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Epidemiologia e Serviços de Saúde

versão impressa ISSN 1679-4974versão On-line ISSN 2337-9622

Epidemiol. Serv. Saúde v.25 n.1 Brasília jan./mar. 2016



Public policies to prevent alcohol-related harm*



Maristela G. Monteiro1

1Pan American Health Organization, Noncommunicable Diseases and Mental Health Department, Washington-DC, USA






Alcohol consumption represents a major social, economical and health challenge and affects millions of people around the world. There is not a unique solution for this complex problem, to which we can add specific difficulties that the different governments face in dealing with the alcohol consumption issue and in implementing the necessary measures to reduce it among their population.

The most reliable epidemiological and biological information available was compiled by the World Health Organization (WHO).1 Alcohol intake is one of the most relevant risk factors for the world population's health.2,3 The consumption itself - not necessarily heavy drinking - is related to overall mortality.1,4 Alcohol (or ethanol) is a psychoactive substance that affects almost all the organs in the body: it is intoxicant, toxic for cells and tissues, with immunosuppressive effects (associated to the risk of HIV-infection, tuberculosis and pneumonia),5,6 it has teratogenic effects (may lead to fetal alcohol syndrome and other fetal-related problems, ascribed to alcohol consumption during pregnancy) and it is a carcinogen, besides the possibility of causing dependence and other mental disorders, and even increase suicide risk.1

Alcohol consumption is associated to more than 200 different codes of the International Statistical Classification of Diseases and Related Health Problems (ICD-10),1,7 related to acute and chronic problems, distributed among drinkers, although being more frequent among alcohol-dependents; and more prevalent among non-dependents, that is, those who consume sporadically and excessively. It means that the total alcohol impact to Public Health is not only related to heavy drinkers, but many times, to the called "social drinkers".8

Extensive analyses8,9 show that the most effective measures to reduce alcohol-related problems are those that consider the consumer population as a whole, independent from sex, age, socioeconomic status and level of consumption. In other words, it is necessary to reduce the population per capita consumption, not only the alcohol dependence and "abuse".

The consequences of alcohol consumption go beyond health harm to the consumer. Alcohol-related harm strikes families, neighbors, friends and other people, who are the victims of other person's consumption, not their own. Among the consequences, we can cite the absenteeism, presenteism, family income losses, unemployment in the family (in order to take care of a family member with alcohol consumption-related problems), violence, property damage, abuse and negligence, raise of health expenses (by the family or the government), impact in family members' mental health (depression, anxiety, childhood traumas due to negligence and abuse, among others), occurrence of work injuries, traffic injuries, and other injuries at home, and in public places.10,11 Harms extend to the fetus, if alcohol is consumed during pregnancy, which may lead to pre-labor complications, and the occurrence of specific fetus disorders, the most severe being the fetal alcohol syndrome.12

Even without estimating all the costs related to alcohol consumption in each country or in the world, they are likely to be high for consumers, family members, society and governments. These costs, in places where they were estimated (e.g. United States, England, European Union),13-15 are much higher than the profit from the sale of alcoholic beverages, including the jobs created, the taxes collected and the economic development resulting from it.

Systematic reviews of the literature and studies conducted in many countries1,8,16 point to a similar conclusion: where there is alcohol consumption, the related problems are also present (which seems obvious, but rarely taken into consideration when discussing public policies). In places where alcoholic beverages are prohibited, the problems are much smaller than in countries where the product is legal. In countries where alcohol is a legal drug, the consumption is directly related to mortality and morbidity. There is no country in the world where the net effects of alcohol on health are positive. The "positive" effects of alcohol consumption (the famous motto that wine is good for the heart) have little relevance for public health,17 regardless of these "benefits" being widely spread by the media and alcohol industry.

The reality is: where there is less availability of alcohol for consumption, there will be less problems. It does not mean that it is politically possible or desirable to ban alcoholic beverages, but actually - more than that, necessary - to control it. In face of it, the most cost-effective measures are those implemented through public policies and government regulation,8,9 restricting the economical, physical and social availability of alcoholic beverages.

The policies towards reducing economic availability includes raising the taxes, and, consequently, the prices, aiming at reducing the consumption. That is what was recently done in Brazil for wines and distilled beverages: Law No. 13,241, dated 30 December 2015.18 The higher the alcohol content is, the more expensive the beverage should be (per unit of consumption), in order to favor the consumption of beverages with less alcohol content. However, it is important to highlight that the main objective of public policies should always be to reduce the total of alcohol consumed including all beverages; therefore, the higher consumption of less concentrated alcoholic beverages, such as the beer, is as harmful as the equivalent consumption of other alcoholic beverages. Sales like happy hour discounts or open bar, credit sales or discounts for buying larger quantities for individuals, free offer in events, among other promotional measures that encourage people to buy and consume beer and other beverages, increase the risk of negative consequences for health. Beer is the most consumed alcoholic beverage in Brazil, and, in general, in Latin America, and is sold for accessible price and is subject of little regulation. Yet, this beverage carries the same harmful risks aforementioned. A great amount of problems caused by alcohol in Brazil can be attributed to beer.

Another effective political area is related to the physical availability of alcoholic beverages. The most restrictive scenario (considering places where alcoholic beverages are legal) is the government monopoly on sales to the public: the government could be the only authorized to sell alcohol (except for specific places for consumption, such as bars and restaurants), and could determine the price and the sale and/or consumption times, better controlling the sale for under aged people, besides regulating the marketing of alcoholic beverages. Sales on supermarkets, gas stations, service stations, drugstores, etc. could be prohibited, limiting the access to alcohol outside bars and restaurants. The license system for selling alcoholic beverages for the public limits its access, establishes minimum sanitary and safety conditions and the corresponding legislation could foresee penalties for selling it to under aged and intoxicated people. The places where consumption is allowed could also be defined, excluding some public places (beaches, public buildings, squares, cultural events, sports events, stadiums, etc.), aiming at reducing risks of violent acts and consequent traumas. Defining the minimum age for buying and consuming alcohol is indispensable; however its effectiveness depends on the strict application and enforcement of the law.

The social availability is related to the marketing control, which includes sponsorships, publicity in all communication media and for all alcoholic beverages, as well as alcohol promotion (including the internet and mobile phones). The full prohibition of alcoholic beverages is the one measure with most impact chances, and the easiest to monitor. Marketing contributes with the perception that the alcohol consumption is necessary to achieve happiness, for entertainment, for culture access, personal success and - also - mental health. Modifying the social acceptance of alcohol, especially to young people, is an important step for creating conditions for more informed citizens choices, without the social pressure to drink, which should be based on facts, not in myths spread by publicity campaigns.

Several studies show the inefficacy of self-regulation by the industry,19 which indicates the need for statutory measures. The notion that drinking and getting drunk is the best way to deal with daily life, having fun and relate to other people is a result of a massive and aggressive marketing. It is the same marketing that for years has misrepresented acknowledged Brazilian cultural symbols, such as the carnival and soccer. The industry's sponsorship in cultural and sports events contributes to this "genuine" alcohol consumption. The publicity of alcoholic beverages is developed based on neuroscience and psychology knowledge seeking to associate positive feelings to this consumption. Young children can recognize beverage brands and want to try them earlier than ever, and are, many times, encouraged by their parents; the parents are influenced by advertisements and have little knowledge that their own behavior can be manipulated by the media. According to morbidity and mortality data in Brazil and in the world, the real situation is different, severe and sad, however almost not seen or understood by the general population.

The influence of the alcohol industry on developing and implementing public policies is a decisive factor over the government inaction. It would be necessary, for example, to limit political campaign sponsorship by these industries, in order to make the debate over alcohol more fair, with the conscious and balanced participation of the society and its representatives. Non-governmental organizations, scientific and health professional societies, could take over an important role in this task, much beyond the defense of Public Health: monitoring the actions of the beverage alcohol industry, which is increasingly committed to "showcasing" their contribution to reducing harmful use of alcohol - when at the same time, moved by the profits, the same industries need to expand their market and sales, encouraging higher consumption and "recruiting" new consumers. Certainly, this market logic raises a conflict of interest with Public Health, and the actions that result from that do not contribute to reducing the problems caused by alcohol.

Public agents need to be independent to make decisions, in a way that the Public Good becomes above commercial interests. Without prohibiting the consumption, it is possible to reduce it, and also the harm associated to it, with important gains to the Health and Economy.



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2. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec;380(9859):2224-60.

3. GBD 2013 Risk Factors Collaborators, Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Dec;386(10010):2287-323.

4. Rehm J, Baliunas D, Borges GL, Graham K, Irving H, Kehoe T, et al. The relation between different dimensions of alcohol consumption and burden of disease: an overview. Addiction. 2010 Mar;105(5):817-43.

5. Rehm J, Samokhvalov AV, Neuman MG, Room R, Parry C, Lonnroth K, et al. The association between alcohol use, alcohol use disorders and tuberculosis (TB): a systematic review. BMC Public Health. 2009 Dec;9:450.

6. Samokhvalov AV, Irving HM, Rehm J. Alcohol consumption as a risk factor for pneumonia: systematic review and metaanalysis. Epidemiol Infect. 2010 Dec;138(12):1789-95.

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17. Friesema IHM, Zwietering PJ, Veenstra MY, Knott nerus A, Garretsen HFL, Kester ADM, et al. The effect of alcohol intake on cardiovascular disease and mortality disappeared after lifetime drinking and covariates into account. Alcohol Clin Exp Res. 2008 Apr;32(4):645-51.

18. BRASIL. Lei 13.241, de 30 de dezembro de 2015. Dispõe sobre a incidência do Imposto sobre Produtos Industrializados - IPI sobre as bebidas classificadas nas posições 22.04, 22.05, 22.06 e 22.08, exceto o código 2208.90.00 Ex 01, da Tabela de Incidência do Imposto sobre Produtos Industrializados - TIPI, aprovada pelo Decreto n° 7.660, de 23 de dezembro de 2011; e altera as Leis n°s 13.097, de 19 de janeiro de 2015, e 11.196, de 21 de novembro de 2005. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2015 dez 31; Seção 1:3.

19. Babor TF, Xuan Z, Damon D, Noel J. An empirical evaluation of the US Beer Institute's self-regulation code governing the content of beer advertising. Am J Public Health. 2013 Oct;103(10):e45-51.



Maristela G. Monteiro -
Pan American Health Organization,
525 23rd St NW, Washington-DC, USA



*Disclaimer.The author holds sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Pan American Health Organization (PAHO).