Alcohol Control Series 1

CONTENTS

• INTRODUCTION
  
• Alcohol Use: What Influences Usage
  
• The Alcohol Industry
  
• Promotion and Sale of Alcohol
  
• Changing Faces and Emerging Trends
  
• Governments and Societies: Confused Scenario
  
• OBJECTIVES
  
• General Objectives
  
• Specific Objectives
  
• METHODOLOGY
  
  • Household Survey
    
  • Literature Review
    
  • Qualitative Methods of Study
    
• RESULTS
  
  • Profile of Enumerated Population
    
  • Prevalence of Alcohol Use
    
  • Socio-Demographic Characteristics
    
  • Pattern of Alcohol Use
    
• ALCOHOL USAGE: IMPACT AND CONSEQUENCES
  
  • Alcohol Use and Attributable Events
    
  • Alcohol and Family
    
  • Alcohol and Society
    
• ECONOMIC ASPECTS OF ALCOHOL USE
  
  • Costs Associated with Alcohol Use
    
  • Experiences from Western Countries
  • Experience from India
    
  • Costing Effort from the Bangalore Study
    
• HIGHLIGHTS OF THE FOCUS GROUP INTERACTION
  
  • WHAT CAN BE DONE
    
• Specific Recommendations
  
• CONCLUSION AND THE WAY FORWARD
• REFERENCES

The increasing production, distribution, promotion and easy availability of alcohol coupled with the changing values of society has resulted in alcohol-related problems emerging as a major public health concern in India. In the absence of rational alcohol policies, and with the belief that alcohol revenues can be used for the development of society, the problem has aggravated further. While revenues earned yield only short-term gains, the impact and losses arising out of increased alcohol use remain to plague society as a long-term phenomenon.

Several epidemiological studies have revealed that nearly 20–40% of men in the age group of 15 to 60 years consume alcohol regularly or intermittently. In recent years there has been a change in alcohol consumption trends, such as early age-of-onset of drinking, increasing usage among women, change in drinking patterns and increasing alcohol dependence problems. These problems are beginning to be noticed across the entire country. Despite the enormity of the problem in India, systematic research has not been undertaken to clearly document the combined social, economic, health and psychological impact of alcohol use. However, even the limited available data indicate the association of alcohol-related problems with several spheres of life. The present study sponsored by World Health Organization, Regional Office for South-East Asia (WHO SEARO) and conducted by the National Institute of Mental Health and Neurosciences, Bangalore, India, was undertaken to assess the burden and socio-economic impact of alcohol use in a select sample, with the intention to extrapolate the findings to the whole of India. The study was conducted on a sample of 3258 individuals in the age group of 16 to 60 years drawn from four different populations of rural, town, slum and urban areas. It has attempted to document the impact of alcohol use by quantitative and qualitative research methods.

Apart from characterizing the patterns of use, the study has compared the impact of alcohol among an equal number of non-users from the same four populations. The study has revealed for the first time the continued negative impact of alcohol on both the users and their families. The study found that nearly 33% of the adult population regularly consumed alcohol for different self-described reasons. Surprisingly, the study also uncovered the hidden fact that 2% of women also regularly consume alcohol. While the problems of women alcohol-users get greater visibility in urban-based media reports, it is a far more serious issue in rural, slum and town areas, especially in select community groups wherein the proportions are said to be in the range of 5–6%. In addition, it needs to be noted that the problem of women alcohol-users could be much higher as the current study was done in a lower socio-economic area of a conservative community. A majority of alcohol-users were in the middle age group, predominantly with low levels of education, were employed as skilled or unskilled workers, were married and had income levels of less than Rs 6000/- per month.

The drinking patterns revealed that nearly three fourths had been using alcohol for more than 5 years, were frequent users and were using spirits with high alcohol content. Hazardous drinking measured in terms of “binge drinking” and pathological drinking was reported by 40% and 25% respectively. These findings suggest not only an increasing use of alcohol but also varying patterns of use in predominantly lower and middle-income segments of society. Findings from the study revealed that the overall health status was poor among users compared with non-users (1.6% v/s 0.7%). This indirectly translates to poor quality of life, enhanced socio-economic hardships to family members and increased expenditure on health problems in deprived economic situations. In the context of either limited or inadequate health care services in rural and transitional areas, alcoholrelated health problems, over a period of time, will pose a major burden on existing health care systems.

A direct unequivocal association between unintentional and intentional injuries and increased alcohol consumption has been proven beyond doubt in the current scientific literature. So also, in the present study, alcohol-users experienced injuries four times more as compared with non-users; the incidence of road traffic injuries, suicides and violence were all comparatively higher in the user group by nearly 2 to 8 times. Suicidal ideations linked to alcohol consumption were twice as frequent in the user group. Interestingly, hidden forms of violence like emotional abuse, sexual abuse, abuse of children and siblings were also higher
among users Even though injuries are predictable and preventable, premature mortality and morbidity continues unabated. Alcohol contributes both directly and indirectly to the occurrence of injuries and thus is a potentially modifiable risk factor. Socially deviant behaviours like staying away from home, running away from home, indulging in gambling and other addictive behaviours was nearly two times higher among users. These are predominantly social problems resulting in stigmatization and isolation of families at the community level. The immediate fallout is disruption of family ties and marital disharmony. This phenomenon is thus an indicator of negligence of the family by the user. In the qualitative studies, it was revealed that a basic level of insecurity persisted in these families leading to many other indirect adverse effects. In terms of work, many alcohol-users had missed going to work, frequently borrowed money from colleagues and friends, had shown poor productivity and faced a lack of respect from employers and colleagues. Many of them were warned by their employers about their hazardous drinking practices, which also resulted in frequent arguments and quarrels with their employers and colleagues, thereby demeaning the individual. Further, increase in borrowings (six times more among users) had resulted in there being a greater economic burden on the individual, while depriving the family members of basic essential needs.

Many of the homes with an alcohol-user also had difficulty in running the day-to-day activities of the household, as the available resources were spent on alcohol rather than on basic needs. This has a great psychological impact on other family members. Consequently this leads to a disturbed emotional and psychological state among family members, which in turn affects their level of happiness and psychological stability. The present study showed that the level of happiness was poor among users as compared with non-users. With respect to the law, the present study once again demonstrated that alcohol-users were more likely to be incriminated by the police for various acts of violation of rules and regulations. Though primarily, this was in the areas of violating traffic rules in an alcohol-intoxicated condition it was also due to their greater involvement in violent acts. The experience in families reveal not only embarrassing situations in day-to-day life due to frequent visits to nearby police stations, but also increased expenditure to meet the legal and related procedures. Several adverse effects of alcohol on physical, social, mental and economic spheres of life are known. Despite this, the subjects’ efforts towards cessation or reduction of alcohol were extremely low in the study population.

Even though nearly 50% of users realized that they need to reduce their drinking, only 5% have approached a health professional for help. This, despite the fact that 53% of alcohol-users were advised by a health professional to reduce or stop drinking. This phenomenal gap reveals the existing disparities between the need and the availability of health care interventions to reduce alcohol-related problems in society. Due to the limitation of small sample size, the study can be considered as a pilot effort in estimating the cost of adverse effects of alcohol use, suggesting the need for larger, well-defined multi-centric studies. Caution has also to be exercised in interpreting and extrapolating the findings because the area of study was a typical urban conservative middle class locality. The present costing effort (with due limitations) is the first systematic effort from India and has raised important questions for policy-makers and even for the Indian public. The study, although based on limited data, has estimated that while gains in terms of revenue from alcohol sales are Rs 216 billion every year, losses from adverse effects of alcohol are estimated to be Rs 244 billion, apart from the immeasurable losses due to multiple and rollover effects of alcohol use. Needless to say, the available estimates are merely the tip of the iceberg. The seeming gain from the existing alcohol policies i.e. the revenue from excise taxes ends up being spent to counter the effects of alcohol use in the medium-and long-term. Similarly short-term gains of economic development such as establishing new breweries end up with social mal-development; which coupled with inefficient enforcement of rules and regulations, leads to a situation best described by the proverbial statement “leaky faucet flooding the floor”. Hence the urgent need is to stop mopping the floor, adopt a comprehensive approach instead of a piece-meal strategy, and evolve long-term commitments by implementing a public health agenda to close the tap. The conclusion is “Are we gaining less or losing more?” It is for everyone to decide.

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