Alcohol use

The higher the alcohol consumption, the higher the risk

This EUphact explores alcohol consumption. Alcohol (ethanol) is consumed in the form of alcoholic beverages. When alcohol is consumed, it passes from the stomach and intestines into the bloodstream (absorption). It is metabolized in the liver, which is only capable of metabolizing a certain amount of alcohol per hour. If more alcohol is consumed than can be metabolized, the alcohol will accumulate in the body and cause intoxication (NIAAA, 1997). The more alcohol is consumed on one occasion, the higher the blood alcohol level and the higher the risk of adverse effects.

A large number of indicators exist that are related to alcohol consumption. The ECHI short-list includes total alcohol consumption, hazardous alcohol consumption and alcohol-related deaths.

Total alcohol consumption expressed in liters per person per year

Total alcohol consumption is expressed by the ‘per capita consumption’ figure for persons over the age of 15. It is the average amount of pure alcohol (in litres) consumed in one year. It is calculated from the total amount of pure alcohol consumed in one year by the whole population (including children and abstainers), divided by the number of adults (in this case persons over the age of 15). Total alcohol consumption is related to the amount of harm done by alcohol in a country. The WHO-HFA database uses estimates of the amount of pure ethanol consumed, calculated from official statistics on local production, sales, import and export, taking into account stocks and home production whenever possible.

Hazardous level of alcohol consumption differs between men and women

Hazardous alcohol consumption is defined within the WHO-CHOICE project as an average rate of consumption of more than 20g pure alcohol daily for women and more than 40g daily for men. It is calculated from total alcohol consumption data combined with data on abstinence, sex and age groups and information on drinking patterns (Rehm et al., 2004). The proportion of hazardous alcohol users is also related to mortality and the disease burden from alcohol (Chisholm et al., 2004).

Different definitions of alcohol-related deaths are used

Alcohol-related deaths is the sum of mortality from selected causes of death which are related to alcohol consumption. It is a rough indicator and it is not the estimate of alcohol attributable mortality. It is a simple pooling of alcohol related deaths, irrespective of the actual proportion of deaths due to alcohol for each cause. It can help to rank countries or to track trends in deaths. A number of different definitions are used. For example, the selection of causes used in the WHO-HFA database to calculate alcohol-related deaths does not match those used by the Mental Health Working Party (MINDFUL, 2007). The WHO-HFA database uses all causes in which alcohol consumption is a risk factor (such as cancer of oesophagus or chronic liver disease), in MINDFUL only causes directly related to alcohol are used (such as alcohol poisoning or alcoholic cardiomyopathy).

Exposure variables: volume of consumption as well as drinking patterns

There is an association between total alcohol consumption, or in other words the volume of alcohol consumption, and several harmful outcomes (Babor et al., 2003; Rehm et al., 2004; WHO, 2004c). For more information see Volume of consumption and drinking patterns. Recognition of the link between drinking patterns and harmful outcomes has also grown (see Consequences for individuals and society).

Europeans heaviest drinkers in the world

The EU is the heaviest drinking region of the world, with on average 11 litres of pure alcohol being consumed per adult each year. This is over two-and-a-half times the rest of the world’s average (Anderson & Baumberg, 2006). The majority (over three quarters) of European citizens drink alcohol. Significantly more men than women drink alcohol and most drinkers drink at low risk levels (TNS Opinion & Social, 2007; Anderson & Baumberg, 2006). An estimated 15% (58 million in the EU-25: see Tabel 1) of those that consume alcohol are hazardous drinkers.

Table 1: Numbers^a of adults^b in the EU-25 at different drinking levels (source: Rehm et al., 2004, amended by Anderson & Baumberg, 2006).

^aestimates for 2001; ^b16+ years

Drinking patterns in Europe show north-south gradient

Within Europe drinking patterns traditionally show a north-south gradient. Leifman divided the EU-15 and Norway roughly into low, medium, and high consumption countries (Leifman, 2002b). The low consumption countries are the Nordic countries, the intermediate group is made up of central European countries and the high consumption group comprises Mediterranean countries. Beverage preference, drinking with meals, daily drinking and levels of consumption also show crude north-south gradients. Nordic countries traditionally show more detrimental drinking patterns. Drinking patterns are explained further in Different drinking patterns in Europe.

Converging trends in consumption levels and beverage preferences

Drinking levels, drinking patterns and beverage preferences are converging in Europe (Anderson & Baumberg, 2006). Trend in the total volume of alcohol consumed in European countries shows the convergence of per capita consumption over time. The interactive map Total volume of alcohol consumption illustrates the converging trend by comparing the 1970 with the 2003 per capita consumption within Europe. Despite remaining underlying differences between the different countries, the EU-15 alcohol consumption levels have been converging over the past four decades. Total alcohol consumption in the southern European countries, which was relatively high, has declined, while in the northern and mid-European countries total consumption, which was relatively low, has risen. As a result the differences in total consumption between the EU-15 countries have declined. Anderson & Baumberg have shown that the consumption levels of the EU-10 countries are currently closer to those of the EU-15 than ever before. However, substantial differences can still be observed between these countries.(Anderson & Baumberg, 2006).

Next to drinking levels, beverage preferences are also harmonizing. Traditional wine-drinking countries in the south are showing an increased level of beer and spirit consumption, while traditional beer and spirit-drinking countries in central and northern Europe are showing an increased level of wine-drinking. Additionally over the last few decades drinking patterns have been illustrating that a trend of increased youth drunkenness is developing in all European countries.

Volume of consumption as well as drinking patterns influence harm

Both the volume of alcohol consumption, and the pattern of drinking, influence the harm caused by alcohol. Whereas the volume of consumption is associated primarily with long-term consequences, risky patterns of drinking are mainly associated with acute consequences. Generally speaking (Anderson & Baumberg, 2006; Rehm et al., 2004; Rehm et al., 2003; WHO, 2004c):

• the higher the total volume of alcohol consumption, the greater the risk of harm; and
• the more alcohol consumed on one occasion, the more serious the injury or crime.

Alcohol consumption results in more negative than positive outcomes

The negative outcomes of alcohol consumption mostly outweigh the positive ones. For some conditions low-dose drinking is associated with a reduced risk. But due to its general adverse effect no alcohol consumption is associated with a lower risk of death than any alcohol consumption. Men over 35 and women over 65 who consume up to one glass of alcohol a day have a lower mortality risk than their compatriots who completely abstain from alcohol use (see The positive effects of low-level alcohol consumption).

Europe has the highest rates of alcohol-related harm in the world.

Europe has the highest per capita alcohol consumption and the highest rates of alcohol-related harm in the world (Rehm et al., 2006; Rehn et al., 2001). Taking into account the prevention of deaths by moderate consumption, alcohol causes an estimated 115.000 deaths in people up to the age of 70 each year in the countries of the EU-25 (Anderson & Baumberg, 2006). In 2002 drinking patterns in the European region were detrimental in all countries except the Mediterranean region and some wealthy western countries (Rehm et al., 2006). When measuring the health impact of alcohol for the whole region, an estimated 6.1% of all deaths and 10.7% of all DALY can be attributed to alcohol consumption. An estimated 11.9% of all DALY in men and 1.4% of all DALY in women can be attributed to the disease burden of alcohol in Western Europe and most of the EU (Rehm et al., 2006). This disease burden does not include the social harm experienced by family members of alcohol dependents or by victims of crime and accidents. This type of harm can be huge and can even exceed the health burden in terms of economic consequences (Catalyst, 2001).

Alcohol-related harm relatively high in young people

Alcohol consumption is related to more mortality in young people than it is in any other age group. Research indicates that over 10% of female mortality and 25% of male mortality in those aged 15-29 years is alcohol-related in Western European countries and most EU countries. The social harm experienced by young people due to alcohol has not yet been clearly recorded (Anderson & Baumberg, 2006; Rehm et al., 2006).

Young people and women are more vulnerable to alcohol

Alcohol consumption affects women and children more than men, probably because of their lower body-weight. Women also have a lower percentage of body water. Young people are additionally affected by their lack of experience and by their still developing body. Heavy consumption during adolescence is a predictor of harmful consumption in early adulthood (Anderson & Baumberg, 2006).

Multiple genes linked to alcohol dependence and risky consumption

There are many genes that play a role in the development of high-risk drinking or alcohol dependence. Genes can, for instance, determine differences in the metabolism of alcohol or in the reaction of the brain to alcohol (NIAAA, 2003). Between 50% and 60% of alcohol dependence is suggested to be hereditary (Anderson & Baumberg, 2006).

Alcohol-related mortality and dependence higher among lower socio-economic groups

Alcohol dependence and alcohol-related mortality is most prevalent among adults with lower socio-economic status. This has been consistently shown to apply throughout the world (Anderson & Baumberg, 2006). But abstinence is also more common in lower socio-economic groups. On average highly educated women drink a larger volume of alcohol than lower educated women. Binge-drinking is associated with unemployment or a low level of education in adults, while in young people it is associated with greater financial means (Kuntsche et al., 2004). Thus socio-economic differences in total alcohol consumption, drinking patterns and alcohol-related problems like dependence are not straightforward. They do not follow the same gradient in cases and vary between countries (Eurothine, 2007) For more detailed information, policy recommendations and data on this issue, see the EUphocus Health Inequalities and the EUphact Alcohol Policies.

Smoking and alcohol consumption closely linked

There is a strong correlation between tobacco and alcohol. People who drink are very likely to smoke and vice versa (Drobes, 2002). Heavy smokers are also more likely to be heavy drinkers (Anderson & Baumberg, 2006). For more information about the impact of smoking on a person's health see Smoking.

Depression, mood disorders and alcohol dependence show comorbidity

People with depression and mood disorders have an increased risk of developing alcohol dependence and vice versa (Anderson & Baumberg, 2006). There is sustained evidence for comorbidity, and co-occurrence is consistently detected throughout the world. The disorder that has the closest link to alcohol dependence is depression: alcohol-dependent individuals have a two to three-fold higher risk of developing depressive disorders (Merikangas et al., 1998; Rehm et al., 2004). Also see Mental Health in the EU.

Several environmental factors are associated with consumption patterns

Several environmental factors are associated with early, high and/or risky alcohol consumption. On a smaller scale these include the availability of alcohol (price and access), alcohol advertising, parenting and peer pressure (Bellis et al., 2007; Chaloupka et al., 2002; Hearst et al., 2007; Saffer & Dave, 2006). On a larger scale different drinking cultures can result in different drinking patterns and more risky patterns can result in more acute outcomes (for more information on drinking patters, see Occurrence and for more information on outcomes, see Consequences for individuals and society).

Young people mainly have social reasons to drink

Young people name mostly social reasons when asked why they drink. Kuntsche et al. concluded from an analysis of different studies that most adolescents have social motives for drinking and that social motives are associated with moderate drinking. Both enhancement motives, in the sense of feeling the effects of alcohol (such as drinking to get drunk), and coping motives are associated with heavy drinking. Additionally the more reasons young people name for drinking, the more likely they are to consume more alcohol (Kuntsche et al., 2005).

Impact of individual treatment on public health is limited

• Policies that reduce drinking and driving.
• Policies that support education, communication, training and public awareness.
• Policies that regulate the alcohol market (regulating physical availability; taxation and pricing; regulating alcohol promotion).
• Policies that support the reduction of harm in drinking and surrounding environments.
• Policies that support interventions for individuals (treatment and early intervention).

Brief interventions can have effect on public health

• Brief preventive interventions by healthcare providers that target hazardous levels of alcohol consumption.
• Motivational enhancement therapy
• Cognitive behavioural therapy.
• 12-step facilitation.
• Marital and family therapies.
• Coping and social skills training.
• Benzodiazepines (medication for alcohol withdrawal).
• Acamprosate and naltrexone (medication for long-term treatment of alcohol addiction).

Volume of alcohol consumption

The following drinking categories were defined for further analysis (Rehm et al., 2004):

• Abstainer: a person not having had a drink containing alcohol within the last year;
• Average volume drinking category I: for females 0-19.99g pure alcohol daily; for males 0-39.99g pure alcohol daily;
• Average volume drinking category II: for females 20-39.99g pure alcohol daily; for males 40-59.99g pure alcohol daily; and
• Average volume drinking category III: for females 40g or more pure alcohol daily; for males 60g or more pure alcohol daily.

Category II and III drinking are considered as hazardous drinking (Chisholm et al., 2004).

Drinking patterns

Patterns of drinking are more difficult to describe than the total volume of alcohol consumption (Rehm et al., 2004). There is not one single element that defines drinking patterns. Therefore, drinking patterns are measured in a variety of ways. Many different indicators are used, such as the drinking context, frequency of drinking, and the frequency of episodic heavy drinking (Anderson & Baumberg, 2006). To determine drinking patterns for the Comparative Quantification of Health Risks, the WHO used values based on the following variables (Rehm et al., 2004):

• heavy drinking occasions (e.g. binge drinking);
• drinking with meals; and
• drinking in public places.

Different drinking patterns in Europe

Leifman divided the EU-15 and Norway roughly into low (Nordic), medium (mid European), and high (Mediterranean) consumption countries. Drinking patterns crudely follow the same north-south gradient (Leifman, 2002b):

• Beverage preference: traditionally the mid-European countries are beer-drinking, the southern European countries are wine drinking and the northern European countries are former spirit-drinking countries (Noström, 2002). Nowadays beer is the dominant beverage in mid and North European countries, although wine consumption has also increased significantly in these countries.
• Drinking with meals: in southern Europe people are much more likely to drink with lunch than elsewhere (Anderson & Baumberg, 2006).
• Daily drinking: is more common in the south of the EU-15 than in the north (TNS Opinion & Social, 2007).
• Drinking levels: the percentage of people drinking at drinking level III (Rehm et al., 2004) appears to be the highest in central European countries (in both the east and west) (Anderson & Baumberg, 2006).
• Drinking to drunkenness: compared to other Europeans, fewer southern Europeans report getting drunk each month. Exceptions to this pattern are evident for ‘binge drinking’, the more objective measure for drunkenness. For example Sweden has one of the lowest rates of binge-drinking in the EU-15 (Anderson & Baumberg, 2006).

Although drinking patterns in European countries have been harmonizing over the last decades, there are still cultural differences to be observed, even within countries.

Medical conditions and social harms related to alcohol consumption

Consumption of alcohol is related to over 60 medical conditions. Alcohol consumption additionally increases the risk of a wide range of social harms, such as crimes and injuries (Rehm et al., 2003). Drinking during pregnancy increases the risk of spontaneous abortion and harms the development of the unborn child. For some conditions (such as cardiomyopathy, acute respiratory distress syndrome and muscle damage), the harm seems to stem from a sustained level of high alcohol consumption. Even at this high level, if the volume of consumption increases, the risk of harm increases even further. Below is an overview of the harms related to alcohol consumption (Anderson & Baumberg, 2006).

• impaired social well-being (negative social consequences; reduced work performance);
• intentional and unintentional injuries (violence; drinking and driving; injuries; suicide);
• neuropsychiatric conditions (anxiety and sleep disorders; depression; alcohol dependence; nerve damage; brain damage; cognitive impairment and dementia);
• gastrointestinal, metabolic and endocrine conditions (liver cirrhosis; pancreatitis; type II diabetes; overweight; gout),
• cancers (gastrointestinal tract; liver; breast);
• cardiovascular diseases (hypertension; stroke; irregularities in heart rhythms; coronary heart disease (CHD); cardiomyopathy);
• impaired immune system (susceptibility to infectious diseases),
• lung diseases (increased risk of acute respiratory distress syndrome (ARDS));
• post-operative complications;
• skeletal conditions (fracture and muscle disease); and
• reproductive conditions.

• negative social consequences (such as being kept awake at night by drunk people);
• violence and crime (such as violence directed at strangers or spouse abuse);
• marital harm (such as separation or divorce);
• child abuse;
• work-related harm;
• drinking and driving; and
• pre-natal conditions (such as spontaneous abortion or intellectual deficits).

Alcohol consumption, intermediate variables and alcohol related outcomes.

Besides its biochemical effects, alcohol dependence also influences harm outcomes by sustaining alcohol consumption. In this way it contributes to the impact alcohol has on the development of short and long-term diseases and social harms. The occurrence of intoxication and episodic heavy drinking can lead to physical as well as social harms, both acute and chronic: for example alcohol intoxication, injuries, and causing injuries to others (Anderson & Baumberg, 2006).

Figure: The relationships between alcohol consumption, intermediate variables and alcohol related outcomes (source: Rehm et al., 2004).

The positive effects of low-level alcohol consumption

A small dose of alcohol consumption is associated with a reduced risk of developing particular conditions, such as heart disease, vascular dementia, gallstones and diabetes. The health benefits associated with alcohol consumption are summarised further below (Anderson & Baumberg, 2006). However, in most cases the positive outcomes are outweighed by the negative outcomes of alcohol consumption.

The scale is tipped from harm to good, where the volume of alcohol consumed lowers the drinker's mortality risk. A study showed that in the UK women under 65 and men under 35 who consume no or nearly no alcohol have the lowest mortality risk. The level of alcohol consumption with the lowest risk of death increases to less than 5g of alcohol a day (less than half a glass) for women aged 65 or over and to less than 10g a day (less than one glass) for men aged 65 or over (White et al., 2002). The lowest risk drinking-level probably returns to zero at a very old age (Anderson & Baumberg, 2006). Alcohol consumption only has a positive effect if a low dosage of alcohol is consumed. A higher volume of alcohol consumption may be associated with negative consequences for the same condition.

• social well being (pleasure; work);
• neuropsychiatric conditions (cognitive functioning; dementia);
• gastrointestinal, metabolic and endocrine conditions (gallstones; type II diabetes);
• cardiovascular diseases (ischaemic stroke; coronary heart disease (CHD)); and
• skeletal conditions (bone mass in woman).

Suicide (attempt)

Breast cancer

Infant mortality

Life expectancy

Blood pressure

Alcohol policies

Diabetes

Health inequalities

Mental Health in the EU

Healthy life expectancy

WHO Global Alcohol Database

WHO health for all database (HFA-DB)

Health-EU Portal, alcohol

Health-EU Portal, EC Health Indicators

WHO lexicon of alcohol and drug terms

WHO-CHOICE project, CHOosing Interventions that are Cost Effective

WHO Collaborative Project on Identification and Management of Alcohol-related Problems in Primary Health Care, Phase IV

ESPAD European School Survey Project on Alcohol and Other Drugs

ECAS European Comparative Alcohol Study

Alcohol Problems in the Family - A Report to the European Union

IATPAD Improvement of access to treatment for people with alcohol- and drug-related problems

PHEPA Primary Health care European Project on Alcohol

EDAP Evidence for Drugs and Alcohol Policy: Cochrane Systematic Reviews

PANACEA Physical Activity, Nutrition, Alcohol, Cessation of smoking, Eating out of home And obesity

Bold CHILD Child Health Indicators of Life and Development

Elisad Internet Gatewabsites on drugs, alcohol, tobacco and other addictions

ALCOWEB, information on alcohol addiction

USA National Institute on Alcohol Abuse and Alcoholism

Trend in the total volume of alcohol consumed (age 15+) in Iceland, Norway, Switzerland and the EU-27, 1970-2003

Total volume of alcohol consumption (age 15+) in Iceland, Norway, Switzerland and the EU-27, 1970 and 2003