heavy drinking or alcohol abuse and unemployment. Here, a causal association may
go in either direction, heavy drinking may lead to unemployment, as suggested by Mustonen,
Paakkaned & Simpura (1994) and Mullahy & Sindelar (1996); but loss of work may also
result in increased drinking, which may become heavy drinking, as indicated by Gallant
(1993), Dooley & Prause (1998) and Claussen (1999).

Blum, Roman & Martin (1993) and Mangione et al. (1999) found that work performance was
related to volume and pattern of drinking. Blum and her colleagues found no significant
relationship between work performance and average daily volume when performance was
assessed by self-reports of the drinker. However, lower performance, lack of self-direction
and problems in personal relations were found to be related to heavy drinking, particularly
when collateral reports were used. In the Mangione et al. study, it was found that although
moderate-heavy and heavy drinkers reported more work performance problems than very
light, or moderate drinkers, the lower-level-drinking employees, since they were more
plentiful, accounted for a larger proportion of work performance problems than did the
heavier drinking groups. A study conducted by Ames, Grube & Moore (1997) found modest
but significant relationships between drinking behaviours and self-reports of workplace
problems.

Some examples may highlight the extent to which alcohol affects work performance. It has
been estimated that 30% of absenteeism and workplace accidents in Costa Rica were caused
by alcohol dependence (Pan American Health Organization, 1990). According to industry
association sources from India, 15% to 20% of absenteeism and 40% of accidents at work are
due to alcohol consumption (Saxena, Sharma & Maulik, 2003). A study by the Department of

WHO Global Status Report on Alcohol 2004

Hygiene and Industrial Safety in three factories in La Paz, Bolivia found that 7.3% of
absenteeism in the first two days of the work week and 1.2% of work-related accidents were
directly related to the consumption of alcohol (Pan American Health Organization, 1990). It
has been estimated that 20–22% of work-related accidents in Chile have a direct or indirect
relationship with recent alcohol use. In a study of patients who required hospitalization for
severe work-related accidents, it was found that 15% reported recent use of alcohol (Trucco et
al., 1998). It has been reported that in Latvia, alcoholism has had adverse impacts on
productivity in the workplace and increased absenteeism. No figures have been published on
the extent of absenteeism due to excessive alcohol use. It is estimated that drinking and
alcoholism have reduced labour productivity by some 10% (Trapenciere, 2000). A recent
survey conducted in the United States of America found that farm residents who drank more
frequently had significantly higher farm work injury incidence rates (3.35 per 10 000 person-
days of observation) than others who consumed less frequently (1.94 injuries per 10 000
person-days) (Stallones & Xiang, 2003).

With regards to trauma, alcohol is the cause of 10% to 20% of work accidents in France
(Costes & Martineau, 2002). A survey conducted in Australia of 833 employees at an
industrial worksite found that problem drinkers were 2.7 times more likely to have injury-
related absences than non-problem drinkers (Webb et al., 1994). In a 1994 survey, 90% of
personnel directors from British organizations cited alcohol consumption as a problem within
their workplace. Their major concerns included loss of productivity, absenteeism, safety,
employee relations, poor behaviour and impacts on company image. About 8–14 million
working days are lost annually to alcohol-related problems. With regard to safety, up to 25%
of workplace accidents and around 60% of fatal accidents at work may be associated with
alcohol (Hughes & Bellis, 2000). It is estimated that the annual alcohol-related costs to
workplaces in the United Kingdom is £6.4 billion (Prime Minister's Strategy Unit, 2003).

Alcohol consumption and the family

It is well established that drinking can severely impair the individual’s functioning in various
social roles. Alcohol misuse is associated with many negative consequences both for the
drinker’s partner as well as the children. Maternal alcohol consumption during pregnancy can
result in fetal alcohol syndrome in children, and parental drinking is correlated with child
abuse and impacts a child’s environment in many social, psychological and economic ways
(Gmel & Rehm, 2003). Drinking can impair performance as a parent, as a spouse or partner,
and as a contributor to household functioning. There are also other aspects of drinking which
may impair functioning as a family member. In many societies, drinking may be carried out
primarily outside the family and the home. In this circumstance, time spent while drinking
often competes with the time needed to carry on family life. Drinking also costs money and
can impact upon resources particularly of a poor family, leaving other family members
destitute. Also, it is worth noting that specific intoxicated events can also have lasting
consequences, through home accidents and family violence (Room, 1998; Room et al., 2002).
A recent paper by Bonu et al. (2004) suggests that adverse child health effects of alcohol use
are primarily through two distal determinants (indirect effects) - forgone household
disposable income and caretakers' time for childcare. Diversion of scant economic resources
for alcohol use that could have otherwise been used for seeking health care, may lead to self-
care or delay in seeking health care. The other potential ways by which alcohol use can reduce
the household income are through morbidity associated with the drinking habit among the
consuming individuals, resulting in increase in medical expenditures and loss of income due

WHO Global Status Report on Alcohol 2004

to lost wages, and, sometimes, resulting in the premature death of sole wage earners in a
household (Bonu et al., 2004).

Implicit in the habitual drinker's potential impact on family life is the fact that the drinking
and its consequences can result in substantial mental health problems of family members.
Such effects, though potentially common, are not often documented. Some insight into this
issue can be gained from interviews with members of Al-Anon, a companion organization to
Alcoholic Anonymous for spouses and family members of people with alcohol dependence.
In interviews with 45 Al-Anon members in Mexico (82% of them the wife of a husband who
was alcohol-dependent), 73% reported feelings of anxiety, fear, and depression; 62% reported
physical or verbal aggression by the spouse toward the family; and 31% reported family
disintegration with serious problems involving money and the children (Rosovsky et al.,
1992, cited in Room et al., 2002).

The effects of men's drinking on other members of the family is often particularly on women
in their roles as mothers or wives of drinkers. The risks include violence, HIV infection, and
an increased burden in their role of economic providers. In a paper that looked at alcohol and
alcohol-related problems facing women in Lesotho, it was noted that as in many other
developing countries, the cultural position of women in Lesotho facilitates a vicious circle in
which women are at one time brewers of alcohol, then sellers, then become excessive
consumers due to the problems created by their drinking husbands (Mphi, 1994).

Case example 1: Botswana

The economic consequences of chronic alcohol use are devastating and can seriously hinder any sense of
development. In a study of alcohol use among the Basarwa of the Kgalagadi and Ghanzi districts in Botswana,
informants stated that since a significant proportion of household income was spent on liquor, less cash was
available for food, clothing and other essential items. As one informant succinctly stated ‘alcohol makes poor
people poorer’. A person who is regularly under the influence of alcohol will have little motivation or interest in
working, unless it is to obtain money to buy more alcohol. One particular problem is that a regular drinker can
easily become economically tied and indebted to alcohol vendors who are only too pleased to provide alcohol
‘on credit’.

Child neglect is an increasing problem when parents are intoxicated so early in the day that they are not able to
prepare food for their children, even if there is food available. A concern is that some parents will sell food to
buy alcohol while others will give alcohol to their children as a food substitute and to stave off hunger.
Generally, the neglect of young children due to alcohol abuse means that these children are under-socialized as
well as malnourished, leading to a refusal to attend school, begging and stealing for food, and other delinquent
activities.

Source: Molamu & MacDonald (1996)

WHO Global Status Report on Alcohol 2004

Case example 2: Nepal

In a large-scale study covering about 2400 households in 16 of Nepal’s 70 districts, the adult respondents
perceived the impact of family members use of alcohol and drugs on children as violence and physical abuse
(33.4%), neglect and mental abuse (28.5%), deprivation from education (20.2%) and push factor for children to
use intoxicants (11.1%), malnutrition and running away from home. 35.9% of children interviewed felt that there
was an impact of parental drinking on the family. The impact included domestic violence (40%), loss of wealth
and indebtedness (27.8%), loss of social prestige and bad relationship with neighbours.

Source: Dhital et al. (2001)

Alcohol and poverty

The economic consequences of expenditures on alcohol are significant especially in high
poverty areas. Besides money spent on alcohol, a heavy drinker also suffers other adverse
economic effects. These include lowered wages (because of missed work and decreased
efficiency on the job), lost employment opportunities, increased medical expenses for illness
and accidents, legal cost of drink-related offences, and decreased eligibility of loans. A recent
study conducted in 11 districts in Sri Lanka examining the link between alcohol and poverty
found that 7% of men said that their alcohol expenditure was greater than their income.
Though a relatively small percentage, this is still a worrying statistic for the families
concerned and for those interested in helping the worst-off families (Baklien & Samarasinghe,
2001).

Case example 3: Cameroon

What is problematic in Cameroon is the high cost of purchasing even one beer a week given the income of an
average rural family. When comparing the price of two major beers sold in a rural village in 1983 as a
percentage of male and female wages, it was found that the cost of one beer represented 60–84% of women’s
and 36–50% of men’s daily wages. Drinking even in these small amounts means that one day’s wages is quickly
consumed. The danger is when individuals start forsaking paying children’s school fees because their money is
spent on beer. Such individuals are considered disruptive of community life because their negligence impedes
others from doing their work or meeting obligations towards friends, association members and kin.

Source: Diduk (1993)

Case example 4: India

In a 1997 study comparing two groups of families within the same community in Delhi, India (Group A having
at least one adult consuming alcoholic drinks at least three times per week in the last month and Group B having
no adult consuming more than one drink in the last month), it was found that Group A, on an average, spent
almost 14 times more on alcohol per month compared with Group B. A larger proportion of families in Group A
had significant debt compared with Group B. The implications of this are towards fewer financial resources for
food and education of children and fewer resources for purchasing daily living consumables. The more heavily
drinking Group A was more likely to report major illnesses or injuries during the past one year and was more
likely to require medical treatment.

Source: Saxena, Sharma & Maulik (2003)

WHO Global Status Report on Alcohol 2004

Case example 5: Malaysia

Alcohol is a major factor in exacerbating poverty. In a month a rural labourer can spend about RM 300 (US$ 80)
on alcohol which is about how much he earns. The alcohol menace ruins families and contributes to the
breakdown of the basic social fabric of society. Often it is the women who bear the brunt of this problem – wife
battery, discord in the home, abused and deprived children, non-working or chronically ill husbands who become
a burden to both the family and society. Besides loss in family income, the burden on the family is worsened
when the drinker falls ill, cannot work and requires medical attention.

Source: Assunta (2001–2002)

Alcohol and domestic violence

Research has found that alcohol is present in a substantial number of domestic violence
accidents. The most common pattern is drinking by both offender and victim. Alcohol has
been shown to be a significant risk factor for husband-to-wife violence. Studies have shown
that the relationship between alcohol and domestic violence is complex.

Drinking frequently has been associated with intrafamily violence. Reviews have found that
excessive alcohol use is a strong and consistent correlate of marital violence, but that violence
rates vary based on research designs, methodologies, and samples. Therefore, the role of
alcohol remains unclear. Studies based on interviews with abused wives tend to report higher
proportions of alcohol involvement than do general population studies or police samples. In a
study examining episodes of domestic violence reported to the police in Zurich, Switzerland,
evidence of alcohol involvement was found in 40% of the investigated situations. Police
officers thus believed there was a clear link between alcohol and violence in at least 26% of
the cases studied (Maffli & Zumbrunn, 2003).

Regarding partner violence, research evidence indicates that it is more strongly associated
with heavy drinking, whether usual or occasional, than is non-partner violence, and conflicts
as to whether drinking by the victim makes violent acts by a partner more likely. That alcohol
consumption has a stronger association with partner violence than with nonpartner violence
may be a matter of access, with partners having more contact and thus more opportunities for
violent encounters (Gmel & Rehm, 2003). Studies also report an association between drinking
patterns and intimate partner violence; excessive drinkers and alcohol-dependent individuals
are more likely to act violently toward their intimate partners (White & Chen, 2002).

To give some examples from the literature, a study conducted in Nigeria showed a strong
association between domestic violence and alcohol use. Alcohol use was involved in 51% of
the cases in which a husband stabbed a wife (Obot, 2000). In a 1998 cross-sectional study of
violence against women undertaken in three provinces in South Africa, it was found that
domestic violence was significantly positively associated with the women drinking alcohol
and conflict over the partner's drinking (Jewkes, Levin & Penn-Kekana 2002).

In a 2000–2001 survey of 5109 women of reproductive age in the Rakai District of Uganda, it
was found that the strength of the association between alcohol consumption and domestic
violence was particularly noteworthy. Women whose partner frequently or always consumed
alcohol before having sex faced risks of domestic violence almost five times higher than those
whose partners never drank before having sex. Of women who recently experienced domestic
violence, 52% reported that their partner had consumed alcohol and 27% reported that their

WHO Global Status Report on Alcohol 2004

Economic and social costs of alcohol use

There is a strong interest in many countries regarding the development of scientifically valid,
credible estimates of the economic costs of alcohol use (and use of other psychoactive
substance use like tobacco and drugs). It is a well established fact that the use of alcohol
entails a large number of adverse consequences in such widely differing areas as physical and
mental health, traffic safety, violence, and labour productivity. There has been much effort in
the past three decades in attempting to estimate these costs and recent investigations have
suggested that they account annually for a substantial part of the Gross Domestic Product of
industrialized countries (Klingemann & Gmel, 2001).

On the assumption that the harmful effects of drinking can be evaluated in monetary terms,
health researchers and economists have attempted to estimate the costs of alcohol
consumption to society. According to Klingemann & Gmel (2001), social costs are largely
defined as costs to society, i.e. all costs arising from alcohol consumption that are not borne
exclusively, knowingly and freely by the drinker, such as spending on the drinks. Thus, social
costs are the negative economic impact of alcohol consumption on the material welfare of
society. When defining costs, a key distinction is made between direct and indirect costs.
According to Harwood, Fountain & Livermore (1998, cited in Klingemann & Gmel, 2001),
direct costs refer to the value of goods and services actually delivered to address the harmful
effects of alcohol consumption. In contrast, indirect costs represent the value of personal
productive services that are not performed because of the adverse consequences of drinking.

Single and colleagues (2003) summarize the many purposes that estimates of the social and
economic costs of alcohol use can serve:

Economic cost estimates can be used to argue or justify certain policies on alcohol i.e.

such policies to reduce the harm associated with alcohol use should be given a high
priority on the public policy agenda. The public is entitled to a quality standard against
which individual cost estimation studies can be assessed.

Cost estimates help to appropriately target specific problems and policies. It is

important for policy makers to be aware of which psychoactive substances involve the
greatest economic costs. For example, the recent study conducted in Australia
concluded that the costs of alcohol (and tobacco) far exceeds the social costs from
illicit drugs, thus drawing greater attention on public policy towards the licit drugs. The
specific types of cost may also draw attention to specific areas which need public
attention, or where specific measures may be effective.

Economic costs studies help to identify information gaps, research needs and desirable

refinements to national statistical reporting systems.

The development of improved estimates of the costs of alcohol abuse offers the

potential to provide baseline measures to determine the efficacy of drug policies and
programmes intended to reduce the damaging consequences of alcohol use.

Relatively few countries have attempted to estimate the costs of alcohol use. Estimating the
costs of alcohol consumption encounters problems over availability of data as well as
methodological difficulties. However, the fact that studies carried out in different countries
using a variety of approaches and methods all seem to lead to convergent results is a positive
indication that results are valid. In all cases, there is confirmation that alcohol consumption
imposes significant damage on society.

WHO Global Status Report on Alcohol 2004

Table 21 presents some data on the estimated social and economic costs of alcohol use in
various countries. Note that this table is not comparable as different methods of estimations
have been used, and for some data, the year of the study/estimate was not available. Most of
the literature on social costs of alcohol consumption comes from the English-speaking, non-
European countries, especially from the United States of America, Canada, Australia and
New Zealand. It is difficult to make any comparisons as such given that a variety of
approaches and methods are used. Please refer to the individual country profiles and the
original sources for a more detailed description of the estimation methods used.

Table 21: Social and economic costs of alcohol abuse for selected countries

Country

Year

Total Cost Estimate

% of GDP

Australia

1998–1999

A$ 7560.3 million

N.A.

Canada 1992

$7.52

billion

1.1

Chile N.A.

$2.969

billion

N.A.

Finland 1990

$3.351-5.738

billion

N.A.

France

1997

115 420.91 FF

1.42

Ireland N.A.

€2.4

billion

N.A.

Italy 2003

€26–66

billion

5–6

Japan

1987

US$ 5.7 billion

N.A.

Netherlands (the)

N.A. €2.577

billion

N.A.

New Zealand

1990

$16.1 billion

4.0

Scotland 2001–2002

$1.071

billion 1.5

South Africa

N.A. $1.7

billion

2.0

Switzerland

1998

6480 million Swiss francs

N.A.

United Kingdom (the)

N.A. £15.4

billion

N.A.

United States (the)

1998 $184.6

billion

N.A.

Note

: Please refer to the individual country profiles to obtain the original source used.

It has been argued that economic cost studies should be conducted within the framework of
cost-of-illness studies. In cost estimation studies, the impact of alcohol use disorders on the
material welfare of a society is estimated by examining the social costs of treatment,
prevention, research, law enforcement and lost productivity plus some measure of the quality
of life years lost. It is recognized that data are frequently lacking for many of these costs.
However, in many countries it will be possible to develop reasonable estimates for some, if
not most, of the costs associated with alcohol consumption. Thus, these guidelines should be
viewed as a framework rather than a rigorous methodology to be applied in every situation
(Single et al., 2003).

WHO Global Status Report on Alcohol 2004

Conclusion

Alcohol is not an ordinary commodity. While it carries connotations of pleasure and
sociability in the minds of many, harmful consequences of its use are diverse and widespread.
As documented in this report, globally, alcohol problems exert an enormous toll on the lives
and communities of many nations, especially those in the developing world. Research has
shown that when extrapolating from historical trends, the role of alcohol as a major factor in
the burden of disease will be increasing in the future. Particularly worrying trends are the
increases in average volume of drinking predicted for the most populous regions of the world
(e.g. in China and India) and the emerging trend of more harmful and risky patterns in
drinking especially among young people.

A global perspective on alcohol policy needs to acknowledge and take into account the
characteristics, effects and consequences of alcohol use in different societies, and yet to focus
and act on the public health goal which is to minimize the harm caused by drinking. Alcohol-
related burden is linked to at least two different dimensions of consumption: average volume
and patterns of drinking. Thus, in order to avoid or reduce burden, both dimensions should be
taken into consideration. In other words, one may reduce burden by decreasing the average
volume of alcohol consumed or by shifting patterns of drinking to less harmful patterns. One
may also change burden by weakening the link between exposure and disease, e.g. by
disaggregating the link between alcohol and traffic injuries by not combining drinking and
driving (Rehm et al., 2003b).

This report has contributed to the knowledge base for doing so, by documenting levels and
trends in alcohol-related problems, and showing how drinking levels and patterns contribute
to these problems. Another recent WHO publication - the

Global status report: alcohol

policy

- seeks to evaluate and disseminate knowledge of strategies and policies that are

effective in reducing the rates of alcohol problems. The Global Alcohol Database, as well as
this report, aims at providing a standardized reference source of information for global
epidemiological surveillance of alcohol use and related problems. It is evident from this report
that there is a need for countries to develop national monitoring systems to keep track of
alcohol consumption and its health and social consequences. This would be particularly useful
in raising awareness among the general public and policy-makers of the serious implications
that alcohol use have within the public health domain.

To effectively reduce the level of harmful social and health consequences from alcohol use
requires much preparation and planning. It is now the responsibility of governments
worldwide and concerned citizens to encourage healthy debate and formulate effective public
health-oriented countermeasures in order to minimize the harm caused by alcohol use.

WHO Global Status Report on Alcohol 2004

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