Noncommunicable diseases and conditions have become

Commentaries on WHO:s alcohol strategy Pekka Puska Alcohol control A global public health issue Noncommunicable diseases and conditions have become the leading cause of mortality worldwide. According to WHO estimates, some 60% of the deaths in the world are due to chronic, noncommunicable diseases and some 10% due to injuries and violence (WHO 2005). This shows the rapid global public health transition: the burden of communicable diseases is diminishing and that of noncommunicable diseases is on the increase. This transition is partly attributable to the successful control of infectious diseases although many challenges remain. But a major reason is changes in lifestyles the westernization of lifestyles, related to urbanization, global marketing, ageing of the population etc. While the causes of communicable diseases are microbes, the causes of noncommunicable diseases are closely associated with certain lifestyles: notably diet, physical activity, tobacco use and alcohol. The public health burden The large global study on the burden of risk factors, coordinated by WHO and published in the World Health Report 2002, shows how alcohol consumption is among the top ten causes of mortality worldwide. The same study estimated that alcohol is responsible for some two million deaths per year in the world (WHO 2002). Since then this figure has certainly clearly increased. The health hazards related to alcohol are multiple and well documented (Babor et al. 2003). They come from both acute consequences (accidents, intoxication) and chronic consequences (liver disease, cancer, cardiovascular disease). And 436 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 26. 2009. 4

the harmful effects range from mortality and morbidity to health and social care costs and other social ills. A special feature of alcohol is its addictive nature. Thus alcohol is no ordinary commodity (Babor et al. 2003). While the harmful consequences are usually a result of harmful use, the prevalence of harmful or addictive use is closely related to the general alcohol consumption level in the population. Thus interventions should not only be high risk interventions among problem users, but also include general alcohol policy and other population based interventions. Effective interventions There is an extensive consensus about effective interventions to reduce alcohol use, which is aptly described in the well known report of the WHO s Alcohol and Policy Group (Barber et al. 2003). Reducing availability and increasing prices through taxation are measures where the evidence of good effectiveness is strong and areas where implementation costs are usually low. The former entails the following measures: government monopoly on retail sales minimum legal purchase age alcohol server liability Increasing alcohol taxes usually, and up to a certain limit, both reduces alcohol consumption and related harms, and moreover yields an increase in public tax revenues. Other useful interventions, but with lesser or less certain effectiveness, are altering the drinking context (e.g. enforcing of on-premise regulations), regulating alcohol promotion, drink-driving countermeasures, treatment and early intervention and education. Of these options education, i.e. informing young people and adults about the health hazards of alcohol is indispensable in modern societies and forms the basis for all public measures, but is not directly effective. Controlling advertising is a popular public topic and attractive to politicians, but partial restrictions are not very effective and a total ban not feasible in many cultures. Drink-driving countermeasures are important not only for alcohol policy but also for prevention of road accidents. Treatment and early interventions are also needed. Even if the treatment results are often disappointing, evidence-based and useful treatments are increasingly available. In spite of the meagre effects of short mini-interventions, if widely used their cost-effectiveness and public health effects are good due to low costs. Thus, as a whole, effective control of alcohol-related harm in the population calls for comprehensive measures and the Health in all policies principle (Puska 2007). Finland Alcohol has become a major issue in public health in Finland. Consumption has increased markedly in the last few decades. In 2008 the average annual consumption of 100% alcohol per capita in Finland was estimated to be 10.4 litres (Karlsson 2009) (Figure 1). The increase coincided post-war with the beginning of the rise in the standard of living in the 1960s. The liberalization of the retail sale of beer exacerbated the increase. The economic recession of the 1990s caused some decline, but thereafter the increase continued accelerating after the reduction of alcohol tax in 2004. NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 26. 2009. 4 437

100% alcohol litres / habitant 12 10 8 Undocumented consumption 6 4 Documented retail sails 2 Documented licensed serving 0 1965 1970 1975 1980 1985 1990 1995 2000 2005 2008 Figure 1. Total consumption of alcohol in 1965 2008, as litres of pure alcohol per capita, broken down by undocumented and documented consumption, as well as documented consumption broken down by retail sales and licensed serving. Source: Valvira and THL It is typical of the alcohol situation in Finland that traditionally Finns have favoured hard spirits (especially vodka) and the problems have largely been those of binge drinking. But with the liberalization of alcohol policy and the Europeanisation of alcohol drinking habits, first beer consumption and later also wine consumption greatly increased thus increasing overall alcohol consumption to a high and harmful level. With this increase both in alcohol consumption and its many visible health, social and economic consequences, public support for a stricter alcohol policy has increased. This has led to a number of strategies, plans and actions by the government. After reducing the alcohol tax in 2004, the government has now gradually raised this taxation. Various measures have been promoted at national and local level by both public authorities and NGOs. Finland has a government retail monopoly of spirits, wines and strong beers (over 4.7% alcohol content). In the present situation this monopoly enjoys strong public support. Because beer currently accounts for a substantial proportion of alcohol consumption, it has been proposed to reduce the upper alcohol content limit of beer sold in ordinary shops and supermarkets. Various measures and proposals have been either taken or proposed, to reduce aggressive marketing (especially to young people), to reinforce control measures on sales and on-premise alcohol serving, to promote mini-interventions and to increase health related education etc. The Nordic, European and global perspective As discussed earlier lifestyles and more generally determinants of public health, are increasingly global. Drinking habits are communicated by global marketing, advertising and media. In this way the west- 438 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 2 6. 2 0 0 9. 4

ernization of drinking habits means an increase in alcohol consumption in many parts of the world, while in some traditionally wine drinking cultures consumption has actually diminished. The alcohol industry especially concerning hard liquor and beer is also increasingly globalized and the big multinational companies have considerable lobbying power to protect their commercial interests. Thus the possibilities for any single country to gain total control of the alcohol situation are limited. Instead, international collaboration is needed. In the case of Finland, the much lower alcohol prices in neighbouring Estonia are significant in the present EU situation, with Finns at liberty to import alcohol from there for their personal use. European marketing and other international influences also play a role. In this situation the Finnish health authorities also look forward to strengthening international collaboration and measures for alcohol control. Nordic collaboration is traditionally considered important. The influence of the European Union with its clashes between agricultural, commercial and public health interests is of increasing importance. In this situation the decision by Sweden to address the alcohol issue during its EU Presidency is indeed welcome. Globally the attention is on the WHO as the specialized health agency of the United Nations. Lobbying by the big alcohol industry has deterred the WHO from any stronger actions, but the World Health Assembly in May 2008 passed a resolution asking the WHO secretariat to draw up a Global Alcohol Strategy to be discussed and decided upon at the World Health Assembly in May 2010. The public health community sees this as a great opportunity to develop global instruments to address the globalized nature and determinants of alcohol use and to counteract alcohol related harm. Many people refer to the examples of the Framework Convention on Tobacco Conrol and the Global Strategy on Diet, Physical Activity and Health. Conclusions Alcohol is a major issue in contemporary public health and an increasing problem in many parts of the world. The health, social and economic consequences are vast. Sound international evidence shows how reducing availability and increasing the price through taxation are effective measures to reduce the public harm. The determinants of alcohol use consumption are increasingly international and global, as the example of Finland shows. Thus effective measures to counteract alcoholrelated problems call for international and even global collaboration and effective actions. Fortunately such measures are being increasingly addressed, and they should be decided upon and effectively implemented. Pekka Puska; MD, PhD, MPolSc Director General, National Institute for Health and Welfare (THL) Mannerheimintie 166 P.O. Box 30 FIN- 00271 Helsinki Finland NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 26. 2009. 4 439

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