Rev Bras Psiquiatr 2004;26(Supl I):7-10

The Social and Health burden of alcohol abuse

José Nino Melonia e Ronaldo Laranjeiraa
aUNIAD (Unidade de Pesquisa em Álcool e Drogas) – Departamento de
Psiquiatria – EPM-UNIFESP

Abstract
Based on the recent report on alcohol-related health and social burdens issued by the World Health Organization (WHO), this paper explores and
discusses the evidence in support of the view that concerns about alcohol consumption extend far beyond consideration of personal and family
health consequences, but should be considered in the context of major socio-political and public health priorities. The global findings of the WHO
report are first discussed, followed by analysis of the specific findings regarding the burden of alcohol problems in Brazil.
The social burden of alcohol problems is quantified by applying a unifying methodology which incorporates outcomes for alcohol-related violence,
family problems, child abuse, public disorder, lost productivity, and other consequences.
By analyzing the epidemiological date on alcohol-related morbidity and mortality data from each continental region and sub-region, and cross-ta-
bulating data on average consumed volume and patterns of consumption, the burden of disease are estimated for the various regions of the world.
The final results provide a comparative analysis of risk, basically using a representative indicator of number of productive years lost because of
illness or premature mortality due to alcohol consumption (“DALYs” – Disability Adjusted Life Years). The DALYs global value in 2000 was 4% of world
mortality, with this rate predicted to increase as global alcohol consumption increases. Variations among various regions in the planet are criti-
cally analyzed on predictive factors.

Keywords: Alcoholic beverages. Alcohol drinking. Attributable risk. Prevention & control.

Introduction dence, in the global population, about how much it is consumed, how it
For being privileged agents in the process of formulating public poli- is consumed, which social problems it causes, how many people get ill
cies, health professionals in general and specifically psychiatrists, and die due to drinking, i.e., which is the impact of the harm caused by
should rely on data that surpass the knowledge supporting their prac- alcohol consumption.
tice, i.e., evidence that is useful for the treatment of alcohol-dependent This analysis includes two dimensions of problems deemed indissocia-
subjects. It is highly important that these professionals keep in mind ble, as they occur always simultaneously: The Global Burden of Social
that alcohol consumption has a huge social burden, and exerts an Harm and The Global Burden of Disease. Generically speaking, the
enormous weight as a cause of health problems. results for each variable considered, as well as the final conclusions,
Based on a recent review by the World Health Organization, from a confirm Edwards’ theses,2 which indicate that, under the perspective
comprehensive study performed in 2000.1 this article displays updated of prevention, it does not suffice knowing that excessive alcohol con-
data on worldwide alcohol-related problems, emphasizing the scarce, sumption generally increases the individual risk of occurring pro-
although incisive Brazilian data. Beyond the mere description of me- blems. The rates of problems in the population vary according to the
thods and results, it is aimed to demonstrate, through consistent evi- culture, social layers and within each culture along time. Moreover, the
dence, an estimation of the high burden caused by alcohol for society. burden of social and health problems lays not only on those who drink
This evidence represents the avant-garde of international and local excessively, a well-illustrated fact in classical and recent publications.3
research efforts. Qualifying the strength of the relationship between the consumption of
Despite the immense methodological difficulties raised by the issue, alcohol and the appearance of problems provides instruments to make
the subtitles of this article only depict the systematic search of evi- decisions about the most adequate prevention policies.
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The global Social Burden range, for example. The average volume of consumption is one of the
It is common to verify that medical issues or those of general health fundamental elements to assess the risk attributable to alcohol as a
prevail in the debates about the harm involved in alcohol consumption. factor implied in the general rates of morbi-mortality, and the study by
However, it is impossible to disconsider that alcohol is closely related Jürgen Rehn et al.6, in which this issue is specifically dealt with, should
to problems in the social field. This has been considered as the ‘forgot- be mentioned. Generally, the higher the average consumed volume, the
ten dimension,4 among other reasons, for the inexistence of metric pat- higher the occurrence of health problems.
terns matcheable with health data, due to the insufficient internatio- In order to reinforce the importance of the association between the
nal systematization of comparative social data and also due to the lim- production of alcoholic beverages and the global consumption it is
itation of the already existent information sources, whose data collec- worth mentioning data compiled by the alcohol industry proper, about
tion does not allow structured studies. the yearly production and sales of distilled beverages in the world
Distinguished from health problems, alcohol-related categories of (Sazerac Company, Inc.2003). These data inform that China is the
social problems include: vandalism, public disarray, familial problems world’s largest producer and consumer of distilled beverages (725 mil-
such as marital conflicts and divorce, interpersonal problems, child lion liters of baijiu have been produced and commercialized), followed
abuse, financial problems, occupational problems other than health by Russia, with a yearly estimated consumption of 350 million liters of
occupational ones, educational difficulties and social costs. Although a vodka. The same sources inform that Brazil is placed, with its cachaça,
direct causality can not be established, the study of these categories of in a worrying fourth place among the largest worldwide producers of
harm, including variables such the volume of consumed alcohol, con- distilled beverages, with nearly 200 million liters commercialized per
sumption patterns and other interactive factors, demonstrated that year, being 195 million liters in the internal market. Brazil produces
the social consequences of alcohol consumption situate this product at and consumes the same amount of cachaça and whisky. The difference
least as an additional or mediating factor among others which con- is that whisky is consumed worldwide and cachaça only in Brazil. If
tribute for the occurrence of a determined problem, a similar conclu- crossed with data of the Brazilian population, whose density is many
sion to that valid for health problems. times inferior to the Asian one, the figures mentioned above are for
The assessment of the social burden related to alcohol demonstrated themselves a strong alert sign about the potential of risks involving the
that the social environment in which alcohol is consumed, according to production and consumption of alcoholic beverages in Brazil.
its economic structuring and cohabitation rules, determines several 2. Consumption Patterns
insertion nuances of alcohol consumption, at the same time in which Consumption patterns of alcoholic beverages vary according to cul-
is directly influenced by the current patterns of use. The article by ture, country, gender, age range, existent social rules and the social
Laranjeira and Hinkly5, which assesses the relationship between social subgroup considered. It is also highly variable the risk associated with
deprivation, violence, and density of points of sales of alcohol, in one the several consumption patterns. As an example, drinking wine regu-
peripheral region of the Greater São Paulo, depicts clearly this dyna- larly at the meals and in moderate amounts is a pattern of lower risk
mics. Social deprivation is related to a higher number of points of sales when compared to the copious intake of distilled beverages, even being
of alcohol and high urban violence. the latter occasional, in public or not.
It is important to highlight that, although there may be some psycho- In order to calculate the global burden of harm related to consumption
logical benefit from alcohol consumption, regarding social problems, of alcohol, the WHO has characterized the consumption patterns of
the lower the global consumption, the lower their rates. each nation on Earth, classifying them in four risk levels which have an
increasing variation from 1 to 4, according to the found pattern.
The Global Weight of harmful effects to health (Figure 1) depicts these results, matching them with data of mortality
There are innumerable indications which allow characterizing the role attribu- table to alcohol.
of alcohol as a risk factor for disease and death. At the individual level, The results may deem strategic, due to the conclusions to which it is
the pathophysiological correlations between alcohol intake and deve- possible to reach from them. In a general way, Western Europe has
lopment of health problems are well established. However, the weigh- consumption patterns with lower risk, contrarily to Central Europe and
ting between the beneficial and pathogenic effects of alcohol is not the former Soviet Union. The United Kingdom, China, Australia, North
always clear. The difficulty is still higher when issues at the population America and the Middle East, compose together with Argentina – the
levels are posed. only representative of Latin America a group whose pattern is situated
Which consequences could be predicted in the case of an increase or in an intermediated range, or of low risk. For most of the remaining
decrease in the consumed volume of alcohol, or else, if occurred a countries, among them Brazil, it was verified the existence of consump-
change in the alcohol consumption patterns in a certain community? tion patterns with high-risk level (level 4). The data show that the con-
In a collective scale, two correlated dimensions should be explored to sumption pattern is reflected in morbid-mortality rates attributable to
measure the impact on health. First is the exposure dimension, which the consumption of alcohol, in a direct proportion to the degree of risk
includes the average volume of per capita alcohol consumption and associated with it.
consumption patterns. The second one comprises the measurement of 3. Epidemiology of the consequences. General Morbi-mortality
the consequences, including an extensive set of data of the general and Fraction of risk attributable to the consumption of alcohol
morbi-mortality and the risk fractions attributable to alcohol. By means of epidemiological methods, the data related to average vo-
Occasional beneficial effects of alcohol are taken into account. If two lume of consumption and the consumption patterns might be correla-
spheres represent these two dimensions, the global burden of health ted to several categories of health problems, which beforehand are
problems attributable to alcohol could be obtained from the intersec- consistently associated with the consumption of alcohol. These pro-
tion between them. The health indicator conventioned to express the blems include: low weight at birth, mouth and oropharingeo cancer,
corresponding value of the Global Harm to Health (GHH) will be hepatic cancer, unipolar depression and other psychiatric disorders
described below. related to the consumption of alcohol, epilepsy, arterial hypertension,
1. Average volume of consumption myocardial ischemia, cerebral-vascular disease, diabetes, hepatic cir-
It is possible to calculate the regional and nation-wide average volume rhosis, accidents with vehicles and auto-propelled machines, falls,
of alcohol consumption in a certain population. It is also possible to intoxications, self-inflicted harm and homicides.
discriminate intake volume by subgroups, according to gender and age Crossing data on alcohol exposure with those related to its conse-
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 The Social and Health burden / Meloni JN & Laranjeira R Rev Bras Psiquiatr 2004;26(Supl I):7-10

quences and performing with these whole data a statistical treatment Although the situation linked to its consumption is also much severe,
adequate to the method, the risk attributable to alcohol in the several the sanitary problems still prevail. In the richer economic blocks,
types of diseases and also its direct influence in the determination of despite the existence of prevention and control policies, the consump-
mortality may be calculated.7 tion of alcohol appears as the third most harmful factor to health,
The results of the study reported by WHO show that, for the male po- being the DALYs of North America, for instance, situated between 4.0
pulation, 5.6% of all deaths which occur in the planet are attributable and 7.9%, and tobacco is the most morbid factor.
to the consumption of alcohol as well as 0.6% of the deaths which For those market-economy countries with intermediate poverty rates,
occurred among women and the conclusion is that alcohol determines among which is Brazil, alcohol is the most important causal factor for
3.2% of the global mortality. In 1990 the estimation reached 1.5%, ha- disease and death, and the total harmful impact, within a percentage
ving occurred an increase that overcame that figure more than twice, scale, may be considered in levels situated between figures that may
in a ten-year period, indicating therefore a hardly auspicious trend. vary from 8.0% up to 14.9% of the total of health problems of these
nations. In Brazil, alcohol consumption is responsible for more than
10% of its health problems.

Discussion
The results of the study on the global burden of problems related to
alcohol-consumption, Global Social Harm and Global Harm to Health,
show that they are very high all over the world. ‘DALYs’ the relative
value of in the specific context of each region of the planet, evidences
the existence of a gradient which differentiates the role of alcohol on
each of these communities.
The difference found in the three realities which were presented in the
precedent topic may be better understood highlighting the availability
and accessibility of alcohol at each scenario considered. In the poorest
countries there is practically no control about accessibility, being
almost inexistent social control programs to attenuate the morbid
impact of alcohol consumption. Although important, the role of alcohol
as a determining factor of social and health problems is blurred
amidst other components, which are proper of extremely poor commu-
nities. In rich countries the availability is high and the accessibility,
although being equally high, is moderated by several forms of social
control, such as regulatory measures for the use, regulated price po-
licy, promotional and advertising control, educational use of the media,
among others. In these communities the problems stemming from
alcohol use, despite the mentioned efforts to reduce them, have such
an impact that situates alcohol among the third most important risk
factors for health problems, causing huge social burden. Regarding
intermediate-economy nations, it may be stated that among them the
consumption of alcohol is scarcely regulated, and there is a dense set
of factors facilitating the access, including for individuals of the lowest
age ranges, implying that the average volume consumed is high and
the patterns of consumption much more risky. The consequences do
Figure 1 – Comparative maps indicating the worldwide consumption pat- not dishonor this tragic conjunction of elements, resulting that alcohol
terns and the risk level for each country (rising scale from 1 to 4) and the is the most important risk factor in the determination of health pro-
respective mortality attributable to the consumption of alcohol. blems, from which obviously the huge financial costs must be inferred.
(Source- World Health Organization -2003.) It is reasonable to state that the problems involved in the consumption
of alcoholic beverages rise as countries develop and, at the same time,
4. The global burden of health harm alcohol becomes one of the main limiting factors for social and eco-
The final finding of alcohol-related problems in 2000 was presented nomic development of these nations. The evidence demonstrated up to
through an elegant health indicator, called DALYs, an English acronym, now, denotes a trend of worsening in the world situation, regarding
which corresponds to the words Disability Adjusted Life Years. This the problems stemming from alcohol consumption, because large and
indicator is related to the percentage of years which are lost due to populous regions are presenting rising figures for the risk fractions
disease or early mortality, attributable to alcohol intake, and in that attributable to the use of alcohol, whereas the intake patterns remain
year it was found a figure of 4% for the entire world. stable or are worsening. Brazil is included in this context and demands
If the data displayed in table 1 cause, by themselves, a negative impres- interventions, which, may be said, are already delayed. The Russian
sion about the whole set of harmful effects of alcohol in the global so- experience in the period of Gorbatchev, dealt with by Shkolnikov et al.8
cieties, it should be informed that when these results are individua- is a demonstration of the efficacy of large-scale interventions for the
lized by each country, it was observed that, among the countries in control of alcohol consumption, in the sense of being capable of mini-
which the consumption patterns and the intake volume were associa- mizing the negative impact of this product in the social and health envi-
ted with higher risk, the DALYs was also significantly higher. ronments.
In the countries in which the market economy is scarcely developed
and the rates of general mortality are higher, such as in Africa, alcohol Conclusions
does not stand among the ten main causes of disease and death. The consumption of alcohol has an immense burden as a cause for ill-
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Source - World Health Organization - 2003

ness and for death in the world, being related, at the same time, to se- 61.
veral negative social consequences. It constitutes an important cause 6. Rehn J, Rehn N, RoomR, Monteiro M, Gmel, Jernigan D, et al. The Global
of morbi-mortality for the poorest nations, as the third highest risk Distribution of Average Volume of Alcohol Consumption and Patterns of
Drinking. Eur Addict Res. 2003; 9: 147 - 156.
factor for health problems in most of the richest countries and as the
7. Rehn J, Room R, Monteiro M, Gmel G, Graham k, Rehn N, et al. Alcohol as a
main factor related to disease and death in the majority of the coun- Risk Factor for Global Burden of Disease.Eur Addict Res. 2003 ; 9:157-164.
tries which pertain to the group of intermediate development. 8. Shkolnikov V, Mckee M and Leon D.A.Changes in life expectancy in Russia in
The average per capita volume and the prevailing consumption pat- The mid-1990s. Lancet.2001; 357 :917-21
terns are important variables related to the harm provoked by alcohol,
and are fundamental elements for the local epidemiological assess-
ments and for more comprehensive surveys, and may direct preven- Correspondence
tion programs aiming to reduce the problems stemming from alcohol José Nino Meloni
use. Rua Lorena, 186, Condomínio Marambaia
The global burden of health problems related to alcohol consumption 13280-000 Vinhedo, SP, Brasil
reached in 2000 an equivalent to 4% of all morbidity and mortality E-mail: [email protected]
occurred in the planet in that year, indicating a rising trend, conside-
ring the estimated value for 1990 (3.5%).
Among the current main public health problems in Brazil, the severest
is the consumption of alcohol, as this is the determining factor for
more than 10% of all morbidity and mortality occurred in this country.
Although further and more comprehensive studies are necessary to
allow a clearer characterization of the alcohol-related social and
health burden in Brazil, the available evidence suffices to situate as
prioritary an agenda of public policies contemplating the elaboration
of interventions for the social control of this product.

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