Unrecorded consumption, quality of alcohol and health consequences

Chemical Analysis of Suspected Unrecorded Alcoholic Beverages from the States of São Paulo and Minas Gerais, Brazil

Our study analyzed 152 samples of alcoholic beverages collected from the states of São Paulo and Minas Gerais, Brazil, using gas chromatography with flame ionization detection (GC-FID) and mass spectrometry (GC-MS), Fourier transform infrared spectroscopy (FT-IR), and inductively coupled plasma atomic emission spectrometry (ICP-AES). The methanol content varied from 20 to 180 ppm in 28 samples, and the limit of the accepted level of 200 ppm was exceeded in only one sample. High content of cyanide derivatives and ethyl carbamate, above the accepted level of 150 ppb, was observed in 109 samples. Carbonyl compounds were also observed in 111 samples, showing hydroxy 2-propanone, 4-methyl-4-hepten-3-one, furfural, and 2-hydroxyethylcarbamate as main constituents. Copper was found at concentrations above 5 ppm in 26 samples; the maximum value observed was 28 ppm. This work evaluated the human health risk associated with the poor quality of suspected unrecorded alcohols beverages.

Contributions of risk factors and medical care to cardiovascular mortality trends

Ischaemic heart disease, stroke, and other cardiovascular diseases (CVDs) lead to 17.5 million deaths worldwide per year. Taking into account population ageing, CVD death rates are decreasing steadily both in regions with reliable trend data and globally. The declines in high-income countries and some Latin American countries have been ongoing for decades without slowing. These positive trends have broadly coincided with, and benefited from, declines in smoking and physiological risk factors, such as blood pressure and serum cholesterol levels. These declines have also coincided with, and benefited from, improvements in medical care, including primary prevention, diagnosis, and treatment of acute CVDs, as well as post-hospital care, especially in the past 40 years. These variables, however, explain neither why the decline began when it did, nor the similarities and differences in the start time and rate of the decline between countries and sexes. In Russia and some other former Soviet countries, changes in volume and patterns of alcohol consumption have caused sharp rises in CVD mortality since the early 1990s. An important challenge in reaching firm conclusions about the drivers of these remarkable international trends is the paucity of time-trend data on CVD incidence, risk factors throughout the life-course, and clinical care.

Relationship between alcohol-attributable disease and socioeconomic status, and the role of alcohol consumption in this relationship: a systematic review and meta-analysis

Background

Studies show that alcohol consumption appears to have a disproportionate impact on people of low socioeconomic status. Further exploration of the relationship between alcohol consumption, socioeconomic status and the development of chronic alcohol-attributable diseases is therefore important to inform the development of effective public health programmes.

Methods

We used systematic review methodology to identify published studies of the association between socioeconomic factors and mortality and morbidity for alcohol-attributable conditions. To attempt to quantify differences in the impact of alcohol consumption for each condition, stratified by SES, we (i) investigated the relationship between SES and risk of mortality or morbidity for each alcohol-attributable condition, and (ii) where, feasible explored alcohol consumption as a mediating or interacting variable in this relationship.

Results

We identified differing relationships between a range of alcohol-attributable conditions and socioeconomic indicators. Pooled analyses showed that low, relative to high socioeconomic status, was associated with an increased risk of head and neck cancer and stroke, and in individual studies, with hypertension and liver disease. Conversely, risk of female breast cancer tended to be associated with higher socioeconomic status. These findings were attenuated but held when adjusted for a number of known risk factors and other potential confounding factors. A key finding was the lack of studies that have explored the interaction between alcohol-attributable disease, socioeconomic status and alcohol use.

Conclusions

Despite some limitations to our review, we have described relationships between socioeconomic status and a range of alcohol-attributable conditions, and explored the mediating and interacting effects of alcohol consumption where feasible. However, further research is needed to better characterise the relationship between socioeconomic status alcohol consumption and alcohol-attributable disease risk so as to gain a greater understanding of the mechanisms and pathways that influence the differential risk in harm between people of low and high socioeconomic status.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1720-7) contains supplementary material, which is available to authorized users.

Impact of a new alcohol policy on homemade alcohol consumption and sales in Russia

AIMS

To describe the effects of Russian policy since 2006 affecting price and availability on the consumption of recorded and unrecorded alcohol, with specific reference to homemade alcohol, and to investigate other factors affecting homemade alcohol consumption and purchasing.

METHODS

Consumption and preferred beverage data were collected from RLMS-HSE nationwide panel surveys from 1994 to 2013, with a detailed analysis of 2012 data (18,221 respondents aged 16+ years). Official statistics on manufactured alcohol sales, regional price increase and real disposable income were used.

RESULTS

Homemade distilled spirits (samogon) consumption decreased together with that of recorded and unrecorded manufactured spirits since 2000. The consumption of spirits was partially replaced by the consumption of beer and wine. These trends in alcohol consumption were interrupted in 2008-2013. The interruption was more likely affected by the economic crisis and recession than by the new alcohol policy. Social networks and availability of unrecorded alcohol were more important predictors of homemade alcohol consumption and purchasing than was a recorded alcohol price increase.

CONCLUSIONS

Homemade alcohol consumption does not replace the declining market for recorded spirits in Russia. The effects of economic and social factors on homemade alcohol consumption are greater than are the short-term effects of the new alcohol policy. The very recent (2015) reduction of the minimum unit price of vodka may be premature.

Aliphatic alcohols in spirits inhibit phagocytosis by human monocytes

A large volume of alcoholic beverages containing aliphatic alcohols is consumed worldwide. Previous studies have confirmed the presence of ethanol-induced immunosuppression in heavy drinkers, thereby increasing susceptibility to infectious diseases. However, the aliphatic alcohols contained in alcoholic beverages might also impair immune cell function, thereby contributing to a further decrease in microbicidal activity. Previous research has shown that aliphatic alcohols inhibit phagocytosis by granulocytes but their effect on human monocytes has not been studied. This is important as they play a crucial role in engulfment and killing of pathogenic microorganisms and a decrease in their phagocytic activity could lead to impaired antimicrobial defence in heavy drinkers. The aim of this study was to measure monocyte phagocytosis following their treatment with those aliphatic alcohols detected in alcoholic beverages. Monocytes were separated from human peripheral blood and phagocytosis of opsonized zymosan particles by monocytes treated with ethanol and aliphatic alcohols individually and in combination was determined. It was shown that these alcohols could suppress the phagocytic activity of monocytes in a concentration-dependent manner and when combined with ethanol, they caused a further decrease in phagocytosis. Due to their additive effects, it is possible that they may inhibit phagocytosis in a clinically meaningful way in alcoholics and episodic heavy drinkers thereby contribute to their increased susceptibility to infectious diseases. However, further research is needed to address this question.

Consumption of Alcohol Surrogates Among Alcohol-Dependent Women

This is the first in-depth study of alcohol and surrogate drinking patterns, types, reasons, and correlates among alcohol-dependent women in Belarus. The structured interviews were performed in 2013 with 103 alcohol-dependent women admitted to a narcological clinic in Grodno, Belarus. The results suggest that at least 30.3% of alcohol-dependent women regularly consume samogon (moonshine) and 10.8% of women use surrogates, the most popular among which are medications with a high percentage of ethanol and industrial spirits. The belief that samogon exceeds licensed vodka in quality is the main motive for its consumption. The results from the present study confirm that noncommercial alcohol use is common among alcohol-dependent women although its use may be underreported. These findings emphasize that the implementation of a comprehensive alcohol policy must take fully into account the consumption of alcohol from illicit sources.

Traditional alcohol production and use in three provinces in Vietnam: an ethnographic exploration of health benefits and risks

Background

Gaps exist in knowledge about the production and use of traditional alcohols, particularly in Asia. This study adds new information about the nature, production and sale of traditional distilled spirit alcohol in Vietnam.

Method

This was an ethnographic study of traditional distilled spirit alcohol production in rural areas of three provinces in Vietnam. Researchers interviewed more than 300 individuals and recorded responses to general open-ended questions about local alcohol production. Interviews were recorded, transcribed, and studied to discern what information about traditional alcohol was important to the speakers.

Results

Methods of production followed long-held traditions. Participants listed both personal and community benefits (economic, health, and social) from traditional alcohol making. Older people favoured traditional alcohol, while younger people favoured brand-name beer. Typically people consumed 2-4 drinks daily, mainly at meal times. People consumed more alcohol at special events and festivals. Distribution patterns ranged from low-risk distribution to family and neighbours to high-risk distribution by an agent who might combine alcohol from several producers, which increases the opportunity for dilution and adulteration. The most commonly listed health risks associated with locally-made alcohol were local air pollution and water pollution; participants also mentioned traffic crashes and bad public behaviour. Depending on the location, community leaders reported that production may be relatively stable or it may be declining.

Conclusions

Traditional alcohol manufacture, sale, and use in Vietnam is a long-standing practice and low- to moderate-risk to health. There do not appear to be instances of accidental or intentional contamination. Urbanization seems to be affecting the market share of traditional alcohol as urbanized youth turn to branded products, mainly beer, making traditional alcohol making and consumption an activity mainly linked to older people in rural areas. In the rural areas surveyed, significant economic and social benefits are derived from traditional alcohol manufacture, sale, and use. Policy makers designing ways to reduce alcohol-related risks and harms need to give thoughtful consideration to the role traditional alcohol plays in the local society and to suggest changes that do not create unintended problems.

Are alcohol policies associated with alcohol consumption in low- and middle-income countries?

AIMS

To examine the associations between alcohol control policies in four regulatory domains with alcohol consumption in low- and middle-income countries (LAMICs), controlling for country-level living standards and drinking patterns.

DESIGN

Cross-sectional analyses of individual-level alcohol consumption survey data and country-level alcohol policies using multi-level modeling.

SETTING

Data from 15 LAMICs collected in the Gender, Alcohol, and Culture: an International Study (GENACIS) data set.

PARTICIPANTS

Individuals aged 18-65 years.

MEASUREMENTS

Alcohol policy data compiled by the World Health Organization; individual-level current drinking status, usual quantity and frequency of drinking, binge drinking frequency and total drinking volume; gross domestic product based on purchasing power parity (GDP-PPP) per capita; detrimental drinking pattern scale; and age and gender as individual-level covariates.

FINDINGS

Alcohol policies regulating the physical availability of alcohol, particularly those concerning business hours or involving a licensing system for off-premises alcohol retail sales, as well as minimum legal drinking age, were the most consistent predictors of alcohol consumption. Aggregate relative alcohol price levels were associated inversely with all drinking variables (P < 0.05) except drinking volume. Greater restrictions on alcohol advertising, particularly beer advertising, were associated inversely with alcohol consumption (P < 0.05). Policies that set legal blood alcohol concentration (BAC) limits for drivers and random breath testing to enforce BAC limits were not associated significantly with alcohol consumption.

CONCLUSIONS

Alcohol policies that regulate the physical availability of alcohol are associated with lower alcohol consumption in low- and middle-income countries.

Influence of unrecorded alcohol consumption on liver cirrhosis mortality

Unrecorded alcohol includes illegally distributed alcohol as well as homemade or surrogate alcohol which is unintended for consumption by humans (e.g., cosmetics containing alcohol). The highest unrecorded alcohol consumption occurs in Eastern Europe and some of these countries have an over proportional liver cirrhosis mortality. Compounds besides ethanol have been hypothesized as being responsible for this observation. On the other hand, chemical investigations were unable to prove that unrecorded alcohol regularly contains contaminants above toxicological thresholds. However, illegally produced spirits regularly contain higher percentages of alcohol (above 45% by volume), but for considerably less costs compared with licit beverages, potentially causing more problematic patterns of drinking. In this review, it is investigated whether patterns of drinking rather than product composition can explain the liver cirrhosis mortality rates. Statistical examination of World Health Organization country data shows that the originally detected correlation of the percentage of unrecorded alcohol consumption and liver cirrhosis mortality rates disappears when the data is adjusted for the prevalence of heavy episodic drinking. It may be concluded that there is currently a lack of data to demonstrate causality between the composition of illicit spirits (e.g., higher levels of certain contaminants in home-produced products) and liver toxicity on a population scale. Exceptions may be cases of poisoning with antiseptic liquids containing compounds such as polyhexamethyleneguanidine, which were reported to be consumed as surrogate alcohol in Russia, leading to an outbreak of acute cholestatic liver injury, histologically different from conventional alcoholic liver disease.

A systematic review of the epidemiology of unrecorded alcohol consumption and the chemical composition of unrecorded alcohol

BACKGROUND AND AIMS

Unrecorded alcohol constitutes about 30% of all alcohol consumed globally. The aims of this systematic review were to determine the epidemiology (occurrence, types, prevalence) of unrecorded alcohol consumption in different countries/regions, analyse the chemical composition of unrecorded alcohol and examine health outcomes caused by the consumption of unrecorded alcohol, based on either epidemiology or toxicology.

METHODS

A systematic search for, and qualitative analysis of, papers with empirical results on the different categories of unrecorded alcohol, based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Unrecorded alcohol was widespread in all regions of the world. Artisanal fermented beverages and spirits were the most common categories of unrecorded alcohol globally, and were available on all continents. In India, industrially produced spirits (country spirits) were most prevalent. In Russia and countries of the former Soviet Union, surrogate alcohols complemented artisanal spirits. Cross-border shopping was the most prevalent method of obtaining unrecorded alcohol in parts of Europe. Ethanol was the most harmful ingredient of unrecorded alcohol, and health consequences due to other ingredients found in unrecorded alcohol were scarce. However, as unrecorded alcohol is usually the least expensive form of alcohol available in many countries, it may contribute to higher rates of chronic and irregular heavy drinking.

CONCLUSIONS

Very large amounts of alcohol are produced globally that go unrecorded. The primary harm from this kind of alcohol arises from the fact that it is typically much cheaper than licit alcohol.

Mortality from diseases, conditions and injuries where alcohol is a necessary cause in the Americas, 2007-09

AIMS

To describe mortality from diseases, conditions and injuries where alcohol was a necessary cause in selected countries in the Americas.

DESIGN

A descriptive, population-based study.

SETTING

The data come from 16 countries in North, Central and South America for the triennium 2007-09 (latest available data).

PARTICIPANTS/CASES

A total of 238 367 deaths were analyzed.

MEASUREMENTS

We calculated age-adjusted and age-specific mortality rates by sex and country using the Pan American Health Organization (PAHO) mortality database.

FINDINGS

The annual average of deaths where alcohol was a necessary cause in the 16 countries was 79, 456 (men comprised 86% and women 14%). People aged 40-59 years represented 55% overall. Most deaths were due to liver diseases (63% overall) and neuropsychiatric disorders (32% overall). Overall age-adjusted rates/100,000 were higher in El Salvador (27.4), Guatemala (22.3), Nicaragua (21.3) and Mexico (17.8) and lower in Colombia (1.8), Argentina (4.0) and Canada (5.7). The age groups at the highest risk were 54-59 to 64-69 years in most countries. In Guatemala, El Salvador and Nicaragua the rates increased earlier, among those aged 30-49 years. Male rates were higher than female rates in all countries, but the male : female ratio varied widely.

CONCLUSIONS

Diseases, conditions or injuries where alcohol is a necessary cause are an important cause of premature mortality in the Americas, especially among men. Some countries show high risk of dying from this group of causes.

Trauma-related mortality among adults in Rural Western Kenya: characterising deaths using data from a health and demographic surveillance system

Background

Information on trauma-related deaths in low and middle income countries is limited but needed to target public health interventions. Data from a health and demographic surveillance system (HDSS) were examined to characterise such deaths in rural western Kenya.

Methods And Findings

Verbal autopsy data were analysed. Of 11,147 adult deaths between 2003 and 2008, 447 (4%) were attributed to trauma; 71% of these were in males. Trauma contributed 17% of all deaths in males 15 to 24 years; on a population basis mortality rates were greatest in persons over 65 years. Intentional causes accounted for a higher proportion of male than female deaths (RR 2.04, 1.37-3.04) and a higher proportion of deaths of those aged 15 to 65 than older people. Main causes in males were assaults (n=79, 25%) and road traffic injuries (n=47, 15%); and falls for females (n=17, 13%). A significantly greater proportion of deaths from poisoning (RR 5.0, 2.7-9.4) and assault (RR 1.8, 1.2-2.6) occurred among regular consumers of alcohol than among non-regular drinkers. In multivariate analysis, males had a 4-fold higher risk of death from trauma than females (Adjusted Relative Risk; ARR 4.0; 95% CI 1.7-9.4); risk of a trauma death rose with age, with the elderly at 7-fold higher risk (ARR 7.3, 1.1-49.2). Absence of care was the strongest predictor of trauma death (ARR 12.2, 9.4-15.8). Trauma-related deaths were higher among regular alcohol drinkers (ARR 1.5, 1.1-1.9) compared with non-regular drinkers.

Conclusions

While trauma accounts for a small proportion of deaths in this rural area with a high prevalence of HIV, TB and malaria, preventive interventions such as improved road safety, home safety strategies for the elderly, and curbing harmful use of alcohol, are available and could help diminish this burden. Improvements in systems to record underlying causes of death from trauma are required.

Global alcohol exposure estimates by country, territory and region for 2005--a contribution to the Comparative Risk Assessment for the 2010 Global Burden of Disease Study

AIMS

This study aimed to estimate the prevalence of life-time abstainers, former drinkers and current drinkers, adult per-capita consumption of alcohol and pattern of drinking scores, by country and Global Burden of Disease region for 2005, and to forecast these indicators for 2010.

DESIGN

Statistical modelling based on survey data and routine statistics.

SETTING AND PARTICIPANTS

A total of 241 countries and territories.

MEASUREMENTS

Per-capita consumption data were obtained with the help of the World Health Organization's Global Information System on Alcohol and Health. Drinking status data were obtained from Gender, Alcohol and Culture: An International Study, the STEPwise approach to Surveillance study, the World Health Survey/Multi-Country Study and other surveys. Consumption and drinking status data were triangulated to estimate alcohol consumption across multiple categories.

FINDINGS

In 2005 adult per-capita annual consumption of alcohol was 6.1 litres, with 1.7 litres stemming from unrecorded consumption; 17.1 litres of alcohol were consumed per drinker, 45.8% of all adults were life-time abstainers, 13.6% were former drinkers and 40.6% were current drinkers. Life-time abstention was most prevalent in North Africa/Middle East and South Asia. Eastern Europe and Southern sub-Saharan Africa had the most detrimental pattern of drinking scores, while drinkers in Europe (Eastern and Central) and sub-Saharan Africa (Southern and West) consumed the most alcohol.

CONCLUSIONS

Just over 40% of the world's adult population consumes alcohol and the average consumption per drinker is 17.1 litres per year. However, the prevalence of abstention, level of alcohol consumption and patterns of drinking vary widely across regions of the world.

Consumption of Noncommercial Alcohol among Alcohol-Dependent Patients

This study explores types of alcohol and surrogates consumed, patterns of consumption, and reasons behind noncommercial alcohol consumption among alcohol-dependent patients in Belarus. The study was conducted in the Belarusian city Grodno in 2012 with 223 alcoholics admitted to narcological clinic using structured interviews. The results suggest that at least 20.2% of alcohol dependent patients regularly consume samogon and 11.8% of patients use surrogates, the most popular among which are medications with a high percentage of ethanol and industrial spirits. The belief that, according to quality criteria, samogon exceeds licensed vodka is the main motive for its consumption. The results of this study suggest the existence of the problem of consumption of noncommercial alcohol among alcohol dependent patients in Belarus.

Alcohol consumption and mortality in Russia since 2000: are there any changes following the alcohol policy changes starting in 2006?

AIMS

To elucidate the possible effects of Russian alcohol control policy on alcohol consumption and alcohol-related mortality for the period 2000-2010.

METHODS

Narrative review including statistical analysis. Trends before and after 2006 are compared, 2006 being the date of implementation of the Russian government's long-term strategy to reduce alcohol-related harms. Mortality data were taken from the World Health Organization (WHO) database 'Health for All'. Data on recorded alcohol consumption were taken from the WHO, based on the Russian Statistical Service (Rosstat). For unrecorded consumption, the calculations of Alexandr Nemtsov were used. Russian public opinion surveys on drinking habits were utilized. Treatment data on alcohol dependence were obtained from the Moscow National Research Centre on Addictions. Information on alcohol policy was obtained from official reports.

RESULTS

Marked fluctuations in all-cause and alcohol-associated mortality in the working-age population were observed during the reviewed period. A decrease in total consumption and mortality was noted since the end of 2005, when the Russian government initially adopted the regulation of alcohol production and sale. The consumption changes were driven by decreases in recorded and unrecorded spirit consumption, only partly compensated for by increases in beer and wine consumption.

CONCLUSIONS

Alcohol is a strong contributor to premature deaths in Russia, with both the volume and the pattern of consumption being detrimental to health. The regulations introduced since 2006 seem to have positive effects on both drinking behavior and health outcomes. However, there is an urgent need for further alcohol-control strategies to reduce alcohol-related harm.

Prevalence, patterns and predictors of alcohol consumption in a mountainous district of Bhutan

INTRODUCTION AND AIMS

South Asian countries, with their diverse cultures, have varying prevalences of alcohol consumption. Little is known about Bhutan, a Himalayan country. The objectives of this study are to estimate the prevalence of alcohol consumption among the residents of a rural community in Bhutan and determine their patterns of and factors associated with drinking.

DESIGN AND METHODS

A cross-sectional household survey using a multistage systematic sampling technique was conducted in eight sub-districts of Tashiyangtse. A total of 442 subjects of 270 households were surveyed in 17 villages using the Alcohol Use Disorders Identification Test (AUDIT), with the tri-level method and face-to-face interviews.

RESULTS

The drinking prevalence (at least one standard drink in the past year) was 38.5% (52% in men and 30% in women). The prevalence of low-, moderate- and high-risk drinking based on the AUDIT was 22.4%, 13.6% and 2.5%, respectively. Annual per capita alcohol consumption was 5442 and 2566 g in men and women, respectively, while the corresponding values of home-made alcohol consumption were 3768 and 2127 g, respectively. Among drinkers, 30.3% of men and 25.9% of women reported encountering financial consequences. The home was almost the exclusive drinking venue (92.4%). Belief in the medicinal use of alcohol was 34.8% in men and 58% in women as the reason to start drinking. This belief was a strong independent predictor for current drinking after adjustment for age and sex.

DISCUSSION AND CONCLUSIONS

Home-made alcohol and home drinking with a belief of medicinal effects were the major cause of drinking and its consequences in the study area.

A review of the validity and reliability of alcohol retail sales data for monitoring population levels of alcohol consumption: a Scottish perspective

AIMS

To assess the validity and reliability of using alcohol retail sales data to measure and monitor population levels of alcohol consumption.

METHODS

Potential sources of bias that could lead to under- or overestimation of population alcohol consumption based on alcohol retail sales data were identified and, where possible, quantified. This enabled an assessment of the potential impact of each bias on alcohol consumption estimates in Scotland.

RESULTS

Overall, considering all the possible sources of overestimation and underestimation, and taking into account the potential for sampling variability to impact on the results, the range of uncertainty of consumption during 2010 was from an overestimate of 0.3 l to an underestimate of 2.4 l of pure alcohol per adult. This excludes the impacts of alcohol stockpiling and alcohol sold through outlets not included in the sampling frame. On balance, there is therefore far greater scope for alcohol retail sales data to be underestimating per adult alcohol consumption in Scotland than there is for overestimation.

CONCLUSION

Alcohol retail sales data offer a robust source of data for monitoring per adult alcohol consumption in Scotland. Consideration of the sources of bias and a comprehensive understanding of data collection methods are essential for using sales data to monitor trends in alcohol consumption.

alcohol, smoking, and caffeine in relation to fecundability, with effect modification by NAT2

PURPOSE

Common polymorphisms in the N-acetyltransferase-2 (NAT2) metabolic enzyme determine slow or rapid acetylator phenotypes. We investigated the effects of alcohol, smoking, and caffeine on fecundability, and determined whether the effects were modified by NAT2.

METHODS

Three NAT2 polymorphisms were genotyped in 319 women office workers participating in a prospective pregnancy study (1990-1994). Women were ages 20-41 and at risk for pregnancy. Discrete-time survival analysis was used to determine the effects of alcohol, smoking, and caffeine on fecundability and evaluate effect modification by NAT2.

RESULTS

We followed 319 women (161 slow acetylators, 158 rapid) for an average of 8 menstrual cycles, resulting in 124 pregnancies. There was no effect of caffeine on fecundability. Drinking ≥1 alcoholic drink per day and current smoking were significantly associated with reduced fecundability, but only among slow acetylators (adjusted fecundability odds ratio [FOR] for smoking = 0.34; 95% confidence interval, 0.22-0.90; adjusted FOR for ≥1 drink per day = 0.20; 0.05-0.92). There was no effect among rapid acetylators.

CONCLUSIONS

NAT2 status significantly modified the effects of alcohol and smoking on fecundability, emphasizing the importance of incorporating genetic and metabolic information in studies of reproductive health. Replication of this study is warranted.

Food-based dietary guidelines for the arab gulf countries

The concept of food-based dietary guidelines (FBDG) has been promoted by several international organizations. However, there are no FBDG for the countries in the Arab region. As the Arab Gulf countries share similar a socioeconomic and nutrition situation, an attempt was made to develop FBDG for these countries. This paper summarizes the steps taken to develope such guidelines by the Arab Center for Nutrition. The FBDG were developed through 6 steps: (1) determination of the purpose and goals for establishing FBDG, (2) characteristics of FBDG, (3) determination of the food consumption patterns, (4) review the current nutrition situation, (5) determination of the lifestyle patterns that are associated with diet-related diseases and (6) formulating the FBDG. The FBDG consist of 14 simple and practical pieces of advice taking into consideration the sociocultural status and nutritional problems in the Arab Gulf countries. The FBDG can be a useful tool in educating the public in healthy eating and prevention of diet-related chronic diseases.

Streptococci-human papilloma virus interaction with ethanol exposure leads to keratinocyte damage

PURPOSE

Ethanol, human papilloma virus (HPV), and poor oral hygiene are risk factors that have been attributed to oral carcinogenesis. Streptococci sp and HPV infections are common in the head and neck, often associated with sexual activity. Although HPV is linked to head and neck squamous cell carcinoma, it is unclear whether there is a similar role for Streptococci sp. This cell study examines whether Streptococci sp and HPV-16 with exposure to ethyl alcohol (ETOH) can act as cofactors in the malignant transformation of oral keratinocytes.

MATERIALS AND METHODS

ETOH (0.1%-20% vol/vol) was used to investigate Streptococci sp attachment with immortalized E6-expressing HPV/HOK-16B cells, human oral buccal keratinocytes, and foreskin keratinocytes. Streptococci sp (Streptococci mutans [LT11]) and various strains of acetaldehyde (AA) producer and nonproducer Streptococcus salivarius (110-1, 109-2, 101-7, and 107-1) and a lactic acid producer bacterium, Lactobacillus rhamnosus (24-1 and 25-2), were examined for interactions with keratinocytes by use of a green dye (percent of cells with colonies after 24 hours). Carcinogens, AA, malondialdehyde, DNA damage, and proliferation (5'-bromo-2-deoxyuridine) among keratinocytes were also quantified.

RESULTS

AA and malondialdehyde production from permissible Streptococci sp significantly increased with attachment to keratinocytes, whereas L rhamnosus did not significantly attach to keratinocytes. This attachment was associated with enhanced levels of AA adduct formation, proliferation (5'-bromo-2-deoxyuridine incorporation), and enhanced migration through integrin-coated basement membrane by HPV oral keratinocytes, which are characteristics of a malignant phenotype.

CONCLUSIONS

These cell studies suggest that oral Streptococci sp and HPV (HPV-16) cooperate to transform oral keratinocytes after low-level ETOH (1%) exposure. These results appear to suggest a significant clinical interaction, but further validation is warranted.

Alcohol consumption and non-communicable diseases: epidemiology and policy implications

AIMS

This paper summarizes the relationships between different patterns of alcohol consumption and various on non-communicable disease (NCD) outcomes and estimates the percentage of NCD burden that is attributable to alcohol.

METHODS

A narrative review, based on published meta-analyses of alcohol consumption-disease relations, together with an examination of the Comparative Risk Assessment estimates applied to the latest available revision of Global Burden of Disease study.

RESULTS

Alcohol is causally linked (to varying degrees) to eight different cancers, with the risk increasing with the volume consumed. Similarly, alcohol use is related detrimentally to many cardiovascular outcomes, including hypertension, haemorrhagic stroke and atrial fibrillation. For other cardiovascular outcomes the relationship is more complex. Alcohol is furthermore linked to various forms of liver disease (particularly with fatty liver, alcoholic hepatitis and cirrhosis) and pancreatitis. For diabetes the relationship is also complex. Conservatively, of the global NCD-related burden of deaths, net years of life lost (YLL) and net disability adjusted life years (DALYs), 3.4%, 5.0% and 2.4%, respectively, can be attributed to alcohol consumption, with the burden being particularly high for cancer and liver cirrhosis. This burden is especially pronounced in countries of the former Soviet Union.

CONCLUSIONS

There is a strong link between alcohol and non-communicable diseases, particularly cancer, cardiovascular disease, liver disease, pancreatitis and diabetes, and these findings support calls by the World Health Organization to implement evidence-based strategies to reduce harmful use of alcohol.

Formaldehyde in alcoholic beverages: large chemical survey using purpald screening followed by chromotropic Acid spectrophotometry with multivariate curve resolution

A strategy for analyzing formaldehyde in beer, wine, spirits, and unrecorded alcohol was developed, and 508 samples from worldwide origin were analyzed. In the first step, samples are qualitatively screened using a simple colorimetric test with the purpald reagent, which is extremely sensitive for formaldehyde (detection limit 0.1 mg/L). 210 samples (41%) gave a positive purpald reaction. In the second step, formaldehyde in positive samples is confirmed by quantitative spectrophotometry of the chromotropic acid-formaldehyde derivative combined with Multivariate Curve Resolution-Alternating Least Squares (MCR-ALS). Calculation of UV-VIS and ¹³C NMR spectra confirmed the monocationic dibenzoxanthylium structure as the product of the reaction and disproved the widely cited para,para-quinoidal structure. Method validation for the spectrophotometric procedure showed a detection limit of 0.09 mg/L and a precision of 4.2–8.2% CV. In total, 132 samples (26%) contained formaldehyde with an average of 0.27 mg/L (range 0–14.4 mg/L). The highest incidence occurred in tequila (83%), Asian spirits (59%), grape marc (54%), and brandy (50%). Our survey showed that only 9 samples (1.8%) had formaldehyde levels above the WHO IPCS tolerable concentration of 2.6 mg/L.

Estimating uncertainty of alcohol-attributable fractions for infectious and chronic diseases

Background

Alcohol is a major risk factor for burden of disease and injuries globally. This paper presents a systematic method to compute the 95% confidence intervals of alcohol-attributable fractions (AAFs) with exposure and risk relations stemming from different sources.

Methods

The computation was based on previous work done on modelling drinking prevalence using the gamma distribution and the inherent properties of this distribution. The Monte Carlo approach was applied to derive the variance for each AAF by generating random sets of all the parameters. A large number of random samples were thus created for each AAF to estimate variances. The derivation of the distributions of the different parameters is presented as well as sensitivity analyses which give an estimation of the number of samples required to determine the variance with predetermined precision, and to determine which parameter had the most impact on the variance of the AAFs.

Results

The analysis of the five Asian regions showed that 150 000 samples gave a sufficiently accurate estimation of the 95% confidence intervals for each disease. The relative risk functions accounted for most of the variance in the majority of cases.

Conclusions

Within reasonable computation time, the method yielded very accurate values for variances of AAFs.

Surrogate alcohol drinking in Estonia

BACKGROUND

Surrogate, nonbeverage alcohols, provide a cheap and concentrated source of ethanol for drinking that has been associated with premature mortality. The aim of this study was to provide the first estimate of the prevalence of surrogate alcohol consumption in a national population sample of Estonia.

METHODS

The Estonian Health Interview Survey conducted in 2006 to 2007 was a nationally representative sample of the population aged 15 to 84 years (N = 6,370). The age-standardized percentage prevalences of ever having drunk surrogates were estimated. The association of age, ethnicity, and education with the prevalence of surrogate drinking was estimated using logistic regression.

RESULTS

Of all respondents who reported drinking at least once in their lifetime (N = 5,423), 65% had consumed alcohol during the previous 4 weeks. In this group (N = 3,525), the age-standardized prevalence rate of surrogate drinking was 1.4% (2.3% men, 0.3% women). Among men, surrogate drinking was rare under the age of 35 years (0.3%). Ethnicity and education were both related to surrogate drinking: relative to Estonian men, non-Estonians (mainly Russians) had an odds ratio (OR) for surrogate drinking (adjusted for age and education) of 2.58 (95% CI 1.41, 4.72), while relative to those with higher education those with secondary education had an OR (adjusted for age and ethnicity) of 2.28 (0.78, 6.67) and those with basic education an OR of 3.91 (1.29, 11.84).

CONCLUSION

Surrogate alcohols are drunk in Estonia, particularly among men. This behavior shows pronounced variation in prevalence by ethnicity and education. Reducing consumption of these substances needs to be part of any strategy to reduce the burden of alcohol-related problems in Estonia today.

Indicators of alcohol consumption and attributable harm for monitoring and surveillance in European Union countries

AIMS

Alcohol is a major risk factor for burden of disease and injury in Europe, and contributes markedly to between region differences in life expectancy. Monitoring and surveillance systems have shown to be a key factor in implementing effective policies. The aim of this paper is to propose a system of indicators for alcohol consumption and attributable harm which can be used as an over-time monitoring tool at the country level as well as for comparisons between countries.

DESIGN

A systematic research in electronic data bases was conducted but most of the information was derived from ongoing international efforts to establish alcohol monitoring and surveillance systems.

SETTING

European Union.

PARTICIPANTS

Countries.

MEASUREMENTS

Exposure to alcohol, mortality, burden of disease.

FINDINGS

Adult per capita alcohol consumption, prevalence of abstention, and frequency of drinking more than 60 g pure alcohol in one occasion are proposed as a minimal set of alcohol exposure indicators, which can quickly be implemented in all EU countries. With respect to health harm indicators, the best minimal choice which can be implemented quickly in all countries of the EU would be alcohol-attributable years of life lost due to premature death. In addition, country specific indicators could be added, when alcohol places specific burden on specific diseases.

CONCLUSIONS

National and European Union-wide monitoring systems for alcohol exposure and attributable harm to inform public health-related policy decisions could be implemented easily. The establishement of such monitoring systems would follow the recent World Assembly resolution for a global strategy to reduce alcohol-related harm.

Is contaminated unrecorded alcohol a health problem in the European Union? A review of existing and methodological outline for future studies

AIMS

Some European countries with high levels of unrecorded alcohol consumption have anomalously high rates of death attributable to liver cirrhosis. Hepatotoxic compounds in illegally produced spirits may be partly responsible. Based on a review of the evidence on the chemical composition and potential harm from unrecorded alcohol, the Alcohol Measures for Public Health Research Alliance (AMPHORA) project's methodology for identifying, analysing and toxicologically evaluating such alcohols is provided.

METHODS

A computer-assisted literature review concentrated on unrecorded alcohol. Additionally, we refer to our work in the capacity of governmental alcohol control authority and a number of pilot studies.

RESULTS

The risk-oriented identification of substances resulted in the following compounds probably posing a public health risk in unrecorded alcohol: ethanol, methanol, acetaldehyde, higher alcohols, heavy metals, ethyl carbamate, biologically active flavourings (e.g. coumarin) and diethyl phthalate. Suggestions on a sampling strategy for identifying unrecorded alcohol that may be most prone to contamination include using probable distribution points such as local farmers and flea markets for selling surrogate alcohol (including denatured alcohol) to focusing on lower socio-economic status or alcohol-dependent individuals, and selecting home-produced fruit spirits prone to ethyl carbamate contamination.

CONCLUSIONS

Standardized guidelines for the chemical and toxicological evaluation of unrecorded alcohol that will be used in a European-wide sampling and are applicable globally are provided. These toxicological guidelines may also be used by alcohol control laboratories for recorded alcohol products, and form a scientific foundation for establishing legislative limits.

Cancer risk assessment of ethyl carbamate in alcoholic beverages from Brazil with special consideration to the spirits cachaça and tiquira

Background

Ethyl carbamate (EC) is a multi-site carcinogen in experimental animals and probably carcinogenic to humans (IARC group 2A). Traces of EC below health-relevant ranges naturally occur in several fermented foods and beverages, while higher concentrations above 1 mg/l are regularly detected in only certain spirits derived from cyanogenic plants. In Brazil this concerns the sugarcane spirit cachaça and the manioc (cassava) spirit tiquira, which both regularly exceed the national EC limit of 0.15 mg/l. This study aims to estimate human exposure in Brazil and provide a quantitative risk assessment.

Methods

The human dietary intake of EC via alcoholic beverages was estimated based on WHO alcohol consumption data in combination with own surveys and literature data. This data comprises the EC contents of the different beverage groups cachaça, tiquira, other spirits, beer, wine, and unrecorded alcohol (as defined by the WHO; including alcohol which is not captured in routine government statistics nor taxed). The risk assessment was conducted using the margin of exposure (MOE) approach with benchmark doses obtained from dose-response modelling of animal experiments. Lifetime cancer risk was calculated using the T25 dose descriptor.

Results

Considering differences between pot-still and column-still cachaça, its average EC content would be 0.38 mg/l. Tiquira contained a considerably higher average EC content of 2.34 mg/l. The whole population exposure from all alcoholic beverages was calculated to be around 100 to 200 ng/kg bw/day, with cachaça and unrecorded alcohol as the major contributing factors. The MOE was calculated to range between 400 and 2,466, with the lifetime cancer risk at approximately 3 cases in 10,000. An even higher risk may exist for binge-drinkers of cachaça and tiquira with MOEs of up to 80 and 15, respectively.

Conclusions

According to our risk assessment, EC poses a significant cancer risk for the alcohol-drinking population in Brazil, in addition to that of alcohol alone. Model calculations show that the implementation of the 0.15 mg/l limit for cachaça would be beneficial, including an increase of the MOE by a factor between 3 to 6. The implementation of policy measures for tiquira and unrecorded alcohol also appears to be advisable.

The relation between different dimensions of alcohol consumption and burden of disease: an overview

AIMS

As part of a larger study to estimate the global burden of disease and injury attributable to alcohol: to evaluate the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injuries; to quantify relationships identified as causal based on published meta-analyses; to separate the impact on mortality versus morbidity where possible; and to assess the impact of the quality of alcohol on burden of disease.

METHODS

Systematic literature reviews were used to identify alcohol-related diseases, birth complications and injuries using standard epidemiological criteria to determine causality. The extent of the risk relations was taken from meta-analyses.

RESULTS

Evidence of a causal impact of average volume of alcohol consumption was found for the following major diseases: tuberculosis, mouth, nasopharynx, other pharynx and oropharynx cancer, oesophageal cancer, colon and rectum cancer, liver cancer, female breast cancer, diabetes mellitus, alcohol use disorders, unipolar depressive disorders, epilepsy, hypertensive heart disease, ischaemic heart disease (IHD), ischaemic and haemorrhagic stroke, conduction disorders and other dysrhythmias, lower respiratory infections (pneumonia), cirrhosis of the liver, preterm birth complications and fetal alcohol syndrome. Dose-response relationships could be quantified for all disease categories except for depressive disorders, with the relative risk increasing with increased level of alcohol consumption for most diseases. Both average volume and drinking pattern were linked causally to IHD, fetal alcohol syndrome and unintentional and intentional injuries. For IHD, ischaemic stroke and diabetes mellitus beneficial effects were observed for patterns of light to moderate drinking without heavy drinking occasions (as defined by 60+ g pure alcohol per day). For several disease and injury categories, the effects were stronger on mortality compared to morbidity. There was insufficient evidence to establish whether quality of alcohol had a major impact on disease burden.

CONCLUSIONS

Overall, these findings indicate that alcohol impacts many disease outcomes causally, both chronic and acute, and injuries. In addition, a pattern of heavy episodic drinking increases risk for some disease and all injury outcomes. Future studies need to address a number of methodological issues, especially the differential role of average volume versus drinking pattern, in order to obtain more accurate risk estimates and to understand more clearly the nature of alcohol-disease relationships.

Rapid and mobile determination of alcoholic strength in wine, beer and spirits using a flow-through infrared sensor

Background

Ever since Gay-Lussac's time, the alcoholic strength by volume (% vol) has been determined by using densimetric measurements. The typical reference procedure involves distillation followed by pycnometry, which is comparably labour-intensive and therefore expensive. At present, infrared (IR) spectroscopy in combination with multivariate regression is widely applied as a screening procedure, which allows one to determine alcoholic strength in less than 2 min without any sample preparation. The disadvantage is the relatively large investment for Fourier transform (FT) IR or near-IR instruments, and the need for matrix-dependent calibration. In this study, we apply a much simpler device consisting of a patented multiple-beam infrared sensor in combination with a flow-through cell for automated alcohol analysis, which is available in a portable version that allows for on-site measurements.

Results

During method validation, the precision of the infrared sensor was found to be equal to or better than densimetric or FTIR methods. For example, the average repeatability, as determined in 6 different wine samples, was 0.05% vol and the relative standard deviation was below 0.2%. Accuracy was ensured by analyzing 260 different alcoholic beverages in comparison to densimetric or FTIR results. The correlation was linear over the entire range from alcohol-free beers up to high-proof spirits, and the results were in substantial agreement (R = 0.99981, p < 0.0001, RMSE = 0.279% vol). The applicability of the device was further proven for the analysis of wines during fermentation, and for the determination of unrecorded alcohol (i.e. non-commercial or illicit products).

Conclusions

The flow-through infrared device is much easier to handle than typical reference procedures, while time-consuming sample preparation steps such as distillation are not necessary. Therefore, the alcoholic strength can be economically and quickly controlled (requiring less than 60 s per sample). The device also gives the opportunity for mobile on-site control in the context of labelling control of wine, beer and spirits, the process monitoring of fermentations, or the evaluation of unrecorded alcohols.

Chemical analysis and risk assessment of diethyl phthalate in alcoholic beverages with special regard to unrecorded alcohol

BACKGROUND

Phthalates are synthetic compounds with a widespread field of applications. For example, they are used as plasticizers in PVC plastics and food packaging, or are added to personal care products. Diethyl phthalate (DEP) may be used to denature alcohol, e.g., for cosmetic purposes. Public health concerns of phthalates include carcinogenic, teratogenic, hepatotoxic and endocrine effects. The aim of this study was to develop and validate a method for determining phthalates in alcohol samples and to provide a risk assessment for consumers of such products.

METHODOLOGY/PRINCIPAL FINDINGS

A liquid-liquid extraction procedure was optimized by varying the following parameters: type of extraction solvent (cyclohexane, n-hexane, 1,1,2-trichlorotrifluoroethane), the ratio extraction solvent/sample volume (1 ratio 1 to 50 ratio 1) and the number of extraction repetitions (1-10). The best extraction yield (99.9%) was achieved with the solvent 1,1,2-trichlorotrifluoroethane, an extraction solvent volume/sample volume ratio of 10 ratio 1 and a double extraction. For quantification, gas chromatography/mass spectrometry with deuterated internal standards was used. The investigated samples were alcoholic beverages and unrecorded alcohol products from different countries (n = 257). Two unrecorded alcohol samples from Lithuania contained diethyl phthalate in concentrations of 608 mg/L and 210 mg/L.

CONCLUSIONS/SIGNIFICANCE

The consumption of the phthalate-positive unrecorded alcohols would exceed tolerable daily intakes as derived from animal experiments. Both positive samples were labelled as cosmetic alcohol, but had clearly been offered for human consumption. DEP seems to be unsuitable as a denaturing agent as it has no effect on the organoleptic properties of ethanol. In light of our results that DEP might be consumed by humans in unrecorded alcohols, the prohibition of its use as a denaturing agent should be considered.