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

Surrogate alcohol containing methanol, social deprivation and public health in Novosibirsk, Russia

Surrogate alcohol, i.e. alcohol not intended or not officially intended for human consumption, continues to play an important role in alcohol consumption in Russia, especially for people with alcohol dependence. Among the different types of surrogate alcohol, there are windshield washer antifreeze liquids; these products are the cheapest kinds of non-beverage alcohol available and thus likely to be used by the most deprived and marginalised groups such as homeless people with alcohol dependence. Although it is well known, that non-beverage alcohol is used for consumption by various groups in Russia, and although there are laws to prohibit the use of methanol as part of windshield washer antifreeze liquids for the very reason that such products could be used as surrogate alcohol, we detected products in retail sale which were a mix of water and methanol only. Methanol poses serious health threats including blindness and death, and there had been repeated methanol deaths from surrogate alcohol in Russia over the last years. If law-enforcement does not change for surrogate products, we can expect more methanol-resulting deaths in the most deprived and marginalized groups of people with alcohol dependence in Russia. In addition, ingredients with questionable safety profiles such as formic acid should also be prohibited in non-beverage alcohol products that are likely to be consumed as surrogate alcohol.

Chemical Components of Noncommercial Alcohol Beverage Samples: A Study With the Viewpoint of Toxic Components in Mashhad, Iran

Background

Iran has one of the lowest alcoholic beverage use rates in comparison with other countries, because it is legally forbidden and because of religious beliefs. Even so, unrecorded and noncommercial alcohol remains a considerable concern, which needs special attention.

Objectives

In the current research, we have studied the general composition of noncommercial alcohol samples to identify potentially toxic components in the context of the city of Mashhad in IR Iran.

Patients and Methods

Using a descriptive study, chemical composition records of alcohol samples obtained from Mashhad and its suburbs (from March 2013 to March 2014) were evaluated in terms of ethanol percentage and methanol percentage using gas chromatography. Likewise, the pH of the alcohol and the location of the sample were also considered. Some substances, such as inorganic elements, were not included because there was no information about these substances in the records.

Results

Of 877 reports of alcohol samples, more than 50% were obtained from Mashhad and the rest were from the suburbs. Of the reports, 57.5% were in the spring and summer, followed by 42.5% in the fall and winter. The mean (min-max) of ethanol percentage was 30.04% (0 - 98.4). In four cases, methanol was detected. The mean (min-max) of methanol percentage was 23% (4 - 95).The majority of the samples had an acidic pH.

Conclusions

The composition of unrecorded samples did not raise major toxicological concern beyond ethanol in alcohol products. However, concentration levels of methanol in some unrecorded alcohol samples made these samples detrimental for human consumption.

Realistically furthering the goals of public health by cannabis legalization with strict regulation: Response to Kalant

Cannabis Policy Framework respond to select issues from Kalant's Commentary (in this issue).

Alcoholic Liver Disease in Asia, Europe, and North America

Alcoholic liver diseases comprise a spectrum of clinical disorders and changes in liver tissue that can be detected by pathology analysis. These range from steatosis to more severe signs and symptoms of liver disease associated with inflammation, such as those observed in patients with alcoholic hepatitis or cirrhosis. Although the relationship between alcohol consumption and liver disease is well established, severe alcohol-related morbidities develop in only a minority of people who consume alcohol in excess. Inter-individual differences in susceptibility to the toxic effects of alcohol have been studied extensively-they include pattern of alcohol consumption, sex, environmental factors (such as diet), and genetic factors, which vary widely among different parts of the world. Alcoholic liver disease is becoming more common in many parts of Asia, but is decreasing in Western Europe. Treatment approaches, including availability of medications, models of care, and approach to transplantation, differ among regions.

How should prevalence of alcohol use disorders be assessed globally?

Alcohol is a major risk factor for global burden of disease, and alcohol use disorders make up a considerable portion of this burden. Up to now, prevalence of alcohol use disorders has been estimated based on general population surveys with the Composite International Diagnostic Interview (CIDI) as the gold standard for assessment. However, three major problems have been identified with the current conceptualization of alcohol use disorders and its measurement via CIDI: cultural specificity of key criteria measured such as loss of control; lack of convergence of diagnoses identified by CIDI with clinically relevant diagnoses in primary health care; and impact of stigma on measurement. As a solution, it is proposed to measure alcohol use disorders via heavy drinking over time, with thresholds taken from the European Medicines Agency (60 and more grams on average per day of pure alcohol for men, and 40+ grams for women). Current data on level of drinking (per capita consumption) assessed via taxation and other means allow for a measure of less bias. If these thresholds are considered too low and there is more emphasis on need for specialized treatment, then thresholds for very heavy drinking can be taken as alternatively (100+, and 60+ grams per day pure alcohol for men and women, respectively). Copyright © 2016 John Wiley & Sons, Ltd.

Correlates of problematic unrecorded alcohol consumption in Sikkim, Northeast India - Results from a cross-sectional pilot survey

The magnitude and consequences of unrecorded alcohol consumption, defined as home brewed or clandestinely produced illicit liquor or surrogate alcoholic beverage has been little investigated in India. A significant portion of all alcohol consumed globally is unrecorded, therefore these consumers constitute a significant population. Sikkim, a province in Northeast India, lies in the foothills of the Himalayas. Unrecorded alcohol use is traditionally prevalent, with more than ten types available. This study investigated correlates of problematic unrecorded alcohol consumption in rural and urban communities of Sikkim. A cross-sectional, community-based pilot survey was conducted. Intensive case-finding recruited current heavy users (at least 3 days/week) of unrecorded alcohol of either sex above 16 years of age. On enrolment, participants responded to a socio-demographic instrument including 12 questions on their pattern of alcohol consumption and a 4-item CAGE questionnaire. Alcohol problems exist significantly among the young adult population. Although consumption of unrecorded alcohol is traditional in Sikkim, it has emerged as an important public health problem, with alarmingly high rates of problematic consumption. This is also expected to have significant economic costs. Therefore, prevention and treatment measures are an urgent need as well as policy decisions on production and sales of unrecorded alcohol.

Modelling the impact of alcohol consumption on cardiovascular disease mortality for comparative risk assessments: an overview

BACKGROUND

Although alcohol consumption has long been considered as a risk factor for chronic disease, the relationship to cardiovascular disease (CVD) is complex and involves at least two dimensions: average volume of alcohol consumption and patterns of drinking. The objective of this contribution was to estimate the burden of CVD mortality caused by alcohol consumption.

METHODS

Risk assessment modelling with alcohol-attributable CVD mortality as primary outcome. The mortality burden of ischaemic heart disease (IHD) and ischaemic stroke (IS) attributable to alcohol consumption was estimated using attributable-fraction methodology. Relative Risk (RR) data for IHD and IS were obtained from the most comprehensive meta-analyses (except for Russia and surrounding countries where alcohol RR data were obtained from a large cohort study). Age-group specific RRs were calculated, based on large studies. Data on mortality were obtained from the World Health Organization's Global Health Estimates and alcohol consumption data were obtained from the Global Information System on Alcohol and Health. Risk of former drinkers was modelled taking into account global differences in the prevalence of sick quitters among former drinkers. Alcohol-attributable mortality estimates for all other CVD causes except IHD and IS were obtained from the 2014 Global Status Report on Alcohol and Health.

RESULTS

An estimated 780,381 CVD deaths (441,893 and 338,490 CVD deaths among men and women respectively) were attributable to alcohol consumption globally in 2012, accounting for 1.4 % of all deaths and 26.6 % of all alcohol-attributable deaths. This is in contrast to the previously estimated 1,128,273 CVD deaths attributable to alcohol consumption globally, and represents a decrease of 30.8 % in alcohol-attributable CVD mortality and of 10.6 % in the global burden of all alcohol-attributable deaths.

CONCLUSIONS

When the most comprehensive and recent systematic reviews and meta-analyses are taken as bases, the net impact of alcohol consumption on CVD is lower than previously estimated.

Temporal changes in alcohol-related mortality and morbidity in Australia

BACKGROUND AND AIMS

Alcohol consumption is an avoidable risk factor for morbidity and mortality. Studies have examined relative risks and outcomes of alcohol-related harms in Australia at discrete times, limiting the ability to examine changes across time. This paper examined alcohol consumption and its contribution to deaths, illness and injury at two time-points, 2001 and 2010.

DESIGN

Alcohol consumption was modelled based on the 2001 and 2010 National Drug Strategy Household Survey, upshifted to reflect alcohol sales data.

SETTING

All data reported are from Australian sources.

MEASUREMENTS

Based on relative risk estimates obtained from meta-analysis, alcohol-attributable fractions were estimated for 42 disease and injury categories in 2001 and 2010 separately for conditions that were not 100% alcohol-attributable. Deaths and hospital separations attributable to alcohol were calculated in 2001 and 2010.

FINDINGS

There was a relatively stable per capita consumption of alcohol across time, with males reporting higher levels of consumption compared with females. While there were increases in the number of abstainers from alcohol across time, the proportion of heavy alcohol consumers also increased. This corresponded with an observed increase in alcohol-attributable burden. For example, alcohol-attributable deaths increased from 4957 [95% confidence interval (CI) = 2867-8770] to 5610 (95% CI = 3398-9408) during the study period.

CONCLUSION

The findings demonstrate that there has been an increase in alcohol-attributable harms between 2001 and 2010 in Australia without a corresponding increase in per capita consumption.

Metabolites of Aliphatic Alcohols Detected in Alcoholic Beverages Inhibit Phagocytosis

AIMS

The aim of our study was to measure granulocyte and monocyte phagocytosis following treatment of cells with some metabolites of aliphatic alcohols alone and in combination with acetaldehyde.

METHODS

The cells were separated from human peripheral blood prior to determination of phagocytosis of opsonized zymosan particles by granulocytes and monocytes treated individually with metabolites of aliphatic alcohols including formaldehyde, 1-propanal, acetone, 1-butanal, and 2-butanone and in combination with acetaldehyde.

RESULTS

The findings revealed that metabolites of aliphatic alcohols inhibited phagocytosis by granulocytes and monocytes in a concentration-dependent manner and when combined with acetaldehyde, they caused a further decrease in phagocytic activity.

CONCLUSION

Due to their additive effects, it is possible that, in combination with acetaldehyde, metabolites of aliphatic alcohols may inhibit phagocytosis at physiologically realistic concentrations in episodic heavy drinkers, thereby contributing to their increased susceptibility to infectious diseases.

Traditional grain alcohol (bai jiu, [Symbol: see text]) production and use in rural central China: implications for public health

Background

An estimated 25 % of the alcohol consumed in China is traditional unrecorded alcohol produced and distributed informally. Consequently there is concern about its safety and its contribution to public health risk. Little has been written about this type of alcohol in China.

Methods

Researchers observed the manufacture of traditional bai jiu in a rural area of Hubei Province, Central China. Two hundred fifty-nine individuals were interviewed, either individually or in small groups, about their use of and attitudes toward bai jiu. Individuals who made or sold bai jiu were interviewed about local production, distribution, and sale. Key community leaders were asked about risks from local bai jiu production, sale, and use.

Results

All of the bai jiu makers followed the same basic traditional procedure. Most had learned their craft from a family member or by apprenticeship, and their product was sold to neighbors or nearby villagers. Bai jiu makers typically had a business license and a health certificate. The shops that bought and sold traditional bai jiu were family-run businesses that sold both traditional bai jiu and commercial alcohol to clientele within a close social network. Alcohol (all types) was consumed by 79.9 % of interviewed villagers (89.7 % of males, 50.0 % of females). Of the 207 drinkers in the sample, 72.9 % drank bai jiu, 59.4 % drank beer, and 22.7 % drank commercial spirits. Bai jiu was most often consumed at mealtimes. Bai jiu drinkers believed moderate drinking was healthy and that drinking improved the social atmosphere, and about one-third of them believed drinking too much could result in quarrels and family problems. The bai jiu business provided two sources of income for makers because spent grain from the distillation process could be fed to livestock.

Conclusions

Production, sale, and use of traditional bai jiu occurred within the context of local traditions, values, customs, and social networks. The data did not suggest any significant issues related to contamination. Drinking patterns were similar to those found in other studies of alcohol use in China. Bai jiu was sold mainly to middle-aged or older men, suggesting bai jiu production and use could gradually disappear without intervention.

Can pricing deter adolescents and young adults from starting to drink: An analysis of the effect of alcohol taxation on drinking initiation among Thai adolescents and young adults

The objective of this study is to assess the relationship between alcohol taxation changes and drinking initiation among adolescents and young adults (collectively "youth") in Thailand (a middle-income country). Using a survey panel, this study undertook an age-period-cohort analysis using four large-scale national cross-sectional surveys of alcohol consumption performed in Thailand in 2001, 2004, 2007 and 2011 (n=87,176 Thai youth, 15-24 years of age) to test the hypothesis that changes in the inflation-adjusted alcohol taxation rates are associated with drinking initiation. Regression analyses were used to examine the association between inflation-adjusted taxation increases and the prevalence of lifetime drinkers. After adjusting for potential confounders, clear cohort and age effects were observed. Furthermore, a 10% increase of the inflation-adjusted taxation rate of the total alcohol market was significantly associated with a 4.3% reduction in the prevalence of lifetime drinking among Thai youth. In conclusion, tax rate changes in Thailand from 2001 to 2011 were associated with drinking initiation among youth. Accordingly, increases in taxation may prevent drinking initiation among youth in countries with a high prevalence of abstainers and may reduce the harms caused by alcohol.

The impact of alcohol consumption on African people in 2012: an analysis of burden of disease

OBJECTIVES

To determine the impact of alcohol consumption on deaths and disability in Africa.

METHODS

We estimated alcohol exposure for 2012, and its impact on deaths and disability in Africa using estimates from the WHO Global Health Estimates for outcome data, and the WHO Global Status Report on Alcohol and Health 2014 for risk relations. We provide a scenario that includes the impact of alcohol on HIV/AIDS incidence, and qualitative predictions on future exposure and harm.

RESULTS

Overall, alcohol consumption has a large impact on burden of disease and mortality in African countries. Alcohol-attributable disease burden is more important when the impact of alcohol consumption on the incidence and course of HIV/AIDS is taken into account, with alcohol being responsible, in 2012, for 6.4% of all deaths and 4.7% of all DALYs lost in the African region. Alcohol exposure is expected to increase in the next years, and thus alcohol-attributable fractions.

CONCLUSIONS

The weight of new evidence, especially of alcohol's role in the incidence and course of HIV/AIDS, is particularly relevant to African countries and points to the need for a strong policy response to reduce the alcohol-related burden of disease on the continent.

Multinational Alcohol Market Development and Public Health: Diageo in India

Alcohol is a risk factor for communicable and noncommunicable diseases, and alcohol consumption is rising steadily in India. The growth of multinational alcohol corporations, such as Diageo, contributes to India's changing alcohol environment. We provide a brief history of India's alcohol regulation for context and examine Diageo's strategies for expansion in India in 2013 and 2014. Diageo is attracted to India's younger generation, women, and emerging middle class for growth opportunities. Components of Diageo's responsibility strategy conflict with evidence-based public health recommendations for reducing harmful alcohol consumption. Diageo's strategies for achieving market dominance in India are at odds with public health evidence. We conclude with recommendations for protecting public health in emerging markets.

Tracking Biases: An Update to the Validity and Reliability of Alcohol Retail Sales Data for Estimating Population Consumption in Scotland

AIMS

To highlight the importance of monitoring biases when using retail sales data to estimate population alcohol consumption.

METHODS

Previously, we identified and where possible quantified sources of bias that may lead to under- or overestimation of alcohol consumption in Scotland. Here, we update findings by using more recent data and by quantifying emergent biases.

RESULTS

Underestimation resulting from the net effect of biases on population consumption in Scotland increased from -4% in 2010 to -7% in 2013.

CONCLUSION

Biases that might impact on the validity and reliability of sales data when estimating population consumption should be routinely monitored and updated.

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.

Food Safety in Low and Middle Income Countries

Evidence on foodborne disease (FBD) in low and middle income countries (LMICs) is still limited, but important studies in recent years have broadened our understanding. These suggest that developing country consumers are concerned about FBD; that most of the known burden of FBD disease comes from biological hazards; and, that most FBD is the result of consumption of fresh, perishable foods sold in informal markets. FBD is likely to increase in LMICs as the result of massive increases in the consumption of risky foods (livestock and fish products and produce) and lengthening and broadening value chains. Although intensification of agricultural production is a strong trend, so far agro-industrial production and modern retail have not demonstrated clear advantages in food safety and disease control. There is limited evidence on effective, sustainable and scalable interventions to improve food safety in domestic markets. Training farmers on input use and good practices often benefits those farmers trained, but has not been scalable or sustainable, except where good practices are linked to eligibility for export. Training informal value chain actors who receive business benefits from being trained has been more successful. New technologies, growing public concern and increased emphasis on food system governance can also improve food safety.

Attempted Training of Alcohol Approach and Drinking Identity Associations in US Undergraduate Drinkers: Null Results from Two Studies

There is preliminary evidence that approach avoid training can shift implicit alcohol associations and improve treatment outcomes. We sought to replicate and extend those findings in US undergraduate social drinkers (Study 1) and at-risk drinkers (Study 2). Three adaptations of the approach avoid task (AAT) were tested. The first adaptation – the approach avoid training – was a replication and targeted implicit alcohol approach associations. The remaining two adaptations – the general identity and personalized identity trainings – targeted implicit drinking identity associations, which are robust predictors of hazardous drinking in US undergraduates. Study 1 included 300 undergraduate social drinkers. They were randomly assigned to real or sham training conditions for one of the three training adaptations, and completed two training sessions, spaced one week apart. Study 2 included 288 undergraduates at risk for alcohol use disorders. The same training procedures were used, but the two training sessions occurred within a single week. Results were not as expected. Across both studies, the approach avoid training yielded no evidence of training effects on implicit alcohol associations or alcohol outcomes. The general identity training also yielded no evidence of training effects on implicit alcohol associations or alcohol outcomes with one exception; individuals who completed real training demonstrated no changes in drinking refusal self-efficacy whereas individuals who completed sham training had reductions in self-efficacy. Finally, across both studies, the personalized identity training yielded no evidence of training effects on implicit alcohol associations or alcohol outcomes. Despite having relatively large samples and using a well-validated training task, study results indicated all three training adaptations were ineffective at this dose in US undergraduates. These findings are important because training studies are costly and labor-intensive. Future research may benefit from focusing on more severe populations, pairing training with other interventions, increasing training dose, and increasing gamification of training tasks.

Analysis of methanol and its derivatives in illegally produced alcoholic beverages

INTRODUCTION

Illegal alcohol production remains as a common issue worldwide. Methanol poisoning mostly occurs because of the methanol used in production of counterfeit alcohol instead of ethyl alcohol due to its low price or by drinking the liquids containing methyl alcohol. Pectolytic enzymes results in an increase of methanol levels in many fermentation products such as ciders or wines. Methanol poisonings are infrequently encountered in forensic medicine practice. However, sporadic cases due to methanol intoxication as well as epidemic cases have been reported. In this study, we aimed to identify existence of methanol and its metabolites in illegally produced alcoholic beverages used in Antakya region.

MATERIAL AND METHODS

Twelve legally produced alcohol samples and Fifty-six different illegally produced alcohol samples were collected from the markets and local producers. Existence of methanol, formic acid, methyl amine, methyl formate and trioxan were determined using GC-MS method in these samples.

RESULTS

Fifty-six different illegal alcohol samples were analyzed in this study and methanol was detected in 39 (75%) of samples. Formic acid was detected in 3, formamide in 1, methyl amine in 6, methyl formate in 10 and trioxan in 2 samples.

CONCLUSION

Overwhelming majority of illegal alcoholic beverages was detected to contain methanol. Interestingly this study also revealed the presence of trioxane, which has not previously reported among toxic agents in illegal alcohol samples.

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.

Prevalence of and potential influencing factors for alcohol dependence in Europe

Alcohol use disorders (AUDs), and alcohol dependence (AD) in particular, are prevalent and associated with a large burden of disability and mortality. The aim of this study was to estimate prevalence of AD in the European Union (EU), Iceland, Norway, and Switzerland for the year 2010, and to investigate potential influencing factors. The 1-year prevalence of AD in the EU was estimated at 3.4% among people 18-64 years of age in Europe (women 1.7%, men 5.2%), resulting in close to 11 million affected people. Taking into account all people of all ages, AD, abuse and harmful use resulted in an estimate of 23 million affected people. Prevalence of AD varied widely between European countries, and was significantly impacted by drinking cultures and social norms. Correlations with level of drinking and other drinking variables and with major known outcomes of heavy drinking, such as liver cirrhosis or injury, were moderate. These results suggest a need to rethink the definition of AUDs.

Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction target: a modelling study

BACKGROUND

Countries have agreed to reduce premature mortality (defined as the probability of dying between the ages of 30 years and 70 years) from four main non-communicable diseases (NCDs)--cardiovascular diseases, chronic respiratory diseases, cancers, and diabetes--by 25% from 2010 levels by 2025 (referred to as 25×25 target). Targets for selected NCD risk factors have also been agreed on. We estimated the contribution of achieving six risk factor targets towards meeting the 25×25 mortality target.

METHODS

We estimated the impact of achieving the targets for six risk factors (tobacco and alcohol use, salt intake, obesity, and raised blood pressure and glucose) on NCD mortality between 2010 and 2025. Our methods accounted for multi-causality of NCDs and for the fact that when risk factor exposure increases or decreases, the harmful or beneficial effects on NCDs accumulate gradually. We used data for risk factor and mortality trends from systematic analyses of available country data. Relative risks for the effects of individual and multiple risks, and for change in risk after decreases or increases in exposure, were from re-analyses and meta-analyses of epidemiological studies.

FINDINGS

If risk factor targets are achieved, the probability of dying from the four main NCDs between the ages of 30 years and 70 years will decrease by 22% in men and by 19% in women between 2010 and 2025, compared with a decrease of 11% in men and 10% in women under the so-called business-as-usual trends (ie, projections based on current trends with no additional action). Achieving the risk factor targets will delay or prevent more than 37 million deaths (16 million in people aged 30-69 years and 21 million in people aged 70 years or older) from the main NCDs over these 15 years compared with a situation of rising or stagnating risk factor trends. Most of the benefits of achieving the risk factor targets, including 31 million of the delayed or prevented deaths, will be in low-income and middle-income countries, and will help to reduce the global inequality in premature NCD mortality. A more ambitious target on tobacco use (a 50% reduction) will almost reach the target in men (>24% reduction in the probability of death), and enhance the benefits to a 20% reduction in women.

INTERPRETATION

If the agreed risk factor targets are met, premature mortality from the four main NCDs will decrease to levels that are close to the 25×25 target, with most of these benefits seen in low-income and middle-income countries. On the basis of mortality benefits and feasibility, a more ambitious target than currently agreed should be adopted for tobacco use.

FUNDING

UK MRC.

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.

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.