Mr Dag Rekve Technical Officer Management of Substance Abuse

1. 4th International Seminar on the Public Health Aspects of Noncommunicable Diseases, Lausanne, 7-12 March 2011 Mr Dag Rekve Technical Officer Management of Substance Abuse Department of Mental Health and Substance Abuse World Health Organization Global and national approaches to reducing the harmful use of alcohol

2. Total adult per capita consumption (world)

3. Lifetime prevalence of abstention (world)

4. Patterns of drinking

5. Causal model of alcohol consumption, intermediate mechanisms and health consequences

6. Risks and consequences Risk to individual drinker  Impact on people other than the drinker Overall health burden Impact on productivity Alcohol, health and economic development

7. Too big burden to be neglected

8. Global distribution of alcohol-attributable deaths and DALYs

9. Different perspectives Percent of total Risk factor

10. Distribution of alcohol-attributable male deaths (of all male deaths)

11. Emerging important issues Alcohol exposure and incidence and clinical course of infectious diseases Alcohol exposure and harms to others including FAS/FASD The positive effects of alcohol consumption and possible implications for policy decisions Potential movements in abstention rates and changes in female drinking patterns

12. Effective measures: regulating the marketing of alcoholic beverages, (in particular to younger people); regulating and restricting availability of alcohol; enacting appropriate drink-driving policies; reducing demand through taxation and pricing mechanisms; raising awareness and support for policies; providing accessible and affordable treatment for people with alcohol-use disorders; and implementing screening programmes and brief interventions for hazardous and harmful use of alcohol Effective counter measures exist

13. Thequestion is how to do it

14. Important milestones • October 2002: World Health Report 2002 • May 2005: WHA58.26 • May 2007: WHA60 • May 2008: WHA61.4 • May 2010: WHA63.13 Plus numerous regional resolutions, strategies and frameworks

15. The development of the strategy Stage I. Broad consultation process • Web-based consultation • Consultation with economic operators • Consultation with NGOs and health professionals • Consultation with UN agencies and IGOs Stage II. Draft strategy development • Regional technical consultations with Member States (February – May 2009) in 6 WHO regions • Draft development by the Secretariat in collaboration and consultation with Member States (May – October 2009) • 126th session of the Executive Board • WHA 63

16. The content of the strategy The global strategy: • complements and supports public health policies in Member States; • gives guidance for action at all levels; • sets priority areas for global action; • contains a portfolio of policy options and measures that could be considered for implementation and adjusted as appropriate at the national level

17. WHO global strategy:Five objectives (a) raised global awareness of the magnitude and nature of the health, social and economic problems caused by harmful use of alcohol, and increased commitment by governments to act to address the harmful use of alcohol; (b) strengthened knowledge base on the magnitude and determinants of alcohol-related harm and on effective interventions to reduce and prevent such harm; (c) increased technical support to, and enhanced capacity of, Member States for preventing the harmful use of alcohol and managing alcohol-use disorders and associated health conditions; (d) strengthened partnerships and better coordination among stakeholders and increased mobilization of resources required for appropriate and concerted action to prevent the harmful use of alcohol; (e) improved systems for monitoring and surveillance at different levels, and more effective dissemination and application of information for advocacy, policy development and evaluation purposes.

18. WHO global strategy:Five objectives • Achieving the five objectives will require global, regional and national actions on the levels, patterns and contexts of alcohol consumption and the wider social determinants of health. • Special attention needs to be given to reducing harm to people other than the drinker and to populations that are at particular risk from harmful use of alcohol, such as children, adolescents, women of child-bearing age, pregnant and breastfeeding women, indigenous peoples and other minority groups or groups with low socioeconomic status.

19. WHO Global Strategy:National policies and measures Member States have a primary responsibility for formulating, implementing, monitoring and evaluating public policies to reduce the harmful use of alcohol. Such policies require a wide range of public health-oriented strategies for prevention and treatment. All countries will benefit from having a national strategy and appropriate legal frameworks to reduce harmful use of alcohol, regardless of the level of resources in the country. Sustained political commitment, effective coordination, sustainable funding and appropriate engagement of subnational governments as well as from civil society and economic operators are essential for success. Health ministries have a crucial role in bringing together the other ministries and stakeholders needed for effective policy design and implementation.

20. Leadership, awareness and commitment Health services' response Community action Drink-driving policies and countermeasures Availability of alcohol Marketing of alcoholic beverages Pricing policies Reducing the negative consequences of drinking and alcohol intoxication Reducing the public health impact of illicit alcohol and informally produced alcohol Monitoring and surveillance Global strategy: recommended ten target areas for policy measures and interventions

21. Area 1. Leadership, awareness and commitment • Sustainable action requires strong leadership and a solid base of awareness and political will and commitment. • The commitments should ideally be expressed through adequately funded comprehensive and intersectoral national policies that clarify the contributions, and division of responsibility, of the different partners involved. • The policies must be based on available evidence and tailored to local circumstances, with clear objectives, strategies and targets. • The policy should be accompanied by a specific action plan and supported by effective and sustainable implementation and evaluation mechanisms. • The appropriate engagement of civil society and economic operators is essential.

22. Area 1. Leadership, awareness and commitment For this area policy options and interventions include: (a) developing or strengthening existing, comprehensive national and subnational strategies, plans of action and activities to reduce the harmful use of alcohol; (b) establishing or appointing a main institution or agency, as appropriate, to be responsible for following up national policies, strategies and plans; (c) coordinating alcohol strategies with work in other relevant sectors, including cooperation between different levels of governments, and with other relevant health-sector strategies and plans; (d) ensuring broad access to information and effective education and public awareness programmes among all levels of society about the full range of alcohol-related harm experienced in the country and the need for, and existence of, effective preventive measures; (e) raising awareness of harm to others and among vulnerable groups caused by drinking, avoiding stigmatization and actively discouraging discrimination against affected groups and individuals.

23. GLOBAL ACTION Given the magnitude and the complexity of the problem, concerted global efforts must be in place to support Member States in the challenges they face at the national level. International coordination and collaboration create the synergies that are needed and provide increased leverage for Member States to implement evidence-based measures. WHO, in cooperation with other organizations in the United Nations system and other international partners will: (a) provide leadership; (b) strengthen advocacy; (c) formulate, in collaboration with Member States, evidence-based policy options; (d) promote networking and exchange of experience among countries; (e) strengthen partnerships and resource mobilization; (f) coordinate monitoring of alcohol-related harm and the progress countries are making to address it.

24. Global action: key components • Public health advocacy and partnership • Technical support and capacity building • Production and dissemination of knowledge • Resource mobilization

25. World Health Assembly Resolution WHA63.13 URGES Member States: (1) to adopt and implement the global strategy to reduce the harmful use of alcohol as appropriate in order to complement and support public health policies in Member States to reduce the harmful use of alcohol, and to mobilize political will and financial resources for that purpose; … REQUESTS the Director-General: … (2) to collaborate with and provide support to Member States, as appropriate, in implementing the global strategy to reduce the harmful use of alcohol and strengthening national responses to public health problems caused by the harmful use of alcohol;…

26. The implementation of the global strategy to reduce the harmful use of alcohol • Strong global and regional leadership • Effective mechanisms for coordination and collaboration between all levels • Appropriate engagement of relevant stakeholders • Sufficient recourses available

27. The role of WHO national counterparts for implementation of the global strategy • establish the working mechanisms and plans for the global network; • elaborate priority areas and implementation plans for reducing the harmful use of alcohol at the global level; • discuss priority areas and plans for implementing the global strategy at the regional level; • discuss monitoring and reporting on the implementation of the global strategy at different levels;

28. WHO global counterparts network1. meeting 8-11 February 2011

29. Implementation structures for the Global strategy to reduce harmful use of alcohol Global level Global network of WHO counter-parts WHO Secretariat International partners and other stakeholders Coordinating council Chair of the global network Chairs of regional networks WHO Secretariat Chairs of task forces Chairs of working groups Task force on Public health advocacy and partnership Task force on Technical support and capacity building Task force on Production and dissemination of knowledge Task force on Resource mobilization Technical working group(s) on selected target areas for national action

30. Challenges of Monitoring • Unreliable or invalid data • Incomparable data • Establishing uniform definitions • Need for historical data • Resources

31. Framework for monitoring and evaluation

32. Data collection, analysis and dissemination

33. Conclusion – "a going concern" • Harmful use of alcohol should be a "going concern" at local, national, regional and global levels with political and professional attention and allocation of resource in line with the magnitude of the problem. • The words are now in place and the global and regional strategies represent a unique opportunity to establish a global and regional fundament for such a going concern

34. Thank you for your attention! Exit the maze of harmful use of alcohol for better global health http://www.who.int/substance_abuse rekved@hwo.int

35. XTRAS

36. Structure of presentation Risk to individual drinker  Impact on people other than the drinker Overall health burden Impact on productivity Alcohol, health and economic development

37. Structure of presentation Risk to individual drinker  Impact on people other than the drinker Overall health burden Impact on productivity Alcohol, health and economic development

38. Risk to individual drinker Intoxicating effects  Immunosuppressant effects Carcinogenic effects Teratogenic effects Neurotoxic effects Dependence producing properties

39. Risk to individual drinker Intoxicating effects  Immunosuppressant effects Carcinogenic effects Teratogenic effects Neurotoxic effects Dependence producing properties

40. Intoxicating effects • As an intoxicant, alcohol is a causal factor for intentional and unintentional injuries, including: • interpersonal violence • suicide • homicide • crime and drink-driving fatalities • and a contributory factor for risky sexual behaviour, sexually transmitted diseases and HIV infection

41. Intoxicating effects The risk of a motor vehicle accident injury related to the amount of alcohol consumed during the last 3 hours. The risk of a non-motor vehicle accident injury related to the amount of alcohol consumed during the last 3 hours. Source: Taylor et al, 2009

42. Immunosuppressant effects Alcohol is an immunosuppressant, increasing the risk of communicable diseases, including pneumonia, tuberculosis, and possibly HIV/AIDS incidence. [Alcohol also leads to HIV/AIDS progression due to poor treatment compliance]

43. Immunosuppressant effects Including alcohol-related infectious diseases would increase the present estimates of alcohol-attributable global disease burden by 13% (from 4.6% to 5.2%), and African disease burden by 50% (from 1.4% to 2.1%).

44. Carcinogenic effects Overall evaluation Alcoholic beverages are carcinogenic to humans (Group 1). Ethanol in alcoholic beverages is carcinogenic to humans (Group 1).

45. Carcinogenic effects As a carcinogen, alcohol increases the risk of cancers of the oral cavity and pharynx, oesophagus, stomach, colon, rectum, liver and female breast in a linear dose–response relationship

46. Risk of female breast cancer Source: Allen et al, 2009

47. Relation with cardiovascular disease • Systematic reviews find that alcohol, with a dose response relationship, increases the risk of: • Hypertension • Arial fibrillation • Haemorrhagic stroke

48. Relation with cardiovascular disease • Systematic reviews find that alcohol has a J-shaped-relationship , with the risk of: • Ischaemic heart disease • Ischaemic stroke • Compared with abstainers, light drinkers have reduced risk; beyond the bottom of the ‘J’ the risk increases with a dose-response relationship

49. Relation with cardiovascular disease • The protective effect: • Is no different between exclusively beer or wine drinkers • Does not exist for young adult drinkers • Is less for very older drinkers • Is less the longer the period of follow-up • Disappears the more the abstaining group includes ex-drinkers • Disappears when light drinkers report at least one heavy drinking occasion per month

50. Relation with cardiovascular disease • Most of the protective effect can be achieved by a consumption of 5g alcohol (half a drink) a day • More protection can be achieved by engaging in other healthier behaviours (e.g., healthy diet, more physical activity)