Bulletin of the World Health Organization

Breaking the vicious circle of determinants and consequences of alcohol use

Vladimir Poznyak, Benedetto Saraceno, Isidore S. Obot

Heavy drinking has been known for centuries to be a health hazard and cause of death. Efforts to quantify the disease burden associated with different risk factors clearly demonstrate that hazardous and harmful alcohol drinking is one of the leading risk factors and is responsible for 4% of the global disease burden (1). This enormous health burden, with its numerous social problems associated with disorders attributable to alcohol use, is distributed unevenly: poor and underprivileged groups are often at higher risk and are deprived of health and social interventions that can help to alleviate individual and family distress. According to the results of the Comparative Risk Assessment (CRA) within the Global Burden of Disease (GBD) study, alcohol is the main risk factor for ill-health in low mortality developing countries, where alcohol consumption is on the rise (2, 3).

In countries with high levels of alcohol consumption and hazardous patterns of drinking, the impact of alcohol use on overall mortality and morbidity can be substantial. The article by Nicholson et al. in this issue (pp. 812–819) demonstrates a linear relationship between frequency of drinking and binge drinking and long-term all-cause mortality trends in men in the Russian Federation. Whereas cultural norms related to alcohol consumption and overall drinking patterns have probably not changed significantly in the recent past, mortality fluctuations in the Russian Federation — which are partly attributed to alcohol consumption — are dramatic. As discussed by Nicholson et al., other factors could be involved in these relationships, and a broad understanding of hazardous drinking patterns includes aspects other than just binge drinking. Social and economic factors are powerful determinants of alcohol and drug use (4, 5), and enormous social changes experienced by the Russian population (6) have affected the broad context of drinking and risks of alcohol-related problems in different population groups. Another important observation is the absence of a protective effect of drinking. Though the authors acknowledge the limitations of their study in this respect, their conclusion is nevertheless consistent with other studies that question the generalizability of any beneficial effects of alcohol in different populations (7).

An association between alcohol use and low social status, low level of education and low standard of living is documented in an Indian national family health survey presented by Subramanian et al. (pp. 829–836). An interesting comparison of levels of alcohol consumption between Indian states with different alcohol policies shows that prohibition policies are not associated with a lower proportion of drinkers among men, though their impact on women appears to be different. It is important to note that this observation was made in a country with reported high levels of unrecorded alcohol consumption that can diminish the effectiveness of state policies, even if they are enforced faithfully.

The two articles on alcohol in this issue of the Bulletin illustrate the importance of considering socioeconomic factors as determinants of alcohol use and related problems. Household budget surveys in different parts of the world show that average expenditure on alcohol in developing countries (where many people live on US$ 1.00 a day) is proportionately higher than average expenditure in developed countries. While low income can limit the frequency of consumption and influence the type of beverage consumed, low income families in developing countries on average spend more of their income on alcohol than do families with higher income (5). Trade agreements impact on alcohol regulation and, consequently, on alcohol consumption and related harm (8). Hazardous and harmful drinking is associated with increased risk of alcohol dependence that often leads to social, financial and interpersonal losses, stigmatization and social marginalization.

Breaking the vicious circle of the social determinants and consequences of the harmful use of alcohol requires a combination of effective measures addressing social inequalities, alcohol availability and the context and patterns of alcohol use, as well as the availability of effective treatment for alcohol use disorders. Though effectiveness and cost–effectiveness of a range of alcohol policies is well documented (9), the impact of different policy measures on different segments of the population needs to be further studied in different cultural and socioeconomic contexts.

A resolution adopted in May 2005 by the Fifty-eighth World Health Assembly urges Member States “to develop, implement and evaluate effective strategies and programmes for reducing the negative health and social consequences of harmful use of alcohol” and to encourage the participation of all concerned social and economic groups in reducing the harmful use of alcohol (10). The enormous health and social burden associated with excessive drinking calls for concerted action at global, regional and country levels, so as to address social determinants of harmful use of alcohol and reduce alcohol-related harm. Effective prevention and control of the negative health and social consequences of alcohol consumption is an important prerequisite for social development and the reduction of health inequalities.


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World Health Organization, 1211 Geneva 27, Switzerland. Correspondence should be sent to Dr Poznyak (email: poznyakv@who.int).

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