Faculty of Medicine Health Economics and Policies 31505391

Faculty of Medicine Health Economics and Policies (31505391) Economic effects of Bad habits including smoking and alcohol consumption By Hatim Jaber MD MPH JBCM Ph. D 29 - 04 + 5 -5 - 2019 1

Presentation outline 29 - 4 - 2018 Time Global Tobacco Epidemic Locally…………. 08: 00 to 08: 20 Health , economic and social effects 08: 20 to 08: 30 Tobacco & Poverty- SDGs 08: 30 to 08: 40 The Economics of Tobacco and Tobacco Control Alcohol economics 08: 40 to 08: 50 2

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Age-standardized fitted and projected rates of prevalence of tobacco smoking among people aged ≥ 15 years, both sexes, by WHO region, 2000– 2025 5

Prevalence of cigarette smoking (%) among children aged 13– 15 years by WHO region and by World Bank country income group 6

Tobacco Key facts • Tobacco kills up to half of its users. • Tobacco kills more than 7 million people each year. More than 6 million of those deaths are the result of direct tobacco use while around 890 000 are the result of non-smokers being exposed to second-hand smoke. • Around 80% of the world's 1. 1 billion smokers live in low- and middle-income countries. 7

Background Ø Smoking, Drinking and Obesity have caused serious public-health concern in the world. Ø 65% of adults aged 21 and over were either overweight or obese. 30% of them were obese. Compared to 30 years ago, it increases almost 50%. (Hedley et al, 2004) Ø In 2000, tobacco smoking caused more than 400, 000 deaths. Ø Smoking has been a leading preventable cause of mortality. Ø Recently, anti-smoking has been an important policy. Ø Evidence from public health has shown that drinking may be associated with smoking behavior. 8

Consequences on Health • Smoking – Cigarette smoking is the leading cause of lung cancer (90% of deaths); chronic bronchitis; emphysema (COPD), and a major cause of heart disease and stroke – Associated with additional cancers (e. g. , bladder, pancreatic, and cervical) – Vision and hearing problems and slowed healing from injuries – Responsible for 435, 000 deaths per year in 2000 • Obesity – Linked to hypertension, high cholesterol, coronary heart disease, type 2 diabetes, depression, and various types of cancer – Responsible for 400, 000 deaths in 2000 – $75 billion in medical care expenditures in 2003 • Excessive Alcohol Consumption – Associated with lost productivity, disability, early death, crime, neglect of family responsibilities – Motor vehicle accidents while driving under the influence – 100, 000 deaths from alcohol abuse in 2000 9

Why does tobacco kill? • Burns at 1000 o C • Cig smoke has > 4, 000 chemicals, 43 known carcinogens/harmful substances (tar, cadmium, lead, cyanide, nitrogen oxides, benzo(a) pyrine, carbon monoxide, vinyl chloride, acetaldehyde…. ) • Damages tissues throughout the body, clogs arteries, causes blood clots/bleeding 10

Nicotine is highly addictive • Nicotine --> release of serotonin, dopamine, norepinephrine • Neuro-adaptation • Each year, nearly 35 million people make a concerted effort to quit smoking. < 7% stay smoke-free for a year; most start smoking again within days. 11

Why does tobacco kill? Tobacco killed an estimated 4 million people worldwide in 2000, about 7% of all deaths. By 2030, tobacco will be responsible for: ten million deaths per year, and 70% of these deaths will be in the developing world, and 30% - 3 million- in developed countries. By then, tobacco will cause almost 11% of all deaths in the developing world, and 17. 7% of all deaths in developed countries. Half a billion people now alive will be killed by tobacco products, and half of the deaths will happen prematurely. • Every 8 seconds someone dies as a result of tobacco use 12

Are some cigarettes better? • No such thing as a safe cigarette • “light”, “low tar” cigarettes are deceptive – - Manipulation by maker - Compensation by smokers so actual yields not = FTC (machine) yield • Nicotine content is very carefully calibrated – nicotine is removed from tobacco, and then added back in carefully controlled amounts to maximize addiction. Ammonia added to speed the absorption of the nicotine. Cigs deliver constant amounts of nicotine. • “A cigarette is a highly engineered nicotine delivery device” 13

Per Capita Cigarette Consumption Among People Age 15 Years and Older, Globally and by Country Income Group, 2000– 2013 Note: Country income group classification based on World Bank Analytical Classifications for 2013. Source: Based on data from Euromonitor International 2016. 14

TOBACCO HARMS ECONOMY AND SUSTAINABLE DEVELOPMENT • The association between tobacco and poverty is now well established “Tobacco poverty: A vicious circle. ” and 15

NCDs: 60% Global Deaths NCD Modifiable Causative Risk Factors Tobacco Use Unhealthy Physical Diet Inactivit y Harmful Use of Alcohol Heart Disease & Stroke √ √ Diabetes √ √ Cancer √ √ Chronic Lung Disease √ Source: WHO, 2010 16

Global Trends in tobacco use • 1. 1 billion smokers, 80% in low- and middle income countries (1 in 3 adults) • 1. 6 billion by 2025 • 85% of all tobacco used is smoked 17

Smoking: Men and Women q 50%-66% of women use “light” q Addiction in M>F q Biological responses to nicotine differ between M & F q Smoking in women is reinforced by less nicotine than in men (Perkins et al. , 1991) 18

Youth Smoking in EMR country profilehttp: //www. emro. who. int/TFI/Country. Profile 19

Smoking: Health Professionals 20

• Tobacco is grown in 124 countries, but by far the largest proportion of tobacco (92% in 2013) is grown in LMICs; more than 40% of the world’s tobacco is produced in China alone. • Tobacco farming accounts for only a small share (<3%) of the global tobacco market • In 2013, ten countries accounted for most of the world’s tobacco leaf production (80%); China alone produced more than 40% of the world’s tobacco leaf. • Tobacco is increasingly grown in low- and middle-income countries, and many of these countries export a large proportion of the world’s tobacco leaf. 21

Global Deaths Currently: Ø 4. 9 million people die per year Ø 13, 400 people per day Ø 560 people every hour By 2030: Ø 10 million people a year will die from tobacco use Ø 70% of those deaths will occur in developing countries 22

Prevalence of tobacco use among males in the Eastern-Mediterranean Region Launched February 2008 23

The poor tend to smoke the most Ø Globally, 84% of smokers live in developing & transitional countries Ø High smoking rates strongly associated with less education Ø Study in Chennai India found 64% of illiterate smoke, while 21% of those with 12+ yrs of schooling smoke 24

Smoking is more common among the less educated Source: Gajalakshmi and others, background paper 25

Tobacco use impoverishes individuals & families 10% of household expenditures go to cigarettes. Ø In poorest households, 26

Tobacco Impoverishes Countries ØEnvironmental Damage ØIncreased Health Care Costs ØLost productivity due to illness and premature death ØForeign exchange losses 27

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Tobacco Costs HEALTH COSTS OTHER ECONOMIC COSTS • Time off for “smoke breaks” • Medical and healthcare costs • Lost production and lower • Higher sickness and absence productivity rates • Fires caused by careless • Loss of skilled workers by smoking premature death • Damage to building fabric • Increased early retirement due • Litter of billions of cigarettes, to ill health matches, packets, lighters • Secondhand smoke risks • Risk of being sued 29

Global Costs of Smoking • Tobacco use is anot only burden on smokers; through its negative effects on health, equality, and the environment, tobacco use harms the wellbeing of all people • Tobacco use hampers development to the point where ultimately no health system or national economy can afford it. 30

Global Costs of Smoking • The total economic cost of smoking globally amounts to 2 trillion dollars • About 30% of these costs are the direct cost of smoking: these are the healthcare-related expenses incurred from treatment of diseases attributable to smoking, which include, but are not limited to, hospitalization, medication, lab tests, consultation fees, etc. 31

Global Costs of Smoking • The majority of the total economic cost of smoking is its indirect costs, which take into account the productivity lost due to either mortality or morbidity attributable to smoking. • “The economic cost of smoking is equivalent to almost 2% of the world’s total economic output” underscores Dr. Nigar Nargis, Director in the Economic and Health Policy Research program at the American Cancer Society, who was a key researcher in the study 32

Global Costs of Smoking • In 2015, tobacco companies spent $ 8. 9 billion marketing cigarettes and smokeless tobacco in the United States. • This amount translates to more than $24 million each day, or about $1 million every hour. 33

The Economic Impact of Cigarette Smoking on the Poor in Jordan Amjad M. Toukan • Cigarette smoking prevalence is the highest among the poorest, with the highest rate (57%) being among adult males with an income of 100 to 250 Jordanian dinars per month as compared with the prevalence rate of 14% among adult males with an income of 500 Jordanian dinars or more per month. • The poorest 40% of adult males are 1. 7 times more likely to smoke cigarettes than the richest 17% of adult males. • The rate of smoking among Jordanian men was 47% in 2011, followed by 42% in Turkey and 39% in the West Bank and Gaza 34

The Economic Impact of Cigarette Smoking on the Poor in Jordan Amjad M. Toukan • • The average poorest adult male cigarette smoker with an income of 100 to 250 Jordanian dinars per month spends approximately 25 times more on cigarettes than on health, approximately 10 times more on cigarettes than on education, approximately 2. 5 times more on cigarettes than on housing, and approximately 1. 5 times more on cigarettes than on food. 35

Yearly expenditures per Jordanian smoker; actual and with monthly cigarette expenditures allocated across categories in 2010 in Mafraq and Amman. Mafraq was the poorest governorate in Jordan in 2010. Mafraq Amman. 36

The Economic Impact of Smoking • The costs of smoking can be classified into direct, indirect, and intangible costs. • About 15% of the aggregate health care expenditure in high-income countries can be attributed to smoking. • The economic burden of smoking estimated in terms of GDP reveals that smoking accounts for approximately 0. 7% of China’s GDP and approximately 1% of US GDP. • As part of the indirect (non-health-related) costs of smoking, the total productivity losses caused by smoking each year in the US have been estimated at US$151 billion. 37

The Economic Impact of Smoking • The costs of smoking notwithstanding, it produces some potential economic benefits. : • The economic activities generated from the production and consumption of tobacco provides economic stimulus. It also produces huge tax revenues for most governments, especially in high-income countries, as well as employment in the tobacco industry. • Income from the tobacco industry accounts for up to 7. 4% of centrally collected government revenue in China. • Smoking also yields cost savings in pension payments from the premature death of smokers. 38

The Economic Impact of Smoking • The cost per life year saved from the use of pharmacological treatment interventions ranged between US$128 and US$1, 450 and up to US$4, 400 per quality-adjusted life years (QALYs) saved. • Price-based policy measures such as increase in tobacco taxes are unarguably the most effective means of reducing the consumption of tobacco. • A 10% tax-induced cigarette price increase anywhere in the world reduces smoking prevalence by between 4% and 8%. • Net public benefits from tobacco tax, however, remain positive only when tax rates are between 42. 9% and 91. 1%. • The cost effectiveness ratio of implementing non-price-based smoking cessation legislations (such as smoking restrictions in work places, public places, bans on tobacco advertisement, and raising the legal age of smokers) range from US$2 to US$112 per life year gained (LYG) while reducing smoking prevalence by up to 30%– 82% in the long term (over a 50 -year period). 39

The Economic Impact of Smoking • School-based smoking prevalence programs tend to reduce short-term smoking prevalence by between 30% and 70%. The cost effectiveness of school-based programs show that one could expect a saving of approximately between US$2, 000 and US$20, 000 per QALY saved due to averted smoking after 2– 4 years of follow-up. • Workplace-based interventions could represent a sound economic investment to both employers and the society at large, achieving a benefit –cost ratio of up to 8. 75 and generating 12 -month employer cost savings of between $150 and $540 per nonsmoking employee. Implementing smoke-free workplaces would also produce myriads of new quitters and reduce the amount of cigarette consumption, leading to cost savings in direct medical costs to primary health care providers. Workplace interventions are, however, likely to yield far greater economic benefits over the long term, as reduced prevalence will lead to a healthier and more productive workforce. 40

The Economics of Smoking • One of the potential problems (from an economic perspective) with smoking is that there may be an externality in consumption, so there may be difference between the private and social optimal level of cigarette consumption. • Smokers might impose costs on persons who do not smoke (e. g. , second hand smoke and low birth weight in pregnant women) as well as society (e. g. , health risks of smoking might lead to higher health care utilization). 41

HOW TO CONTROL THE TOBACCO EPIDEMIC Tobacco control efforts should be focused on several fronts: 1. Preventing people from taking up tobacco consumption; 2. Promoting cessation 3. Protecting non-smokers from the exposure to tobacco smoke 4. Regulating tobacco products. 42

Tobacco control measures could be classified in various ways. WHO classifies interventions into two major groups, those aimed at reducing the demand for tobacco: 1. Price and tax measures 2. Protection from exposure to second-hand tobacco smoke 3. Regulation and disclosure of the contents of tobacco products 4. Packaging and labeling 5. Education, communication, training and public awarenessraising 6. Comprehensive bans and restriction on tobacco advertising, promotion and sponsorship 7. Tobacco-dependence cessation measures; 43

Tobacco control measures • Regulation option to try reduce smoking might include: – Warning labels on cigarette packaging highlight the dangers of smoking – Bans or restrictions on cigarette advertising – Bans on smoking in public spaces or indoors – Restrictions on sales of cigarettes (e. g. , must be a certain age to purchase cigarettes) – Regulation of ingredients in cigarette manufacturing (i. e. , reducing “tar” levels as discussed in Viscusi’s paper on the reading list) – There can be differences across countries in how they pursue these regulatory options. 44

Taxation is the most effective measure • Higher taxes induce quitting and prevent starting • A 10% price increase reduces demand by: – 4% in high-income countries – 8% in low or middle-income countries • Young people and the poor are the most price responsive 45

Raising Tobacco Taxes: A Critical Strategy • Significantly increasing the excise tax and price of tobacco products is the single most effective tool for reducing tobacco use. 10% PRICE INCREASE 5% 4% Decreased Consumption in LMICs Decreased Consumption in HICs Source: WHO report on the global tobacco epidemic, 2015 (Figure) 46

Regulation = taxes. • Alternative to regulation is taxes. • Can use taxes to make smokers take into account external costs and reduce their consumption of taxes • Revenues from taxes can sometimes be directed to at particular public projects. – As an example, gasoline taxes revenues are often used to build and maintain roads and highways. Since people who drive use the roads the fuel taxes can collect revenues who actually use the roads 47

Regulation = taxes • Can make a similar argument for smoking, taxes from cigarettes can be used to pay for the healthcare costs of smokers. • Another reason for taxing cigarettes is to reduce consumption of cigarettes. • Taxes can also be used for corrective purposes. (smoking is second hand smoke, non-smokers ) 48

Respond to taxes? ? • Complication, smokers can respond to taxes in other ways – Switch to discount brands (cost less than a premium brand) – Switch to different cigarettes (e. g. , a cigarette with more “tar” and nicotine) – Adjust how they smoke (e. g. , inhale, frequency) – Switch to smuggled cigarettes – Heated Tobacco Products/Vaping/E-cigarettes 49

Tobacco Control: Raising Taxes Key Economic Messages • Tobacco is debit to the economy • Tobacco control is cost-effective • Price increases most effective • tobacco tax does not govt revenue • tobacco tax does not smuggling • tax on other NCD risk factors (e. g. alcohol, certain foods); tax on vegetables? ?

Obstacles to Tobacco Control Lack of awareness of risk factors Preoccupation with other diseases Tobacco may not yet cause many deaths Focus on curative medicine, not prevention Smoking, alcohol, diet seen as personal behaviour Tobacco industry: promotion, distortion of health and economic evidence, financial might, challenge/threats to governments other industries not far behind • Tobacco tax revenue (but not debit) seen • Misperceived economic costs • Lack of funds for research and intervention • • • 51

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Giving up tobacco has some immediate and long-term health benefits: AFTER 20 Minutes • • Blood pressure and pulse drop to a normal rate • • Temperature of hands and feet increases to normal 8 Hours • • Carbon monoxide level in blood drops to normal • • Oxygen level in blood goes up to normal 24 Hours • • Chance of heart attack starts going down 48 Hours • • Nerve endings start growing again • • Ability to smell and taste begins to improve 54

Giving up tobacco has some immediate and long-term health benefits: 2 Weeks to 3 Months • • • Circulation improves • Walking gets easier • Lung function improves up to 30% “I can talk again when I walk up stairs!” “It’s great to not have to clear my throat all the time. ” 1 Month to 9 Months • • Coughing, sinus congestion, tiredness and shortness of breath decrease • • Cilia (small hairs) grow back in lungs to better handle mucous, clean the lungs and reduce infection • “I’ve missed so much less work because I get fewer colds and sore throats. ” • “It’s such a relief to not be bogged down with those headaches. ” 55

Giving up tobacco has some immediate and long-term health benefits: 1 Year • • Risk of coronary artery disease is half that of a smoker • “I’m not scared by heaviness in my chest in the morning anymore. ” 5 Years • • Lung cancer death rate goes down by one half • • Risk of stroke becomes same as non-smoker • • Risk of cancer of the mouth, throat, oesophagus, bladder, kidney and pancreas goes down • In addition: If you have a chronic illness like diabetes, asthma or kidney failure, quitting can • dramatically improve your health. • Source: http: //www. quittobacco. org/ 56

Economic Benefits of Smoking Cessation • The economic benefits of smoking cessation are characterized as costs to an individual, family, or economy that are eliminated or reduced because a smoker stops buying and smoking cigarettes • In some low-income countries, the poorest households spend 10%– 15% of their income on tobacco 57

Economic Benefits of Smoking Cessation • The cost of lost productivity—lost wages and contributions to household activities—as a result of illnesses • In the United States, each smoker incurs an estimated additional US$ 1, 623 in excess medical expenditures and US$ 1, 760 in lost productivity annually 58

9 Major Conclusions 1. The global health and economic burden of tobacco use is enormous and is increasingly borne by LMICs. 2. Failures in the markets for tobacco products provide an economic rationale for governments to intervene in these markets. 3. Effective policy and programmatic interventions are available to reduce the demand for tobacco products and the death, disease, and economic costs that result from their use, but these interventions are underutilized. 4. Policies and programs that work to reduce the demand for tobacco products are highly cost-effective. 59

9 Major Conclusions (continued) 5. Control of illicit trade in tobacco products, now the subject of its own international treaty, is the key supply-side policy to reduce tobacco use and its health and economic consequences. 6. The market power of tobacco companies has increased in recent years, creating new challenges for tobacco control efforts. 7. Tobacco control does not harm economies. 8. Tobacco control reduces the disproportionate burden that tobacco use imposes on the poor. 9. Progress is now being made in controlling the global tobacco epidemic, but concerted efforts will be required to ensure that progress is maintained or accelerated. 60

Median Price of a Pack of Cigarettes, by Country Income Group, 1990– 2011 Notes: Using the official exchange rate, the prices of local brands of cigarettes, as collected by the Economist Intelligence Unit, were converted to U. S. dollars (not adjusted for inflation). Countries were discarded from the dataset if more than approximately one-third of the time series data were missing, if the country experienced a serious bout of hyperinflation or introduced a new currency, or if price data were so unstable over time that they were simply not credible. With these countries removed, the subsequent analysis was performed on 40 countries. Data were collected from large urban areas and may not reflect the full range of prices within the country. Source: Economist Intelligence Unit 2012. 61

Effective Interventions ü Information ü Health warnings on tobacco products ü Comprehensive bans on ALL advertising and promotion ü Smoking bans in public places (including work places) ü Cessation support 62

What about Smuggling? • More smuggling if : – Public is tolerant – Controls are weak – corruption in the country is high – tobacco industry is complicit – organized crime plays a big role 63

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What social and economic problems are linked to alcohol use? • How can work performance be affected by alcohol consumption? • How can the family be affected by alcohol consumption? • What is the link between alcohol and poverty? • What is the link between alcohol and violence between partners? • What are the estimated economic and social costs? 65

How can work performance be affected by alcohol consumption? Alcohol consumption can affect work performance in several ways: • Absences - There is ample evidence that people with alcohol dependence and drinking problems are on sick leave more frequently than other employees, with a significant cost to employees, employers, and social security systems. estimated 30% of absenteeism may be due to alcohol. • Work accidents - In Great Britain, up to 25% of workplace accidents and around 60% of fatal accidents at work may be linked to alcohol. In India about 40% of work accidents have been attributed to alcohol use. • Productivity - Heavy drinking at work may reduce productivity. 10% of productivity losses are attributed to alcohol. Performance at work may be affected both by the volume and pattern of drinking. • Unemployment- Heavy drinking or alcohol abuse may lead to unemployment and unemployment may lead to increased drinking. 66

How can the family be affected by alcohol consumption? • • Drinking can impair how a person performs as a parent, a partner as well as how (s)he contributes to the functioning of the household. It can have lasting effects on their partner and children, for instance through home accidents and violence. Children can suffer Fetal Alcohol Spectrum Disorders (FASD), when mothers drink during pregnancy. After birth, parental drinking can lead to child abuse and numerous other impacts on the child’s social, psychological and economic environment. The impact of drinking on family life can include substantial mental health problems for other family members, such as anxiety, fear and depression. Drinking outside the home can mean less time spent at home. The financial costs of alcohol purchase and medical treatment, as well as lost wages can leave other family members destitute. When men drink it often primarily affects their mothers or partners who may need to contribute more to the income of the household and who run an increased risk of violence or HIV infection. 67

What is the link between alcohol and poverty? • The economic consequences of alcohol consumption can be severe, particularly for the poor. • Apart from money spent on drinks, heavy drinkers may suffer other economic problems such as lower wages and lost employment opportunities, increased medical and legal expenses, and decreased eligibility for loans. A survey in Sri Lanka indicated that for 7% of men, the amount spent on alcohol exceeded their income. 68

What is the link between alcohol and violence between partners? • Alcohol plays a role in a substantial number of domestic violence incidents, especially in the case of abusing husbands. Often both the offender and the victim have been drinking. • Studies conducted for instance in Nigeria, South Africa, Uganda, India, and Colombia show that a large fraction of reported domestic violence incidents is related to alcohol use by the male partner. For instance, in Uganda, 52% of the women who recently experienced domestic violence reported that their partner had consumed alcohol, and in India, 33% of abusing husbands were using alcohol. 69

What are the estimated economic and social costs? • • • Alcohol abuse can cause social and economic problems Social and economic costs cover the negative economic impacts of alcohol consumption on the material welfare of the society as a whole. They comprise both direct costs - the value of goods and services delivered to address the harmful effects of alcohol, and indirect costs - the value of personal productive services that are not delivered as a consequence of drinking. In industrialized countries, estimates of social and economic costs of alcohol use can reach several percent of the Gross Domestic Product (GDP), ranging for instance from 1. 1% in Canada to 5 -6% in the case of Italy. 70

Different cost categories related to alcohol use: Direct Costs • 1. Hospitalization • 2. Physician visits • 3. Crime related costs (to include public criminal justice system cost, corrections, private expenditure for legal defence, value of property destroyed in crimes due to alcohol abuse) • 4. Motor vehicle crashes (to include legal and court proceedings, insurance administration, accident investigation, vehicle damage and traffic delay) • 5. Nursing home stay 71

Different cost categories related to alcohol use: Direct Costs • 6. Property and forest fires (only include damage and cleaning of damaged goods; consequent injuries and deaths are excluded in this category) • 7. Specialty institutions (to include treatment centres other than hospitals and alcohol correctional facilities) • 8. Professional services other than physicians (eg: psychologists, social workers, nurses, physical and occupational therapists, pharmacists, technicians, etc. ) • 9. Prescription drugs for treatment • 10. Medical and health services research • 11. Programme administration (including alcohol-related programmes and • social welfare programmes) • 12. Administrative costs of private insurance to treat alcohol disorders • 13. Direct costs related to AIDS due to drug abuse not included elsewhere • 14. Costs of alcohol • 15. Prevention programmes (screening, education programmes and mass media campaigns to inform public about the hazards of alcohol abuse) 72

Different cost categories related to alcohol use: Direct Costs • 16. Ambulance costs (including total costs of transportation) • 17. Training costs for physicians and nurses • 18. Fetal alcohol syndrome including extra neonatal care • 19. Customs and immigration • 20. Home care • 21. Household help (care of house) • 22. Counseling, retraining and re-education • 23. Special equipment for rehabilitation (e. g. wheel chair) • 24. Employee assistance programs • 25. Avoidance behavior costs • 26. Group life insurance 73

Different cost categories related to alcohol use: Indirect Costs • 1. Morbidity costs: income loss due to alcohol abuse • 2. Alcohol-related productivity loss • 3. Mortality costs: present value of life-time earnings • 4. Foregone consumption 74

Different cost categories related to alcohol use: Intangible Costs • 1. Homelessness • 2. Pain and suffering of victims and rest of the community • 3. Value of lost life to the deceased (estimated by willingness to pay to avoid death) • 4. Loss of consumption by prematurely deceased • 5. Alcohol abuse-related pain and suffering • 6. Family disruptions • 7. Community disruptions 75

1980/1981 1976/1977 1972/1973 1968/1969 1964/1965 1960/1961 Excise tax on beer and spirits, Rand per litre of pure alcohol, constant 2009/10 prices Financial year Cigarettes (secondary axis) Beer Real excise tax on beer, spirits and cigarettes, 1960 -2013 200 10 180 9 160 8 140 7 120 6 100 5 80 4 60 3 40 2 20 1 0 0 Excise tax per pack of 20 cigarettes, constant 2009/10 prices 2012/2013 2008/2009 2004/2005 2000/2001 1996/1997 1992/1993 1988/1989 1984/1985 Excise taxes on alcohol and tobacco Spirits 76

Illicit and ‘informally produced’ alcohol • 27% alcohol consumption worldwide unrecorded (WHO) • varies across the world: o slovenian wine mainly unrecorded o one-third consumption in Russia unrecorded o two-thirds consumption in India , , o 90% consumption in East Africa , , • average Ukranian consumes 8 litres unrecorded alcohol per annum 77

DALYs lost attributable to 10 leading risk factors for the age group 15– 59 years in the world, 2004 WHO Global Status Report on alcohol and health 2011 78

patterns of drinking and harm Binge drinking • The consequences of getting drunk: • Violence, accidents • STD’s, sexual mishaps Regular drinking • the consequences of repeated heavy exposure • Cirrhosis • Other physical damage • Psychosocial harms But note that these patterns are not mutually exclusive 79

Liver cirrhosis mortality rates in Europe • up to 20 -fold differences between countries (range 4/100, 000 for Icelandic males, 75/100, 000 for Hungarian males) • rates tend to be much higher in East than West Europe, particularly in under 45 years • male female ratio across countries very constant, men being 2 -3 x higher • liver mortality correlates with other alcohol- related deaths, especially in <45 yr age group 80

Why is alcohol such a large health inequalities issue? • Mean consumption across the social scale similar • Is it under-reporting? • Is it another factor eg obesity? • Is it the distribution of drinking patterns? 81

Alcohol control policies • • taxation and price regulation regulating marketing regulating availability providing information and education managing the drinking environment reducing drink-driving brief interventions and treatment 82

Final thoughts…. . • Alcohol use is Illlllllegal and firmly embedded in our society and will remain so. • The cardiovascular benefits, if real, are seen at very low consumption levels, affect only the middle aged + and are not a reason for nondrinkers to drink • Health and other harms are a major societal issue and are not confined to those who obviously misuse alcohol. • We need to better understand the links to low socio-economic status 83

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