Public Health Measures and Prevention of Alcohol-Associated Liver Disease

Abstract

Hazardous alcohol consumption causes approximately 4% of deaths globally, constituting one of the leading risk factors for the burden of the disease worldwide. Alcohol has several health consequences, such as alcohol-associated liver disease, hepatocellular carcinoma, nonliver neoplasms, physical injury, cardiac disease, and psychiatric disorders. Alcohol misuse significantly affects workforce productivity, with elevated direct and indirect economic costs. Due to the high impact of alcohol consumption on the population, public health has led to the development of a range of strategies to reduce its harmful effects. Regulatory public health policies (PHP) for alcohol can exist at the global, regional, international, national, or subnational levels. Effective strategies incorporate a multilevel, multicomponent approach, targeting multiple determinants of drinking and alcohol-related harms. The World Health Organization categorizes the PHP into eight categories: national plan to fight the harmful consequences of alcohol, national license and production and selling control, taxes control and pricing policies, limiting drinking age, restrictions on alcohol access, driving-related alcohol policies, control over advertising and promotion, and government monitoring systems. These policies are supported by evidence from different populations, demonstrating that determinants of alcohol use depend on several factors such as socioeconomic level, age, sex, ethnicity, production, availability, marketing, and others. Although most policies have a significant individual effect, a higher number of PHP are associated with a lower burden of disease due to alcohol. The excessive consequences of alcohol constitute a call for action, and clinicians should advocate for developing and implementing a new PHP on alcohol consumption.

Human alcohol consumption dates to antiquity, yet it is an inherent fact of modern-day life. However, alcohol use is estimated to cause approximately 4% of deaths globally, constituting a major factor for morbimortality.¹ Furthermore, scientific research regarding alcohol problems has yielded substantial advances in understanding alcohol-related conditions during the past 30 years.² The epidemiologic role of alcohol in public health has led to developing a range of strategies to reduce its harmful effects. These strategies are difficult to implement, as alcohol also holds an important place in the economy, hindering the efforts to address the problem significantly. Nevertheless, the cumulative evidence has made it clear that alcohol has a major contribution to the global burden of disease and generates substantial economic costs in human resources. Countries are estimated to spend more than 1% of their gross domestic product (GDP; adjusted by purchasing power) on economic costs attributable to alcohol.³ Cost-effective, affordable, scalable, and evidence-based interventions to restrict harm exist and could be promoted by any healthcare professional. This review explores how these strategies are implemented and the evidence that encourages their development worldwide.

Impact of Harmful Alcohol Consumption

Globally, the estimated alcohol per capita consumption was 6.4 L in 2016, having risen notably during the last years.⁴ Hazardous alcohol consumption is a leading risk factor for disease burden and constitutes the seventh leading risk factor for disability-adjusted life years (DALYs) worldwide.^5,6 Thus, hazardous alcohol consumption causes approximately 3.3 million deaths globally per year, and its related DALYs have increased by more than 25% from 1990 to 2016.^1,5 There are several striking health consequences attributable to alcohol consumption, including alcohol-associated liver disease (ALD), hepatocellular carcinoma, nonliver neoplasms, cardiac disease, and psychiatric disorders such as depression and suicide.7, 8, 9, 10 Alcohol misuse has been widely linked to physical injury, explaining 19.6% of physical injuries based on self-report, 16.4% from estimated blood alcohol concentration (BAC) in breath samples, and 25.7% from BAC in blood specimens.¹¹

Excessive alcohol consumption has direct economic consequences due to the loss of workforce productivity, absenteeism, injury, early retirement, mortality, and the direct health care cost derived from pathologies associated with it.¹² Unfortunately, a major proportion of people affected by alcohol are in the most productive years of their lives. Costs related to alcohol consumption were estimated at 125 billion Euros in the European Union in 2003 and 249 billion dollars in the United States (USA) in 2010 (accounting for 1.3% and 3.3% of the GDP, respectively).⁵ The interventions to decrease alcohol consumption might positively impact the world economy. For example, Japan estimated that reducing high-risk drinkers would have a huge economic impact on costs (direct or indirect) attributable to alcohol, saving 1.4 billion United States dollars (USD).¹³

Alcohol has several chronic consequences on the liver, ranging from isolated steatosis to decompensated cirrhosis.¹⁴ To date, half of the cirrhosis cases are attributable to alcohol consumption worldwide.¹ High alcohol intake can cause alcohol-associated hepatitis, which is also one of the leading causes of acute-on-chronic liver failure (ACLF).^15,16 Globally, in 2017, 27.3% of cirrhosis deaths were caused by ALD in males, and 20.6% in females.¹⁷ ALD mortality is increasing in some areas, including the United States, Eastern Europe, and central Asia.^17,18 Since most of the damage is cumulative, cessation of alcohol abuse could significantly impact liver diseases. Alcohol abstinence decreases mortality and constitutes one of the best predictors of survival in ALD and AH.^14,19 In addition, recent evidence suggested that the unique level of consumption that minimizes health consequences is zero consumption.²⁰

Several characteristics and conditions could increase the risk of health consequences from alcohol misuse, including ethnicity, sex, and income level, among others. Regarding race and genetic polymorphisms, one of the most studied is the Patatin-like Phospholipase Domain-containing 3 (PNPLA3) rs738409 polymorphism, which contributes to the development of ALD and is more frequent in individuals with Native American ancestry.^21,22 Although men have a higher harmful alcohol use prevalence, women are more susceptible to the effects of alcohol.²³ Even with the same levels of alcohol intake, the risk of cirrhosis is double in women than in men.²⁴ Also, a recent study using population-based data from the USA demonstrated that women and Hispanic patients have more ALD-related burden and a higher risk of ACLF.²⁵ Several mechanisms could explain this susceptibility, including a relatively higher fat mass and lower gastric alcohol dehydrogenase activity compared to men.^26,27 An additional element to consider is the “alcohol harm paradox,” in which alcohol consumption, alcohol use disorder (AUD) prevalence, and ALD are positively associated with a higher socioeconomic status.²⁸ Thus, high-income individuals have higher levels of alcohol consumption, prevalence of ALD and AUD than low-income individuals. However, both alcohol-related and alcohol-attributable deaths occur more often among disprivileged socioeconomic groups than populations from more affluent areas.²⁹ This “paradox” has several potential mechanisms, including higher exposure to alcohol, frequent binge drinking episodes, consumption of formulations with higher alcohol content, beverages of poorer quality containing toxic substances (like formaldehyde and methanol), as well as harmful drinking patterns (e.g., having started drinking at a younger age and family history of consumption).28, 29, 30, 31, 32 Other factors such as malnutrition, poorer education, health literacy, and access to healthcare facilities also influence this phenomenon.^33,34 Alarming evidence has demonstrated increased alcohol misuse in high-risk groups (including women) during the last years.³⁵ Therefore, adequate public health policies (PHP) to address the consequences of harmful alcohol consumption are urgently needed.³¹

Public Policies on Alcohol Consumption

Regulatory PHP for alcohol can exist at the global, regional, international, national, or subnational levels. Effective strategies incorporate a multilevel, multicomponent approach, targeting multiple determinants of drinking and alcohol-related harms.¹ PHP for alcohol can also interact with other public policies (i.e., hypertension, diabetes, obesity, among others), which might impact the overall burden of liver disease.³⁶ The World Health Organization (WHO) has persistently called on countries to generate preventive policies and measures to reduce alcohol consumption and its associated damage.¹ In 1996, the WHO developed the Global Alcohol Database, including data about alcohol misuse and policies worldwide. The gathered information has been published in a comprehensive report called Global Status Report on Alcohol, and the latest version was released in 2018. The WHO categorizes the PHP into eight categories in this report, including (1) National plan to fight the harmful consequences of alcohol, (2) National license and production and selling control, (3) Taxes control and pricing policies, (4) Limiting Drinking age, (5) Restrictions to alcohol access, (6) Driving-related alcohol policies, (7) Control over advertising and promotion, and (8) Government monitoring systems (Figure 1 and Table).

Figure 1.

Different public health policies to decrease alcohol-attributable health consequences.

Table.

Different Public Policies to Decrease Alcohol Consumption and Its Harmful Consequences and Their Implementation Rate per Continent in 2016.

Intervention	Efficacy	Implementation rate (%)
1. National plan to fight the harmful consequences of alcohol	-An ecological study showing the strongest association with lower ALD mortality and AUD.39 -However, it is one of the less implemented public policies worldwide. -Existent frameworks can be easily adopted by countries without a national plan.	Europe 35/46 (76%) Asia 23/33 (70%) Oceania 3/5 (60%) Africa 20/50 (40%) America 10/35 (29%)
2. National license for the control of production and selling of alcohol	-The control of the sellers is an effective way of enforcement. -This can be done through government monopolies, by enforcing minimum purchase age, and through the regulation of density of outlets, and limiting days and hours of sale.46,85	Asia 32/33 (97%) America 31/35 (89%) Africa 44/50 (88%) Europe 37/46 (80%) Oceania 4/5 (80%)
3. Taxes control & pricing policies for alcohol products	-A rise in alcohol prices leads to lesser alcohol consumption and alcohol-related harm (independent of income level).46,54 -Excise tax also increases government revenue, which can be used to treat alcohol-related health consequences. -Caution should be taken in countries with illegal production. -Setting minimum prices can also reduce acute and chronic harms.56	Europe 45/46 (98%) Asia 32/33 (97%) America 32/35 (91%) Africa 45/50 (90%) Oceania 4/5 (80%)
4. Limiting drinking age	-Alcohol consumption early in life has been shown to predict the development of cirrhosis in adults. -A drinking age rule might decrease the development of cirrhosis.64	Europe 46/46 (100%) America 31/35 (89%) Asia 29/33 (88%) Africa 43/50 (86%) Oceania 4/5 (80%)
5. Restrictions to alcohol access	-Regulation based on the time of sales and times of alcohol consumption could reduce incidents related to alcohol consumption, crimes, emergency visits, and homicides.89	Europe 42/46 (91%) Asia 30/33 (91%) America 30/35 (86%) Africa 42/50 (84%) Oceania 3/5 (60%)
6. Driving-related alcohol policies	-Most widely implemented. -Effective drunk-driving policies have many benefits, and have more effectiveness if there is widespread public support for their implementation.75	Asia 33/33 (100%) Europe 46/46 (100%) Africa 48/50 (96%) America 32/35 (91%) Oceania 4/5 (80%)
7. Control over advertising and promotion of alcohol products	-It is suitable for all countries to decrease alcohol intake. -Several studies showed that these policies do not prevent marketing content that affects young people.72,75	Asia 31/33 (94%) Europe 43/46 (93%) Africa 33/50 (66%) America 19/35 (56%) Oceania 2/5 (40%)
8. Government monitoring systems	-Detection of individuals at risk. Brief advice is the most effective evidence-based treatment method.46 -Government oversight must exist to ensure that producers and consumers adhere to them. -A public health infrastructure to implement policies found effective in reducing alcohol-related harms.82	Europe 44/46 (96%) America 32/35 (91%) Asia 27/33 (82%) Oceania 3/5 (60%) Africa 28/50 (56%)

Data were obtained from the WHO Global Status Reports on Alcohol in 2018.

Abbreviations: ALD, Alcohol-Associated Liver Disease; AUD, Alcohol Use Disorder.

There are only a few well-designed studies assessing the impact of PHP on the burden of alcohol and ALD.³⁷ Although most studies evaluated the decrease of alcohol consumption as a mediated outcome since the development of ALD requires long-term alcohol exposure, PHP to decrease alcohol intake could also impact the burden of ALD. Some studies have shown that implementing PHP may reduce alcohol-associated mortality.³⁷ In particular, a recent modeling study from the USA evidenced that under the current conditions, deaths due to ALD are expected to increase from 8.2 to 15.2 per 100,000 person-years in 2040.³⁸ Even under a moderate intervention scenario, deaths would increase up to 14.5 per 100,000 person-years. Therefore, only under a strong intervention scenario would the number of deaths peak and then decrease to 7.6 per 100,000 person-years in 2040.³⁸

The number of policies implemented is not trivial since alcohol consumption and its health consequences are influenced by many factors, including access to alcohol, socioeconomic status, alcohol price, and psychiatric comorbidities. Thus, the development and implementation of different categories of alcohol-related PHP at the same time could have a higher benefit in countries.³⁹ In fact, a recent ecological study, including 20 Latin-American countries, demonstrated that the establishment of PHP on alcohol consumption is strongly associated with lower mortality due to ALD and AUD prevalence.³⁹ The global implementation and evolution of alcohol-related PHP between 2010 and 2016 are summarized in Figure 2. Since some policies could have a higher impact on alcohol consumption and ALD, we will review the individual evidence for each category of policies in the following sections.

Figure 2.

Development of alcohol-related public health policies worldwide in 2010 (A) and 2016 (B). Data were obtained and categorized from the WHO Global Status Reports on Alcohol in 2014 and 2018. Countries in gray did not have information available.

National Plan to Fight Harmful Consequences of Alcohol Consumption

The development of a written national alcohol policy is one of the most critical indicators of a country’s commitment to reducing health consequences due to alcohol. These policies could be established as separate documents or included in a broader PHP and should have clear responsibilities, objectives, strategies, and targets.¹ In the last WHO Global status report, 46% of responding countries had written national alcohol policies (up to 2016). In addition, 6% of responding countries had a total ban on alcohol.¹ Although written national alcohol policy has been one of the less implemented PHP worldwide, it showed the strongest association with lower ALD mortality and AUD in a recent ecological study.³⁹

Countries vary in how they implement and commit to strategies against harmful alcohol use. One example is Russia; once the highest consumer of alcohol globally, it managed to increase its life expectancy from 57 years in 1994 to 68 years for men and 78 years for women. This was accomplished in a 20-year-period in which marketing restrictions, monitoring alcohol production, a ban on internet alcohol sales, and a 50% tax increase on ethyl alcohol were implemented with great success.⁴⁰

Another example is Chile, which has a long history of harmful alcohol use, and this is deeply tied to its economy and cultural and historical heritage.⁴¹ In this case, models were used to examine the social factors that contribute to this problem.⁴² For example, they address cultural aspects, like advertisements, alternative recreational activities, and social inequalities. It also attempts to focus on vulnerable populations like teenagers and pregnant women. This, coupled with economic strategies (such as taxation), may prove to have a more profound impact on harmful alcohol use.⁴³

Australia is also a country with an unhealthy culture of intoxication. This was worsened by active lobbying to liberalize alcohol licensing, advertising, and drinking normalization. In this case, the most successful strategy was drunk-driving countermeasures. They set a low BAC limit for drivers (0.05% and zero for probationary drivers), enforcing strict penalties for breaches of the law and mounting a successful social marketing campaign that countered normalization by stigmatizing drunk driving.⁴⁴ It also reduced trading hours for licensed venues and the density of alcohol outlets, particularly in disadvantaged neighborhoods. These benefits are decreasing domestic violence and chronic disease.⁴⁵ Australia has also implemented community interventions, including a levy on alcoholic beverages with more than 3% alcohol to fund education, increased alcohol availability control, and expanded treatment and rehabilitation services.⁴⁶ This intervention significantly reduced acute alcohol-related deaths mainly due to the tax levy.⁴⁷

One particularly interesting approach was carried out in Canada, which studied the implementation of “Safer Bars” programs. These establishments offer “responsive beverage service” aimed at preventing intoxication and underage drinking.⁴⁸ Studies of patients with violence-related injuries generally presented higher prevalence estimates for alcohol use (varying from 29.6% to 51.2%, with a mean average of 41%) than those covering unintentional injuries (7%–32.8%, with a mean average of 19.4%), regardless of the measure used to estimate alcohol use.¹¹ Furthermore, there is evidence for a dose–response relationship between increased amounts of alcohol consumed and the risk of injury, which rises even with low levels of drinking.⁴⁹ In this context, a study that examined the implementation of “Safer Bars” programs showed a 34% reduction in violence and aggressive behavior and a decrease in 3.4% of violent crimes.^48,50

Finally, multilateral accords have been made to establish a framework for action in individual nations. In 2006, 37 countries of the WHO Western Pacific Region endorsed a regional strategy to reduce alcohol-related harm.⁵¹ The welfare sector led it; however, education, finance, transportation and traffic, public order, and law enforcement are essential.³ Core measures were: raising awareness and advocacy about alcohol-related harm, regulation of alcohol marketing, BAC limits for driving and random breath testing, encouraging law-enforcement sector responses to alcohol-related crime, regulating accessibility and availability through production and sales, taxation, and development of nationally appropriate alcohol policies, among others.

Taxes Control and Pricing Policies

Alcohol has an important role in many markets, and worldwide trade policies have accelerated its expansion in all levels of commerce, leading to an increase in availability, affordability, and marketing.⁵² Although harmful use of alcohol causes a substantial economic burden to societies, including criminal justice costs, health care expenses, and lost productivity, the world trade organization has not recognized alcohol as a health-damaging product.³ Furthermore, many trade agreements have excluded alcohol from their scope of action. This may be, in part, due to the influential lobby that favors fewer effective strategies, such as campaigning against driving while under the influence of alcohol and programs against drinking by minors.⁵³ This is why tax regulations and pricing policies are, for the time being, one of the best courses of action to control the alcohol-attributable health consequences.

Prior studies have shown that taxation reduces acute and chronic alcohol-related harms.^54,55 There are several strategies with strong empirical support for their impacts on consumption and related harms, including (1) Alcohol volumetric tax (AVT) are applied comprehensively across all-beverage types at a rate per unit of pure alcohol, and this results in drinks with higher alcohol content being more expensive; (2) Per unit of alcohol and indexed to inflation tax rates, which are applied to ensure that their real values do not erode over time; (3) “Floor” or minimum prices are set, also at a rate per unit of pure alcohol, to restrict the availability of cheap and high strength alcohol.⁵⁶ Unfortunately, in many countries excise tax rates and pricing do not follow these principles.

Public health experts and economists recommend a stepwise approach to initiate alcohol control, starting with taxation. Excise tax graded by volume of ethanol and inflation-adjusted taxes is among the first strategies.³ These strategies are also more effective if they are supported by international agreements. In the example stated above, 37 countries of the western Pacific region endorsed strategies to reduce alcohol-related harm. In terms of alcohol-specific taxes, it included recommendations for regulating alcohol marketing, accessibility, and availability through taxation.¹

Taxation has other benefits; for example, it can be reused to fund other alcohol-related programs. In Thailand, a 2% earmarked tax on alcohol and tobacco was used to support the Thai Health Promotion Foundation.⁵⁷ This can be complemented with strategies such as taxation scaled according to the alcohol content, adjusted by inflation. This strategy has shown to be particularly beneficial in slowing the recruitment of young drinkers with long-term health gains.⁴⁶ It has also been shown to affect rates of cirrhosis mortality, motor vehicle deaths, and violent crime.² An example of this is Australia, where a study found that after the varying nominal rates of tax were introduced for beer products according to three alcohol content levels, the higher tax rates showed a decrease in consumption.⁵⁸ However, this approach can be ineffective in countries where non-taxed (illegal or informal) alcohol markets are not adequately regulated.

Optimally this would also be complemented with increases in minimum price to reduce affordability, restrictions on packaging, product design, and marketing. Consumption of alcohol is responsive to price. For example, in the United Kingdom, a change in tax, accompanied by a price increase of 10% would be expected to diminish consumption by 4.8- 13.1%.^2,59 Taxation and price increases have been shown to decrease violent offenses and suicides, increase traffic safety outcomes, rates of sexually transmitted diseases, and other drug use.⁶⁰ Overall, in most countries, taxation is a cost-effective way to impact alcohol use positively. Furthermore, this impact can directly improve health outcomes.⁶¹

One element to note is how alcohol is taxed. A study-of taxation data from Canada-modeled effects of alternative price and tax policies: revenue-neutral taxes, inflation-adjusted taxes and minimum unit prices (MUPs); on consumption revenues and harms.⁶² The results showed that other things being equal, revenue-neutral AVT would have minimal influence on overall alcohol consumption and related harms, but an inflation-adjusted AVT would result in 3.8% less consumption, fewer death, and hospital admissions. One study showed that the Canadian government lost substantial revenue over recent decades by not indexing alcohol excise taxes to the cost of living, between 1985 and 2017, with attendant negative impacts on public health.⁶²

Drinking Age and Youth Focus Policies

One truism of alcohol use is that consumption at an early age is an important risk factor for its harmful effects and persistence over time.^61,63 Alcohol consumption early in life has been shown to predict the development of cirrhosis in adults, so reducing early consumption could theoretically decrease the prevalence of cirrhosis.⁶⁴ In global reports on alcohol and health, 27% of all population between 15 and 19 years old are current drinkers. This percentage is higher in the European region (44%). Moreover, school surveys indicate that in many countries, alcohol use starts early in life, before 15 years old. For example, data from countries like New Zealand that show heavier consumption in younger groups are worrisome (9.8 L in the last six months for 18 to 19 years compared to 6.9 L in 25 to 34 years). Furthermore, young drivers are more vulnerable to the risk of a drunk-driving-related accident due to inexperience. Therefore, BAC restrictions for young drivers under 21 years old should be implemented.⁶⁵ For instance, many studies have shown that increasing the minimum drinking age reduces 8%–24% of fatal drunk-driving-related deaths and 6% of non-fatal motor vehicle injuries.^46,66 Other strategies include “responsive beverage service.” ⁴⁸ As stated before, these are measures that aim to provide safer drinking experiences in bars and restaurants by avoiding underage drinking and intoxication.⁵⁰ A systematic review conducted in 2007 showed that parenting interventions that most effectively reduce their children’s alcohol consumption appear to be those that actively involve parents and emphasize social skills or personal responsibility amongst young people.⁶⁷

It is important to note that not all strategies are equally effective. Many systematic reviews have assessed school-based education programs and concluded that classroom-based education is ineffective or is a scarcely effective intervention to reduce alcohol-related harm.^68,69 Worryingly, the most robust evidence is the effect of alcohol marketing. Longitudinal studies show that exposure to alcohol advertising in traditional media impacts youth drinking patterns.^70,71 These effects are cumulative, and in markets with greater availability of alcohol advertising, young people are likely to continue to increase their drinking as they move into their mid-20s. In contrast, drinking decreases at an earlier age in people who are less exposed to it. Furthermore, evidence has shown that since alcohol marketing relies on self-regulation, these voluntary systems do not prevent marketing content from affecting young people.⁷²

Driving-Related Alcohol Policies

Several strategies can influence drunk-driving-related problems. This may include increasing prices of alcohol, minimum purchase age laws, and outlet density, supported by mass media campaigns.⁷³ The implementation of effective drunk-driving policies has many benefits and has more effectiveness if there is widespread public support for their implementation.⁷⁴

In particular, the introduction and reduction of alcohol concentration in the blood have shown to be effective in reducing drunk-driving casualties. A meta-analysis of nine studies in the USA reported that implementing a legal concentration of 0.8 g/L of alcohol in the blood resulted in a 7% decrease in alcohol-related motor vehicle fatalities.⁷⁵ Another strategy is sobriety checkpoints and unrestrictive (random) breath testing. In a meta-analysis of 23 studies, it showed to be effective in reducing alcohol-related injuries and fatalities in fatal crashes, reducing them by 23% after the introduction of sobriety checkpoints and by 22% after random breath testing.⁶⁶ Intensive random breath-testing, via regular police, stops for drivers at random to check the concentration of alcohol in their blood, and sobriety checkpoints, at which all vehicles are stopped, and drivers suspected of drunk-driving are breath tested, reduces alcohol-related injuries and fatalities.⁴⁶

Although restrictions on young or inexperienced drivers (by lowering concentrations of alcohol in blood for novice drivers) have less evidence, they have shown positive results. A systematic review of three studies showed that lowering BAC reduced up to 24% of fatal accidents.⁶⁶ Concerning this, a meta-analysis of 215 assessments of remedial programs and mandatory treatment for drivers caught over the limit noted the reduction of recurrence of alcohol-impaired driving offenses and alcohol-related accidents by 8–9%.⁷⁶ A more technical-based approach is alcohol locks. A systematic review of one randomized controlled trial and 13 controlled trials noted that interlock participants had a lower recurrence of offenses than did controls; however, this effect was not sustained once the interlock was removed.⁷⁷ Finally, a systematic review of nine studies did not demonstrate the effectiveness of designated driver and safe-ride programs.⁶⁸

Control Over Advertising and Promotion

Mainstream media has a strong effect on the cultural perception of alcohol and its harms. More so, alcohol is marketed through new and sometimes unregulated forms of advertising. For example, product placements link alcohol brands to sports and cultural activities through sponsorship.^46,78 Furthermore, new forms of media, such as YouTube, significantly impact youths. One study found alcohol imagery appeared in 45% of all videos.⁷⁸ Although direct marketing may be regulated, many of these, such as the internet, podcasting, and mobile telephones, may have important legal loopholes.⁷⁹ This is important as young people consume more internet-based media. As stated before, the strongest evidence linking alcohol consumption and advertising shows that it affects the initiation of youth drinking and riskier patterns.^70,71

In some countries, alcohol marketing relies on self-regulation implemented by economic operators; however, these may include advertising, media, and alcohol producers. Evidence from several studies shows that these voluntary systems do not prevent marketing content that affects young people.⁷² A cross-sectional study from 16 countries suggested that nations with higher detrimental drinking patterns and greater acceptance of heavy alcohol consumption were more likely to have increased rates of alcohol-related injuries.⁸⁰

Researchers and legal experts have proposed that an international alcohol marketing code could be developed, with the global Framework Convention on Alcohol Control as a platform for a nonbinding accord for WHO Member States.⁸¹ An international alcohol marketing code could address the promotion of alcoholic products to the public, advertising at the point of sale, and product labels. This could also help limit the promotion of alcohol to specific media, restrictions on alcohol sponsorship (i.e., at public events such as festivals), and restrictions on product placement of alcohol in movies and shows.⁸²

On the other hand, counter-advertising has little scientific research and inconclusive results.⁸³ It is a variant of public information campaigns that provide information about a product, its effects, and the industry that promotes it to decrease its appeal and use.⁸³ Furthermore, no rigorous assessments of whether or not publicizing drinking guidelines have any effect on alcohol-related harm have been done.

Restrictions to Alcohol Access, National License, Production, and Selling Control

The greater availability of access to alcohol purchase is an essential environmental determinant for the greater consumption of this and alcohol-related harm as a consequence. For example, studies revealed that violence-related injuries had a greater likelihood of occurring in streets and public spaces where alcohol was accessible.⁸⁴ Therefore, it follows that reducing the availability to access alcohol through public policies could generate a substantial decrease in its consumption and consequences. Proposed strategies include licensing policies, as this limits availability by regulating all production and sale, licensing places for sale and consumption, ensuring that sellers do not serve intoxicated patrons, placing restrictions on drinking in some public places, and differentiating the availability of drinks depending on potency, among others.

Different reviews have concluded that there is good evidence that introducing or maintaining existing limits to days or hours of alcohol sale reduces consumption and alcohol-related harm.85, 86, 87 Furthermore, availability limitations policies have proven to be cost-effective interventions to control alcohol consumption and its problems, including a decrease in violent crimes.^83,88 A recent systematic review found that the regulation of control based on the time of sales and times of alcohol consumption could reduce incidents related to alcohol consumption, crimes, emergency visits, and homicides.⁸⁹ However, some argue that such policies are dependent on alcohol availability in surrounding areas.

Another factor to consider is that communities with a higher density of alcohol sales centers also impact availability and lead to greater consumption, accidents, crime, and violence. For example, regarding alcohol-related injuries, evidence shows that acute alcohol intoxication before injury significantly reduces the likelihood of a positive outcome following medical treatment.⁹⁰ This relationship is dose-dependent,⁴⁹ showing a higher increase for violence-related injuries than unintentional injuries at higher consumption levels.⁹¹ The regulation of alcohol outlet density may be a useful public health tool for reducing excessive alcohol consumption and related harms.⁹²

Comprehensive and stringent alcohol control policies, particularly policies affecting alcohol availability and marketing, are associated with lower prevalence and frequency of adolescent alcohol consumption and age of first alcohol use.⁹³ The application of these interventions originating from national or regional public policies could positively impact lower alcohol consumption to mitigate its enormous social and financial cost for the whole society.^94,95

Governmental Limits to Regulation

For effective implementation of PHP, government oversight must exist to ensure that producers and consumers adhere to them. However, several barriers exist, which impede the execution of statutory regulation. Leaders and countries may lack the political will, power, or public health infrastructure to implement policies to reduce alcohol-related harms.⁸² Furthermore, there are notable contradictions between alcohol industry efforts and evidence-based strategies to reduce harmful drinking.^96,97 This could be in part due to lobbying from special interest groups. For example, a review identified strategies that the alcohol industry uses to influence marketing regulations. This includes the promotion of self-regulation and disputing the evidence on the effectiveness of statutory regulations.⁹⁸

There are organizations like the WHO Global Alcohol Strategy, which provide technical support to countries seeking to reduce harmful alcohol consumption. Although this is not a regulatory entity for alcohol marketing nor an international treaty, this platform could serve to create binding international treaties to reduce harmful alcohol use and related problems.⁸² A global Framework Convention on Alcohol Control could allow governments to agree upon a minimum set of actions to enforce the strategies outlined in this review, such as price, taxation, physical availability, advertising, and marketing regulation.

Clinical Interventions and Opportunities for Screening

Many studies point to routine screening for alcohol misuse and brief behavioral counseling sessions provided by family physicians to high-risk drinkers as having the potential to reduce the prevalence of hazardous drinking by increasing remission rates and reducing disability.⁹⁹ The main tool for screening that is simple yet effective is the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test-Concise (AUDIT-C). In studies, AUDIT-C had a higher area under the curve (AUC) than the full AUDIT for detecting heavy drinking (0.891 vs. 0.881, respectively; P = 0.03), and both questionnaires performed similarly for detecting heavy drinking and/or active abuse or dependence (0.880 vs. 0.881, respectively). Therefore, either one may be implemented in strategic points to screen for AUD.¹⁰⁰ If an AUDIT score is used, guidelines recommend that patients with scores between 8 and 15 receive a brief intervention with periodic reassessment, and a score of 16–19 warrants an intervention and regular monitoring while an AUDIT score of over 20 should receive a diagnostic assessment, and depending on the severity of physical dependence, detoxification, and other treatments.² In addition, the AUDIT-C includes the first three questions of the AUDIT about alcohol consumption, and the thresholds for alcohol misuse screening are ≥4 in men and ≥3 in women (Figure 3).¹⁰¹

Figure 3.

Algorithm for the use of AUDIT-C in clinical practice.

AUD is a chronic disease with a range of severity from mild to severe. Treatments can be divided into three general categories: brief intervention, specialized treatment programs, and mutual help groups. For mild cases, publicly available resources (i.e., online or telephone interventions) may be useful. For more severe diseases, dedicated/specialist alcohol and drug service involvement may be sought.¹⁰²

As for clinical interventions, even brief interventions (5-min) can reduce harmful alcohol consumption by nearly one-third.¹⁰³ The objective of these interventions is to provide prophylactic treatment before or soon after the onset of alcohol-related problems. Usually, they are designed to motivate high-risk drinkers to moderate their alcohol consumption rather than promote total abstinence.¹⁰³ They are also made to be applied by primary care practitioners and are especially appropriate for patients whose hazardous drinking meets ICD-10 criteria for harmful use rather than dependence.² The effectiveness of these interventions is supported by some studies that show clinically significant effects on drinking behavior and related problems.104, 105, 106 Nevertheless, these interventions are not beneficial for alcohol-dependent individuals.¹⁰⁷

Hazardous alcohol consumption constitutes one of the leading risk factors for disease burden worldwide. However, current studies are limited by a dearth of information regarding relevant factors that influence the risk of injury associated with alcohol consumption. The lack of strong public policies to regulate alcohol-related harm can be detrimental from a health perspective as well as an economic standpoint. These policies should consider all aspects of the problem, including raising awareness and advocacy, enhancing the capacity of the health and welfare workforce, regulating accessibility and availability, and establishing mechanisms to facilitate the development of nationally appropriate alcohol policies, as well as regional goals and support. We have to advocate for evidence-based and cost-effective public health policies to decrease alcohol misuse.

Credit authorship contribution statement

- Gustavo Ayares: Investigation, Writing - Original Draft, Writing - Review and Editing.

- Francisco Idalsoaga: Writing - Review and Editing.

- Jorge Arnold: Writing - Review and Editing.

- Eduardo Fuentes-López: Writing - Review and Editing.

- Juan Pablo Arab: Writing - Review and Editing.

- Luis Antonio Díaz: Conceptualization, Writing - Review and Editing, Supervision.

Conflicts of interest

All authors have none to declare.

Acknowledgments

Figure was partially created with BioRender.com.

Funding information

This article was partially supported by the Chilean government through the Fondo Nacional de Desarrollo Científico y Tecnológico (FONDECYT 1200227 to JPA), the Comisión Nacional de Investigación Científica y Tecnológica (CONICYT, AFB170005, CARE Chile UC), and the Colegio Médico de Chile (COLMED grant to LAD).