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Perspectives in Health - The magazine of the Pan American Health Organization
Volume 10, Number 1, 2005
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The Problem With Drinking

Alcohol dependence takes a major toll on individuals and their families. But a growing number of experts say overconsumption is a far greater threat to public health.
Photo by Carlos Gaggero

Efraím was already drunk when he left the wedding at 2 a.m. It had been a "nice wedding," which in Costa Rica means only hard liquor was served. The 21-year-old headed to a local bar for a "sarpe," or nightcap, with some friends. At 5 a.m., one of them finally sent him home in a taxi. Shivering and wrapped in towels, he sat on the carpet near the toilet and threw up.

Hours passed before his father found him in the same spot around 6 in the evening and rushed him to the hospital. The nightmare finally ended after an emergency room doctor injected him with medication for alcohol poisoning.

Tadeo, a young Costa Rican, went to the beach with three friends for a few laughs and a lot of drinks. After eight beers each, they drove home on the dark highway. A truck sped by, its rear lights obscuring the curve ahead. Their car skidded off the road and into a tree. Pinned in the wreckage, Tadeo broke three ribs, fractured his skull, fell unconscious, and remained in a coma for a week.

In Costa Rica, as in most Latin American countries, social gatherings more often than not include alcohol. Weddings and funerals, births and baptisms rely at least in part on drinks to ease grieving or encourage celebration. Aside from special occasions, many homes keep well-stocked bars that facilitate impromptu gatherings.

The drive home, particularly in the half-year-long rainy season, can entail a mix of alcohol and slick, winding roads, with potentially catastrophic results. But no one abstains for this reason. Statistics reflect the outcome: 13 percent of emergency room consultations in 1987 and 33 percent of auto fatalities in 2003 were alcohol related. Yet only 5 percent of Costa Ricans are alcohol dependent.

"The biggest misconception people have is that the problem of alcohol is alcohol dependence, or alcoholism," says Maristela Monteiro, regional advisor on alcohol and substance abuse at the Pan American Health Organization (PAHO). "In terms of society, most public health problems come from acute intoxication."

Medical research shows that long-term alcohol abuse causes liver diseases such as cirrhosis and hepatitis, as well as memory loss, ulcers, anemia, impaired blood clotting, impaired sexual performance, malnutrition, depression, cancer and even brain damage. But from a public health perspective, alcohol's greatest impact comes from occasional high-risk drinking by normally light to moderate drinkers.

Photo by Carlos Gaggero

"Homicides, traffic accidents, suicides, violent behavior, domestic violence, child abuse or mistreatment, neglect—these are from heavy drinking occasions, but most of these people are not alcohol dependent," says Monteiro.

Studies in the United States show that alcohol is a factor in 25 percent of deaths among people aged 15 to 29. Its direct costs to the U.S. health care system add up to some $19 billion a year, and for the economy as a whole, some $148 billion. As a risk factor for the global burden of illness, alcohol rivals tobacco: It is ranked number five among risks to health worldwide (tobacco is number four), and number one in all but two countries—Canada and the United States—in the Americas.

Experts note that alcohol takes a disproportionate toll on the poor, despite the fact that alcohol consumption tends to increase with educational levels and development. Poor people spend a greater proportion of their income on alcohol, and when drinking problems occur, they have less access to services, may lose their jobs, and bring major hardship on their families.

For all these reasons, many public health experts believe that alcohol policy should be a top priority in every country of the Americas.

Costa Rica is one of many countries that have instituted programs to reduce the toll of alcohol using a variety of measures: taxes and licensing, restrictions on advertising, minimum-age laws, and controls on the hours of operation and location of outlets that sell alcohol.

In addition, Costa Rican law bans alcohol consumption in most public buildings, at sporting events, in the workplace, in parks or on the street, within 100 meters of churches, and on public transportation.

"It is important to use various measures to be effective," says Julio Bejarano, head of research at the Instituto sobre Alcoholismo y Farmacodependencia (IAFA) in San José.

Programs like Costa Rica's are the outcome of a 30-year trend toward viewing alcohol less as an individual malady and more as a problem of public health. The shift began with the 1975 publication of Alcohol Control Policies in Public Health Perspective by the Finnish Foundation for Alcohol Studies. Since then, new definitions of alcohol use and abuse have emerged, including classifications for levels of drinking according to their risks to health.


Photo by Carlos Gaggero

According to the emerging consensus, people with what the U.S. health sector calls "alcoholism" and what the World Health Organization (WHO) calls "alcohol dependence" need to seek treatment. But those engaged in occasional overuse that causes mental or physical health problems—"alcohol abuse" in the United States and "harmful use" disorder for WHO—should be made aware of its impact on their health and urged to reduce their consumption before they become alcohol dependent. A third WHO category, "hazardous use," implies high-risk consumption, or what is sometimes referred to as "binge drinking." "You never had a car accident," Monteiro explains, "but you drink too much and drive." This is a large group of people who also need to cut back.

But the bottom line, says Monteiro, is that good public health policies must aim at preventing intoxication. And the best way to do this is by reducing consumption.

"What has been proven over and over in developed countries and more and more in developing countries, is that we need to reduce the overall consumption of the population," she says.

Monteiro says that experience shows that the most effective way of reducing overall consumption is by increasing prices and taxes on alcohol and restricting availability—that is, where it can be sold, to whom, how much, at what times and on which days.

"Once you reduce the hours of sale, for example, you also control the amount of alcohol people can access and drink. You reduce homicides, accidents, violence—many of the acute consequences decrease significantly. There are several examples—for a long time in Europe, the U.S., and Canada, and now in Latin America and elsewhere—that show that closing bars earlier reduces both accidents and violence."

A 2003 book, Alcohol: No Ordinary Commodity, published by Oxford and WHO, reviewed three decades of research and concluded that reducing consumption is key. Their top-10 list of specific measures includes minimum-age laws, government monopolies, restrictions on outlets and hours of sale, taxes, drunk-driving countermeasures and brief interventions for hazardous drinkers.

Limiting access

Raising the minimum age for purchasing alcohol has long been one of the most effective means of reducing access. Only a handful of countries have emulated the U.S. minimum age of 21, but this has proven to be an effective policy. When all 50 U.S. states raised their minimum age from 18 to 21, the country as a whole saw a 19 percent net decrease in fatalities among young drivers. The National Highway Traffic Safety Administration estimates that raising the minimum age has saved 17,359 lives since 1975.

 Woman pouring drink

Government monopolies on alcohol have also proven effective, but these are increasingly unpopular. Until 1968, Finland prohibited the sale of beer anywhere but in government-owned outlets. In 1968, the country began to allow grocery stores to sell beer, and alcohol consumption climbed by 46 percent overall (increasing particularly among 13- to 17-year-olds). Government monopolies today oversee production, sales or distribution (but not all three) in parts of the United States, Canada, Russia, India, southern Africa and Costa Rica. In Scandinavia, multinational companies have waged legal battles invoking international trade rules to break up longstanding government monopolies on alcohol, increasingly limiting their ability to restrict consumption.

Short of holding monopolies, governments can control where, when and to whom alcohol is sold, restricting the density of outlets through limited licensing and restricted hours of sale. They can also restrict the availability of high- and medium-strength alcoholic beverages. Before 1965, Swedish grocery stores could not sell beer with more than 3.5 percent alcohol. When 4.5 percent beer became legally available in grocery stores, total alcohol consumption increased nearly 15 percent. Twelve years later, Sweden returned to the 3.5 percent limit, and consumption dropped again by the same amount.

Hours of sales are equally important. When Norway closed bars on Saturdays, researchers noted that those most affected by the restricted access were also those deemed likely to engage in domestic violence or disruptive intoxication. An Australian Aboriginal community, Tennant Creek, closed bars on Thursdays and noted that fewer women required hospital attention for domestic injuries.

The personal toll of alcohol
Gregorio Rodríguez, 62, is a 30-year veteran of Alcoholics Anonymous (AA) in Costa Rica. He says that before he joined AA, alcohol dependence nearly destroyed his life....[Read more]

In Latin America and the Caribbean, Colombia provides one of the leading success stories of limiting alcohol consumption through restricted hours of operation. Rodrigo Guerrero, a physician and public health expert, served as mayor of the second-largest city, Calí, in the mid-1990s and dedicated much of his effort to tackling the city's surging violence problem. He commissioned surveys that found that 40 percent of violence victims and 26 percent of violent death victims in his city were intoxicated. In response, Calí passed a ley semi seca ("semi-dry law"), which closed bars and discotheques at 1 a.m. on weekdays and 2 a.m. on Fridays and Saturdays. These and other measures reduced homicides from 80 per 100,000 to 28 per 100,000 in eight years.

Costa Rica also limits hours and days of sale. The law prohibits selling or purchasing alcohol in public places after midnight, the day before and the day after a national election, and during Holy Week, "the period of highest alcohol consumption in Costa Rica," IAFA's Bejarano notes.

Probably the most effective policy to reduce consumption, however, is raising taxes on alcoholic beverages. Worldwide, raising the price of alcohol always reduces consumption. According to the recent WHO report Global Status Report: Alcohol Policy, the price of beer should always be more than the price of a soda. And because the harmful effects of alcohol use stem from alcohol content, higher-content beverages should be taxed at higher rates.

Drinking and driving

After restricting access, the next most effective policies are those aimed at reducing drunk driving. WHO's Global Status Report: Alcohol Policy lists among the most effective countermeasures sobriety checkpoints, lowered blood-alcohol limits, license suspension and graduated licensing for novice drivers. Enforcement is key. Police intervention must be visible and frequent, and lawbreakers must be punished to the extent of the law.

 Crashed car

Blood-alcohol limits are a critical part of these efforts. "Very little alcohol impairs motor coordination," explains Monteiro. "If you drink just over a drink, you are at risk—actually, it's less than a drink."

Costa Rica sets the legal blood-alcohol limit for drivers at 0.05 percent, although many experts say that problems often begin at 0.04 percent. Belize, Guatemala, Mexico, Nicaragua, Paraguay, Canada and the United States set the limit at 0.08 percent. These limits are most effective when used with checkpoints and random breath testing, according to research.

Other effective measures include screening and "brief interventions," prevention tools that have become a cornerstone of WHO's alcohol policy recommendations. During routine visits to health facilities or the family doctor, patients are asked simple questions that screen them for behavioral risk factors—including alcohol, cigarettes, poor diet, physical inactivity and seatbelt use—and doctors provide brief counseling sessions based on the responses.

"This is the epitome of low-technology medicine," says Thomas Babor, one of the researchers who designed the Alcohol Use Disorders Identification Test, or AUDIT.

"It's not the kind of thing, like MRIs, that seem to capture the interest of clinicians. But it probably is of equal importance, because it provides a way to prevent problems before they occur and to minimize problems if they've already started to develop."

AUDIT has been tested in a variety of countries and has proven easy to use, inexpensive to implement, and effective in reducing alcohol consumption at all levels of the population. Translated into many languages (including a Spanish version available through PAHO), the test and booklet include everything a clinician needs to give the 10-question test, to score it for one of four levels of risk for alcohol use, and to talk to patients about cutting back (including scripts for doctors who are unsure of what to say).

Patients take the test in about one minute, a nurse or receptionist scores it in another minute, and the clinician takes a few minutes to talk to the patient. Those testing in the first risk level are cautioned and advised to avoid drinking at least two days a week. Clinicians tell second-level scorers to minimize the number of drinks per day or week and to cut back on heavy drinking. Those in the third level receive brief counseling with more tools and goal-setting. Only fourth-level scorers are referred to an alcohol specialist.

A 1999 study by Michael Fleming, at the University of Wisconsin–Madison Medical School, showed that, with a single counseling session, subjects cut back on their drinking in the first six months and kept it down for four years. The study also found that every $10,000 invested in interventions saved $43,000 in health costs, with even greater savings when researchers factored in societal benefits, such as fewer auto accidents and crimes.

 Beer ad from Peru
A billboard in Lima, Peru, advertises a domestic beer brand with the tag line "And you? What would you do for its flavor?" Restrictions on advertising are effective but can run afoul of free-trade requirements. (Photo by Carlos Gaggero)

Other policies have been found to be somewhat less effective, but combined with the "top 10," they help minimize the burden of alcohol. These include having alcohol outlets refuse to serve intoxicated patrons; training their staff to prevent and manage aggression; promotion of alcohol-free events; community mobilization; and public service campaigns in schools and colleges, on television, and in print, including warning labels. Bans and restrictions on alcohol advertising and marketing can help reduce youth exposure to pro-alcohol messages. In Latin America, Costa Rica and Guatemala have completely banned alcohol companies from sponsoring youth and sporting events, and several other countries forbid alcohol advertising on Sundays and holidays.

The challenge ahead, says PAHO's Monteiro, is to build on the work of international alcohol policy experts, using the available scientific evidence to judge which mix of policies works best. But she offers a note of caution: "In Europe, there's almost a reversal of the gains they had before because of trade agreements. The trade agreements that opened the markets for equal opportunity for everyone mean that you cannot have higher taxes or higher prices. You have to allow advertising for everyone."

She notes that in Sweden, foreign companies have challenged laws forbidding alcohol advertising, arguing that they give local, better-known products an unfair advantage.

"That is a point that will be critical in the region," says Monteiro, "how to deal with the economic benefits of alcohol in certain countries while protecting public health and reducing its social costs."

Moving forward, Monteiro and researchers from 11 countries are embarking on a multicountry study that will show, with precision and hard data, the public health burden of alcohol in the Americas. The study will focus on alcohol use in Belize, Nicaragua, Paraguay and Peru. The results will be added to existing data from Argentina, Brazil, Costa Rica, Mexico, Uruguay, the United States and Canada.

Monteiro believes the new study is particularly timely, as several trends in the region point to a growing alcohol problem. For example, in most countries, women drink more as their educational levels rise. In Costa Rica, the percentage of children 13 to 15 who have tried alcohol rose from 16.3 percent in 1990 to 28.4 percent in 2000. In many countries, pressure from industry has been growing along with the spread of public health measures aimed at reducing alcohol sales.

All these developments call for more research and more action, says Monteiro, because "people not only die from drinking too much; they harm and kill those who don't drink, too."

Cheryl Harris Sharman is a freelance journalist based in New York City.


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