"First the man takes a drink; then the drink takes a drink; then the drink takes the man."

--Proverb

"Alcoholism isn't a spectator sport. Eventually the whole family gets to play."

--Joyce Rebeta-Burditt, author

Facing the challenges

The European Region of WHO is the one with the highest alcohol intake in the world. Alcohol is the third largest preventable risk factor in the Region and a major cause of mental disorders, accidents and injuries (1). Alcohol consumption is an important mental health issue and a major factor in the global burden of disease.

Alcohol-use disorders are recognized and classified as mental disorders. Hazardous and harmful use of alcohol is associated with a wide range of mental and behavioural problems. It also has social consequences, affecting the lives and indeed the mental health of the people who live or work with an alcohol-dependent person.

Alcohol-use disorders are preventable and, although it is not realistic to expect to eradicate them completely, evidence shows that a whole array of measures can significantly reduce the harm done.

Alcohol can interact with mental health disorders in several ways:

* people with mental ill-health are at higher risk of experiencing alcohol-related problems;

* people with alcohol-use disorders are more likely to suffer from other mental health problems;

* alcohol use by a person with mental ill health can:

--lead to a poorer treatment outcome;

--make the symptoms worse;

--increase the risk of alcohol dependence;

--have harmful interactions with prescribed medicine;

--contribute to a worse mood in the long run.

Management of alcohol-related problems should be incorporated into any public health response to mental health problems. Evidence-based preventive measures are available at both the individual and population levels, with alcohol taxes, restrictions on alcohol availability and drink--driving countermeasures among the most effective policy options. Despite the scientific advances, alcohol problems continue to present a major challenge to medicine and public health.

The scale of the problem

Worldwide, alcohol use causes 1.8 million deaths and 4% of the total disease burden as measured by the WHO Global Burden of Disease study. Unintentional injuries alone account for about one third of the 1.8 million deaths, while neuropsychiatric conditions account for close to 40% of the overall disease burden (2).

In the European Region, there are 86.8 million people (99 per 1000 population) who have harmful levels of alcohol consumption, causing 15.4 million DALYs each year. Of that figure, 5 million DALYs (32%) are lost owing to neuropsychiatric conditions.

Men have a far greater alcohol-related disease burden than women, the ratio being 5:1 (Fig. 9.1). The health damage and social harm caused by alcohol fall not only on the drinker but also on others. Women bear a disproportionate share of the burden of harm from others' drinking (3).

[FIGURE 9.1 OMITTED]

Policies that affect the rates of alcohol-related harm thus not only improve the health and save the lives of those who drink but potentially have a broader impact on the health and well-being of families, communities and society at large.

Alcohol and depression

The evidence indicates a close relationship between alcohol consumption and depression. Heavy drinking can lead to depression, and depression can lead to hazardous and harmful drinking and alcohol-use disorder. Studies of people in treatment have shown that one of the effects of long-term high alcohol consumption is an increase in depressive symptoms, which tend to disappear when alcohol consumption is reduced or stopped. Policies that reduce consumption, especially among heavier drinkers, might be expected to reduce the burden of disease related to depression.

Alcohol and suicide

The relationship between alcohol consumption and suicide or attempted suicide is well established among heavier drinkers. The risk of suicidal behaviour in this group increases with psychiatric comorbidity. Suicide rates are also found to rise with increased per capita consumption. The suicide rate for younger people seems to be more significantly related to per capita consumption than that for older people. In addition, research suggests that suicide rates tend to be more responsive to changes in per capita alcohol consumption in drinking cultures characterized by irregular heavy drinking occasions. Thus, cultural factors condition the association between alcohol consumption and suicide at the population level, and the strength of the overall relationship is greater in cultures where intoxication is a more prominent characteristic.

Alcohol and schizophrenia

A person with alcohol dependence is more likely to have schizophrenia and a patient with schizophrenia is more likely to exhibit alcohol dependence, than is the general population. Most clinical studies, patient reports and anecdotal clinical observations suggest that excessive use of alcohol leads to a clear exacerbation of the symptoms of schizophrenia. Furthermore, about 30% of patients with comorbidity appear to show a harmful use of alcohol before the first signs of schizophrenia emerge.

Alcohol, aggression and violence

Alcohol is strongly associated with violent crime, and research suggests that it contributes to aggression. The strength of the relationship seems to be culturally dependent, and the pattern of drinking seems to play an important role in causing violence. Thus, both the environment and the characteristics of the drinker influence the effects of alcohol.

Building solutions

Drinking alcoholic beverages is an accepted social custom in most parts of the world. Nevertheless, as it is closely associated with mental disorders and is one of the most important contributors to disease, injury, disability and premature death, greater attention to public health policies for alcohol control and harm prevention, brief interventions and treatment could prevent a considerable amount of human misery.

For example, the anti-alcohol campaign from 1985 to 1988 in the USSR produced a sharp decline in consumption. It was accompanied by a sudden sharp decline in mortality in the same period. For each litre reduction in pure alcohol consumption per capita in the latter half of the 1980s, the age-standardized mortality rate dropped by 2.7%. Alcohol consumption rose again in the early 1990s, also mirrored in a dramatic increase in mortality from 1990 to 1994. The situation improved in the period 1994-1998, but mortality started to rise again from 1999. The change in life expectancy in the Russian Federation in the past 20 years is a consequence of a complex pattern of trends in different causes of death. Evidence suggests that alcohol has played an important part in this fluctuation.

Even brief interventions can reduce alcohol use. A meta-analysis of 43 brief interventions in primary care and related settings for non-treatment-seeking populations showed that brief advice was effective in reducing drinking-related outcomes--including intoxication, alcohol dependence symptoms and problems in multiple life areas--by 12% more in the intervention group than the control group.

Nevertheless, in spite of the importance of alcohol in many mental health problems, there is little evidence that strategies to promote mental health have specifically targeted harmful and hazardous drinking.

Recent research has contributed substantially to the understanding of the relationship between alcohol consumption and the associated burden on society. There is thus a strong need for the health professions to step up their advocacy of policies that reduce the harm done by alcohol, including in the case of comorbid mental and behavioural disorders.

As a risk factor, alcohol consumption has two dimensions: average volume and patterns of drinking (Fig. 9.2). Research indicates a causal relationship between average volume of alcohol consumption and more than 60 types of disease and injury. Evidence is accumulating that patterns of drinking are an important factor in the link between alcohol and harm. In addition, 40% of the disease burden caused by alcohol arises from acute conditions and is thus almost immediately preventable.

[FIGURE 9.2 OMITTED]

Average consumption figures hide wide variations in individual levels of alcohol consumption and drinking habits. For instance, any population includes people who drink no alcohol. The majority of the drinking population is composed of moderate or light drinkers. Even if a minority, heavy drinkers account for quite a large part of the total alcohol intake.

However, the adverse effects of drinking are not confined to a minority of easily identified heavy or problem drinkers or people dependent on alcohol.

Many moderate or occasional drinkers also suffer from alcohol-related problems, especially when they use alcoholic beverages as intoxicants. And no matter how drinking is measured, the risk of alcohol dependence begins at low levels of drinking and increases linearly with both the volume of consumption and a pattern of drinking larger amounts on occasion.

On the other hand, most alcohol consumers must see some benefits from drinking alcohol, since they are willing to buy it. Just as the patterns and culture of drinking vary greatly in different societies, so do the incidence and character of alcohol-related benefits and problems.

In the longer term, sustainable alcohol policies and programmes are needed:

* to reduce hazardous and harmful patterns of drinking;

* to separate drinking from certain activities and situations such as driving or operating machinery, working and being pregnant;

* to reduce the overall volume of drinking;

* to provide adequate help to people with alcohol problems, especially those with co-occurring mental and behavioural disorders.

Regional response

Alcohol problems arise in many different situations and affect a variety of people. Appropriate policies will therefore be a mix of different measures.

Three major instruments adopted by WHO have provided a framework for action in the European Region.

Since 1992, the European Alcohol Action Plan has provided a basis for the development and implementation of alcohol policies and programmes in the Member States. The Action Plan for the period 2000-2005 (6) aims to prevent and reduce the harm that can be done by alcohol consumption throughout the European Region.

The European Charter on Alcohol (7), adopted by Member States in 1995, sets out the guiding principles and goals for promoting and protecting the health and well-being of all people in the Region. The Charter calls on all Member States to draw up comprehensive alcohol policies and implement programmes, as appropriate in their differing cultures and social, legal and economic environments.

The Declaration on Young People and Alcohol (8), adopted by Member States in 2001, aims to protect children and young people from the pressures to drink and reduce the direct or indirect harm done to them by alcohol. The Declaration reaffirms the five principles of the Charter and underlines the need for public health policies concerning alcohol to be formulated on the basis of public health interests, without interference from commercial interests.

The Action Plan, Charter and Declaration have offered paths for the development and implementation of effective measures on alcohol and therefore contributed to general health policy in the Region.

European Alcohol Action Plan

The overall objectives of the Action Plan for 2000-2005 (6) are to:

* generate greater awareness of, provide education in, and build up support for public health policies that address the task of preventing the harm that can be done by alcohol;

* reduce the risk of alcohol-related problems that may occur in a variety of settings such as the home, workplace, community or drinking environment;

* reduce both the breadth and depth of alcohol-related harm such as fatalities, accidents, violence, child abuse and neglect, and family crises;

* provide accessible and effective treatment for people with hazardous and harmful alcohol consumption and those with alcohol dependence;

* provide greater protection from the pressures to drink for children, young people and those who choose not to drink alcohol.

European Charter on Alcohol

The Charter (7) was adopted at the European Conference on Health, Society and Alcohol, held in Paris on 12-14 December 1995. It establishes five ethical principles and goals for work to reduce the negative consequences of alcohol consumption in Europe.

* All people have the right to a family, community and working life protected from accidents, violence and other negative consequences of alcohol consumption.

* All people have the right to valid impartial information and education, starting early in life, on the consequences of alcohol consumption on health, the family and society.

* All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages.

* All people with hazardous or harmful alcohol consumption and members of their families have the right to accessible treatment and care.

* All people who do not wish to consume alcohol, or who cannot do so for health or other reasons, have the right to be safeguarded from pressures to drink and be supported in their non-drinking behaviour.

Declaration on Young People and Alcohol

Young people are more vulnerable to the effects of drinking, and alcohol is the most important avoidable risk for the burden of disease in adolescents and young adults. The WHO European Ministerial Conference on Young People and Alcohol, held in Stockholm on 19-21 February 2001, adopted a Declaration (8) recognizing:

* alcohol as an important issue in young people's health;

* the need to involve young people themselves in the policy-making process;

* the need to determine, at the national and local levels, targets to reduce the impact of alcohol on young people's health;

* the need for alcohol policies directed at young people to be part of a broader societal response, since drinking among young people to a large extent reflects the attitudes and practices of wider adult society.

Further reading (7)

Chisholm D et al. Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. Journal of Studies in Alcohol, 2004, 65(6):782-793.

Klingemann H, Gmel G, eds. Mapping the social consequences of alcohol consumption. Dordrecht, Kluwer Academic Publishers, 2001.

Maffli E. Problem drinking and relatives. In: Klingemann H, Gmel G, eds. Mapping the social consequences of alcohol consumption. Dordrecht, Kluwer Academic Publishers, 2001.

Neuroscience of psychoactive substance use and dependence. Geneva, World Health Organization, 2004 (http://www.who.int/substance_abuse/publications/en/ Neuroscience.pdf).

Petrakis IL et al. Comorbidity of alcoholism and psychiatric disorders. Alcohol Research and Health, 2002, 26(2):81-89.

Rehm J. Alcohol. In: Ezzati M et al, eds. Comparative quantification of health risks: global and regional burden of disease due to selected major risk factors. Geneva, World Health Organization, 2004.

Shkolnikov VM, Nemtsov A. The anti-alcohol campaign and variations in Russian mortality. In: Bobadilla JL, Costello CA, Mitchell F, eds. Premature death in the new independent states. Washington DC, National Academy Press, 1997.

Shkolnikov VM, McKee M, Leon DA. Changes in life expectancy in Russia in the mid-1990s. Lancet, 2001, 357:917-921.

Tikkanen M. The love story of the century. San Bernardino CA, Borgo Press, 1984.

(7) All web sites were accessed on 18 July 2005.

References (7)

(1.) Rehm J. The global distribution of average volume of alcohol consumption and patterns of drinking. European Addiction Research, 2003, 9:147-156.

(2.) The world health report 2002. Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002 (http://www.who.int/whr/2002/en).

(3.) Room R et al. Drinking and its burden in a global perspective: policy considerations and options. European Addiction Research, 2003, 9:165-175.

(4.) Rehm J. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease--An overview. Addiction, 2003, 98:1209-1228.

(5.) Babor T et al. Alcohol: no ordinary commodity: research and public policy. Oxford, Oxford University Press, 2003.

(6.) European Alcohol Action Plan 2000-2005. Copenhagen, WHO Regional Office for Europe 2000 (http://www.euro.who.int/document/E67946.pdf).

(7.) European Charter on Alcohol. Copenhagen, WHO Regional Office for Europe, 1995 (http://www.euro.who.int/AboutWHO/Policy/20010927_7).

(8.) Declaration on Young People and Alcohol. Copenhagen, WHO Regional Office for Europe, 2001 (http://www.euro.who.int/AboutWHO/Policy/20030204_1).