Alcohol's Global Burden of Disease and Social Harm
Alcohol use is deeply embedded in many societies and contributes considerably to global morbidity, mortality and social harms. The total global burden of disease for alcohol (4.0 percent) and tobacco (4.1 percent) are on a par.1 Overall, there are causal relationships between alcohol consumption and more than 60 types of disease, disability, and injury, including traffic fatalities.
Fetal alcohol syndrome and fetal alcohol effects, preventable causes of mental retardation, may result from alcohol consumption during pregnancy. Growing scientific evidence has demonstrated the harmful effects of consumption prior to adulthood on the brains, mental, cognitive and social functioning of youth and increased likelihood of adult alcohol dependence and alcohol related problems among those who drink before full physiological maturity. Moreover there is increasing evidence that genetic vulnerability to alcohol dependence is a risk factor for some individuals.2
Alcohol consumption in adolescents, especially binge drinking, negatively affects school performance, increases participation in crime and leads to risky sexual behavior. Beyond the numerous chronic and acute health effects, alcohol use is associated with an equal burden of widespread social, mental and emotional consequences. Alcohol-related problems are the result of a complex interplay between individual use of alcoholic beverages, and the surrounding cultural, economic, physical environment, political and social contexts.
Alcohol-related social harms include violence, vandalism, public disorder, family problems, other interpersonal financial and work-related problems and educational difficulties. Heavy drinkers and those with alcohol-related problems or alcohol dependence cause a significant share of the problems resulting from consumption. However, in most countries, the majority of alcohol-related problems in a population are associated with harmful or hazardous drinking by non-dependent 'social' drinkers, particularly when intoxicated. This is particularly a problem of young people in many regions of the world who drink with the intent of becoming intoxicated.3
Worldwide, the scope of the damage makes alcohol consumption a major public health problem.3,4 Alcohol cannot be considered an ordinary beverage or consumer commodity since it is a drug that causes substantial medical, psychological and social harm by means of physical toxicity, intoxication and dependence.2,4
Problems related to alcohol exist in almost every country and region, with the highest rates in Europe. Alcohol consumption is the leading risk factor for disease burden in low mortality developing countries and the third largest risk factor in developed countries. Alcohol is the foremost risk to health in low-mortality developing countries with the highest economic growth where it is responsible for 6.2 percent of disability-adjusted years lost.1 In the Americas, alcohol has been found to be the most important single risk factor contributing to the burden of disease, surpassing smoking, obesity, and high blood pressure.5
In recent years some constraints on the production, mass marketing and patterns of consumption of alcohol have been weakened and have resulted in increased availability and accessibility of alcoholic beverages (to include indigenous sources) and changes in drinking patterns across the world.6 Continued global economic advancement together with the erosion of public health policies create the "perfect storm" for alcohol related problems particularly in developing countries.7 This has created a global health problem which urgently requires governmental, citizen, medical and health care intervention.
Lessons for Alcohol Control from the Tobacco Movement
Similarly, the tobacco control movement faces an international problem, with 70 percent of deaths from tobacco consumption taking place in developing countries by 2030. The tobacco industry is a global industry that is stepping up its activities in developing countries in search of new markets. Tobacco advocates considered "intergovernmental resolutions" insufficient as an isolated strategy to slow the growth of tobacco consumption.8 Use of an "intergovernmental code of conduct" calling on governments to implement that code through enacting national legislation, and asking industries to voluntarily comply with the code, was not a sufficient strategy to address tobacco control. International action was needed to deal with the trans-boundary issues of global marketing campaigns and smuggling of cigarettes.9 In response, the World Health Organization adopted a Framework Convention on Tobacco Control which entered into force on Feb. 27, 2005.10
Rationale for an International Treaty on Alcohol
In light of the growing problem of unhealthy alcohol consumption and significant global marketing campaigns, alcohol control requires an international coordinating mechanism similar to the Framework Convention on Tobacco Control (FCTC). There is no pre-existing international convention or framework within which alcohol control could fit. However, the World Health Organization (WHO) has the competence as the "directing and coordinating authority on international health work" to undertake the creation of international instruments relevant to health. The WHO has powers under article 19 of its Constitution to develop a legally binding international convention on alcohol.12
Key elements such as trade, transnational ownership of alcohol production, sales, promotion and advertising, distribution and smuggling hinder the management and reduction of these problems and transcend national boundaries. Alcohol problems have proven difficult or impossible to mitigate by countries acting in isolation. There is illicit transnational trade in some regions and pressure by trading partners to reduce alcohol control measures which are often characterized as barriers to trade.4,11 Adjudications of trade disputes and negotiations of trade agreements have constrained the abilities of national and sub-national governments to restrict the alcohol market.
A binding public alcohol control agreement is becoming more necessary to counter such developments. An international Framework Convention on Alcohol Control (FCAC), in the interests of public health, could usefully counter developments in trade agreements which seek to expand alcohol markets, reduce prices and weaken national and local regulation of alcohol.4,12,13
A Framework Convention on Alcohol Control could serve as a counterweight and an alternative to trade agreements that threaten domestic policies and provisions and could provide more latitude for countries to protect health than without the treaty. Moreover, a FCAC may be able to take advantage of the World Trade Organization (WTO) Agreement on Technical Barriers to Trade that permits countries to enact technical regulations to protect human health provided that international standards exist now or soon will be adopted. A FCAC could establish a body to set minimum standards without serving as a ceiling.13
A FCAC could further international alcohol control
While an alcohol convention could seek international action on trade and cross broader problems, the principle effect would likely be at the national and sub-national level by setting new norms and practices of alcohol control. Based on experience of the FCTC, in addition to specific obligations and principles contained within a framework convention, the process of negotiating the treaty would strengthen alcohol control efforts within countries by giving governments greater access to scientific research and examples of best practice and motivating national leaders to rethink priorities as they respond to an ongoing international process. The process would engage powerful ministries, such as finance and foreign affairs along with health ministries, more deeply in alcohol control and raise public awareness about the strategies and tactics employed by the multinational alcohol companies. The international collaboration would mobilize technical and financial support for alcohol control at both national and international levels and make it politically easier for developing countries to resist the alcohol industry opposition to effective measures, for example, raising taxes and other restrictions on advertising. The convention would help mobilize non-governmental organizations (NGOs) and other members of civil society in support of stronger alcohol control.10 Moreover, it would create a sense of obligation in States that are acting in good faith and wish to comply with their treaty commitments. It would serve to deter violations. Even without enforcement mechanisms, an alcohol treaty could bring about positive changes in how states, and ultimately individuals, behave.13
Funding for a FCAC
The mechanism for funding the tobacco convention, as outlined in Article 26, could be applied to an alcohol convention. The FCTC has each party provide financial support in respect to its national activities intended to achieve the objectives of the Convention. Moreover, the WHO Secretariat shall advise developing countries on available resources. The Parties shall review existing and potential resources and determine the necessity of a voluntary global fund to channel resources to developing nations, including from international organizations and agencies, and from nongovernmental and governmental sources.13,14
Climate Favoring a Framework Convention on Alcohol Control
A FCAC is a viable concept at a time when international organizations are considering global public health policy issues related to alcohol. In 2005, the WHO adopted a resolution, Public Health Problems Caused by Harmful Use of Alcohol. The resolution called for a report to the 60th World Health Assembly in May 2007 that would include evidence-based strategies and interventions to reduce alcohol-related harms.17 The report is expected to discuss the option of a Framework Convention on Alcohol Control. Moreover, the World Medical Association in October 2005 adopted a "Statement on Reducing the Global Impact of Alcohol on Health and Society," which urges national medical associations and all physicians to take action to help reduce the impact of alcohol including promoting "of a Framework Convention on Alcohol Control" similar to the WHO tobacco treaty.3
Lastly, the APHA has a precedent with previous resolutions to support an international tobacco control policy15 and a global financing mechanism to assist developing countries in strengthening their tobacco control programs pursuant to the WHO Framework Convention on Tobacco Control.16
Therefore, the American Public Health Association:
- Calls on the World Health Organization to adopt and implement a binding international treaty, a Framework Convention on Alcohol Control, modeled after the Framework Convention on Tobacco Control;
- Urges national public health organizations and other non-governmental organizations to support development of a Framework Convention on Alcohol Control; and
- Solicits the U.S. government to support consideration of and planning for such Convention.
- Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL, Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet. 2000;360:1347-1360.
- Zeigler, DW, Wang, CC, Yoast, RA, Dickinson, BD, McCaffree, MA, Robinowitz, CB, and Sterling, ML. (January. 2005). The neuro-cognitive effects of alcohol on adolescents and college students. Preventive Medicine. 40(1): 23-32.
- World Health Organization. World Health Report: Reducing Risks, Promoting Healthy Life. Geneva: World Health Organization; 2002.
- Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N, Sempos C, Jernigan D. Alcohol as a risk factor for global burden of disease. European Addiction Research. 2003;9:157-164.
- Rehm J, Monteiro M. Alcohol consumption and burden of disease in the Americas: implications for alcohol policy. Revista Panamericana de Salud Publica/Pan American Journal of Public Health. 2005;18:241-248.
- Report by the Secretariat: Public health problems caused by alcohol. WHO Executive board, 115th Session, Provisional agenda item 4.12 EB115/37 23 December 2004.
- Caetano R, Laranjeira R. A "perfect storm" in developing countries: economic growth and the alcohol industry. Soc Study Addiction. 2006;101:149-152.
- Taylor AL, Roemer R. International strategy for tobacco control. Geneva: World Health Organization. Programme on Substance Abuse. WHO/PSA/96.6; 1996.
- The Framework Convention Alliance for Tobacco Control. The Framework Convention on Tobacco Control FAQ http://www.fctc.org/treaty/index.php#further (accessed June 7, 2006).
- World Health Assembly. WHO Framework Convention on Tobacco Control. 56th World Health Assembly; WHA56.1; May 21, 2003. Available at: http://www.who.int/tobacco/fctc/text/en/fctc_en.pdf.
- Zeigler DW. International trade agreements challenge tobacco and alcohol control policies. Alcohol and Drug Review, in press.
- 2 Gould E, Schacter N. Trade liberalization and its impacts on alcohol policy. SAIS Rev 22;1: 119-139. Winter-Spring, 2002.
- World Health Assembly. Public health problems caused by harmful use of alcohol. 58th World Health Assembly; WHA58.26, Agenda item 12.13; May 15, 2005. Available at: http://www.who.int/substance_abuse/wha_resolution_58_26_public_health_problems_alcohol.pdf .
- Open-Ended Intergovernmental Working Group on the WHO Framework Convention on Tobacco Control. Potential sources and mechanisms of support: Report by the Secretariat A/FCTC/IGWG/1/INF.DOC./1. 27 May 2000.
- American Public Health Association. An International Tobacco Control Policy. Resolution 9809. January 1, 1998. Available at: http://www.apha.org/legislative/policy/policysearch/index.cfm?fuseaction=view&id=161.
- American Public Health Association. Trust Fund for Developing Countries to Meet National Commitment under the WHO Framework Convention for Tobacco Control. Resolution 200124. January 1, 2001. Available at: http://www.apha.org/legislative/policy/policysearch/index.cfm?fuseaction=view&id=263.
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