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On monitoring unrecorded alcohol consumption
Alcoholism and Drug Addiction 28 (2015) 79–89 HOSTED BY
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Leading article/Artykuł redakcyjny
On monitoring unrecorded alcohol consumption Monitoring nierejestrowanej konsumpcji alkoholu Jürgen Rehm 1,2,3,4,5,6,*, Vladimir Poznyak 7 1
Centre for Addiction and Mental Health, Toronto, Canada Addiction Policy, Dalla Lana School of Public Health, University of Toronto, Canada 3 Institute of Medical Science, University of Toronto, Faculty of Medicine, Toronto, Canada 4 Department of Psychiatry, University of Toronto, Canada 5 Institute of Clinical Psychology and Psychotherapy & Center of Clinical Epidemiology and Longitudinal Studies (CELOS), Technische Universität Dresden, Germany 6 World Health Organization Collaborating Centre for Addiction and Mental Health, Toronto, Canada 7 World Health Organization, Geneva, Switzerland 2
ARTICLE INFO
ABSTRACT
Article history: Received: 20.01.2015 Accepted: 21.06.2015 Available online: 02.07.2015
Unrecorded alcohol consumption is a global problem, with about 25% of all alcohol consumption concerning this category. There are different forms of unrecorded alcohol, legally produced versus illegally produced, artisanal vs industrially produced, and then surrogate alcohol, which is officially not intended for human consumption. Monitoring and surveillance of unrecorded consumption is not well developed. The World Health Organization has developed a monitoring system, using the Nominal Group Technique, a variant of the Delphi methodology. Experiences with this methodology over the past two years are reported. Finally, conclusions for the monitoring and surveillance at the national level are given. © 2015 Institute of Psychiatry and Neurology. Production and hosting by Elsevier Sp. z o.o. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Alcohol Per capita consumption Unrecorded Surrogate alcohol Monitoring Surveillance
STRESZCZENIE
Słowa kluczowe: alkohol spożycie per capita
Nierejestrowana konsumpcja alkoholu, której udział w spożyciu alkoholu ogółem wynosi około 25%, jest problemem o charakterze globalnym. Istnieje wiele źródeł konsumpcji nierejestrowanej, takie jak produkcja legalna
* Corresponding author at: Centre for Addiction and Mental Health, 33 Russell Street, Toronto, ON M5S 1S5, Canada. Tel.: +1 416 535 8501x36173. E-mail address: [email protected] (J. Rehm). Peer review under responsibility of Institute of Psychiatry and Neurology. http://dx.doi.org/10.1016/j.alkona.2015.06.003 0867-4361/© 2015 Institute of Psychiatry and Neurology. Production and hosting by Elsevier Sp. z o.o. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
80 konsumpcja nierejestrowana alkohol niespożywczy monitoring
J. Rehm, V. Poznyak / Alcoholism and Drug Addiction 28 (2015) 79–89
i nielegalna, rzemieślnicza i przemysłowa, a także alkohol, który oficjalnie nie jest przeznaczony do spożycia. Monitorowanie tej konsumpcji jest słabo rozwinięte. Dopiero ostatnio, Światowa Organizacja Zdrowia wypracowała system monitoringu oparty na Nominalnej Technice Grupowej (Nominal Group Technique), która mieści się w szerszej kategorii metodologii delfickiej. Artykuł przedstawia doświadczenia z zastosowaniem tej metodologii zebrane w ciągu ostatnich dwóch lat oraz propozycje krajowego monitoringu konsumpcji nierejestrowanej. © 2015 Institute of Psychiatry and Neurology. Production and hosting by Elsevier Sp. z o.o. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Unrecorded consumption: definition, categories and estimated size Unrecorded consumption, referring to alcohol that is outside the usual system of governmental control because it is produced, distributed, and sold outside of formal channels and, therefore, not registered by routine data collection [1, 2], represented about 25% of all the consumption globally in the year 2012 [3]. The relative proportion is much higher in low-income than in high-income countries [3]: in fact, the relative proportion of unrecorded consumption increases almost proportionally with decreasing wealth (highincome countries: 9%; upper middle-income countries: 24%; lower middle-income countries: 42%; lowerincome countries: 44%). The reasons for this relation are at least twofold: first, there is more informal traditional fermented beverages and spirits production in low- and middle-income countries [4, 5], irrespectively if such artisanal production is legal, tolerated or illegal; and second, the overall enforcement of taxation rules is lower and corruption is higher in less wealthy countries [6]. However, while this relationship between economic wealth and unrecorded consumption exists on a country level based on current data, potential measurement bias in volumes of unrecorded consumption should be acknowledged despite attempts of the World Health Organization to reduce this bias [3, 7]. As a result of high prevalence of unrecorded alcohol products, monitoring and surveillance efforts of alcohol as a major risk factor for health [7–9] need to take consumption of unrecorded alcohol into consideration, to both estimate consumption and alcohol-attributable harms, and to evaluate policy measures. Many countries are interested in knowing what proportion of overall alcohol consumption stems from unrecorded sources, and the composition of unrecorded differs widely by culture. Unrecorded alcohol comprises the following categories [1, 3, 4, 10]:
Alcohol that is originally not produced for human consumption (such as medicinal products that contain alcohol, perfume or industrial alcohol); in some countries (e.g., Russia), such surrogate alcohol may only officially be declared as not for human consumption to avoid taxes. This is the case when the respective products (e.g., industrial alcohol, medicinal alcohol or perfume) are taxed at a markedly lower rate than are usual alcoholic beverages [11]. Alcohol produced at home or artisanal (either legally or illegally). Alcohol that is procured from any illegal source (smuggled alcohol or industrially produced illegal alcohol). Alcohol that is purchased at duty free outlets or abroad, and consumed not in the jurisdiction where it is recorded. Recorded consumption can be measured via sales and taxation, or via production, export, and import, and many national governments regularly monitor this part of alcohol per capita consumption [3, 12]. Harder to obtain data are required to estimate and monitor unrecorded consumption at the country level. Only a few countries, like Sweden, have regular national monitoring system of unrecorded consumption, which in Sweden had been in place for over a decade [13]. Most other countries do not monitor unrecorded consumption, and only occasionally there had been specific efforts to estimate the impact of unrecorded consumption in research studies (for an overview of studies [4]; for a systematic effort by the EU to analyse unrecorded consumption in several countries [14]). Thus, for systematic monitoring of unrecorded consumption within the WHO efforts associated with the Global strategy to reduce the harmful use of alcohol [7] and the Global Monitoring Framework for non-communicable diseases [15], a different
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methodology had to be adopted. In the next sections this effort will be described in detail. Monitoring unrecorded alcohol consumption within the WHO Global Information System on Alcohol and Health The Global Information System on Alcohol and Health (GISAH) has been developed to be the major tool for assessing and monitoring the health situation and trends related to alcohol consumption, alcoholrelated harm, and policy responses in countries (http://www.who.int/gho/alcohol/en/). The main mechanism for gathering data is regular surveys (i.e., iterations of the WHO Global Survey on Alcohol and Health) to all WHO membership countries, where information on alcohol exposure (surveys, recorded per capita consumption as derived from regular statistics), alcohol-attributable harm and alcohol policy are collected [12]. This information is complemented by regular systematic searches of the literature, and statistical analyses to estimate missing data (see methods section of the Global Status Report [3], also [16]), and to triangulate different data sources [2, 17, 18]. The last (2012) as well as previous iterations of the WHO Global Survey on Alcohol and Health had questions on unrecorded consumption, but not surprisingly given the problems described above, not many countries indicated to have data on unrecorded consumption. The systematic search of other sources for unrecorded consumption yielded several hundred publications mostly about chemical composition and health consequences [4], but not enough data to reliably estimate volume of unrecorded consumption in all member states, even with the most sophisticated methodologies for missing value imputation. Thus, it was decided to supplement the Global Survey with a specific study on unrecorded consumption using the Nominal Group Technique [19, 20], a variant of Delphi methods [21, 22]. Delphi methodology denotes a group of techniques, originally developed as a systematic, interactive forecasting method, which relies on a panel of experts. It is now more widely used for any estimates where no algorithmic answers are possible. The experts answer questionnaires in two or more rounds. After each round, an anonymous summary of the experts' judgments from the previous round is sent back to the experts as well as the reasons they provided for their judgments. In the Nominal Group Technique
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variant, no interaction is possible between the members of the expert panel. For round one of the estimation of unrecorded consumption, the experts were thus provided with the prior estimate of unrecorded consumption of their country, both in absolute terms (litre pure alcohol adult per capita), and as a proportion of the overall alcohol consumed (as an example see the question 1 in the attached questionnaire for Poland in the Appendix). They are then asked for their best estimate, and the basis for this estimate, and their subjective confidence in the judgement. After providing a summary of round one and the reasons, the same experts are then asked again for their final judgement. The answers of the round two are then averaged as best estimate for the respective country, unless there are better empirical data available. The following countries were included into the study on unrecorded consumption, because they either had high absolute levels of unrecorded consumption, or the proportion of unrecorded consumption was high, or there had been some controversy about the levels of unrecorded consumption in the past: Angola, Azerbaijan, Belarus, Bolivia, Brazil, Burkina Faso, Cambodia, Cameroon, Chad, China, Columbia, Cote d'Ivoire, Democratic Republic of Congo, Ecuador, Estonia, Ethiopia, Ghana, Guatemala, India, Italy, Kenya, Latvia, Lithuania, Mexico, Nepal, Pakistan, Peru, Philippines, Poland, Republic of Korea, Republic of Moldova, Romania, Russian Federation, Rwanda, South Africa, Sweden, Thailand, Turkey, Ukraine, United Republic of Tanzania, Uzbekistan, Viet Nam, Zambia. Overall, the experts invited to participate were selected from the literature, reviewed by the Canadian Centre for Addiction and Mental Health, and from the respective Ministries of Health (via World Health Organization). It turned out that there was much more expertise on unrecorded consumption than could be found in the published literature. Estimates based on the following categories were most prominently mentioned: Unpublished efforts to estimate unrecorded consumption via proxies [23]. This method has historically been used in Russia with sugar as the proxy [24–26]. This method has since been abandoned, for using time series of closely alcohol-related disease categories (like alcohol psychosis or poisoning in Russia) to estimate total consumption and then subtracted recorded consumption to get unrecorded [27, 28]. The latter
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method enables to include not only illegal spirits (“samogon”) based on sugar, but all forms of alcohol such as surrogate alcohol, which plays an important role in Russia [4, 11]. In the example of Poland, one of the participants presented calculations based on first hospitalisations due to alcoholic psychoses, a method which had been used historically to indirectly estimate unrecorded consumption in Poland [29, 30]. Information from customs and police on the illegal part of unrecorded consumption often based on seizures (as the example of one country see the following of the UK: https://www.gov.uk/ government/uploads/system/uploads/attachment_ data/file/293883/03679_Tackling_alcohol_ smuggling_Q1_v1_accessible.pdf). When customs officers are invited to the rounds using Nominal Group Technique or other Delphi techniques, they often provided internal data on confiscated alcohol (e.g., counterfeit, for a general review see [31]; for alcohol counterfeits in Thailand see [32]). However, as not all unrecorded alcohol is illegal, and as the seized amount of alcohol may represent only the tip of the iceberg and depend a lot on customs/police activity, it is very hard to judge on the level of unrecorded consumption from customs and police data alone. While it is hard to generalise, many estimates based on these data seem to underestimate the true level of unrecorded consumption, either because other sources of unrecorded or because the proportion undetected illegal alcohol are underestimated. Small scale regional surveys, or one-time national surveys on unrecorded consumption, which had not been published (grey literature which may include unpublished STEPwise surveys; e.g. www. drugfightmalawi.com/docs/taskforcefinal.doc). While each of these sources has strengths and weaknesses, the Nominal Group process, while systematically collecting different estimates and allowing local experts to judge on their relative strength, will allow a more informed estimate on unrecorded alcohol consumption. However, while the Nominal Group Technique certainly has important strengths in summarising existing evidence [19– 22], it relies crucially on selecting the most knowledgeable experts in each country to the table, and its results can only be as good as the implicit knowledge bases. In a situation where there is no knowledge base at all, combining different sources will not lead to a good estimate.
Shifting the monitoring effort of unrecorded alcohol consumption to the national level While monitoring of unrecorded consumption on the international level in important, especially in light of the WHO global strategy for alcohol [7] and of the obligations of the global monitoring framework for non-communicable diseases [15], monitoring on the national level would be even more important. As indicated above there are in principles four ways to monitor unrecorded consumption: Using the indirect method described above [23]. While this method is quite inexpensive once established and can rely on routine data, the problem may be that the association between the indirect indicator and the alcohol consumption may change. As mentioned above, the indirect estimation of unrecorded consumption in Russia via sugar, can no longer be used, as it would not cover “samogon” from other sources than sugar, surrogate alcohol or unrecorded wine, which all play a role in today's alcohol consumption in Russia [4, 28, 33]. Also, when drinking patterns change as may be true for Russia [33, 34], associations which were based on patterns of drinking like binge and acute outcomes (like alcohol poisoning) may change in strength thus affecting the estimates and the conclusions. Thus, any monitoring effect based on indirect indicators must be re-validated from time to time. Direct monitoring via general population surveys is another tool possibility. One of the prerequisites for this method is that unrecorded must be sufficiently prevalent in the general population like it is in Sweden or other Nordic countries, where the main source of unrecorded alcohol is cross-border shopping [13, 14] (for a description of an ongoing survey based monitoring system in Sweden for unrecorded alcohol consumption see [35]). For several other countries, where unrecorded consumption is mainly prevalent in marginalised and/or institutionalised populations (for example [4]), this methodology works less well, as many such populations are not part of the sampling frame [36]. However, including questions about unrecorded consumption into general monitoring surveys is valuable as a first approximation (e.g., the WHO STEPwise approach to Surveillance survey; http://www.who.int/chp/ steps/en/) even though this methodology may be underestimating the true level. After all, the
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overwhelming majority of WHO membership nations did indicate very little knowledge about unrecorded consumption. The general population surveys could be augmented with surveys of specialised populations such as institutionalised populations. As indicated above, unrecorded alcohol, as it is often considerably cheaper than recorded alcohol, is overproportionally consumed by marginalised people who drink large quantities of alcohol, and such people can be found in the formal specialised alcohol treatment systems or in social institutions with high proportion of alcohol-dependent people such as – depending on the country – halfway houses, shelters or hostels [37–39]. Single studies to try to establish all kinds of unrecorded consumption in a country, which of course have to be tailored to local circumstances. For example, so-called “shebeens”, alcohol outlets which partly sell unrecorded alcohol and have also been implicated in the relationship between alcohol and infectious disease transmission, could be used as part of a research design to estimate unrecorded alcohol in South Africa and surrounding countries [40, 41]. Overall, given the extent of the unrecorded consumption and the impact of alcohol on health as one of the most important risk factors for global mortality and burden of disease [42], monitoring and surveillance efforts for unrecorded alcohol consumption should be initiated or increased also at the national level, and efforts should be made to reduce consumption of unrecorded alcohol (for specific alcohol policy measures see [43, 44]). This conclusion can be drawn irrespective of the question, whether unrecorded alcohol has an effect on health over and above the effect of ethanol itself ([4, 45] for overviews). Authors' contributions/Wkład autorów According to order. No ghostwriting and guest authorship declared. Conflict of interest/Konflikt interesów None declared. Financial support/Finansowanie None declared.
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Ethics/Etyka The work described in this article has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals; the ethical principles defined in the Farmington Consensus of 1997. Acknowledgements/Podziękowania We would like to thank M. Tortolo for referencing this document. E. Larsen and D. Revke were instrumental in selecting experts for both rounds; A. Fleischmann, G. Gmel and M. Rylett helped in the construction of the questionnaire. Work on unrecorded consumption was part of the workplan of the WHO Collaborating Centre for Addiction and Mental Health, Toronto, Canada. References/Piśmiennictwo [1] Lachenmeier DW, Gmel G, Rehm J. Unrecorded alcohol consumption. In: Boyle P, Boffetta P, Lowenfels AB, Burns H, Brawley O, Zatonski W, et al., editors. Alcohol: science, policy, and public health. Oxford, UK: Oxford University Press; 2013. p. 132–42. [2] Rehm J, Klotsche J, Patra J. Comparative quantification of alcohol exposure as risk factor for global burden of disease. Int J Methods Psychiatr Res 2007;16:66–76. [3] World Health Organization. Global status report on alcohol and health. Geneva, Switzerland: World Health Organization; 2014. [4] Rehm J, Kailasapillai S, Larsen E, Rehm MX, Samokhvalov AV, Shield KD, et al. A systematic review of the epidemiology of unrecorded alcohol consumption and the chemical composition of unrecorded alcohol. Addiction 2014;109:880–93. [5] Room R, Jernigan D, Carlini BH, Gmel G, Gureje O, Mäkelä K, et al. El alcohol y los países en desarrollo. Una perspectiva de salud pública. Mexico: Organización Panamericana de la Salud & Fondo de Cultura Económica; 2013. [6] Shao J, Ivanov PC, Podobnik B, Stanley HE. Quantitative relations between corruption and economic factors. Eur Phys J B 2007;56:157–66. [7] World Health Organization. Global strategy to reduce the harmful use of alcohol. Geneva, Switzerland: World Health Organization; 2010. [8] Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N, et al. Alcohol as a risk factor for global burden of disease. Eur Addict Res 2003;9:157–64. [9] Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol use disorders. Lancet 2009;373:2223–33.
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[10] Lachenmeier DW, Rehm J, Gmel G. Surrogate alcohol: what do we know and where do we go? Alcohol Clin Exp Res 2007;31:1613–24. [11] Gil A, Polikina O, Koroleva N, McKee M, Tomkins S, Leon DA. Availability and characteristics of nonbeverage alcohols sold in 17 Russian cities in 2007. Alcohol Clin Exp Res 2009;33:79–85. [12] Poznyak V, Fleischmann A, Rekve D, Rylett M, Rehm J, Gmel G. The World Health Organization's global monitoring system on alcohol and health. Alcohol Res 2013;35:244–9. [13] Ramstedt M. Change and stability? Nordic Stud Alcohol Drugs 2010;27:409–23. [14] Leifman H. Estimations of unrecorded alcohol consumption levels and trends in 14 European countries. Nordisk Alkohol- Narkotikatidskrift 2001;18:54–70. [15] World Health Organization. Draft comprehensive global monitoring framework and targets for the prevention and of noncommunicable diseases. Geneva, control Switzerland: World Health Organization; 2013. [16] Shield KD, Parry C, Rehm J. Chronic diseases and conditions related to alcohol use. Alcohol Res 2013;35: 155–71. [17] Rehm J, Kehoe T, Gmel G, Stinson F, Grant B, Gmel G. Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the example of the US. Popul Health Metrics 2010;8:3. [18] Kehoe T, Gmel Jr G, Shield K, Gmel Sr G, Rehm J. Determining the best population-level alcohol consumption model and its impact on estimates of alcohol-attributable harms. Popul Health Metrics 2012;10:6. [19] Delbecq AL, Van de Ven AH, Gustafson DH. Group techniques for program planning: a guide to nominal group and Delphi processes. Glenview, IL: Scott Foresman and Company; 1975. [20] Van de Ven AH, Delbecq AL. The effectiveness of nominal, Delphi, and interacting group decision making processes. Acad Manage J 1974;17:605–21. [21] Linstone HA, Turoff M. Delphi method: techniques and applications. Boston: Addison-Wesley; 1975. [22] Rehm J, Gadenne V. Intuitive predictions and professional forecasts. Cognitive processes and social consequences. Oxford: Pergamon Press; 1990. [23] Razvodovsky YE. Unrecorded alcohol consumption: quantitative methods of estimation. Alcoholism 2010;46:15–24. [24] Treml V. Alcohol in the USSR: a statistical study. Durham, NC: Duke University Press; 1982. [25] Treml V. Soviet and Russian statistics on alcohol consumption and abuse. In: Bobadilla JL, Costello CA, Mitchell F, editors. Premature death in the new independent states. Washington, DC: National Academy Press; 1997. p. 220–38. [26] Balan-Cohen A. Sobering up: the impact of the 1985– 1988 Russian anti-alcohol campaign on child health. Boston, MA: Tufts University; 2007. [27] Nemtsov AV. Estimates of total alcohol consumption in Russia, 1980–1994. Drug Alcohol Depend 2000;58: 133–42. [28] Nemtsov AV. A contemporary history of alcohol in Russia. Stockholm, Sweden: Södertörns högskola; 2011.
[29] Wald I, Jaroszewski Z. Alcohol consumption and alcoholic psychoses in Poland. J Stud Alcohol 1983;44 (6):1040–8. [30] Simpura J, Tigerstedt C, Hanhinen S, Lagerspetz M, Leifman H, Moskalewicz J, et al. Alcohol misuse as a health and social issue in the Baltic Sea region. A summary of findings from the Baltica Study. Alcohol Alcohol 1999;34:805–23. [31] Staake T, Thiesse F, Fleisch E. The emergence of counterfeit trade: a literature review. Eur J Market 2009;43: 320–49. [32] Green RT, Smith T. Executive insights: countering brand counterfeiters. J Int Market 2002;10:89–106. [33] Radaev V. Impact of a new alcohol policy on homemade alcohol consumption and sales in Russia. Alcohol Alcohol 2015;50:365–72. [34] Neufeld M, Rehm J. Alcohol consumption and mortality in Russia since 2000 – are there any changes following the alcohol policy changes starting in 2006. Alcohol Alcohol 2013;48:222–30. [35] World Health Organization. Global strategy to reduce the harmful use of alcohol: Implementation toolkit. Geneva, Switzerland: World Health Organization; 2015. [36] Shield K, Rehm J. Difficulties with telephone-based surveys on alcohol in high-income countries: the Canadian example. Int J Methods Psychiatr Res 2012;21: 17–28. [37] Baker TB, Sobell MB, Sobell LC, Cannon DS. Halfway houses for alcoholics: a review, analysis and comparisons with other halfway house facilities. Int J Soc Psychiatry 1976;22:130–9. [38] Lovisi GM, Mann AH, Coutinho E, Morgado AF. Mental illness in an adult sample admitted to public hostels in the Rio de Janeiro metropolitan area, Brazil. Soc Psychiatry Psychiatr Epidemiol 2003;38:493–8. [39] Freed A. Letter: Alchoholism: wet hostels. BMJ 1976;2:476. [40] Morojele NK, Kachieng'a MA, Mokoko E, Nkoko MA, Parry CDH, Nkowane AM. Alcohol use and sexual behaviour among risky drinkers and bar and shabeen patrons in Gauteng province, South Africa. Soc Sci Med 2006;62:217–27. [41] Scott-Sheldon LA, Carey KB, Carey MP, Cain D, Simbayi LC, Kalichman SC. Alcohol use disorder, contexts of alcohol use, and the risk of HIV transmission among South African male patrons of shebeens. Drug Alcohol Depend 2014;1:198–204. [42] Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224–60. [43] Lachenmeier DW, Taylor BJ, Rehm J. Alcohol under the radar: do we have policy options regarding unrecorded alcohol? Int J Drug Policy 2011;22:153–60. [44] Lachenmeier DW. Reducing harm from alcohol: what about unrecorded products? Lancet 2009;374:977. [45] Rehm J, Kanteres F, Lachenmeier DW. Unrecorded consumption, quality of alcohol and health consequences. Drug Alcohol Rev 2010;29:426–36.
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Appendix
(Day/Month/Year)
Date: Country:
Poland
Questionnaire completed by: Last name:
First name:
Title/Position: Institute/Organization/etc.: Phone: Fax: Email:
Contact details for questions or clarifications: World Health Organization Management of Substance Abuse Department of Mental Health and Substance Abuse World Health Organization 20, avenue Appia CH-1211 Geneva 27, Switzerland Phone: +41 22 791 33 34; Fax: +41 22 791 48 51; E-mail: [email protected] Centre for Addiction and Mental Health, Toronto, Canada Social and Epidemiology Research Department, PAHO/ WHO Collaborating Centre for Addiction and Mental Health Centre for Addictions and Mental Health (CAMH) 33 Russell Street Toronto, Ontario, Canada, M5S 2S1 Tel: ++1 416 535 8501 ext. 36173; Fax: ++ 1 416 595 6033; E-mail: [email protected]
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Doste˛pne online www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/alkona
Leading article/Artykuł redakcyjny
On monitoring unrecorded alcohol consumption Monitoring nierejestrowanej konsumpcji alkoholu Jürgen Rehm 1,2,3,4,5,6,*, Vladimir Poznyak 7 1
Centre for Addiction and Mental Health, Toronto, Canada Addiction Policy, Dalla Lana School of Public Health, University of Toronto, Canada 3 Institute of Medical Science, University of Toronto, Faculty of Medicine, Toronto, Canada 4 Department of Psychiatry, University of Toronto, Canada 5 Institute of Clinical Psychology and Psychotherapy & Center of Clinical Epidemiology and Longitudinal Studies (CELOS), Technische Universität Dresden, Germany 6 World Health Organization Collaborating Centre for Addiction and Mental Health, Toronto, Canada 7 World Health Organization, Geneva, Switzerland 2
ARTICLE INFO
ABSTRACT
Article history: Received: 20.01.2015 Accepted: 21.06.2015 Available online: 02.07.2015
Unrecorded alcohol consumption is a global problem, with about 25% of all alcohol consumption concerning this category. There are different forms of unrecorded alcohol, legally produced versus illegally produced, artisanal vs industrially produced, and then surrogate alcohol, which is officially not intended for human consumption. Monitoring and surveillance of unrecorded consumption is not well developed. The World Health Organization has developed a monitoring system, using the Nominal Group Technique, a variant of the Delphi methodology. Experiences with this methodology over the past two years are reported. Finally, conclusions for the monitoring and surveillance at the national level are given. © 2015 Institute of Psychiatry and Neurology. Production and hosting by Elsevier Sp. z o.o. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Alcohol Per capita consumption Unrecorded Surrogate alcohol Monitoring Surveillance
STRESZCZENIE
Słowa kluczowe: alkohol spożycie per capita
Nierejestrowana konsumpcja alkoholu, której udział w spożyciu alkoholu ogółem wynosi około 25%, jest problemem o charakterze globalnym. Istnieje wiele źródeł konsumpcji nierejestrowanej, takie jak produkcja legalna
* Corresponding author at: Centre for Addiction and Mental Health, 33 Russell Street, Toronto, ON M5S 1S5, Canada. Tel.: +1 416 535 8501x36173. E-mail address: [email protected] (J. Rehm). Peer review under responsibility of Institute of Psychiatry and Neurology. http://dx.doi.org/10.1016/j.alkona.2015.06.003 0867-4361/© 2015 Institute of Psychiatry and Neurology. Production and hosting by Elsevier Sp. z o.o. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
80 konsumpcja nierejestrowana alkohol niespożywczy monitoring
J. Rehm, V. Poznyak / Alcoholism and Drug Addiction 28 (2015) 79–89
i nielegalna, rzemieślnicza i przemysłowa, a także alkohol, który oficjalnie nie jest przeznaczony do spożycia. Monitorowanie tej konsumpcji jest słabo rozwinięte. Dopiero ostatnio, Światowa Organizacja Zdrowia wypracowała system monitoringu oparty na Nominalnej Technice Grupowej (Nominal Group Technique), która mieści się w szerszej kategorii metodologii delfickiej. Artykuł przedstawia doświadczenia z zastosowaniem tej metodologii zebrane w ciągu ostatnich dwóch lat oraz propozycje krajowego monitoringu konsumpcji nierejestrowanej. © 2015 Institute of Psychiatry and Neurology. Production and hosting by Elsevier Sp. z o.o. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Unrecorded consumption: definition, categories and estimated size Unrecorded consumption, referring to alcohol that is outside the usual system of governmental control because it is produced, distributed, and sold outside of formal channels and, therefore, not registered by routine data collection [1, 2], represented about 25% of all the consumption globally in the year 2012 [3]. The relative proportion is much higher in low-income than in high-income countries [3]: in fact, the relative proportion of unrecorded consumption increases almost proportionally with decreasing wealth (highincome countries: 9%; upper middle-income countries: 24%; lower middle-income countries: 42%; lowerincome countries: 44%). The reasons for this relation are at least twofold: first, there is more informal traditional fermented beverages and spirits production in low- and middle-income countries [4, 5], irrespectively if such artisanal production is legal, tolerated or illegal; and second, the overall enforcement of taxation rules is lower and corruption is higher in less wealthy countries [6]. However, while this relationship between economic wealth and unrecorded consumption exists on a country level based on current data, potential measurement bias in volumes of unrecorded consumption should be acknowledged despite attempts of the World Health Organization to reduce this bias [3, 7]. As a result of high prevalence of unrecorded alcohol products, monitoring and surveillance efforts of alcohol as a major risk factor for health [7–9] need to take consumption of unrecorded alcohol into consideration, to both estimate consumption and alcohol-attributable harms, and to evaluate policy measures. Many countries are interested in knowing what proportion of overall alcohol consumption stems from unrecorded sources, and the composition of unrecorded differs widely by culture. Unrecorded alcohol comprises the following categories [1, 3, 4, 10]:
Alcohol that is originally not produced for human consumption (such as medicinal products that contain alcohol, perfume or industrial alcohol); in some countries (e.g., Russia), such surrogate alcohol may only officially be declared as not for human consumption to avoid taxes. This is the case when the respective products (e.g., industrial alcohol, medicinal alcohol or perfume) are taxed at a markedly lower rate than are usual alcoholic beverages [11]. Alcohol produced at home or artisanal (either legally or illegally). Alcohol that is procured from any illegal source (smuggled alcohol or industrially produced illegal alcohol). Alcohol that is purchased at duty free outlets or abroad, and consumed not in the jurisdiction where it is recorded. Recorded consumption can be measured via sales and taxation, or via production, export, and import, and many national governments regularly monitor this part of alcohol per capita consumption [3, 12]. Harder to obtain data are required to estimate and monitor unrecorded consumption at the country level. Only a few countries, like Sweden, have regular national monitoring system of unrecorded consumption, which in Sweden had been in place for over a decade [13]. Most other countries do not monitor unrecorded consumption, and only occasionally there had been specific efforts to estimate the impact of unrecorded consumption in research studies (for an overview of studies [4]; for a systematic effort by the EU to analyse unrecorded consumption in several countries [14]). Thus, for systematic monitoring of unrecorded consumption within the WHO efforts associated with the Global strategy to reduce the harmful use of alcohol [7] and the Global Monitoring Framework for non-communicable diseases [15], a different
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methodology had to be adopted. In the next sections this effort will be described in detail. Monitoring unrecorded alcohol consumption within the WHO Global Information System on Alcohol and Health The Global Information System on Alcohol and Health (GISAH) has been developed to be the major tool for assessing and monitoring the health situation and trends related to alcohol consumption, alcoholrelated harm, and policy responses in countries (http://www.who.int/gho/alcohol/en/). The main mechanism for gathering data is regular surveys (i.e., iterations of the WHO Global Survey on Alcohol and Health) to all WHO membership countries, where information on alcohol exposure (surveys, recorded per capita consumption as derived from regular statistics), alcohol-attributable harm and alcohol policy are collected [12]. This information is complemented by regular systematic searches of the literature, and statistical analyses to estimate missing data (see methods section of the Global Status Report [3], also [16]), and to triangulate different data sources [2, 17, 18]. The last (2012) as well as previous iterations of the WHO Global Survey on Alcohol and Health had questions on unrecorded consumption, but not surprisingly given the problems described above, not many countries indicated to have data on unrecorded consumption. The systematic search of other sources for unrecorded consumption yielded several hundred publications mostly about chemical composition and health consequences [4], but not enough data to reliably estimate volume of unrecorded consumption in all member states, even with the most sophisticated methodologies for missing value imputation. Thus, it was decided to supplement the Global Survey with a specific study on unrecorded consumption using the Nominal Group Technique [19, 20], a variant of Delphi methods [21, 22]. Delphi methodology denotes a group of techniques, originally developed as a systematic, interactive forecasting method, which relies on a panel of experts. It is now more widely used for any estimates where no algorithmic answers are possible. The experts answer questionnaires in two or more rounds. After each round, an anonymous summary of the experts' judgments from the previous round is sent back to the experts as well as the reasons they provided for their judgments. In the Nominal Group Technique
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variant, no interaction is possible between the members of the expert panel. For round one of the estimation of unrecorded consumption, the experts were thus provided with the prior estimate of unrecorded consumption of their country, both in absolute terms (litre pure alcohol adult per capita), and as a proportion of the overall alcohol consumed (as an example see the question 1 in the attached questionnaire for Poland in the Appendix). They are then asked for their best estimate, and the basis for this estimate, and their subjective confidence in the judgement. After providing a summary of round one and the reasons, the same experts are then asked again for their final judgement. The answers of the round two are then averaged as best estimate for the respective country, unless there are better empirical data available. The following countries were included into the study on unrecorded consumption, because they either had high absolute levels of unrecorded consumption, or the proportion of unrecorded consumption was high, or there had been some controversy about the levels of unrecorded consumption in the past: Angola, Azerbaijan, Belarus, Bolivia, Brazil, Burkina Faso, Cambodia, Cameroon, Chad, China, Columbia, Cote d'Ivoire, Democratic Republic of Congo, Ecuador, Estonia, Ethiopia, Ghana, Guatemala, India, Italy, Kenya, Latvia, Lithuania, Mexico, Nepal, Pakistan, Peru, Philippines, Poland, Republic of Korea, Republic of Moldova, Romania, Russian Federation, Rwanda, South Africa, Sweden, Thailand, Turkey, Ukraine, United Republic of Tanzania, Uzbekistan, Viet Nam, Zambia. Overall, the experts invited to participate were selected from the literature, reviewed by the Canadian Centre for Addiction and Mental Health, and from the respective Ministries of Health (via World Health Organization). It turned out that there was much more expertise on unrecorded consumption than could be found in the published literature. Estimates based on the following categories were most prominently mentioned: Unpublished efforts to estimate unrecorded consumption via proxies [23]. This method has historically been used in Russia with sugar as the proxy [24–26]. This method has since been abandoned, for using time series of closely alcohol-related disease categories (like alcohol psychosis or poisoning in Russia) to estimate total consumption and then subtracted recorded consumption to get unrecorded [27, 28]. The latter
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method enables to include not only illegal spirits (“samogon”) based on sugar, but all forms of alcohol such as surrogate alcohol, which plays an important role in Russia [4, 11]. In the example of Poland, one of the participants presented calculations based on first hospitalisations due to alcoholic psychoses, a method which had been used historically to indirectly estimate unrecorded consumption in Poland [29, 30]. Information from customs and police on the illegal part of unrecorded consumption often based on seizures (as the example of one country see the following of the UK: https://www.gov.uk/ government/uploads/system/uploads/attachment_ data/file/293883/03679_Tackling_alcohol_ smuggling_Q1_v1_accessible.pdf). When customs officers are invited to the rounds using Nominal Group Technique or other Delphi techniques, they often provided internal data on confiscated alcohol (e.g., counterfeit, for a general review see [31]; for alcohol counterfeits in Thailand see [32]). However, as not all unrecorded alcohol is illegal, and as the seized amount of alcohol may represent only the tip of the iceberg and depend a lot on customs/police activity, it is very hard to judge on the level of unrecorded consumption from customs and police data alone. While it is hard to generalise, many estimates based on these data seem to underestimate the true level of unrecorded consumption, either because other sources of unrecorded or because the proportion undetected illegal alcohol are underestimated. Small scale regional surveys, or one-time national surveys on unrecorded consumption, which had not been published (grey literature which may include unpublished STEPwise surveys; e.g. www. drugfightmalawi.com/docs/taskforcefinal.doc). While each of these sources has strengths and weaknesses, the Nominal Group process, while systematically collecting different estimates and allowing local experts to judge on their relative strength, will allow a more informed estimate on unrecorded alcohol consumption. However, while the Nominal Group Technique certainly has important strengths in summarising existing evidence [19– 22], it relies crucially on selecting the most knowledgeable experts in each country to the table, and its results can only be as good as the implicit knowledge bases. In a situation where there is no knowledge base at all, combining different sources will not lead to a good estimate.
Shifting the monitoring effort of unrecorded alcohol consumption to the national level While monitoring of unrecorded consumption on the international level in important, especially in light of the WHO global strategy for alcohol [7] and of the obligations of the global monitoring framework for non-communicable diseases [15], monitoring on the national level would be even more important. As indicated above there are in principles four ways to monitor unrecorded consumption: Using the indirect method described above [23]. While this method is quite inexpensive once established and can rely on routine data, the problem may be that the association between the indirect indicator and the alcohol consumption may change. As mentioned above, the indirect estimation of unrecorded consumption in Russia via sugar, can no longer be used, as it would not cover “samogon” from other sources than sugar, surrogate alcohol or unrecorded wine, which all play a role in today's alcohol consumption in Russia [4, 28, 33]. Also, when drinking patterns change as may be true for Russia [33, 34], associations which were based on patterns of drinking like binge and acute outcomes (like alcohol poisoning) may change in strength thus affecting the estimates and the conclusions. Thus, any monitoring effect based on indirect indicators must be re-validated from time to time. Direct monitoring via general population surveys is another tool possibility. One of the prerequisites for this method is that unrecorded must be sufficiently prevalent in the general population like it is in Sweden or other Nordic countries, where the main source of unrecorded alcohol is cross-border shopping [13, 14] (for a description of an ongoing survey based monitoring system in Sweden for unrecorded alcohol consumption see [35]). For several other countries, where unrecorded consumption is mainly prevalent in marginalised and/or institutionalised populations (for example [4]), this methodology works less well, as many such populations are not part of the sampling frame [36]. However, including questions about unrecorded consumption into general monitoring surveys is valuable as a first approximation (e.g., the WHO STEPwise approach to Surveillance survey; http://www.who.int/chp/ steps/en/) even though this methodology may be underestimating the true level. After all, the
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overwhelming majority of WHO membership nations did indicate very little knowledge about unrecorded consumption. The general population surveys could be augmented with surveys of specialised populations such as institutionalised populations. As indicated above, unrecorded alcohol, as it is often considerably cheaper than recorded alcohol, is overproportionally consumed by marginalised people who drink large quantities of alcohol, and such people can be found in the formal specialised alcohol treatment systems or in social institutions with high proportion of alcohol-dependent people such as – depending on the country – halfway houses, shelters or hostels [37–39]. Single studies to try to establish all kinds of unrecorded consumption in a country, which of course have to be tailored to local circumstances. For example, so-called “shebeens”, alcohol outlets which partly sell unrecorded alcohol and have also been implicated in the relationship between alcohol and infectious disease transmission, could be used as part of a research design to estimate unrecorded alcohol in South Africa and surrounding countries [40, 41]. Overall, given the extent of the unrecorded consumption and the impact of alcohol on health as one of the most important risk factors for global mortality and burden of disease [42], monitoring and surveillance efforts for unrecorded alcohol consumption should be initiated or increased also at the national level, and efforts should be made to reduce consumption of unrecorded alcohol (for specific alcohol policy measures see [43, 44]). This conclusion can be drawn irrespective of the question, whether unrecorded alcohol has an effect on health over and above the effect of ethanol itself ([4, 45] for overviews). Authors' contributions/Wkład autorów According to order. No ghostwriting and guest authorship declared. Conflict of interest/Konflikt interesów None declared. Financial support/Finansowanie None declared.
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Ethics/Etyka The work described in this article has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals; the ethical principles defined in the Farmington Consensus of 1997. Acknowledgements/Podziękowania We would like to thank M. Tortolo for referencing this document. E. Larsen and D. Revke were instrumental in selecting experts for both rounds; A. Fleischmann, G. Gmel and M. Rylett helped in the construction of the questionnaire. Work on unrecorded consumption was part of the workplan of the WHO Collaborating Centre for Addiction and Mental Health, Toronto, Canada. References/Piśmiennictwo [1] Lachenmeier DW, Gmel G, Rehm J. Unrecorded alcohol consumption. In: Boyle P, Boffetta P, Lowenfels AB, Burns H, Brawley O, Zatonski W, et al., editors. Alcohol: science, policy, and public health. Oxford, UK: Oxford University Press; 2013. p. 132–42. [2] Rehm J, Klotsche J, Patra J. Comparative quantification of alcohol exposure as risk factor for global burden of disease. Int J Methods Psychiatr Res 2007;16:66–76. [3] World Health Organization. Global status report on alcohol and health. Geneva, Switzerland: World Health Organization; 2014. [4] Rehm J, Kailasapillai S, Larsen E, Rehm MX, Samokhvalov AV, Shield KD, et al. A systematic review of the epidemiology of unrecorded alcohol consumption and the chemical composition of unrecorded alcohol. Addiction 2014;109:880–93. [5] Room R, Jernigan D, Carlini BH, Gmel G, Gureje O, Mäkelä K, et al. El alcohol y los países en desarrollo. Una perspectiva de salud pública. Mexico: Organización Panamericana de la Salud & Fondo de Cultura Económica; 2013. [6] Shao J, Ivanov PC, Podobnik B, Stanley HE. Quantitative relations between corruption and economic factors. Eur Phys J B 2007;56:157–66. [7] World Health Organization. Global strategy to reduce the harmful use of alcohol. Geneva, Switzerland: World Health Organization; 2010. [8] Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N, et al. Alcohol as a risk factor for global burden of disease. Eur Addict Res 2003;9:157–64. [9] Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol use disorders. Lancet 2009;373:2223–33.
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Appendix
(Day/Month/Year)
Date: Country:
Poland
Questionnaire completed by: Last name:
First name:
Title/Position: Institute/Organization/etc.: Phone: Fax: Email:
Contact details for questions or clarifications: World Health Organization Management of Substance Abuse Department of Mental Health and Substance Abuse World Health Organization 20, avenue Appia CH-1211 Geneva 27, Switzerland Phone: +41 22 791 33 34; Fax: +41 22 791 48 51; E-mail: [email protected] Centre for Addiction and Mental Health, Toronto, Canada Social and Epidemiology Research Department, PAHO/ WHO Collaborating Centre for Addiction and Mental Health Centre for Addictions and Mental Health (CAMH) 33 Russell Street Toronto, Ontario, Canada, M5S 2S1 Tel: ++1 416 535 8501 ext. 36173; Fax: ++ 1 416 595 6033; E-mail: [email protected]
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