Alcohol consumption in India: a systematic review and modelling study for sub-national estimates of drinking patterns

Changes in prevalence of alcohol and tobacco consumption across districts of India, 2016 and 2021

BACKGROUND

India witnessed a rise in alcohol and tobacco consumption in the last few decades. However, the burden varies because of the huge population, diverse socioeconomic, cultural, and geographical characteristics, and different liquor policies across states. To understand the burden and progress, it is crucial to examine the consumption patterns at smaller geographical units. This study examines the trends and patterns in alcohol and tobacco consumption across 720 districts nested within 36 states (Union Territories) between 2016 and 2021.

METHODS

We used the fourth (2015-16) and fifth (2019-21) rounds of the National Family Health Survey of India. Both rounds provide the district-representative sample for the estimation. We used a 4-level (level 1-individuals; level 2-clusters; level 3-districts; level 4-states) random effects model to compute the predicted probabilities of alcohol and tobacco consumption (among males and females) for 720 districts in India. We used decile positions to map the consumption prevalence across districts.

RESULTS

Between 2016 and 2021, alcohol and tobacco consumption among men in India declined significantly, with national alcohol usage dropping from 29.2% to 17.5% and tobacco from 44.5% to 32.6%. The variation attributable to states for both alcohol (40.5% in 2016 and 56.6% in 2021) and tobacco (58% in 2016 and 68.3% in 2021) consumption among men was higher in 2021 as compared to 2016. The consumption of both tobacco and alcohol was notably high in the north-eastern states among both men and women. More than 80% of the districts reported a moderate to high reduction in alcohol consumption for men between the two rounds.

CONCLUSIONS

The national decline in tobacco and alcohol consumption indicates progress. However, there remains a need for continuous and targeted interventions to target high-consumption pockets and address geographic disparities. The results of the present study indicate that interventions focusing on changing tobacco and alcohol consumption should consider the geographical variation at smaller administrative units. By implementing evidence-based policies and interventions suited to the needs of the local areas, public health authorities can continue to make significant strides in improving the health and well-being of the population and reducing the burden of alcohol and tobacco-related diseases.

Trends in economic indicators, alcohol use, and alcohol-attributable health indicators in India

AIMS

Economic development leading a country from a low- to middle-income status is usually associated with increases in alcohol consumption and decreases in all-cause mortality, despite increases in alcohol-attributable mortality. We analyzed this tradition for India during the years 2000-19, with attention to alcohol policy.

METHODS

Joinpoint analysis identified points of trend change and associated slopes for alcohol-attributable mortality and burden (disability-adjusted life years) between 2000 and 2019. Structural equation modeling assessed the relationship among adult alcohol per capita consumption, gross domestic product per capita at purchasing power parity (GDP-PPP per capita), alcohol-attributable mortality, and all-cause mortality, where mortality rates were log-transformed in the models. Pearson correlation was evaluated among study variables. Literature review examined alcohol policies in India.

RESULTS

During the first decade between 2000 and 2019, a rapidly and steadily increasing GDP-PPP per capita was associated with marked increases in alcohol consumption and decreases in all-cause mortality, despite increasing alcohol-attributable mortality. After 2010, the economic growth still increased, but the increase in alcohol consumption halted, likely due to strong alcohol control policies in availability restrictions (dry states, dry periods, high legal purchasing age and restrictions in density, and purchasing hours), as well as a high tax share on final price.

CONCLUSION

Alcohol policies seem to have prevented further increases in alcohol consumption and attributable harm and thus should be upheld. Otherwise, increases in these harms will prevent India from fully reaping the health benefits of economic development.

Mapping the journey of families navigating problem drinking in South Asia: a scoping review

BACKGROUND

Problem drinking is a serious issue as it affects persons with problem drinking and family members including children, adolescents, spouses, and extended family members, thus affecting the entire family environment. This review aims to explore the evidence regarding challenges faced by family members including adolescent children, spouses, and extended family members due to a person with a problem drinking. The findings from the review will help inform further research to develop interventions for family members and for parents having problem drinking issues.

METHODS

This scoping review was undertaken using the Joanna Briggs Institute framework. Six online databases were searched for relevant articles published in English from January 2003 to June 2023. Both quantitative and qualitative studies conducted in South Asia on challenges faced by family members living with either parent/s with problem drinking were included. Challenges were sorted into physical, psychological/emotional, social, and financial, as faced by family members.

RESULTS

Forty-seven articles met the inclusion criteria. Of the 47 studies, 37 studies described challenges faced by spouses while 10 studies described challenges among adolescent children in households with parental problem drinking. Most studies focused on psychological/emotional challenges while more than half reported physical challenges. Since the scoping review aimed to map the evidence available on challenges faced by family members of a person with problem drinking, data was presented narratively.

CONCLUSIONS

This scoping review explored multifaceted challenges and consequences among families affected by a person with problem drinking. The review has provided insights into the complexities of problem drinking leading to disruptive family relationships, poor parenting, emotional vulnerabilities, and psychiatric morbidities. Healthcare professionals need to consider the challenges that affect the family while also considering each individual in the family in managing parental problem drinking.

Alcohol-Attributable Cancer: Update From the Global Burden of Disease 2021 Study

BACKGROUND AND AIMS

Alcohol is a major risk factor for cancer development. Our study aimed to provide the updated global, regional and national burden of alcohol-attributable cancer.

APPROACH AND RESULTS

We analysed the Global Burden of Disease Study 2021 to determine the death and age-standardised death rate (ASDR) from alcohol-attributable cancer and the change of these measures between 2000 and 2021 (reflected as annual percent change [APC]), classified by region, nation and country's developmental status, which is based on the sociodemographic index (SDI).

RESULTS

In 2021, there were 343,370 deaths globally from alcohol-attributable cancer, which was an increase from 2000 by 51%. Alcohol-attributable cancer accounted for 3.5% of all cancer deaths. Among alcohol-attributable cancer, liver cancer (27%) accounted for the highest mortality from alcohol, followed by oesophageal (24%) and colorectal cancer (16%). From 2000 to 2021, ASDR from alcohol-attributable cancer decreased (APC: -0.66%). Regionally, from 2000 to 2021, the fastest-growing ASDR was observed in South Asia. Classified by SDI, low (APC: 0.33%) and low-to-middle SDI countries (APC: 1.58%) exhibited an uptrend in ASDR from alcohol-attributable cancer. While the ASDR from all other cancers decreased, ASDR from early-onset (15-49 years) lip and oral cavity cancer increased (APC: 0.40%).

CONCLUSIONS

From 2000 to 2021, although the ASDR from alcohol-attributable cancer declined, the total number of deaths continued to rise. This trend was accompanied by variations across sociodemographic groups and cancer types, particularly gastrointestinal cancers. Urgent efforts are needed both globally and at regional levels to address the burden of alcohol-attributable cancers.

Perspectives on addiction-related problems in India

AIMS

To offer insights into various salient substance use and addictive behaviours related aspects as applicable to India.

METHODS

We synthesised the published literature on addictive disorders from India. While not a systematic review of all available literature, the synthesis captures relevant themes including salient epidemiological findings, issues related to the prevention and management services targeted at addictive disorders, key observations in the context of the state of addiction science in the country, the policy status and its implications for the country.

RESULTS

In general, the prevalence of substance use in India seems to be lower compared with global averages. For opioids, the prevalence rate is higher than the global average. Addiction prevention and treatment options for persons with addictive disorders in India can be best described as 'diverse': there is a wide range of services available, which vary across settings. Some models, services and products aimed at prevention and treatment of addictive disorders have been developed in the country. The policy, regulatory framework and programs targeted at addictions are not entirely in sync with the science. India has a substantial body of addiction science research.

CONCLUSIONS

The addiction landscape in India is complex and evolving. There is a heterogeneity not only across the different themes related to addiction, but also within the themes across different parts of the country.

Regional disparities and correlates of alcohol use during pregnancy in India: Insights from the National Family Health Survey-5

INTRODUCTION

Alcohol use during pregnancy is a significant public health concern due to its adverse outcomes for the mother and developing fetus. This study aims to estimate the national and state-wise prevalence of alcohol use during pregnancy in India and examine associated social, demographic and health-related correlates using data from the National Family Health Survey (NFHS-5) conducted in 2019-2020.

METHODS

Data from NFHS-5, a large-scale, nationally representative survey, were analysed. The survey included comprehensive interviews with 724,115 women aged 15-49 years, covering all 28 states and 8 union territories of India. The main outcome was self-reported alcohol use during the respondents' current or most recent pregnancy. Explanatory variables included age, economic status, education level, tribal affiliation, urban/rural residence, planned/unplanned pregnancy, adequacy of antenatal care and tobacco use. Statistical analyses included chi-square tests for unadjusted comparisons and logistic regression for adjusted odds ratios (AOR).

RESULTS

The prevalence of alcohol use during pregnancy was 1.26% nationally, with significant regional variations. The highest prevalence rates were in Arunachal Pradesh (13.03%), Chhattisgarh (5.77%) and Assam (5.62%). Key correlates included belonging to Scheduled Tribes (AOR 7.987, 95% CI 5.73-11.134), having no education (AOR 1.733, 95% CI 1.025-2.931) and tobacco use (AOR 3.389, 95% CI 2.647-4.338). Regional analysis showed the highest adjusted odds for the Northeast (AOR 19.753, 95% CI 4.87-80.116) region.

DISCUSSION AND CONCLUSIONS

Alcohol use during pregnancy in India shows significant regional and socio-demographic disparities. The findings highlight the need for targeted public health interventions and policies, particularly in high-risk groups and regions.

Association between alcohol sales and facial fracture rates: an ecological analysis

AIMS

This study aimed to evaluate national alcohol sales and their association with the number of maxillofacial fractures in Southern Finland.

METHODS

Patient data of all facial fracture patients admitted to tertiary trauma centers (Helsinki University Hospital, Helsinki, Finland) from January 2014 to October 2020 were reviewed retrospectively. Information on alcohol sales in Finland was obtained from the Finnish Institute for Health and Welfare.

RESULTS

The annual number of facial fractures increased, as did the number of facial fractures caused by interpersonal violence. Unexpectedly, we found a mostly inverse association between alcohol sales and facial fractures, although three months were associated positively: April, June, and November.

CONCLUSION

We conclude that although the significance of alcohol use in the etymology of facial fractures has been unmistakably proven neither population-level alcohol use nor interpersonal violence as an injury mechanism explains the increase in facial fractures. However, there are some associations between the seasonality of alcohol consumption and facial fractures, suggesting the same predisposing factors in both. Further, certain groups of users, exceeding a threshold of alcohol use, appear to be responsible for the traumatic presentations in emergency units. Elucidating the associations between alcohol use and facial fractures requires an assessment of patient-specific factors, rather than population-level alcohol use, for a detailed understanding and justification of alcohol policy.

Addressing India's alcohol misuse crisis: The urgent need for screening and brief intervention to bridge the healthcare gap

India faces a significant challenge with alcohol misuse, as evidenced by the national survey revealing that 57 million out of 160 million persons with alcohol use exhibit harmful or dependent patterns, necessitating professional assistance. The Global Status Report on Alcohol and Health (2018) indicates a rising per capita alcohol consumption in the Southeast Asian Region, with India contributing substantially. To address this, implementing policies and programs to curb hazardous alcohol use is crucial. Despite a shortage of mental health professionals in India, they remain the primary caregivers for those with alcohol-related issues. Only one in five individuals with problematic alcohol use can access professional help. I argue for adopting Screening and Brief Intervention (SBI) to bridge this healthcare gap. SBI is a concise, structured counseling approach that proves effective and scalable. It can be delivered by various healthcare providers, including doctors, nurses, counselors, and paramedics. Hence, it can be seamlessly integrated into primary care, emergency, and nonclinical settings. The efficacy of SBI extends to electronic formats, providing a scope of expansion through telehealth. The WHO advocates SBI by its SAFER initiative aimed at reducing negative alcohol-associated health and social consequences. SBI is effective across age groups, including adolescents and young adults, constituting most of India's population. Emerging evidence suggests that SBI is acceptable, feasible, and effective in the Indian context. Universal or targeted SBI can be a pivotal tool in achieving the Sustainable Development Goals (2030) and global commitments for noncommunicable diseases, fortifying efforts to prevent and treat alcohol misuse.

Alcoholic Liver Disease in China: A Disease Influenced by Complex Social Factors That Should Not Be Neglected

Alcoholic liver disease (ALD) encompasses liver damage caused by chronic, excessive alcohol consumption. It manifests initially as marked hepatocellular steatosis and can progress to steatohepatitis, liver fibrosis, and cirrhosis. With China's rapid economic growth, coupled with a complex social background and the influence of a deleterious wine culture, the number of patients with ALD in China has increased significantly; the disease has become a social and health problem that cannot be ignored. In this review, we briefly described the social factors affecting ALD in China and elaborated on differences between alcoholic and other liver diseases in terms of complications (e.g., cirrhosis, upper gastrointestinal bleeding, hepatic encephalopathy, hepatocellular carcinoma, addiction, and other extrahepatic diseases). We also emphasized that ALD was more dangerous and difficult to treat than other liver diseases due to its complications, and that precise and effective treatment measures were lacking. In addition, we considered new ideas and treatment methods that may be generated in the future.

High prevalence of MAFLD in general population: A large cross-sectional study calls for concerted public health action

BACKGROUND

Metabolic associated fatty liver disease (MAFLD) is a relatively new term with limited studies done in South Asian population.

AIM

To determine prevalence and clinico-epidemiological characteristics of MAFLD in general population.

METHODS

A cross-sectional study was conducted in randomly selected regions across Delhi, India. Data were collected on socio-demographic particulars, health status and lifestyle factors. Anthropometric measurements, transient elastography, and laboratory investigations were carried out.

RESULTS

Altogether 6146 participants (mean age: 43.1 ± 13.9 years, 48.1% males) were included. The prevalence of MAFLD was 56.4% (n = 3468), of which lean MAFLD constituted 11.3%. Higher age (OR: 2.47; 95% CI: 2.21-2.76), low education level (OR: 1.23; 95% CI: 1.09-1.39), upper socio-economic class (OR: 1.32; 95% CI: 1.17-1.49), and low physical activity (OR: 1.15; 95% CI: 1.03-1.28) were more common in MAFLD. The association of female sex with MAFLD differed in age groups <40 years (OR: 0.64 and 95% CI: 0.55-0.75) and >40 years (OR: 1.40 and 95% CI: 1.22-1.62) in both magnitude and direction (p < 0.001). Liver fibrosis was present in 23% of the study population (32.2% among MAFLD group). Advanced liver fibrosis was three times more common in MAFLD group (6.2% vs 1.8%, p < 0.001). Obesity and fibrosis had a statistically significant relationship and 75.8% of the individuals with advanced stages of fibrosis had obesity.

CONCLUSION

Nearly half of study population was found to have MAFLD. Advanced hepatic fibrosis was three times more common in these subjects. Aggressive public health measures are urgently required to raise awareness and introduce interventional strategies.

Understanding clinical complexity in organ and organizational systems: Challenges local and global

INTRODUCTION

Complexity in healthcare systems has been arbitrarily defined as tasks or systems ranging from complicated to intractable, with a general view of these not being 'simple'. Complexity in healthcare systems in first-world countries has been well elucidated, however, data from third-world countries is still scant. MATERIALS AND METHODS: We present four cases each from three different organ systems-chronic kidney disease, alcohol use disorder, and heart failure-in the backdrop of our healthcare organization. We present our analysis of the complexities faced clinically and, in our local healthcare system which led to these events.

RESULTS

Analysis of these cases showed that patients with chronic kidney disease had vertebral-spinal pathologies due to poor infection control measures during haemodialysis. All these patients were young with a long history of secondary hypertension. In patients with alcohol use disorder, a common theme of how government regulations and peer pressure promote alcohol use is analysed. In the four patients with unexplained heart failure, vascular health is viewed as a fractal dimension and the various factors affecting vascular health are elaborated.

CONCLUSION

Complexities exist clinically in making a diagnosis, and organizationally, in the variables and nodes dictating patient outcomes. Clinical complexities cannot be simplified but have to be navigated in an optimized way to improve clinical outcomes.

The Pattern of Alcohol Use in Alcohol-Related Cirrhosis in Indian Patients: AUDIT Indian Liver Study

Background

Alcohol is one of the most common causes of liver cirrhosis. Yet, the pattern of alcohol consumption in cirrhosis is rarely studied. This study aims to study the drinking patterns along with the educational, socioeconomic, and mental health in a cohort of patients with and without liver cirrhosis.

Methods

This prospective observational study was conducted at a tertiary-care hospital and included patients with harmful drinking. Demographic, alcohol intake history, assessment of socioeconomic and psychological status by modified Kuppuswamy scale and Beckwith Inventory, respectively, were recorded and analyzed.

Results

Cirrhosis was present in 38.31% of patients with heavy drinking (64%). Cirrhosis was more among illiterates (51.76%) with early onset (22.4. ± 7.30 yrs P = 0.0001) and longer duration of alcohol (12.5 ± 6.5 vs. 6.8 ± 3.4 P = 0.001). Higher education qualification was associated with lower cirrhosis (P < 0.0001). With the same employment and education qualifications, net income in cirrhosis was lower [USD 298 (175-435) vs. USD 386 (119-739) P = 0.0001]. Whiskey (86.8%) was the commonest drink consumed. Similar median alcoholic drinks per week were consumed by both groups [34 (22-41) vs. 30 (24-40), P = 0.625], while indigenous alcohol was more consumed in cirrhosis [105 (98.5-109.75) vs. 89.5.0 (69.25-110.0) P = 0.0001]. Loss of jobs (12.36%) and partner violence were more in cirrhotic (9.89% vs. 5.80%) with similar borderline depression.

Conclusion

Alcohol use disorder-related cirrhosis is present in a quarter of patients with harmful early onset and longer duration of drinking and is inversely related to the education status and affects the socioeconomic, physical, and family health of patients.

Worldwide Prevalence of Alcohol Use in Non-Fatally Injured Motor Vehicle Drivers: A Systematic Review and Meta-Analysis

Drunk driving is an important risk factor significantly contributing to traffic accidents and their associated lethality. This meta-analysis of observational studies aims to provide the estimates of drunk driving prevalence in non-lethally injured motor vehicle drivers in relation to the world region, blood alcohol concentration (BAC), and quality of the primary study. A systematic search for observational studies that examined the prevalence of drunk driving in injured drivers was performed, and 17 studies comprising 232,198 drivers were included in the pooled analysis. The pooled prevalence of drunk driving in injured drivers was found to be 16.6% (95% CI: 12.8-20.3%; I² = 99.87%, p < 0.001). In addition, the prevalence of alcohol use ranged from 5.5% (95% CI: 0.8-10.1%) in the Middle East, North Africa, and Greater Arabia region to 30.6% (95% CI: 24.6-36.5%) in the Asia region. As for the subgroups with different thresholds of BAC, the maximum value of 34.4% (95% CI: 28.5-40.3%) was found for a dose of 0.3 g/L. The prevalence of alcohol use reported by high-quality studies was 15.7% (95% CI: 11.1-20.3%), compared to 17.7% (95% CI: 11.3-24.2%) reported by studies of moderate quality. These findings could inform law enforcement efforts to promote road safety.

Status and Determinants of Early Detection of Oral Premalignant and Malignant Lesions in India

It has been over four decades since the launch of the National Cancer Control Programme in India, yet the cancer screening rates for oral cancer remain unremarkable. Moreover, India is bracing a large burden of oral cancer with poor survival rates. An effective public health programme implementation relies on a multitude of factors related to cost-effective evidence-based interventions, the healthcare delivery system, public health human resource management, community behaviour, partnership with stakeholders, identifying opportunities and political commitment. In this context, we discuss the various challenges in the early detection of oral premalignant and malignant lesions and potential solutions.

How and What are Indians Drinking? Findings from the National Family Health Survey

Aims

To assess recent changes in the extent and pattern of alcohol use in India using the National Family Health Survey (NFHS) data.

Methods

We used unit-level data from both rounds of NFHS. The pattern of alcohol use was categorized as: ‘almost every day’, ‘almost once a week’ and ‘less than once a week’. The information was segregated for the urban and rural settings. Information was also available on the type of alcoholic beverage used by the respondents. The z test for differences in proportions was carried out for the study variables.

Results

Findings suggest a 22.37 and 39.02% reduction in the proportion of men and women who reported alcohol use, respectively. The proportion of men reporting ‘almost every day’ and ‘about once a week’ consumption of alcohol increased by 24.19 and 7.14%, respectively.

Conclusions

With the caveats of expected limitations of surveys, the findings suggest an overall decrease in alcohol use in India, though the proportion of men with more frequent alcohol has increased. There is a need to strengthen the investment in the initiatives targeted at the harms due to alcohol use.