10.2. Individual characteristics
10.2.1. Lifestyles
10.2.1.1. Tobacco
use
Acronyms
10.2.1.1.1.
Introduction
According to the WHO Report on the Global Tobacco Epidemic
2008, 100 million people worldwide were killed by the tobacco epidemic in the 20th
century.
Smoking is the largest single cause
of preventable death and disease in Europe. Active smoking kills over 650,000
people every year in Europe. Many of these deaths occur prematurely, the
victims losing on average 21 years of life expectancy. In the EU, tobacco kills
more than AIDS, car accidents, alcohol, homicides, illegal drugs, suicides and
fires combined.
Around 35% of men and 25% of women
in the EU smoke. In general, men smoke more than women, although the trend is
showing a narrowing difference. Those with less education and of younger age
smoke more. In most European countries smoking is prevalent among lower
socio-economic groups. European youth has the highest smoking prevalence rates
in the world.
The patterns of smoking
attributable mortality are indicative of smoking trends two to three decades
ago. The smoking attributable mortality in western European countries is
declining for both males and females. In Eastern Europe, mortality for males is
now peaking or just beginning to decline, while still increasing among females.
Cigarette smoking harms nearly
every organ of the human body, causing a wide range of diseases, 24 of which
are fatal. Cancers (43%), cardiovascular diseases (28%) and respiratory
diseases (18%) together account for the majority of deaths attributed to smoking.
Moreover, smoking harms the society. In the EU, smoking is one of the
preventable risk factors with the greatest impact on total disease burden (both
mortality and morbidity) in terms of DALYs lost. Very conservative estimates
put the costs for only two smoking related diseases (COPD and CVD) for the EU
at an equivalent of 1% of region's GDP.
Success of interventions geared at
smoking behaviour will determine the future health of the EU populations.
Collective interventions, such as anti-smoking campaigns raise awareness on the
adverse effects of smoking, induce individual cessation efforts and prevent the
youth from taking up smoking. Individual interventions, such as pharmacological
and behavioural therapies significantly increase the probability of long term
smoking cessation.
As shown in Figure 10.2.1.1.1,
tobacco use is a risk factor for six of the eight leading causes of death in
the world (WHO, 2008). All the diseases caused by direct smoke and second-hand
smoke have been identified in Tables 10.2.1.1.1 and 10.2.1.2.
Figure 10.2.1.1.1. Tobacco as a risk
factor for several world leading causes of death.
Table
10.2.1.1.1. Diseases caused by smoking and by second-hand
smoke
Source: CDC
(2004); CDC (2006)
|
Diseases
caused by smoking
|
Diseases
caused by second-hand smoke
|
|
Cancers
|
Chronic diseases
|
Childen
|
Adults
|
|
Larinx
|
Stroke
|
Brain tumors*
|
Stroke*
|
|
Oropharinx
|
Blindness, cataract
|
Middle ear disease
|
Nasal irritation
|
|
Oesophagus
|
Periodontitis
|
Lymphoma*
|
Nasal sinus cancer*
|
|
Trachea, bronchus or lung
|
Aortic aneurism
|
Respiratory symptoms, impaired lung
function
|
Breast cancer*
|
|
Acute myeloid leukemia
|
Coronary heart disease
|
Asthma*
|
Coronary heart disease
|
|
Stomach
|
Pneumonia
|
Sudden infant death syndrome (SIDS)
|
Lung cancer
|
|
Pancreas
|
Atheroschlerotic peripheral vascular
disease
|
Leukemia*
|
Atherosclerosis*
|
|
Kidney and ureter
|
COPD, asthma and other respiratory
effects
|
Lower respiratory illness
|
COPD*, chronic respiratory symptoms*,
asthma*, impaired lung function*
|
|
Colon
|
Hip fractures
|
|
Reproductive effects in women: low birth
weight
|
|
Cervix
|
Reproductive effects in women (including
reduced fertility)
|
|
Reproductive effects in women: pre-term
delivery*
|
|
Bladder
|
|
|
|
|
For the diseases caused by second-hand
smoke: Evidence of causation is sufficient, or, where marked with an
asterisk, suggestive
|
Sources: ASPECT, 2004 and ASH)
10.2.1.1.2. Data
sources
Key indicators pertaining to
smoking are the prevalence of smoking and the smoking-attributable mortality.
Countries estimate the percentage of
adult smokers mostly on the basis of health interview surveys which can yield
variable data, due to the lack of standardisation in regard to definitions,
methods of data collection, stratification variables, sample sizes and age
limits. For example, the definition of a 'smoker' can be a 'daily smoker', a
'regular smoker' or includes 'all smokers', thus also occasional smokers.
Likewise, ages defined as 'adult' or '15 years and over' may mean the lower age
limit is at the ages from 13 - 20 years and the upper age limit from 64 - 84
years. Moreover, population samples are not always representative of the whole
country.
The data sources concerning smoking prevalence and
mortality in the EU, most commonly found in the literature include Eurostat,
WHO Health for All database (HFA)
and OECD. All three sources provide
methodological information on data collection. Eurostat uses data from the
European Community Household Panel (ECHP) carried out during the period 1994-2001. In the future, new sources will replace the ECHP, such as data collection from survey modules
of the European Health Interview Survey (EHIS) planned to start in 2007 and to
be repeated every five years. For WHO-HFA database, the adult smoking
prevalence is assessed from the standard questionnaire during a health
interview of a representative sample of the population aged 15 years and above.
Many countries are carrying out such health interview surveys on a more or less
regular basis. However, most of the data are collected from multiple sources by
the Tobacco or Health unit at WHO/EURO. OECD also uses a standard health
interview survey instrument to measure smoking habits in a population, warning
that “international comparability is limited due to the lack of standardization
in the measurement of smoking habits in health interview surveys across OECD
countries. There is variation in the wording of the question, the response
categories and the related administrative methods.”
Mortality from smoking in developed countries is estimated
directly from national vital statistics for the most frequently used source: Peto et al, 2006;
updated in June of 2006. The WHO Tobacco Control database uses these data and
they have well described sources and methodology.
The estimated data for the prevalence of the environmental
smoke exposure were published in the “Lifting the smokescreen report” (European
Commission, 2006 ), while directly reported data were collated for the
European Community Respiratory Health Survey (Janson et
al, 2006).
The data on prevalence of snuff use in Sweden are gathered
through annual surveys conducted by Statistic Sweden or the national public
health survey, “Health on Equal Terms”, carried out by the National Institute
of Public Health.
10.2.1.1.3. Data
description and analysis
Prevalence and mortality
Smoking prevalence varies widely among EU27 member States.
The proportion of adults who smoke in the EU27 ranges from 15.9% in
Sweden to 37.6% in Greece. Despite wide variations in smoking prevalence among
member States, the overall average for the 25 member States is broadly the same
as it was before the EU enlargement in 2004. Consistent large-scale patterns
are not apparent, although regional differences do occur. There are countries
with higher and lower prevalence of smoking in Southern and Northern, as well
as in Eastern and Western Europe.
In general, men smoke more than women. However, trends
over the past decades show that the differences in smoking prevalence for men
and women are declining. In Sweden, for example, the percentage of smokers is
now higher among women than among men, whereas in Ireland the two sexes show
similar rates.
Figures 10.2.1.1.2. 10.2.1.1.3. illustrate the trends in
smoking prevalence among European men and women between 1990 and 2006.
Figure
10.2.1.1.2. Regular daily smokers in the male population aged 15+
Figure
10.2.1.1.3. Regular daily smokers in the female population aged 15+
More men than women are dying from smoking attributable
diseases in all EU countries (Figure 10.2.1.1.4.).
Figure 10.2.1.1.4.
Percentage of all deaths attributable to smoking in 2000
The proportion of deaths attributed to smoking is
presented in Table 10.2.1.1.3., for the main categories of diseases for the
year 2000.
Table 10.2.1.1.3.
Deaths from selected causes (%), attributable to smoking, all ages, year 2000
Smoking, along with other behavioural factors, plays an
important role in premature mortality or
mortality before the age of 65. In the EU, these early deaths account for one
third of general mortality, with death rates twice as high for men as for
women.
Overall, the proportion of smoking attributable deaths
among women is still rising, while male mortality peaked in the 1980s, as shown
in Figure 10.2.1.1.5. It is important to keep in mind that mortality data today
reflect the smoking prevalence of two to three decades ago. That is why still
more men are dying from smoking attributable diseases in all EU countries.
Female mortality will probably increase in due time to reflect the current high
prevalence of tobacco use among European women.
Figure 10.2.1.1.5.
Trends in smoking attributable mortality 1965-2000 in the EU25
The term 'Tobacco epidemic' refers to certain, regular
patterns in tobacco consumption across the globe. There are four distinctive
stages of tobacco consumption prevalence in a population. These trends are
followed by similar patterns in smoking attributable mortality two to three
decades later (Figure 10.2.1.1.6).
Figure 10.2.1.1.6.
Features of the tobacco epidemic
The tobacco epidemic is at different stages in different
European countries. Some countries are in stage four of the tobacco epidemic -
e.g. Denmark, Germany, Finland and the UK. In central and eastern European
countries the awareness of the harmful effects of tobacco smoking was low until
the late 1980s. These countries, as well as some southern European countries
are now at stage three of the epidemic, with smoking prevalence among males
peaking or just beginning to decline, and smoking prevalence among women still
increasing (ASPECT,
2004).
Germany, for example, showed a decrease in total, male and female prevalence of
smoking between 2000 and 2003, while Belgium recorded a drop in overall
prevalence, but mainly due to the decrease of smoking in the male population
between 2000 and 2002.
Sex, age and socio-economic status as smoking determinants
Men generally smoke more than women. Although more and
more women are taking up smoking, this trend is not likely to reverse. The
female smoking rates in some countries reached a plateau at lower levels than
male rates, while in some countries it has started to decrease. The Global
Youth Tobacco Survey however showed a worrisome trend: the difference in
smoking rates between boys and girls is narrower than expected, especially in
the Americas and in Europe. In the Americas, more girls smoke than boys, and
there is only a small difference between sexes in Europe - 19.9% among boys,
and 15.7% among girls. The unexpected increase in cigarette consumption among
girls is likely to double the death toll from tobacco-related illnesses by the
year 2020 (Warren
et al, 2006).
Younger people generally smoke more than older ones. The Global
Youth Tobacco Survey also revealed that Europe has the highest incidence of
youth smoking in the world. Nearly 18% of Europeans aged 13 to 15 are smokers,
more than twice the global average of 8.9% (Warren
et al, 2006).
During the smoking epidemic there is a reversal from a
positive to a negative association between socio-economic status and smoking.
For what concern the socio-economic aspects of the tobacco epidemic, four
stages can be distinguished (Cavelaars
et al, 2000):
·
In stage 1, smoking is
an exceptional behavior and mainly a habit of higher socio-economic groups;
·
In stage 2, smoking
becomes increasingly common. Rates among men peak at 50%-80% and are equal
among socioeconomic groups or higher among higher socioeconomic groups. Among
women, these patterns usually lag 10-20 years behind those of men. Smoking is
first adopted by women from higher socioeconomic groups;
·
In stage 3, prevalence
rates among men decrease to about 40% since many men stop smoking, especially
those with a higher educational level. Women reach their peak rate (35%-45%)
during this stage, while at the end of this stage also their rates start to
decline;
·
In stage 4, prevalence
rates keep declining slowly for both men and women, and smoking becomes
progressively more a habit of the lower socio-economic groups.
In most countries smoking is more prevalent among the
lower educated, whereby the education is an indicator of the socio-economic
status. However, there are variations among regions and countries.
A north-south pattern, with strong social gradients in
northern European countries and weaker or reversed gradients in southern
European countries, was found for women and to a lesser extent for men, in the
45-74 years of age group. This observation did not apply to younger men. The
differences found reflect the tobacco epidemic stages.
Social gradients in smoking prevalence are steeper for
younger men and women than for older generations. These steeper gradients of
smoking prevalence are likely to translate into steeper gradients in smoking
attributable morbidity and mortality in future (Cavelaars
et al, 2000).
Consequences of smoking for the individual and the society
Smoking harms virtually every organ in the human body
causing a wide range of diseases and a massive burden of chronic illness.
Cardiovascular disease (CVD) is the largest single cause
of death in the EU, accounting for about 40% of deaths in both sexes (see
Chapter 5.2.). Smoking contributes significantly to mortality from cardiovascular
diseases. It has a synergistic effect with other risk factors for
cardiovascular disease, such as high cholesterol levels in blood and hypertension
(Keil U, et al., 1998).
Cancers (see Chapter 5.3) of the respiratory tract (lungs,
bronchi, and larynx) are responsible for one in 20 deaths in the EU. These
cancers are mainly due to smoking (European Communities, 2002).
Mortality due to COPD (see Chapter 5.7) varies from
country to country and is influenced by smoking, as well as by other factors.
Smoking is, according to the estimates from vital statistics, the cause of 62%
of all deaths from COPD in the EU-25 (Peto et al., 2005).
Not only active smoking, but also passive inhalation of
environmental tobacco smoke (ETS) causes adverse health
effects, including lung cancer, COPD and CVD. It is estimated that
79,500 people die each year in the EU as a result of passive smoking (ERS, 2006; European Commission,
2003).
In 1990–1994, the self-reported prevalence in the European
Community of passive smoking in nonsmokers was 17.9% at home and 20.6% at work.
At the follow up, ten years later, the prevalence of passive smoking at home
had declined by 8.7%, while the prevalence of passive smoking at work decreased
by 10.9% (Janson et
al, 2006).
Objective biomarkers for involuntary exposure to tobacco,
such as serum cotinine, have been identified and validated. Measurements taken
over a number of decades indicate a significant decline in serum cotinine
concentration levels among non-smokers during the 1990s. This decline probably
reflects the decrease in exposure on ETS due to anti-smoking interventions,
such as restrictions of smoking in the workplace and other public places (Pirkle,
2006).
Disease burden
Tobacco is the leading cause for disease burden in the EU.
The term 'Burden of disease' denotes the gap between the current health status
and an ideal situation in which everyone lives into old age free of disease and
disability. It is usually measured in disability adjusted life years (DALYs).
Tobacco is a leading risk factor for disease burden in developed world,
accounting for 12% of total DALYs (Lopez, 2005).
Tobacco is strongly linked to COPD and lung cancer and is
known to have a synergistic effect with risk factors causing ischemic heart
disease and cerebrovascular disease. The WHO has estimated that in 2000,
non-communicable diseases (NCDs) accounted for about 75% burden of disease
expressed in DALYs in European region. The most prominent NCDs, such as CVD,
cancer and COPD have one preventable risk factor related to lifestyle in
common: tobacco use (WHO, 2002).
Economic burden
The economic burden of smoking probably exceeds 1% of GDP
in Europe. The impact of tobacco morbidity and mortality on the society can be
expressed as
·
“Direct
costs”, associated with health care (hospitalisation, ambulatory care,
prescription drugs, home health care and nursing home services) for smoking
related diseases among smokers and second-hand smoke (SHS) victims, and
·
“Indirect
costs”, associated with the loss of human capital due to smoking attributable
premature deaths, productivity losses, foregone income taxes and contributions
to social security among smokers, patient-SHS victims and carers who would
otherwise be in paid employment (informal care).
The current existing estimates of the total
smoking-attributable costs for the two leading categories of smoking related
diseases: COPD and CVD, in Europe amount to between €105.83 billion and €130.31
billion for the year 2000, or about 1% of the region’s GDP. The indirect costs
of smoking account for two thirds of this amount. This is a very conservative
estimate, considering the fact that only two major diseases have been included,
and even for these two not all costs have been taken into account (e.g. the
costs of informal care, the costs linked to the treatment of reproductive
problems, the costs related to SHS and budgetary costs related to social
services). A more comprehensive estimate of net social costs for Australia
ranges between 2.1% and 3.4% of GDP (ASPECT, 2004; Collins & Lapsley,
2002).
Nicotine and addiction
The reason underlying the regular, daily smoking is
nicotine addiction. Cigarette is a very efficient drug delivery system. When
tobacco is smoked, nicotine rapidly peaks in the bloodstream and enters in the
brain. Immediately after exposure to nicotine, there is a “kick” caused in part
by the drug’s stimulation of the adrenal glands resulting in a discharge of adrenaline. The rush of adrenaline
stimulates the body and causes a sudden release of glucose, as well as an
increase in blood pressure, respiration and heart rate (NIDA,
2006).
Nicotine has several effects on the brain. The activation
of reward
pathways,
the brain circuitry that regulates feelings of pleasure is of primary
importance to the addictive potential of nicotine. The calming effect of
nicotine reported by many users is probably associated to a decline in the
withdrawal effects in addicted individuals, rather than the direct effects of
nicotine (NIDA,
2006).
Nicotine is only one of the 2000 chemical constituents of
tobacco. When tobacco is burned incompletely during smoking, almost 4000
chemicals can be found in the smoke.
Three kinds of smoke can be distinguished, each differing
in terms of toxicant concentration, size of particles, effects of temperature
and a host of other characteristics. Mainstream smoke is what emerges from the
“mouth” or butt end of a puffed cigarette. Sidestream smoke is what arises from
the lit end of a cigarette, mostly between puffs. Environmental tobacco
smoke, smoke present in air, consists of exhaled mainstream smoke and
sidestream smoke.
Dependence is stronger when tobacco
smoke is inhaled into the lungs and increases with the quantity and
speed of nicotine absorption. An improved understanding of addiction and of
nicotine as an addictive drug has been instrumental in developing medications
and behavioral treatments for tobacco addiction (NIDA,
2006).
Snuff is another efficient nicotine delivery system. Snuff
is fine ground moist tobacco that is used in small portions of 1-2 grams that are placed between the lip or cheek and gum. Nicotine from oral tobacco is absorbed more
slowly, but the peak levels are similar and the high level remains constant for
a much longer time than after smoking. The average snuff dipper keeps the snuff
pinch in their mouth approximately 11-14 hours per day (ENSP, 2003).
Health impact of smokeless tobacco
There is no safe or harmless tobacco product. Smokeless
tobacco use, however, appears to be less harmful than smoking tobacco. An
incomplete tobacco combustion that occurs during smoking releases 4000 chemical
substances. In contrast, snuff contains more than 2500 chemical substances, of
which 28 are known cancerogens. Major contributors are tobacco specific
nitrosamines (TSNAs), the most common carcinogens in unburnt tobacco that are
formed in the process of ageing, fermentation and curing of tobacco. The
Swedish snuff manufacturer has developed a set of standards called the
Gothiatek Standard that sets limits for harmful constituents in its product,
known as snus.
Health effects of oral tobacco use include an increased
risk of cancer (Boyle
et al, 2003).
Especially cancers of the oral cavity and pancreas are associated to snuff use,
although an increased risk for oral cancer development could not be proven for
Swedish snuff (SCENIHR,
2007).
A recent study, however, reported an increased risk for pancreatic cancer in snus users (Luo et al, 2007). Other known health
effects of snuff use include increase of blood pressure, increased risk for
diabetes, musculoskeletal injuries, pregnancy and early childhood
complications. The association with the cardiovascular disease is not
unequivocally clear. (ENSP, 2003).
10.2.1.1.4.
Tobacco harm reduction
Individual interventions
An individual approach to smoking cessation includes
pharmacotherapy and behavioral therapy. These are most effective when combined
with collective interventions.
Only 3% of smokers manage to quit smoking using will power
alone (ASH, 2006). Success depends
to a great extent on motivation, but a combination of pharmacotherapy and
behavioral therapy probably yields best results.
Nicotine replacement therapy (NRT) in the form of patches,
chewing gum, lozenges, inhalers and nasal sprays helps relieve the withdrawal
symptoms that prevent many smokers from quitting. It contains nicotine, but
does not contain thousands of other harmful substances found in cigarettes and
snuff.
The non-nicotine pharmacotherapy includes several drugs
from different categories. Two of the most promising are bupropion and
varenicline. They are both prescription drugs approved by national authorities
of some countries to help patients stop smoking. Bupropion is an antidepressant
drug that reduces withdrawal symptoms and lessens the urge to smoke.
Varenicline, recently approved both in Europe and USA, is a partial nicotine
agonist that prevents the nicotine-withdrawal symptoms and eliminates the
reward from smoking.
Certain moods, times of the day or activities may present
strong triggers for craving a cigarette. Pharmacotherapy is not a cure for
these smoking triggers. Furthermore, the motivation to quit smoking determines
the success rate of smoking cessation to a large extent. Some studies found
that the integration of behavioral therapy can increase the quitting rate by
another 50-100% (Fiore et al, 2000). Psychosocial interventions are
helpful at all phases of tobacco addiction treatment, not only as a first-line
intervention (Foulds et al, 2006). There is a wide range of
psychosocial treatment options, including counselling via internet and
telephone, as well as individual and group counselling.
Collective interventions – tobacco control in the EU
Collective interventions geared towards the reduction of
tobacco related harm can be categorized as follows:
·
measures
to reduce the demand for tobacco products (price, taxation);
·
measures
to reduce exposure to environmental tobacco smoke (smoking
bans in public places);
·
measures
to limit tobacco industry advertising, promotion and sponsorship;
·
measures
to raise awareness about the addictive nature and health hazards of tobacco
use; and
·
measures
to raise awareness about treatment possibilities.
Curbing tobacco use is a longstanding EU health priority.
The EU has been actively contributing to the reduction of tobacco consumption
for more than twenty years. This contribution has evolved from prevention,
training and research within the scope of the fight against cancer, to a broad
strategic tobacco control approach. The current EU-wide efforts are based on
four mutually reinforcing pillars:
·
legislative
measures, based on the Community Treaties as well as more specific, secondary
legislation;
·
support
for Europe-wide and cross-national smoking prevention and cessation activities,
financed via action programmes and the Community Tobacco Fund;
·
mainstreaming
of tobacco control into a range of other Community policies; and
·
ensuring
the Community’s achievements also have an impact outside the EU region by
fostering international co-operation and taking on a major role in tobacco
control at global level.
EU action focuses on supporting prevention, collaboration
between Member States and research. The quest for a smoke free EU also forms
part of the Environment and Health Action Plan through which passive smoking is
now more actively tackled.
Legally, these efforts are firmly grounded in the
Community Treaties and supported further by a range of specific regulations. The legal
competencies of the EU enable it to make some unique contributions to tobacco
control both in Europe and globally. The WHO Framework Convention on Tobacco
Control (FCTC), which all Member States and the Community have signed, has been
a significant factor in the further advancement of tobacco control at EU and
Member State level.
Within the Treaties of the Community, articles 152 and 95 EC provide the legal base for EU policy and
action in the area of tobacco control. These articles are concerned
respectively with public health and internal market issues. Through the
application of these two articles, a range of more specific measures and
agreements have been developed to support the EU’s efforts in the area of
tobacco control.
The provisions in the Treaty have been given force through
a range of secondary legal measures to support tobacco control. Together, they
underpin and complement the Community’s action, including a range of smoking
prevention and cessation activities.
Binding legal measures include Directives on:
·
the
advertising and sponsorship of tobacco products;
·
the
structure and rates of excise duty applied on manufactured tobacco;
·
the
manufacture, presentation and sale of tobacco products;
·
television
broadcasting, banning the advertising of tobacco products; and
·
minimum
safety and health requirements for the workplace.
Non-binding legal measures include:
1) a Council Recommendation on the prevention of smoking
and on initiatives to improve tobacco control. This recommendation pays
particular attention to measures restricting youth access to tobacco; and
2) a Resolution on banning smoking in public places. Since
the adoption of the resolution in 1989, Member States’ governments have
developed their own specific action to implement this resolution, which has
been done at different pace.
EU competencies in health and safety as well as in
taxation have also provided legal ground for tobacco control measures. There is
a broad consensus on the effectiveness of six policy measures that can be
implemented at (sub)national level. These measures differ as to the extent of
their impact. Prices and taxation policies are attributed the greatest impact,
followed by smoking bans in workplaces and public places. Bans on advertising
of tobacco products , appropriate consumer information, warning labels and
treatment for those wanting to quit smoking complete the six effective
measures. A comprehensive strategy incorporating all six measures is most
effective.
Policy makers can therefore build on a range of policy
options that have been proven to be effective in the past. It is, however, also
important that they remain vigilant to newly emerging challenges, such as
whether to lift the ban on snuff use.
International organisations
The WHO Framework Convention on Tobacco Control (FCTC) is
the first-ever global health treaty providing a comprehensive tobacco control
framework (WHO, 2005). The FCTC objective is
'to protect present and future generations from the devastating health, social,
environmental and economic consequences of tobacco consumption and exposure to tobacco
smoke.' The EU Council approved the FCTC in June 2004, and
subsequently ratified it on 30 June 2005.
Significant measures to reduce the demand for tobacco,
supported by the FCTC include:
·
price and tax measures;
·
protection from exposure
to tobacco smoke, particularly in workplaces, public
transport and indoor public places;
·
regulation of the
contents of tobacco products;
·
regulation of tobacco
product disclosures;
·
packaging and labeling
of tobacco products, requiring large health warning labels and prohibiting the
use of deceptive labels such as "light", "low tar", and
"mild";
·
education,
communication, training and public awareness;
·
tobacco advertising,
promotion and sponsorship. Countries are to undertake a comprehensive ban on
tobacco advertising, promotion and sponsorship within five years of ratifying
the treaty if their constitutions allow this. If there are constitutional
constraints, countries are required to put restrictions in place; and
·
demand reduction
measures concerning tobacco dependence and cessation.
The FCTC also supports measures to reduce the supply of
tobacco. These include:
1. illicit trade in tobacco
products (smuggling);
2. sales to and by minors,
and
3. provision of support for
economically viable alternative activities.
By signing the Treaty, countries also commit themselves to
take supportive measures at national level. Key examples of these measures are:
·
the establishment of a
national coordinating mechanism or focal point for tobacco control;
·
the inclusion of tobacco
cessation services in national health programmes, and
·
promoting the
participation of NGOs in the development of national tobacco control
programmes.
Under the UN Charter, identifying solutions to
international social and health problems falls within the remit of the Economic
and Social Council (ECOSOC). Their Resolution
2004/62
on Tobacco Control supports the WHO Framework Convention on Tobacco Control and
urges UN Member States to strengthen tobacco control measures and programmes.
On 7 February 2008 the WHO released a new Report on
“Global Tobacco Epidemic” showing that while progress has been made, not a
single country has fully implemented all key tobacco control measures. The
report also outlined an approach that governments can adopt to prevent tens of
millions of premature deaths by the middle of this century. In this new report
which presents the first comprehensive analysis of global tobacco use and
control efforts, the WHO has found that only 5% of the world’s population lives
in countries that fully protect their population with any one of the key
measures that reduce smoking rates. The report also reveals that governments around
the world collect 500 times more money in tobacco taxes each year than they
spend on anti-tobacco efforts. It finds that tobacco taxes, the single most
effective strategy, could be significantly increased in nearly all countries by
providing a source of sustainable funding to implement and enforce the
recommended approach, i.e. a package of six policies called MPOWER. The six
MPOWER strategies are:
·
Monitor tobacco use and prevention policies
·
Protect people from tobacco
smoke
·
Offer help to quit tobacco use
·
Warn about the dangers of tobacco
·
Enforce bans on tobacco advertising,
promotion and sponsorship
·
Raise taxes on tobacco
The report documents the epidemic's shift to the
developing world, where 80% of the more than eight million annual
tobacco-related deaths projected by 2030 are expected to occur. The global
analysis, collated by the WHO from the information provided by 179 Member
States, gives governments and other groups a baseline for monitoring efforts to
stop the epidemic in the years to come. The MPOWER package provides countries
with a roadmap to help them meet their commitment towards the WHO Framework
Convention on Tobacco Control, which came into force in 2005. Other key
findings in the report include:
·
Only 5% of the global
population is protected by comprehensive national smoke-free legislation and
40% of countries still allow smoking in hospitals and schools;
·
Only 5% of the world’s
population lives in countries with comprehensive national bans on tobacco
advertising and promotion;
·
Just 15 countries,
representing 6% of the global population, mandate pictorial warnings on tobacco
packaging;
·
Services to treat
tobacco dependence are fully available in only nine countries, covering 5% of
the world’s population;
·
Tobacco tax revenues are
more than 4000 times greater than spending on tobacco control in middle-income
countries and more than 9000 times greater in lower-income countries.
High-income countries collect about 340 times more money in tobacco taxes than
they spend on tobacco control.
Snuff and tobacco harm reduction debate
Tobacco harm reduction is a “strategy which aims at
minimizing the damage to the population’s health resulting from the use of
tobacco products or their substitutes” (McKee and Gilmore, 2007).
Current tobacco control policies seek to reduce the supply
of tobacco (e.g. through price and taxation policies) and the demand for
tobacco (by e.g. raising awareness about its effects on health and supporting
those who wish to quit). Most smokers will at some point attempt quitting and
most of those will repeatedly fail, due to the addictive power of nicotine. The
available treatments for nicotine addiction show modest success and are either
based on medicinal nicotine (NRT) use or on abstinence (“quit-or-die” approach)
(Martinet
et al, 2007).
Sweden is the only country of the European Union where
snuff is not banned. It is undisputed that the low smoking prevalence, and
consequently, the low smoking-attributable mortality among Swedish men are at
least in part effects of the established and widespread use of snuff in that
population. In the light of these facts, a part of the public health community
promotes lifting a ban on snuff as an acceptable harm reduction strategy.
The advocates of this approach assert that the evidence
from Sweden suggests that snuff is used as a substitute for smoking and for
smoking cessation. Smokers who will not or cannot quit smoking should not be
withheld a less hazardous form of tobacco. An alternative to the classical
“quit or die” approach could be legalizing snuff (Bates et al, 2003).
The critics of this approach maintain that smokeless
tobacco is a risk to health and as such should not be legalised. In particular,
the public health message on tobacco-related harm could be confusing for the
general public. Furthermore, it remains unclear whether snuff in Sweden indeed
has a role as an aid for quitting smoking. Results from different studies
remain inconclusive, as they could not sufficiently demonstrate causal
relationship between snuff use and quitting smoking. Other factors, such as
effective tobacco control policies in Sweden may have contributed to this
effect, commonly associated to snuff use. Other concerns include the gateway
effect – snuff users may later become smokers - an argument which has not been
proven (McKee
and Gilmore, 2007; ENSP, 2003). The Swedish experience is limited to its male
population – female smoking rates are still relatively high and prevalence of
snuff use low, despite its
availability. Finally, due to societal and cultural differences, it would be
impossible to extrapolate future patterns of smoking or oral tobacco prevalence
if oral tobacco were made available in EU countries where it is now unavailable
(European
Commission, 2007).
The European Commission is in the process of reviewing the
ban and its Scientific Committee on Emerging and Newly Identified Health Risks
(SCENHIR) has published a preliminary report on the Health Effects of Smokeless
Tobacco Products in 2007, while the final opinion on the health effects of
smokeless tobacco products was adopted in February 2008. The conclusions of
this report and the final opinion of the SCENHIR are that smokeless tobacco products
(STP) are addictive and hazardous to health, and that there is insufficient
scientific evidence to support the use of STP as a smoking cessation aid.
Furthermore, relative trends in progression from STP into and from smoking
differ between countries; thus, it is not possible to extrapolate the patterns
of tobacco use from one country where oral tobacco is available to other
countries, due to societal and cultural differences (European Comission, 2008).
10.2.1.1.5.
Progress in tobacco control in 30 European countries, 2005-2007
The "Progress in Tobacco Control in 30 European
Counrties 2005-2007" report (Joossens and Raw, 2008) describes the results
of a survey on tobacco control activity in 30 European countries between 2005
and 2007 using the Tobacco Control Scale (TCS) and based on the six policies
described by the World Bank.
Table 10.2.1.1.4. Selected EUGLOREH countries and total TCS score in
2007
The average overall score has risen over the two years
from 47 to 52 out of the scale maximum of 100. This increase is mainly due to
three TCS subscales: the smoking bans in public places, the spending on tobacco
control and advertising bans. No increase in average scores for pricing, health
warnings and tobacco dependence treatment subscales was recorded. The best
scoring countries, UK, Estonia, Spain, Romania, Switzerland, Lithuania, Latvia
and Luxembourg, recorded increases of 10 points or more over the two years.
A significant improvement in tobacco control in Europe
in this period is attributed to the success of the 2003 EU directive banning
tobacco advertising and to the adoption of smoke-free legislation.
The report defines six areas for improvement in the
reduction of tobacco use:
·
Tobacco control
programmes should be comprehensive and should include at least the six measures
described by the World Bank.
·
Countries should spend a
minimum of € 3 per capita per year on tobacco control.
·
Countries should
introduce comprehensive smoke-free legislation. This should include a total ban
on smoking in work and public places, including bars, restaurants, health and educational
facilities, and public transport.
·
Regular increases in
tobacco taxes should be the policy at EU and Member State levels. The number of
cigarettes that can be imported for personal consumption between EU countries
should be reduced to 200 per person.
·
Pictorial health
warnings on the two main sides of tobacco product packages should be mandatory
for all EU countries.
10.2.1.1.6.
Future developments
Despite the progress made in tobacco control, smoking
continues to be the largest single cause of death and disease in the European
Union. Tobacco causes one in seven deaths in the EU, killing over 650 000
people every year. Worldwide, it causes 5,4 million deaths annually.
The tobacco epidemic is shifting its focus towards low
income population, youth and women – the new, vulnerable target. It is
estimated that within a few decades, 80% of tobacco-related deaths will occur
in the developing world.
European youth is particularly vulnerable to tobacco
advertising and its smoking rates exceed those of their peers elsewhere in the
world. Consequently, more effort has to be invested into protecting this
population from the tobacco-related harm.
Smoking is almost invariably more common among the
poor. Consequently, the harmful effects of smoking add to their existing
disproportionate health burden. There is clear evidence that tobacco control
measures can make a considerable contribution to reducing social inequalities
in health in Europe (Mackenbach et al, 2004).
Smoking epidemic is man-made and entirely preventable.
It can and must be stopped through a concerted action of governments and civil
society. There is broad consensus on the effectiveness of the six policy
measures that can be implemented at (sub)national level. These measures differ
as to the extent of their impact. Prices and taxation policies (1) are
attributed most impact, followed by smoking bans in workplaces and public
places (2). Bans on advertising of tobacco products (3), appropriate consumer
information (4), warning labels (5) and treatment for those wanting to quit
smoking (6) complete the six effective measures. A comprehensive strategy
incorporating all six measures is most effective.
In Europe, research has shown that the implementation
of these strategies for reducing tobacco-related harm has been successful, but
also that more can be done (Joosens & Raw, 2007). In particular, increase
of spending on tobacco control and the implementation of a comprehensive
smoke-free legislation are seen as two areas that could bring further
improvement. Economic evidence shows that tobacco control interventions are the
second most cost effective way to spend health funds, after childhood
immunization (ASPECT, 2005). The ban on smoking in public places that include
all work places, health and educational facilities and public transport should
become a priority for European governments.
10.2.1.1.7.
References
Action on smoking and health (ASH) (2007): Stopping
smoking: the benefits and aids to quitting; ash.essential information on.
Sept. 2007. Available at:
http://www.ash.org.uk/files/documents/ASH_116/ASH_116.html
ASPECT Consortium Tobacco or health in the European
Union: past, present and future. European Commission, DG Health and Consumer
Protection, 2004. Available at:
http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/tobacco_fr_en.pdf
Bates C, Fagerström K, Jarvis MJ, Kunze M, McNeill A,
Ramström L (2003): European Union policy on smokeless tobacco: a statement in
favour of evidence based regulation for public health. Tobacco Control;
12:360-367
Boyle P, Autier P, Bartelink H, Baselga J, Boffetta P,
Burn J, Burns HJG, Christensen L, Denis L, Dicato M, Diehl L, Doll R,
Franceschi S, Gillis CR, Gray N, Griciute L, Hackshaw A, Kasler M, Kogevinas M,
Kvinnsland S, La Vecchia C, Levi F, McVie JC, Maisonneuve P, Martin-Moreno JM,
Newton Bishop J, Oleari F, Perrin P, Quinn M, Richards M, Ringborg U, Scully C,
Siracka E, Storm H, Tubiana M, Tursz T, Veronesi U, Wald N, Weber W, Zaridze
DG, Zatonski W, zur Hausen H (2003): European Code Against Cancer and
scientific justification: third version (2003). Annals of Oncology; 14:
973–1005. Available at: http://annonc.oxfordjournals.org/cgi/content/full/14/7/973.
Cavelaars AEMJ, Kunst AE, Geurts JJM, Crialesi R, Grötvedt
L (2000): Educational differences in smoking: international comparison.
BMJ, 2000; 320(7242): 1102-1107.
CDC (2004): 2004 Surgeon General's Report—The Health Consequences of Smoking
[on-line publication available at: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/chapters.htm]
CDC (2006): The Health Consequences of Involuntary
Exposure to Tobacco Smoke A Report of the Surgeon General
[on-line publication available at: http://www.surgeongeneral.gov/library/secondhandsmoke/report/fullreport.pdf]
Collins DJ, Lapsley HM (200): Counting the cost: Estimate
of the social costs of drug abuse in Australia in 1998-1999. National Drug
Strategy Monograph Series No. 49. Canberra: Commonwealth Department of Health
and Ageing.
ECOSOC Resolution 2004/62. Available at:
http://www.who.int/tobacco/communications/events/2004/ecosoc_resolution/en/
European Commission (2003): European Opinion Research
Group Smoking and the Environment (EEIG, 2003): Actions and Attitudes. Special
Eurobarometer 2003; 183. Available at:
http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/eb582_smoking_env_en.pdf
European Commission (2004), ASPECT Consortium Tobacco or
health in the European Union: past, present and future. European Commission, DG
Health and Consumer Protection, 2004. Available at: http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/tobacco_fr_en.pdf
European Commission (2007): SCENHIR – Health Effects of
Smokeless Tobacco Products, Preliminary Report. European Commission, 2007.
Available at:
http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_009.pdf
European Commission (2008): SCENHIR – Health Effects of
Smokeless Tobacco Products, Preliminary Report. European Commission, 2007.
Available at: http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_013.pdf
European Network for Smoking Prevention (ENSP) (2003):
Status Report on Oral Tobacco. Available at: http://www.ensp.org/files/ACF36E1.zip
European Respiratory Society (ERS) (2006): Smokefree
Partnership - Lifting the smokescreen - 10 reasons for a smoke free Europe.
ERSJ Ltd. Available at: http://www.ersnet.org/ers/show/default.aspx?id_attach=13509
Fiore MC, Baily WC, Cohen SJ (2000): Treating tobacco use
and dependence: Clinical Practice Guideline. Rockville, MD: US Department of
Health and Human Services, Public Health Service. Available at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf
Foulds J, Steinberg MB, Williams JM, Ziedonis DM (2006):
Developments in pharmacotherapy for tobacco dependence: past, present and
future. Drug and Alcohol Review, 2006; 25: 59-71
Janson C, Künzli N, de Marco R, Chinn S, Jarvis
D, Svanes C, Heinrich J, Jõgi R, Gislason T, Sunyer J, Ackermann-Liebrich U,
Antó JM, Cerveri I, Kerhof M, Leynaert B, Luczynska C, Neukirch F, Vermeire P,
Wjst M and Burney P (2006): Changes in active and passive smoking in the
European Community Respiratory Health Survey. Eur Respir J 2006; 27:517-524
Joossens L, Raw M (2008): Progress in tobacco control in
30 European countries, 2005 to 2007. Bulletin
Épidémiologique hebdomadaire. 21-22:198-200 [On-line
publication available at http://www.ensp.org/files/30_european_countries_text_final.pdf
Keil U, Liese AD, Hense HW, et al Classical risk factors
and their impact on incident non-fatal and fatal myocardial infarction and
all-cause mortality in south Germany. Results from the MONICA Augsburg cohort
study 1984-1992. Eur Heart J, 1998; 19: 1997-1207.
Kunst AE, Giskes K, Mackenbach JP. Socioeconomic inequalities in
smoking in the European Union: applying an equity lens to tobacco control
policies. Brussels: ENSP, 2004. Available at: http://www.ensp.org/files/ensp_socioeconomic_inequalities_in_smoking_in_eu.pdf
Lopez A (2005) The evolution of the Global Burden of
Disease framework for disease, injury and risk factor quantification:
developing the evidence base for national, regional and global public health
action. Globalization and Health; 1: 5.
Lopez AD, Collishaw NE, Piha T (1994): A descriptive model
of the cigarette epidemic in developed countries. Tobacco Control, 1994;
3: 242-247.
Luo J, Ye W, Zendehdel K, Adami J, Adami H-O, Bofetta P,
Nyrén O (2007): Oral use of Swedish moist snuff (snus) and risk for cancer of
the mouth, lung, and pancreas in male construction workers: a retrospective
cohort study. Lancet, 2007; 369: 2015-20Martinet Y, Bohadana A, Fagerström K
(2007): Introducing oral tobacco for tobacco harm reduction: what are the main
obstacles? Harm Reduction Journal, 2007; 4:17
McKee M, Gilmore A (2007): Commentary - Smokeless tobacco:
seeing the whole picture. Int. J. Epidemiol. 2007; 36(4):805-808
National Institute on Drug Abuse (NIDA, USA) (2006):
Research report series: tobacco addiction. Available at: http://www.nida.nih.gov/PDF/RRTobacco.pdf
Peto R, Lopez AD, Boreham J, Thun M (2005) Mortality From
Smoking In Developed Countries 1950-2000 (2nd edition: data updated 9 December
2005). Available at: http://rum.ctsu.ox.ac.uk/~tobacco/.
Pirkle JL, Bernert JT, Caudill SP, Sosnoff CS, Pechack TF
(2006): Trends in the Exposure of Non smokers in the US Population to Second
hand Smoke: 1998-2002. Environ Health Perspect, 2006; 114(6): 853-858.
Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1480505
SCENHIR. Health Effects of Smokeless Tobacco Products,
Preliminary Report. European Commission, 2007
Warren CW, Jones NR, Eriksen MP, Asma S. (2006): Patterns
of global tobacco use in young people and implications for future chronic
disease burden in adults. Lancet, 2006; 367: 749-53.
WHO (2002): The World Health Report - Reducing Risks,
Promoting Healthy Life. Geneva. Available at: http://www.who.int/whr/2002/en/
WHO (2002): The European health report 2002. European
Series no. 97. Copenhagen: WHO Regional Office for Europe. Available at: http://www.euro.who.int/europeanhealthreport
WHO (2005): Framework Convention on Tobacco Control. Available at:
http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf
WHO (2008): Report on the Global Tobacco Epidemic. The
MPower package. Availableat: http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf
Data sources:
Eurostat. Statistical Database of the European Union
OECD Health Data. OECD Health Data database
WHO tobacco control database
WHO-HFA. WHO - Health For All
10.2.1.2. Alcohol
Acronyms
10.2.1.2.1.
Introduction
Alcohol can affect almost every organ of the body and is
related to more than 60 different disorders and diseases with short and long-term
consequences. For a number of conditions, there is an increasing risk with
increasing levels of alcohol consumption. Alcohol is a health determinant,
leading to the need for better health statistics and available information for
Member States to manage
harmful alcohol use.
Alcohol-related harm includes those health and social
problems that occur to the drinker and those surrounding the drinker at both
individual and societal levels, in which alcohol plays a causal role.
Alcohol-related harm includes the “harmful use of alcohol”, a category in the
ICD-10 classification of mental and behavioural disorders, which refers to a
condition in which physical or psychological harm has occurred to the
individual as a result of his or her drinking. A public health perspective also
includes the risk of harm or hazardous alcohol consumption, as it is
associated, for instance, to particular amounts or patterns of drinking.
Binge drinking has increased much among young people and
is increasing among adults. The harm done by alcohol has a larger
disporptionate effect on young men. Alcohol consumption is associated with
violence.
10.2.1.2.2. Data sources
The main information sources derived from Anderson &
Baumberg (2006) are:.
European Commission
·
Updated
country profiles provided by the members of the Alcohol Policy Network (APN),
co-financed by the European Commission
(http://www.ias.org.uk/btg/countryreports/index.html)
·
Eurostat
NewCRONOS database
·
Eurobarometer
surveys
Commission-funded projects
·
European
Comparative Alcohol Study (ECAS) reports (2001-2)
World Health Organization (WHO)
·
Comparative
Risk Assessment Study, carried out within the Global Burden of Disease (GBD)
project
·
CHOsing
Interventions that are Cost-Effective project (CHOICE)
·
Global
Status Report on Alcohol
·
Global
Status Report on Alcohol Policies
·
WHO-EURO
Health for All Database
·
WHO-EURO
Alcohol Control Database
·
WHO
Global Alcohol Database
International comparative surveys
·
European
Schools Project on Alcohol and Other Drugs (ESPAD; part-financed by Council of
Europe)
·
Health
Behaviour in School-aged Children (HBSC; WHO-EURO)
Food and Agriculture Organization
·
Statistical
division (FAOSTAT) database
Organisation for Economic Co-operation and Development
(OECD)
·
OECD
Statistics Portal
·
International
Handbook of Alcohol Problems and Dependence
10.2.1.2.3. Data
description and analysis
The European Union is the heaviest drinking region of the
world, with each adult drinking on average 11 litres of pure alcohol each year – a level over 2.5 times the rest of the world’s average. Within
the EU there is a considerable variation in levels of recorded consumption,
with Luxembourg drinking 2.5 times as much per adult as Malta, and even lower
levels visible in non-EU European countries such as Iceland and Norway (
however, in the case of Luxembourg, consumption data may be affected by very
large trans-border sales due to low taxes on alcohol).
Despite the present differences between countries, the
recorded consumption is much closer together than it was previously (Figure
10.2.1.2.1). Across the 20 countries, with data going back to the 1960s, the
amount of variation has more than halved (Anderson & Baumberg 2006). While
these trends are sometimes the accumulation of many years of gradual variation,
it is also possible for large changes to occur in a short time period. For
example, consumption rose by nearly 27% in Ireland between 1994 and 2000 and
17% in Finland between 2000 and 2005, while it dropped by 22% in Italy between 1974 and 1978.
Figure 10.2.1.2.1.
Trends in recorded alcohol consumption in population aged ≥15 years
Some 53 million adults (14% of the adult population aged
16+) do not drink alcohol at all, and some 58 million can be classified as
heavy drinkers (16% of the adult population), defined as women who consume on
average more than 20g alcohol per day and men who consume more than 40g/day.
According to the 2006 Eurobarometer survey, 75% of EU25
citizens aged 15+ consumed alcohol at least once during the previous 12 months,
and 65% had consumed alcohol during the previous 30 days. Twenty eight percent
of past year EU25 drinkers (80 million people) reported that they consumed five
or more drinks (50g alcohol) on one occasion at least once a week on average
during the previous 12 months Table 10.2.1.2.1. The proportion of the total
population who were binge drinkers was 54% in Ireland and 33% in Spain, being much higher than in Finland (17%) and Sweden (11%). A much higher proportion of all men
(31%) than women (12%) had binged at least once a week. Whereas 24% of all of
those aged 15-24 had binged at least once a week, binge drinking was also
common amongst those aged 55+, with 18% binging at least once a week.
Table 10.2.1.2.1.
Frequency of having had five or more drinks in a single occasion during
previous year
Of the two thirds of EU25 citizens aged 15+ who had drunk
alcohol at least once during the previous 30 days, one in ten reported that
they usually had 5 or more drinks (50g alcohol) on one occasion when they
consumed alcohol. Of the past month drinkers, a pattern of binge drinking was
most common in Ireland, where 36% reported to drink 3-4 drinks (30-40g alcohol)
on one occasion and a further 34% 5 or more drinks (50g alcohol). The
proportion of EU15 adults who normally drank five or more drinks on a drinking
occasion remained the same in 2006 as in 2003 (10%). However, given that 67% of
EU15 adults reported alcohol consumption within the past 30 days in 2006
compared to 61% in 2003, the actual number of EU15 adults who normally drank
five or more drinks (50g alcohol) on an occasion increased by 10% between 2003
and 2006.
Nearly all (over 9 in 10) 15-16 year-old students have drunk alcohol at some point in their life, starting on average just after 12½
years of age. Data from the 2003 European School Survey Project on Alcohol and
Other Drugs (ESPAD) found that the average amount of alcohol drunk by 15-16
year olds on the last drinking occasion was 60g of alcohol. No EU15 country
outside of southern Europe has an average level below 56g, while in the UK and
Ireland the amount drunk on the last occasion even reaches over 80g of pure
alcohol. Last occasion drinking levels are slightly lower in the EU10 and
significantly lower in southern Europe, which averaged 38g of pure alcohol. The
highest levels of both binge-drinking and drunkenness are found in the Nordic
countries, UK, Ireland, Slovenia and Latvia. This contrasts with the low levels
found in France, Italy, Lithuania, Poland and Romania – for example,
binge-drinking 3+ times in the last month was reported by 31% of boys and 33%
of girls in Ireland, but only 12%-13% of boys and 5%-7% of girls in France and
Hungary. Across the whole EU though, over 1 in 8 (13%) of 15-16 year old students have been drunk more than 20 times in their life, and over 1 in 6 (18%) have binged (5+ drinks on a single occasion) three times or more in the last month.
Binge-drinking in young people has increased across much of Europe in the last
10 years, more so in the early part of this period.
Acute harm from alcohol
A substantial proportion of
incidents of aggression and violent crime involve one or more participants who
have been drinking, with
25%-85% of violent crimes relating to alcohol, the proportion varying across
countries and cultures. There
is a relationship between alcohol consumption and the risk of involvement in
violence, including homicide, which is stronger for intoxication than for
overall consumption. Episodic heavy drinking, frequency of drinking and drinking volume are all independently associated with the
risk of aggression, with frequency of drinking appearing to be the most
important. There is an overall relationship between greater alcohol use and
criminal and domestic violence, with particularly strong evidence from studies
of domestic and sexual violence. The relationship is attenuated when other
characteristics, such as culture, gender, age, social class, criminal status,
childhood abuse and use of other drugs in addition to alcohol are taken into
account. Generally the higher the level of alcohol consumption, the more
serious is the violence
Parental drinking can affect the
environment in which a child grows up through financial strain, poor parenting,
marital conflicts and negative role models. A large number of studies have
reported a variety of childhood mental and behavioural disorders to be more
prevalent among children of heavy drinkers than others. Systematic reviews have
suggested that alcohol is a cause of child abuse in 16% of cases.
The risk of drinking and driving
increases with both the amount of alcohol consumed and the frequency of high
volume drinking occasions, as well as blood alcohol concentration levels. A
review of 112 studies provided strong evidence that impairment in driving
skills begins with any departure from a zero blood alcohol concentration level
(BAC). Comparison of blood alcohol concentrations (BACs) of drivers in
accidents with the BACs of drivers not involved in accidents find that male and
female drivers at all ages who had BACs between 0.2g/l and 0.49g/l had at least
a three times greater risk of dying in a single vehicle crash. The risk
increased to at least 6 times with a BAC between 0.5g/L and 0.79g/L and 11
times with a BAC between 0.8g/l and 0.99 g/L.
There is a relationship between the use of
alcohol, largely in the short term, and the risk of fatal and non-fatal
accidents and injuries. People who usually drink alcohol at lower levels, but
who engage periodically in drinking large quantities of alcohol, are at
particular risk. Alcohol increases the risk of attendance at hospital emergency
rooms in a dose dependent manner; between 20% and 80% of emergency room
admissions can be alcohol-related. Alcohol alters the treatment course of
injured patients and can lead to surgical complications and a greater
likelihood of death.
Heavy drinking is a major risk factor for
suicide and suicidal behaviour among both young people and adults. There is a
direct relationship between alcohol consumption and the risk of suicide and
attempted suicide, which is stronger for intoxication than for overall
consumption.
Each year in the European Union, it has
been estimated that alcohol is related to:
-
2,000
homicides (4 in 10 of all murders)
-
17,000
deaths from road traffic accidents (1 in 3 of all road traffic fatalities), including 10,000 deaths of people other than the drink-driver
-
27,000
accidental deaths
-
10,000
suicides (1 in 6 of all suicides)
-
16% of all
child abuse / neglect
-
5-9 million
children living in families adversely affected by alcohol.
Table 10.2.1.2.2.
Change in death rates, by cause, from a 1 litre increase in per capita alcohol
consumption
As can be seen in Table 10.2.1.2.2, there are significant
relationships between a 1 litre increase in alcohol consumption and death rates
from a number of conditions, which are stronger in lower consuming than higher
consuming countries partially reflecting the increased proportional size of a
one-litre change in low-consuming countries.
Chronic harm from alcohol
Alcohol is a toxic substance that
is a cause of 60 or more different disorders. Alcohol consumption can result in
addiction. The risk of alcohol dependence increases with both the volume of
alcohol consumption and a pattern of drinking larger amounts on an occasion.
For many conditions there is an increasing risk with increasing levels of
alcohol consumption, with no evidence of a threshold effect, including, for
example, cancer of the oral cavity, haemorrhagic stroke, hypertension,
pancreatitis and breast cancer in women. The total amount of alcohol consumed
over a lifetime alcohol intake increases the risk of harm. For example, a
consumption of 15-30 g ethanol /day throughout life increases the risk of breast
cancer in women by one third.
There is a linear relationship
between alcohol consumption and symptoms of depression and anxiety, with an
increasing prevalence of symptoms with greater consumption. Alcohol-dependent
individuals demonstrate a two- to three-fold increase in the risk of depressive
disorders, while there is evidence for a continuum in the magnitude of
co-morbidity as a function of the level of alcohol use. There is a straight
line relationship between the amount of alcohol consumed over a lifetime and a
decreased volume of brain grey matter.
Long term exposure to alcohol
increases the risk of liver cirrhosis and acute and chronic pancreatitis. The
reduction in alcohol consumption, which took place in Southern European
Countries after the 70s is associated to a strong reduction (almost 3 times) of
liver cirrhosis (Figure 10.2.1.2.2).
Figure 10.2.1.2.2.
Alcohol consumption and cirrhosis rates in southern Europe
Alcohol is a carcinogen; long term
exposure increases the risk of cancers of the mouth, oesophagus (gullet),
larynx (upper airway), liver and female breast, and - to a lesser extent -
cancers of the stomach, colon and rectum in a linear relationship, with no
evidence of a threshold effect.
The risk of coronary heart disease
decreases to about 80% of the level of non-drinkers at 20 grams (two drinks) of alcohol
per day, with most of the reduction in risk occurring by a consumption of one
drink every second day. Some reviews have suggested that the protective effect
is due to a systematic misclassification due to the inclusion as ‘abstainers’
of many people who had reduced or stopped drinking, a phenomenon associated
with ageing and ill health. Alcohol raises blood pressure and increases the
risk of hypertension and haemorrhagic stroke in a dose dependent manner. There
is a J-shaped relationship between alcohol consumption and the risk of ischemic
stroke. Episodic heavy drinking increases the risk of heart arrhythmias and
sudden coronary death, even in people without any evidence of pre-existing
heart disease.
Alcohol shows reproductive
toxicity. Prenatal exposure to alcohol can be associated to a distinctive
pattern of intellectual deficits that become apparent later in childhood,
including reductions in general intellectual functioning and academic skills as
well as deficits in verbal learning, spatial memory and reasoning, reaction
time, balance, and other cognitive and motor skills. Although these deficits
are most severe and have been documented most extensively in children with
Foetal Alcohol Syndrome (FASD), children pre-natally exposed to lower levels of
alcohol can also exhibit similar problems.
Heavy drinking during adolescence
and young adulthood is associated with poorer neurocognitive functioning during
the young adult years, and particularly with impairment of attention and
visuospatial skills.
It has been estimated that each year in the
European Union, alcohol causes:
-
45,000
deaths from liver cirrhosis
-
50,000
cancer deaths, of which 11,000 are female breast cancer deaths
-
17,000
deaths due to neuropsychiatric conditions
-
200,000
episodes of depression.
Overall burden
Adding up all the harm done by alcohol means that 7.4% of
all ill-health and premature death in the European Union is due to alcohol,
placing alcohol as the third most important risk factor after tobacco and high
blood pressure. This is mainly for men, accounting for 12% of all male
ill-health and premature death and a smaller but still sizeable 2% of all
female ill-health and premature death. The larger proportion of the burden arises
from alcohol-related neuropsychiatric conditions and accidents, Figure
10.2.1.2.3.
Figure 10.2.1.2.3.
Alcohol-attributable burden of death and ill-health in the European Union
Economic costs of alcohol consumption
The burden of ill-health due to
alcohol is disproportionally shouldered by young men in Europe, 13,000 of whom
die in the EU each year, Figure 10.2.1.2.4. This represents 1 in every 4 deaths of young
men, rising to nearly 1 in 3 in the EU10. Alcohol is responsible for a slightly
smaller but still substantial death toll in young women, with the 2,000 deaths
corresponding to 11% of female mortality at this age across the EU.
The high level of harm to young people is due to the
importance of intentional and unintentional injury as primary causes of death
in young people, as opposed to heart disease later in life.
Figure 10.2.1.2.4. The share of deaths
attributable to alcohol in EU per age group (year 2000)
There is a substantial health gap across Europe, with a
difference in life expectancy at birth between EU countries of as much as 10
years. Against this background, it is clear that many of the individual
conditions that contribute to the health gap are linked to alcohol. For males
dying between the ages of 20 and 64, injuries are responsible for nearly half
(46%) of the difference in life expectancy between the three Baltic states
(Estonia, Latvia and Lithuania) and the EU15, and for one fifth (22%) of the
difference between central and eastern Europe (Poland, Czech
Republic, Slovakia, Hungary, Slovenia, Romania, Bulgaria) and the
EU15 (Zatonski 2008). Whereas in the EU15, alcohol is responsible for 29% of
all male injuries and 19% of all female injuries, in the central and eastern
European countries, the proportions are 38% and 29%, and in the three Baltic
states 48% and 42% respectively. The estimates suggest that alcohol is
responsible for a difference in the crude death rate of approximately 90 extra
deaths per 100,000 people for men and 60 per 100,000 for women (as well as
16,000 DALYs per million people for men and 4,000 DALYs per million for women)
in the EU10, compared to the EU15 (Anderson and Baumberg 2006).
Alcohol is a cause of health inequalities within
countries. For example, in Sweden, alcohol is the 2nd most important cause of
inequalities in the burden of ill-health for men (7th for women), with several
other alcohol-related diseases such as ischemic heart disease and self-inflicted
injuries also prominent (Ljung et al, 2005). Many of the conditions
that are responsible for health inequalities are strongly linked to alcohol,
including external causes (e.g. violence, accidents), stroke and liver disease
(across the EU15), ischemic heart diseases (northern Europe) and cancer
(southern Europe). The role of alcohol in
these inequalities may be different in different countries. However, for
example, the two countries with the largest inequalities in men aged 45-59 are
France and Finland, but while the former finds this to be mainly due to liver
cirrhosis and alcohol-related cancers, the latter finds this related primarily
to violent deaths (Kunst et al, 1998). Research from Finland further suggests
that socioeconomic variables act on the collective as well as the individual level.
Areas with the most manual workers had 20% more mortality directly attributable
to alcohol than areas with the least, even after accounting for the individual
relationship of occupation to mortality (Blomgren et al, 2004).
This harm also has its social cost, which has been
estimated to be €125 billion each year, equivalent to 1.3% of GDP. Actual
spending on alcohol-related problems (Figure 10.2.2.5) accounts for €66bn,
while potential production not realised due to absenteeism, unemployment and
premature mortality accounts for a further €59bn.
Figure 10.2.1.2.5. The tangible cost of
alcohol in Europe per cost element (year 2003)
10.2.1.2.4. Control tools and policies.
Risk reduction strategies include a set of measures in a
jurisdiction or society aimed at minimizing the health and social harms that
result from alcohol consumption. They are implemented by alcohol policies,
which include authoritative decisions that are made by governments through
laws, rules and regulations, coming from the legitimate purview of legislators
and other public interest group officials, and not from private industry or
related advocacy groups (Babor et al, 2003). In the context of public health,
the central purpose of alcohol policies is to serve the interests of public
health and social well-being through their impact on health and social
determinants, such as drinking patterns, the drinking environment and the
health services available to treat problem drinkers.
Alcohol is a major economic commodity associated to
substantial governmental tax receipt. Europe can be considered the centre of
the global alcohol industry, acting as both the largest market and the major
producer of alcoholic drinks. Therefore, it may be appropriate to recall that
the trade in alcohol in the whole European Union accounts for 1.3% of all
exports and 0.3% of all imports, thereby contributing €8.9bn to the goods
account balance, with such trade not necessarily affected by European and
domestic policy to reduce the harm done by alcohol (Anderson and Baumberg
2006).
Maintaining the relative price of alcohol
When other factors are held constant, the more affordable
alcohol is, the more it is consumed; and the less affordable it is, the less it
is consumed (Anderson and Baumberg 2006). The way drinkers respond to and
compensate for price changes is complex, because of the possibilities for
substitution. Drinkers tend to shift to more expensive beverages if relative
prices decrease, either within the same beverage category or across beverage
categories. If prices are raised, they both reduce overall consumption but also
shift to cheaper beverages. Heavy drinkers tend to buy the cheapest products
within their favourite beverage category. The impact of an increase in alcohol
price is stronger in the longer term than it is in its immediate effects. From
a public policy perspective, it is the long term effects - taking into account
alcohol’s dependence producing properties - that are more important. Young
people are particularly sensitive to price. Policies that increase alcohol
prices have been shown to reduce the proportion of young people who are heavy
drinkers, reduce underage drinking and reduce per occasion binge drinking.
Higher prices also delay intentions among younger teenagers to start drinking
and slow progression towards drinking larger amounts. Heavy drinkers are also
sensitive to price, with higher alcohol taxes or prices leading to reductions
in deaths from liver cirrhosis, mortality rates from traffic accidents and
reduced rates of crime, including assault, violence related injury, homicide,
family violence, child abuse and other violence towards children.
While it may be predicted that the revenues from tax on
alcohol depend on the total amount of alcohol drunk in a country, evidence
suggests that this is not the case. There is no apparent correlation between
the revenue from alcohol-specific taxes (as a % of government revenue or % of
GDP) and per capita consumption (Figure 10.2.1.2.6). The best predictors of the
importance of alcohol-specific taxes are unsurprisingly the average alcohol tax
rates, which relate very closely to the income from alcohol taxes.
Figure 10.2.1.2.6.
Alcohol consumption and alcohol tax revenue
Managing the sale of alcohol
The smaller the number of outlets for alcoholic beverages,
the greater the difficulty in obtaining alcohol, a situation that is likely to
deter alcohol use and problems (Anderson and Baumberg 2006). A number of
studies have indicated that although changing either hours or days of alcohol
sale can redistribute the times in which many alcohol related accidents and
violent events related to alcohol take place, this occurs at the cost of an
overall increase in problems.
Around-the-clock opening in Reykjavik, for instance,
produced net increases in police work, emergency room admissions and drinking
& driving cases (Ragnarsdottir et al, 2002).
There is also evidence that restricting days and hours of
sale reduce problems. In the 1980s Sweden re-instituted Saturday closing for
spirits and wine off-premise sales after studies showed that Saturday sales
were associated with increased rates of domestic violence and public
drunkenness (Olsson and Wikström 1982). SSaturday opening of government alcohol stores was
re-instituted, there was a 3.6% increase in alcohol sales (Norstrom and Skog
2005).
Almost all countries legally restrict alcohol sales to
minors. There is very strong evidence that changes in minimum drinking age laws
can substantially effect youth drinking and alcohol-related harm, particularly
road traffic accidents; however, the full benefits of a higher drinking age are
only realized if the law is enforced (Anderson and Baumberg 2006).
Advertising controls
One Belgian and eight US-based well designed longitudinal
studies show that the volume of advertisements and media exposure increase the
likelihood of young people to start drinking, the amount they drink and the
amount they drink on any one occasion (Anderson 2007). There have been no
published longitudinal studies that do not find such an effect. These findings
are similar to the impact of advertising on smoking and eating behaviour. It is
difficult to study the relationship between expenditure on commercial
communications, or whether or not there are bans on alcohol advertisements in a
jurisdiction and drinking by young people. Where this has been done, some
studies have found that increased expenditure on advertising is associated with
increased alcohol-related harm amongst young people and that total bans have
reduced alcohol-related harm, whereas others have not. In general, later
studies seem to have found more of an effect of commercial communications. The
evidence would thus show that there is a need to specify the extent to which
alcohol advertising in certain categories of media and publications is allowed,
and it would suggest that, as is the case with tobacco, consideration should be
given to the prohibition of advertising of alcohol products on television and
radio and in specified certain print media.
There are good examples of regulations on alcohol
marketing in some countries. France’s Loi Evin is one such model which bans
most advertising and sponsorship and restricts permitted advertising to the
mere description of the product without any of the messages which make
advertising particularly attractive to younger people. When the Loi Evin was
challenged in the European Court of Justice, it was upheld, noting that it is
in fact undeniable that advertising acts as an encouragement to consumption;
the French rules on TV advertising are appropriate to ensure their aim of
protecting public health and do not go beyond what is necessary to achieve such
an objective (ECJ, 2004).
Setting and controlling blood
alcohol levels.
Establishing a maximum blood-alcohol level (BAL) for
driving is a well-established and widely diffused drinking-driving
countermeasure. Over the years, the level specified as maximum has been lowered
in a number of countries, (i.e. as low as zero or 0.2g/l in a number of
countries and 0.5g/l or lower in most countries in Europe). Both establishing a
BAL and lowering it are effective in reducing drinking-driving casualties
(Anderson and Baumberg 2006). There is also convincing evidence that both
intensive random breath testing, where police regularly stop drivers on a
random basis to check their BAL, and sobriety checkpoints, where all cars are
stopped and drivers suspected of drinking driving are breath-tested, reduce
alcohol-related injuries and fatalities.
Setting lower BALs (including a zero level) for young or
novice drivers; administrative driver's license suspension for a driver caught
with a positive BAL particularly in legal systems in which a criminal
drinking-driver case may be delayed or successfully fought by a defence lawyer;
and the use of an ignition interlock, a mechanical device which does not allow
a car to be driven by a driver with a BAL above a low level, for reducing
repeat infractions by convicted drinking drivers are all effective measures for
reducing drinking & driving casualties.
Finally, there are a number of measures that have shown to
be not effective in reducing drinking and driving (Anderson and Baumberg 2006).
These include designated drivers and ride services, such as the BOB campaign.
No study has evaluated whether the use of designated drivers actually decreases
alcohol-related motor vehicle-related injuries (Ditter et al, 2005). However,
although the BALs of designated drivers are generally lower than those of their
passengers they are still often higher than the legal limit for drinking and
driving. Furthermore, an increase in passenger alcohol consumption is often
found when a designated driver is available.
Educational programmes and information
campaigns
Whilst the provision of information and persuasion to
reduce alcohol related harm might seem appealing, particularly in relation to
younger people, it is unlikely to achieve sustained behavioural change in an
environment in which many competing messages are received in the form of
marketing and social norms supporting drinking, and in which alcohol is readily
available. Many careful systematic reviews have evaluated school based
education which aimed at reducing alcohol related harm and found that classroom
based education is not an effective intervention to reduce alcohol related
harm; although there is evidence of positive effects on the increased knowledge
about alcohol and in improved attitudes, there is no evidence for a sustained
effect on behaviour (Jones et al, 2007).
In general, public information campaigns are also an
ineffective antidote to the high quality, pro-drinking messages that appear far
more frequently in the media (Anderson and Baumberg 2006). Furthermore, counter
advertising (a variant of public information campaigns which provides
information about a product, its effects and the industry that promotes it in
order to decrease its appeal and use) has inconclusive effects. Whilst drinking
guidelines have been used in a number of countries, there have been no
evaluations that find an impact of these guidelines on alcohol related harm
(Anderson and Baumberg 2006). The United Kingdom’s ‘sensible drinking
guidelines’ when relied upon as a key prevention strategy in a liberalizing
policy environment failed to deter increases in alcohol consumption. The
exception to this evidence of inefficacy is the evidence for the impact of mass
media campaigns to reduce drinking and driving, particularly in jurisdictions
with strong policies in place for what concerns drinking and driving.
Drinking context
Licensed drinking environments are associated with
drunkenness, drinking & driving and problem behaviours such as aggression
and violence, with some licensed premises being associated with a
disproportionate amount of harm. Nearly all evaluations in training bar staff
in responsible beverage service when backed up with enforcement have
demonstrated improved knowledge and attitudes among participants, although this
wears off over time (Anderson and Baumberg 2006). These studies have also shown
some effects on serving practices, but not always. Whilst servers are usually
willing to intervene with customers who are visibly intoxicated, they generally
will not intervene with individuals solely on the basis of the customer’s
estimated blood alcohol concentration (BAC) or number of drinks consumed. In
terms of the effects on customer intoxication, several studies have found that
server training results in lower BAC levels of customers generally and fewer
customers with high BAC levels. Studies on the impact of adhering to bar
policies for avoiding intoxication have also found modest effects in reducing
heavy consumption and high risk drinking, but were not as successful as
originally expected. The impact of responsible beverage service is greatly
enhanced when there is active, but ongoing enforcement of laws prohibiting the
sale of alcohol to intoxicated customers.
Community based prevention programmes can be effective in
reducing drinking and driving, alcohol related traffic fatalities and assault
injuries (Giesbrecht, 2003). Community mobilization has been used to raise
awareness of problems associated with on-premise drinking, develop specific solutions
for the problems, and pressure bar owners to recognize that they have a
responsibility towards the community in terms of such bar-related issues as
noise level and customer behaviour. Evaluation results from community
mobilization approaches as well as documentation from grassroots projects
suggest that community mobilization can be successful in reducing aggression
and other problems related to drinking in licensed premises.
Advice and treatment
Healthcare-based interventions for hazardous and harmful
alcohol consumption reduce alcohol consumption, alcohol related problems and
alcohol-related mortality. The community based Malmö study, undertaken during
the 1970s, demonstrated that under the right conditions, the effects can be
dramatic (Kristenson et al, 2002). An intervention for heavy drinkers resulted
in half the deaths that occurred in the control group without the intervention
at six year follow-up.
There is extensive evidence that shows the effectiveness
and cost-effectiveness of opportunistic screening and brief interventions for
people with hazardous and harmful alcohol use in the absence of severe
dependence (Kaner et al, 2007). The population impact on excessive drinking
could be significant if these programs were widely adopted in health care
systems,.
For people with more severe alcohol dependence and related
problems, a wide variety of specialized treatment approaches have been
evaluated, including behavioural, psychosocial and pharmacological
interventions of varying intensities in both community and residential settings
(Miller and Wilbourne 2002). Evidence shows that individuals exposed to these
treatments, especially when delivered in a timely manner, achieve better
outcomes than those not receiving treatment. Moreover, for the average person,
the effectiveness of these treatments tends to be comparable regardless of
intensity, modality or setting.
For other relevant issues, check the
following documents:
Television Without Frontiers Directive
http://europa.eu.int/eur-lex/en/consleg/pdf/1989/en_1989L0552_do_001.pdf
Commission Recommendation on maximum permitted blood
alcohol content, 2001
http://europa.eu.int/eur-lex/lex/LexUriServ/LexUriServ.do?uri=CELEX:32001H0115:EN:HTML
Council Recommendation on the drinking of alcohol by young
people, in particular children and adolescents, 2001
http://europa.eu/scadplus/leg/en/cha/c11564.htm
European Commission Road Safety Action Programme 2003-2010
http://europa.eu/scadplus/leg/en/lvb/l24257.htm
European Commission Communication on EU alcohol strategy,
2006
http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/alcohol_com_625_en.pdf
European alcohol and health forum, 2007
http://ec.europa.eu/health/ph_determinants/life_style/alcohol/alcohol_charter_en.htm
Projects funded under the Public Health
Programme 2003-2008:
PHEPA: Primary Health Care European Project
http://www.phepa.net
EUROCARE – Alcohol Policy Network in the Context of a
Larger Europe: Bridging the Gap
http://ec.europa.eu/health/ph_projects/2003/action3/action3_2003_02_en.htm
ELSA – Enforcement of national Laws and Self-regulation on
advertising and marketing of Alcohol
http://ec.europa.eu/health/ph_projects/2004/action3/action3_2004_16_en.htm
Research projects on alcohol:
Genomics, mechanism and treatment of addiction
http://cordis.europa.eu/
European Prospective Investigation into Cancer, Chronic
Diseases, Nutrition and Lifestyle
http://cordis.europa.eu/fetch/
DRUID: Driving under influence of drugs, alcohol and
medicine
http://cordis.europa.eu/eoi/dsp_details.cfm?ID=2638
DG SANCO pages on Alcohol
http://ec.europa.eu/health/ph_determinants/life_style/alcohol_en.htm
10.2.1.2.5.
References
Anderson P, Baumberg B (2006): Alcohol in Europe: A Public Health
Perspective
- Report to the European Commission. London: Institute of Alcohol Studies.
Available at:
http://ec.europa.eu/health-eu/news_alcoholineurope_en.htm
Anderson P, (2007): Commercial Communications and
Alcohol.
Utrecht: National Foundation for Alcohol
Prevention.
Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N,
Graham K, Grube JW, Gruenewald PJ, Hill L, Holder HD, Homel R, Österberg E,
Rehm J, Room R and Rossow I (2003): Alcohol: No Ordinary Commodity.
Research and Public Policy. Oxford, Oxford Medical Publication, Oxford University
Press.
Blomgren J, Martikainen P, Mäkelä P, Valkonen T, (2004):
"The Effects of Regional Characteristics on Alcohol-Related Mortality—a
Register-Based Multilevel Analysis of 1.1 Million Men." Social Science and
Medicine,
58: 2523-35.
Ditter SM, Elder RW, Shults RA, Sleet DA, Compton R,
Nichols JL (2005): Effectiveness of designated driver programs for reducing
alcohol-impaired driving a systematic review Am J Prev Med Jun;28(5 Suppl):280-7.
Eurobarometer (2007). Attitudes towards Alcohol.
Available at:
http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/ebs272_en.pdf. Accessed June 2007.
European Court of Justice (ECJ) (2004): C-262/02 and
C-429/02.
Jones L, James M, Jefferson T, Lushey C, Morleo M, Stokes
E, Sumnall H, Witty K, Bellis M (2007): A review of the effectiveness and
cost-effectiveness of interventions delivered in primary and secondary schools
to prevent and/or reduce alcohol use by young people under 18 years old Alcohol
and schools: Review of effectiveness and cost effectiveness - Main report
(PHIAC 14.3a). Available at: http://guidance.nice.org.uk/page.aspx?o=427775
Giesbrecht N (2003): Alcohol, tobacco and local control. A
comparison of several community-based prevention trials. Nordic Studies on
Alcohol and Drugs 20 25-40.
Kristenson H, Osterling A, Nilsson JA, Lindgarde F (2002):
Prevention of alcohol-related deaths in middle-aged heavy drinkers, Alcoholism, Clinical and
Experimental Research, 26, 478-484.
Kunst AE, Groenhof F, Mackenbach JP, EU Working Group on
Socioeconomic Inequalities in Health (1998): Occupational Class and Cause
Specific Mortality in Middle Aged Men in 11 European Countries: Comparison of
Population Based Studies. British Medical Journal, 316: 1636-42.
Ljung R, Peterson S, Hallqvist J, Heimerson I, Diderichsen
F (2005): Socioeconomic Differentials in the Burden of Disease in Sweden.
Bulletin of the World Health Organization, 83: 92-99.
Miller W, Wilbourne P (2002): Mesa Grande: a
methodological analysis of clinical trials of treatments for alcohol use
disorders. Addiction, 97, 265-277.
Kaner EFS, Beyer F, Dickinson HO, Pienaar E, Campbell F,
Schlesinger C, Heather N, Saunders J, Burnand B (2007): Effectiveness of brief
alcohol interventions in primary care populations. Cochrane Database of Systematic
Reviews
2007, Issue 2. Art. No.: CD004148. DOI: 10.1002/14651858.CD004148.pub3.
Olsson O, Wikström PH (1982): Effects of the experimental
Saturday closing of liquor retail stores in Sweden. Contemporary Drug Problems 11, 325-353.
Rehm J (2005): Volume of Alcohol Consumption, Patterns of
Drinking and Burden of Disease in the European Region - Implications for
Alcohol Policy. 10th meeting of national counterparts for alcohol policy in the
WHO European Region, Stockoholm 13-15 April 2005 [conference proceeding]
10.2.1.3. Drugs
and substance misuse1
Acronyms
10.2.1.3.1. Introduction
The most commonly used illicit substances in Europe, with
some variations among countries, are cannabis, amphetamine-type
stimulants, amphetamine, ecstasy, methamphetamine, cocaine and opioids (mainly
heroin and illicitly acquired/used prescription opioid medications). Other
substances, such as LSD, GHB, Ketamine and a wide range of other - often
synthetic - drugs are also sometimes used. Finally, the use of inhalants and
the misuse of legally (or not legally) acquired medications (benzodiazepines
besides opioids) can also play a significant role from the public health point
of view2.
Increases in the prevalence of
cocaine use in young adults (15-34 y) have been registered in all countries
according to recent survey data. Use of cocaine and
other stimulant drugs by socially integrated individuals is currently
increasing. It is estimated, that one million
current or former IDUs are infected with hepatitis C virus in Europe. Regular use of cannabis
and the co-use of several substances are also increasing.
Drug use occurs overall mainly among adolescents and young
adults, with usually higher prevalence among males than females, especially
when considering regular drug use. The routes of administration of the drugs
are, depending on the physical properties of the substances, smoking, snorting,
swallowing and/or injecting. The last one is generally considered as one of the
most harmful and can thus be used as an indicator of problem drug use. The
frequency of use is also an important indicator to understand the
characteristics of drug problems at individual and population levels.
The health problems related to drug use include acute
problems such as poisoning, which can lead to death; severe mental or physical
health problems; or different risk behaviours (e.g. drugged driving). These
behaviours may cause fatal accidents or injuries as well as chronic problems
such as drug dependence and other mental health (psychosis, depression,
suicide) or physical health (infectious diseases, cirrhosis, cancer) problems
typical consequence of or often associated with long term use of illicit drugs.
The social situation of long term problem drug users should also be taken into
account as employment rates and housing conditions are often bad.
The overall health burden associated with drug use in
Europe is still difficult to estimate. However, between 1990 and 2004, more
than 122 000 direct drug-related deaths were reported and it is estimated
that there are between 100 000 and 200 000 former or current drug
injectors living with HIV and about 1 million of them infected with the
hepatitis C virus in Europe.
10.2.1.3.2. Data
sources
Data provided in this chapter, unless otherwise indicated,
haveb been collected by the European Monitoring Centre for Drugs and Drug
Addiction (EMCDDA) through a network of national focal points (Reitox). These
data are summarized every year in an annual report on the drug situation in
Europe and in a statistical bulletin which are both available online.3
The EMCDDA monitors among others intensive forms of drug
use, including problem drug use and addiction/dependence.
The data collected by the EMCDDA are organised along 5 key
epidemiological indicators ((i) drug use among the general population; (ii)
problem drug use; (iii) drug related infectious diseases; (iv) drug-related
deaths and mortality among drug users; (v) demand for drug treatment), but also
other important indicators and data in the following areas: interventions to
reduce drug-related problems (prevention, treatment, harm reduction, etc.),
drug market and crime (seizures, prices, drug-related offences, etc.), policy
and legal frameworks etc.4
10.2.1.3.3. Data
description and analysis
Overall estimates on the prevalence of use of the most
frequently used drugs among the general population based on general population
surveys have been presented in Table 10.2.3.1.
Table 10.2.1.3.1.
Conservative estimates of prevalence and total numbers of users of different
drugs in the European Union and Norway
Cannabis is by far the most frequently used illicit drug
in Europe, but most individuals having used it at least once in their lifetime
are not current users anymore. However, last year use of different drugs shows
that more than 10% of Europeans have recently used cannabis and more than 1%
cocaine. The variables most strongly associated with current drug use across
the EU are young age, male gender, living in an urban area and preference of
certain recreational environments such as nightclubs and bars5.
Use of illicit drugs can begin as early as in school age.
According to the 2003 ESPAD survey, between 1 and 13% (on average 4%) of school
children reported having tried cannabis for the first time when 13 years old or
younger. Among 15-16 year olds, lifetime (i.e. at least once in their life)
cannabis use ranges from more than 40% in some European countries to below 10%
in others, with an average of 4% who have already used the drug 40 or more
times in their lives (countries range in prevalence between 0 and 10%).
Overall prevalence rates for other illicit drug use are
much lower than for cannabis among 15-16 year olds. In most countries, lifetime
prevalence of cocaine use is 2% or lower. Lifetime ecstasy use was reported by
0 to 8% of school children with 6 EU countries reaching the prevalence of 5% or
more. Amphetamines have been used by 0 to 7% of school children, with 4 EU
countries having a prevalence of 5% or more6.
Data from the ESPAD survey shows an overall increase in
the prevalence of cannabis use among school children between 1995 and 2003,
with a more marked increase between 1995 and 1999 (Figure 10.2.3.1). An
increase in the lifetime prevalence of the use of other drugs has also
occurred.
Figure
10.2.1.3.1. Lifetime prevalence of cannabis among 15-16y-old students
Most drug use is taking place among 15-34 year olds and
lifetime prevalence might grow dramatically at the beginning of this age
period. There are, however, considerable variations between countries in the prevalence
of the use of different substances.
On average, 30% (3-50%) of young adults in Europe report
lifetime use of cannabis, 13% (3-20%) used it in the last year (Figure
10.2.3.2) and over 7% (1.5–15.5%) report use in the last month. For cocaine,
the figure is 5.3% for average lifetime use, with six countries reporting
prevalence levels of at least 5%. In the past year, 2.4% of young adults have
used the drug and 1% have used it in the past month. For amphetamines and
ecstasy, the average figures are 5.1% and 5% for lifetime use and 1.5% and 2%
for last year use. Lifetime prevalence of LSD use ranges from 0.3% to 7.6%.
Figure
10.2.1.3.2. Overview of
last year drug prevalence estimates from various studies in selected EU Countries
for young adults (aged 15 to 34)
Drug use in the European Union has generally increased in
the 1990-ties both for all adults (aged 15-64) and young adults (15-34).
Nowadays, we can observe some signs of stabilisation in the case of cannabis,
amphetamines and ecstasy, but generally not for cocaine.
Increases in last year’s prevalence of cocaine use among
the 15–34 age group have been registered in all countries reporting recent
survey data, although there may be some levelling off in the Member States with
the highest prevalence levels. See Figure 10.2.1.3.3 for trends in countries
with available time-series data.
There is evidence of stabilising or even decreasing trends
in amphetamine and ecstasy consumption but in some countries (United Kingdom,
Spain and Denmark) data suggest a possible replacement between stimulants, with
amphetamines and ecstasy use decreasing and cocaine use increasing7.
Figure 10.2.1.3.3. Trends in last year
prevalence of cocaine among young adults, measured by population surveys
Most of illicit drug use recorded in general population
surveys tends to be discontinued after some time (typically after the
vulnerable age period, when a person starts an adult life with work and
family). However, the EMCDDA is currently working on understanding the
proportion of cannabis users that go on to more intensive patterns of use,
closely with a number of Member States. A crude estimation made by EMCDDA in
2004, based on limited data, suggested that around 1% of European adults, or
about 3 million people, may be 'daily or almost daily' cannabis users.
General population surveys might not be able to
realistically describe more intensive to dependent forms of drug use,
especially for substances with high addictive potential (e.g. heroin), mainly
due to sampling frame-related methodological specificities8. Therefore,
other important sources of information such as indirect estimates of the hidden
population consisting of problem drug users (PDUs), treatment demands and drug
overdoses statistics also have to be considered.
Problem drug use is defined by the EMCDDA as ‘injecting
drug use or long duration / regular use of opioids, cocaine and / or amphetamines’.It
is usually estimated as yearly prevalence rate per inhabitants aged 15-64 by
indirect statistical methods. In total, problem drug users estimates from
different countries suggest an annual prevalence of roughly between 1 and 8
cases per 1000 inhabitants aged 15-64.
In spite of the EMCDDA definition, most countries’
estimates include only injecting drug users (IDUs) and problem opioids users
(POUs), due to various reasons (e.g. unavailability of data, epidemiological
situation in the country)9.
Three countries (Czech Republic,
Slovakia and Finland) provided an estimate of problem
amphetamines/methamphetamines users ranging from 1.5–5.3 cases 1 000
inhabitants aged 15–64, whilst three other countries (Spain, Italy and United
Kingdom) provided an estimate of problem cocaine users in the range of 3 to 6
per 1 000 inhabitants aged 15–64.
Problem opioid users and injecting drug users still remain
the main problem drug use subgroups found in almost all countries and experiencing
the most severe problems related to the use of drugs (Table 10.2.1.3.2).
Table 10.2.1.3.2
– Problem Drug Use estimates: Problem opioid use and injecting drug use
Recent estimates on the prevalence of problem opioid users
at national level range roughly between one and six cases per 1 000
population aged 15–64. From the limited data available, an average annual
prevalence of POUs of between four and five cases per 1 000 of the
%202006%3c/p%3e%3c/a%3e','../images/reference_1.gif');)
.%20Accessed%20at:%20http:%20//rum.ctsu.ox.ac.uk/~tobacco/.%20CTSU%20website,%202005%3c/p%3e','../images/reference_1.gif');)
%3c/p%3e%3ca%20class=\'alertUrl\'%20target=\'_blank\'%20href=\'http://www.nida.nih.gov/PDF/RRTobacco.pdf\'%3e%3cp%3eResearch%20report%20series:%20tobacco%20addiction.%202006%3c/p%3e%3c/a%3e','../images/reference_1.gif');)
;)