Lifetime costs of alcohol consumption in Thailand: protocol for an incidence-based cost-of-illness study using Markov model

INTRODUCTION

Several prevalence-based cost-of-illness (COI) studies have been conducted to estimate the economic burden of alcohol consumption borne by a particular society in a given year. Yet there are few studies examining the economic costs incurred by an individual drinker over his/her lifetime. Thus, this study aims to estimate the costs incurred by an individual drinker's alcohol consumption over his or her lifetime in Thailand.

METHODS AND ANALYSIS

An incidence-based COI approach will be employed. To project individuals' associated costs over a lifetime, a Markov modelling technique will be used. The following six alcohol-related diseases/conditions will be considered in the model: hypertension, haemorrhagic stroke, liver cirrhosis, liver cancer, alcohol use disorders and road injury. The analysis will cover both direct (ie, direct healthcare cost, costs of property damage due to road traffic accidents) and indirect costs (ie, productivity loss due to premature mortality and hospital-related absenteeism). The human capital approach will be adopted to estimate the cost of productivity loss. All costs will be presented in Thai baht, 2022.

ETHICS AND DISSEMINATION

The Institutional Review Board of Mahidol University, Faculty of Dentistry/Faculty of Pharmacy has confirmed that no ethical approval is required (COE.No.MU-DT/PY-IRB 2021/010.0605). Dissemination of the study findings will be carried out through peer-reviewed publications, conferences and engagement with policy-makers and public health stakeholders.

Stakeholder-Informed Solutions To Address Barriers for Alcohol Screening and Brief Intervention in Thai Hypertension Care

Premature deaths from NCDs disproportionately affect people in low- and middle-income countries. Since alcohol use is one of the most common causes of reversible hypertension, interventions targeting alcohol use may be a feasible and effective low-cost approach to synergistically reduce the prevalence of harmful drinking and high blood pressure. This study sought to identify key factors in successfully implementing alcohol use screening and brief intervention in hypertension care in Thailand. For this purpose, we surveyed participants (NRound 1 = 91, NRound 2 = 27) from three different groups of Thai stakeholders (policy- and decisionmakers, primary healthcare practitioners, and patients diagnosed with hypertension) in a two-round stakeholder elicitation. In round 1, we identified limited resources, lack of clear guidelines for lifestyle intervention, stigmatization, and inconsistent monitoring of patients' alcohol use as important barriers. In round 2, we sought to elicit solutions for the barriers identified in round 1. While stakeholders emphasized the need for adaptability to existing realities in Thai primary healthcare such as a high workload and limited digitization, they favorably evaluated a digital alcohol assessment tool with integrated, tailored advice for brief intervention as a potential scalable solution. Findings suggest that as one possible route to reduce the NCD burden caused by hypertension in Thailand, primary healthcare services may be enhanced by digital tools that support resource-effective, intuitive, and seamless delivery of alcohol screening and brief intervention.

Cannabis legalization and driving under the influence of cannabis and driving under the influence of alcohol among adult and adolescent drivers in Ontario, Canada (2001-2019)

BACKGROUND

The impacts of cannabis legalization on driving under the influence of cannabis and driving under the influence of alcohol among adults and adolescents were examined in Ontario, Canada.

METHODS

Data were sourced from adult (N=38,479) and adolescent (N=23,216) populations-based surveys (2001-2019). The associations between cannabis legalization and driving within an hour of using cannabis and driving within an hour of drinking two or more drinks of alcohol were quantified using logistic regression, with testing of multiplicative interactions between cannabis legalization and age and sex. All analyses were conducted separately for adults and adolescents and restricted to participants with a valid driver's license.

RESULTS

Cannabis legalization was not associated with driving within an hour of using cannabis among adults (OR, 95% CI: 1.21, 0.69-2.11). However, a multiplicative interaction indicated that there was an increased likelihood of driving within an hour of using cannabis among adults ≥55 years of age (4.23, 1.85-9.71) pre-post cannabis legalization. Cannabis legalization was not associated with driving within an hour of using cannabis among adolescents (0.92, 0.72-1.16), or with driving within an hour of consuming two or more drinks of alcohol among adults (0.78, 0.51-1.20) or adolescents (0.87, 0.42-1.82).

CONCLUSIONS

An increased likelihood of driving under the influence of cannabis among adults ≥55 years of age was detected in the year following cannabis legalization, suggesting the need for greater public awareness and education and police monitoring and enforcement concerning driving under the influence of cannabis, particularly among older adults.

The cost-effectiveness of improved brief interventions for tobacco cessation in Thailand

Background

This study estimated the cost-effectiveness of four strategies enhancing the quality and accessibility of Brief Intervention (BI) service for smoking cessation in Thailand during 2022-2030: (1) current-BI (status quo), (2) the effective-training standard-BI, (3) the current-BI plus the village health volunteers (VHV) mobilization, and (4) the effective-training BI plus VHV mobilization.

Methods

By interviewing five public health officers, nine healthcare professionals aiding these services, and fifteen BI service experts, we explored the status quo situation of the Thai smoking cessation service system, including main activities, their quantity assumptions, and activities' unit prices needed to operate the current cessation service system. Then, we modeled additional activities needed to implement the other three simulated scenarios. We estimated the costs and impacts of implementing these strategies over a nine-year operating horizon (2022-2030), covering 3 years of service system preparation and 6 years of full implementation. The modeled costs of these four strategies included intervention and program costs. The study focused on current smokers age 15 years or older. The assessed impact parameters encompassed smoking prevalence, deaths averted, and healthy life-years gained. An Incremental Cost-Effectiveness Analysis compared the four simulated strategies was employed. Data analysis was performed using the One Health Tool software, which the World Health Organization developed.

Results

The findings of this investigation reveal that all three intervention strategies exhibited cost-effectiveness compared to the prevailing status quo. Among these strategies, Strategy 2, enhancing BI service quality, emerged as the most efficient and efficacious option. Therefore, the expansion of quality services should be synergistically aligned with augmented training, service delivery optimization, and managerial enhancements.

Conclusion

This approach is particularly poised to enhance accessibility to and the efficacy of smoking cessation interventions across Thailand.

Evaluating the efficacy of a community participatory intervention to prevent suicide in Thailand: a randomised controlled trial protocol

INTRODUCTION

The age-standardised suicide mortality rate in Thailand has been stable at a high level in recent years, highlighting the need for suicide prevention interventions. In Thailand, community involvement plays a key role in health promotion. The aim of this ongoing trial is to evaluate the efficacy of a community participatory intervention in two subdistricts in Thailand for reducing suicidality symptoms among individuals considered at high risk for suicide and compare the outcomes to two control subdistricts.

METHODS AND ANALYSIS

In this cluster (subdistrict) randomised controlled trial, we randomised two districts to either the community participatory intervention arm or the control arm. From each district, we selected one large and one small subdistricts. We estimated that we need 235 participants per study arm, who were recruited from subdistrict health centres. The primary outcome is suicidality symptoms. Secondary outcomes are depression symptoms, quality of life, stress level and health and community service accessibility.

ETHICS AND DISSEMINATION

This trial has been approved by the Research Ethics Committee, Faculty of Nursing, Chiangmai University (number 050/2022). All participants were required to provide informed consent. The findings of the study will be disseminated in peer-reviewed journals and via conferences.

TRIAL REGISTRATION NUMBER

TCTR20220620003; the Thai Clinical Trials Registry.

Assessing data availability of NCD prevention and control in six ASEAN countries based on WHO global monitoring framework and the progress monitor indicators

BACKGROUND

To tackle noncommunicable disease (NCD) burden globally, two sets of NCD surveillance indicators were established by the World Health Organization: 25 Global Monitoring Framework (GMF) indicators and 10 Progress Monitoring Indicators (PMI). This study aims to assess the data availability of these two sets of indicators in six ASEAN countries: Cambodia, Lao PDR, Malaysia, Myanmar, Thailand, and Vietnam.

METHODS

As data on policy indicators were straightforward and fully available, we focused on studying 25 non-policy indicators: 23 GMFs and 2 PMIs. Gathering data availability of the target indicators was conducted among NCD surveillance experts from the six selected countries during May-June 2020. Our research team found information regarding whether the country had no data at all, was using WHO estimates, was providing 'expert judgement' for the data, or had actual data available for each target indicator. We triangulated their answers with several WHO data sources, including the WHO Health Observatory Database and various WHO Global Reports on health behaviours (tobacco, alcohol, diet, and physical activity) and NCDs. We calculated the percentages of the indicators that need improvement by both indicator category and country.

RESULTS

For all six studied countries, the health-service indicators, based on responses to the facility survey, are the most lacking in data availability (100% of this category's indicators), followed by the health-service indicators, based on the population survey responses (57%), the mortality and morbidity indicators (50%), the behavioural risk indicators (30%), and the biological risk indicators (7%). The countries that need to improve their NCD surveillance data availability the most are Cambodia (56% of all indicators) and Lao PDR (56%), followed by Malaysia (36%), Vietnam (36%), Myanmar (32%), and Thailand (28%).

CONCLUSION

Some of the non-policy GMF and PMI indicators lacked data among the six studied countries. To achieve the global NCDs targets, in the long run, the six countries should collect their own data for all indicators and begin to invest in and implement the facility survey and the population survey to track NCDs-related health services improvements once they have implemented the behavioural and biological Health Risks Population Survey in their countries.

Canada’s Cannabis Legalization with Strict Public Health Control

Abstract: Aims: To describe the impact of the legalization of cannabis for recreational use under strict public health control in 2018 on the following outcomes: cannabis use and use patterns, attributable harm, economic considerations. Methodology: Narrative review based on government documents, surveys, and published literature. Results: The 12-month prevalence increased after legalization and has decreased during the COVID-19 pandemic. Little change in prevalence for adolescents. Persons with daily use remained stable. No rigorous studies on changes in attributable health harm, but some indication that harm, as measured in prevalence of cannabis use disorders, treatment rate, and attributable traffic injury remained stable. No data yet available for cancer. Cannabis attributable emergency visits increased, including among children (poisoning). Cannabis-related offences decreased as biggest public health gain. Economic predictions were not realized, and there is some pressure from cannabis industry to loosen public health regulations in order to increase use. Conclusions: Overall, while not achieving its main objectives of more youth protection and decreases in cannabis-attributable health harm, legalization with strict public health control resulted in less cannabis-related offences and up to now did not seem to increase cannabis-attributable disease burden.

Alcohol: No Ordinary Commodity-a summary of the third edition

BACKGROUND AND AIMS

This article summarizes the findings and conclusions of the third edition of Alcohol: No Ordinary Commodity. The latest revision of this book is part of a series of monographs designed to provide a critical review of the scientific evidence related to alcohol control policy from a public health perspective.

DESIGN

A narrative summary of the contents of the book according to five major issues.

FINDINGS

An extensive amount of epidemiological evidence shows that alcohol is a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. Trends in alcohol products and marketing are described, indicating that a large part of the global industry has been consolidated into a small number of transnational corporations that are expanding their operations in Asia, Africa and Latin America. The main part of the book is devoted to a review of strategies and interventions designed to prevent or minimize alcohol-related harm. Overall, the most effective strategies to protect public health are taxation that decreases affordability and restrictions on the physical availability of alcohol. A total ban on alcohol marketing is also an effective strategy to reduce consumption. In addition, drink-driving counter-measures, brief interventions with at-risk drinkers and treatment of drinkers with alcohol dependence are effective in preventing harm in high-risk contexts and groups of hazardous drinkers.

CONCLUSION

Alcohol policy is often the product of competing interests, values and ideologies, with the evidence suggesting that the conflicting interests between profit and health mean that working in partnership with the alcohol industry is likely to lead to ineffective policy. Opportunities for implementation of evidence-based alcohol policies that better serve the public good are clearer than ever before as a result of accumulating knowledge on which strategies work best.

Addressing alcohol use among blood pressure patients in Thai primary care: Lessons from a survey-based stakeholder consultation

Alcohol use is a major risk factor for noncommunicable diseases in Thailand, and one of its pathways is high blood pressure. Given that brief intervention can effectively reduce hazardous alcohol consumption, this study aimed to investigate how hypertensive patients with concomitant alcohol use are identified and treated in Thai primary care settings and what this may mean for screening and lifestyle intervention strategies. In a cross-sectional, mixed-method design, we surveyed 91 participants from three different groups of Thai stakeholders: policy- and decisionmakers; healthcare practitioners; and patients diagnosed with hypertension. Data was collected between December 2020 and May 2021. Responses were analyzed descriptively and using open coding tools to identify current practices, barriers, facilitators, and implications for interventions. All stakeholder groups regarded alcohol use as an important driver of hypertension. While lifestyle interventions among hypertensive patients were perceived as beneficial, current lifestyle support was limited. Barriers included limited resources in primary healthcare facilities, lack of continuous monitoring or follow-up, missing tools or procedures for risk assessment and lifestyle intervention, and stigmatization of alcohol use. Our results suggest that although screening for lifestyle risk factors (including alcohol use) and lifestyle interventions are not yet sufficiently established, a wide range of stakeholders still recognize the potential of interventions targeted at hazardous alcohol use among hypertensive patients. Future interventions may establish standardized assessment tools, be tailored to high-risk groups, and include electronic or remote elements.

Understanding injecting drug use in Afghanistan: A scoping review

Background

Several reports have described a growing prevalence of illicit drug use in Afghanistan, with recognition of a recent shift from traditional modes of consumption involving inhalation and oral ingestion to injecting drug use.

Objective

Conduct a comprehensive review of existing literature to map the injecting drug use situation in Afghanistan. The review intends to describe risk factors and impacts of injecting drug use, drug use characteristics and risk behaviours among people who inject drugs (PWID), and access to harm reduction and treatment.

Methods

We searched Embase, Global Health, Medline, PsycINFO, Web of Science, and grey literature to identify English language publications up to March 26^th, 2022. Studies were eligible for inclusion if they explicitly targeted PWID or injecting drug use in Afghanistan and provided information relevant to the review questions. Two reviewers independently screened titles and abstracts for inclusion and extracted information based on the review objectives.

Results

A total of 25 articles were identified representing 15 studies (11 quantitative, 2 qualitative, 2 mixed methods). All but one studies were cross-sectional. In majority of the studies, over 95% of the participants were male and most were conducted over a decade ago, in urban settings, mainly Kabul. Only one study examined risk factors of injecting drug use. Eleven studies described drug use characteristics and 9 reported risk behaviours among PWID. Health and social burden of injecting drug use were reported by 8 and 5 studies, respectively. Nine studies described access to harm reduction and treatment. Afghan PWID had high levels of injecting and sexual risk behaviours compared to global estimates. They reported high prevalence of incarceration and displacement. Access to harm reduction and treatment was very limited. This scoping review revealed important knowledge gaps including a gender gap in research with serious implications for drug policy and substance use care.

Conclusions

Development of a national public health-oriented drug policy and substance use care programme is warranted along with efforts to develop health research capacity to address the need for epidemiological data. The current humanitarian crisis necessitates continued access to evidence-based harm reduction and treatment in Afghanistan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-022-00491-1.

The impact of alcohol taxation changes on unrecorded alcohol consumption: A review and recommendations

BACKGROUND

The diverse forms of unrecorded alcohol, defined as beverage alcohol not registered in official statistics in the country where it is consumed, comprise about one fourth of all alcohol consumed worldwide. Since unrecorded alcohol is usually cheaper than registered commercial alcohol, a standard argument against raising alcohol excise taxes has been that doing so could potentially result in an increase in unrecorded consumption. This contribution examines whether increases in taxation have in fact led to increases in consumption of unrecorded alcohol, and whether these increases in unrecorded alcohol should be considered to be a barrier to raising taxes. A second aim is to outline mitigation strategies to reduce unrecorded alcohol use.

METHODS

Narrative review of primary and secondary research, namely case studies and narrative and systematic reviews on unrecorded alcohol use worldwide.

RESULTS

Unrecorded alcohol consumption did not automatically increase with increases in taxation and subsequent price increases of registered commercial alcohol. Instead, the level of unrecorded consumption depended on: a) the availability and type of unrecorded alcohol; b) whether such consumption was non-stigmatized; c) the primary population groups which consumed unrecorded alcohol before the policy change; and d) the policy measures taken. Mitigation strategies are outlined.

CONCLUSIONS

Potential increases in the level of unrecorded alcohol consumption should be considered in the planning and implementation of substantial increases in alcohol taxation. However, unrecorded consumption should not be considered to be a principal barrier to implementing tax interventions, as evidence does not indicate an increase in consumption if mitigation measures are put in place by governments.

Global burden of cancer in 2020 attributable to alcohol consumption: a population-based study

BACKGROUND

Alcohol use is causally linked to multiple cancers. We present global, regional, and national estimates of alcohol-attributable cancer burden in 2020 to inform alcohol policy and cancer control across different settings globally.

METHODS

In this population-based study, population attributable fractions (PAFs) calculated using a theoretical minimum-risk exposure of lifetime abstention and 2010 alcohol consumption estimates from the Global Information System on Alcohol and Health (assuming a 10-year latency period between alcohol consumption and cancer diagnosis), combined with corresponding relative risk estimates from systematic literature reviews as part of the WCRF Continuous Update Project, were applied to cancer incidence data from GLOBOCAN 2020 to estimate new cancer cases attributable to alcohol. We also calculated the contribution of moderate (<20 g per day), risky (20-60 g per day), and heavy (>60 g per day) drinking to the total alcohol-attributable cancer burden, as well as the contribution by 10 g per day increment (up to a maximum of 150 g). 95% uncertainty intervals (UIs) were estimated using a Monte Carlo-like approach.

FINDINGS

Globally, an estimated 741 300 (95% UI 558 500-951 200), or 4·1% (3·1-5·3), of all new cases of cancer in 2020 were attributable to alcohol consumption. Males accounted for 568 700 (76·7%; 95% UI 422 500-731 100) of total alcohol-attributable cancer cases, and cancers of the oesophagus (189 700 cases [110 900-274 600]), liver (154 700 cases [43 700-281 500]), and breast (98 300 cases [68 200-130 500]) contributed the most cases. PAFs were lowest in northern Africa (0·3% [95% UI 0·1-3·3]) and western Asia (0·7% [0·5-1·2]), and highest in eastern Asia (5·7% [3·6-7·9]) and central and eastern Europe (5·6% [4·6-6·6]). The largest burden of alcohol-attributable cancers was represented by heavy drinking (346 400 [46·7%; 95% UI 227 900-489 400] cases) and risky drinking (291 800 [39·4%; 227 700-333 100] cases), whereas moderate drinking contributed 103 100 (13·9%; 82 600-207 200) cases, and drinking up to 10 g per day contributed 41 300 (35 400-145 800) cases.

INTERPRETATION

Our findings highlight the need for effective policy and interventions to increase awareness of cancer risks associated with alcohol use and decrease overall alcohol consumption to prevent the burden of alcohol-attributable cancers.

FUNDING

None.

Abstract 43: Global Burden of Cancer in 2020 Attributable to Alcohol Consumption: A Population-Based Study

Purpose: Alcohol use is causally linked to multiple cancer sites. We present global, regional and national estimates of alcohol-attributable cancer burden in 2020 to inform alcohol policy and cancer control across different settings globally.

Methods: In this population-based study, we calculated population attributable fractions (PAFs) using relative risk estimates and alcohol use prevalence by age, sex, and country. Assuming a 10-year latency period between alcohol consumption and cancer occurrence, we used alcohol consumption prevalence from 2010 and GLOBOCAN 2020 data to estimate new cancer cases attributable to alcohol consumption. We also calculated the contribution of moderate (&lt;20 g alcohol per day), risky (20 to 60 g per day), and heavy (&gt;60 g per day) drinking to the total alcohol-attributable cancer burden.

Results: Globally, an estimated 702 900, or 3.9%, of all new cases of cancer in 2020 were attributable to alcohol consumption. Males represented 71.1% of the total alcohol-attributable cancer cases. The cancer sites which contributed the most alcohol-attributable cases were cancers of the esophagus (183 000 cases), liver (142 600 cases), and breast (114 300 cases). PAFs were lowest in Northern Africa and Western Asia (less than 1%) in both sexes, and highest in Eastern Asia (7.7%) and Central and Eastern Europe (6.9%) in men, and in Central and Eastern Europe (3.8%), Western Europe (3.5%) and Australia and New Zealand (3.55%) in women. Risky and heavy drinking contributed most to the burden of alcohol-attributable cancers (42.6% and 42.5%, respectively), and moderate drinking contributed 14.9%.

Conclusion: Our findings highlight the need for effective policy and interventions to increase awareness of cancer risks associated with alcohol use and decrease overall alcohol consumption to avoid future rises in alcohol-attributable cancer burden in several regions of the world.

Citation Format: Harriet Rumgay, Kevin Shield, Hadrien Charvat, Pietro Ferrari, Bundit Sornpaisarn, Isidore Obot, Farhad Islami, Valery Lemmens, Jürgen Rehm, Isabelle Soerjomataram. Global Burden of Cancer in 2020 Attributable to Alcohol Consumption: A Population-Based Study [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 43.

The association between the time of alcohol drinking and injury risk in Thailand: a cross-sectional emergency department study

BACKGROUND

Although the relationship between acute alcohol consumption and injuries is well recognized, studies exploring how the time of day the drinking commences affects alcohol-related injuries have been scarce. This contribution examines the associations between the time at which the drinking began and the duration of the drinking, the volume of alcohol consumed, the injury type, and the blood alcohol concentration (BAC) level.

METHOD

This study employed a cross-sectional survey, which was conducted in two hospital emergency departments (ED) in Chiangmai Province, Thailand. The sample was composed of 519 injured patients aged 18 years and older. Outcome measures included the BAC and type of injury. Exposures included the quantity of alcohol consumed, the time the drinking commenced, and the pattern of drinking involved.

RESULTS

The injured patients who drank alcohol within six hours prior to sustaining their injury were more likely to get injured and present themselves at the ED at night (20:00-04:00) compared to those who sustained an injury but did not drink in the hours prior. However, this relationship was only true for unintentional injuries, not intentional ones. The majority of participants consumed their first drink between 16:00 and 20:00. On average, among the 104 patients who drank prior to sustaining an injury, the total amount of alcohol consumed was 6.9 drinks, the duration of drinking was 2.6 h, the rate of drinking was 6.0 drinks/hour, and the BAC was 0.119 gm%. Every drink increased the BAC by 0.012 gm% and each year of increasing age increased the BAC by 0.003 gm%. People who were older, less educated, and drank more frequently tended to have their first drink earlier than other drinkers. An earlier start to their drinking resulted in a faster pace of drinking and a higher BAC.

CONCLUSIONS

BAC increased with the total amount of alcohol consumed and the age of the drinker. Different groups of people had their first drink at different times of the day, resulting in differences in the rate of drinking, the BAC, the time of injury, and the time they presented to the ED after injury.

A supportive school environment may reduce the risk of non-medical prescription opioid use due to impaired mental health among students

Canada is in the midst of an ongoing, escalating opioid crisis, with significant impacts on adolescents and young adults. Accordingly, mental health impairment was examined as a risk factor for non-medical prescription opioid use (NMPOU) among high school students. In addition, the moderating effects of the school environment, in terms of the availability of mental health services and substance use policies, were characterized. Self-reported, cross-sectional data were obtained from the COMPASS study, including 61,239 students (grades 9-12) in 121 secondary schools across Canada. Current and lifetime NMPOU were ascertained. Categorical indicators of mental health impairment and school environment were derived. The main analytical strategy encompassed hierarchal multilevel logistic regression, including the addition of interaction terms to characterize the moderation effects. Current and lifetime NMPOU were reported by 5.8% and 7.2% of the students, respectively. After adjusting for confounders, students in the highest quintile of mental health impairment had odds ratios (OR) of 2.60 (95% confidence interval [CI] 2.29-2.95) and 2.96 (95% CI 2.64-3.33) for current and lifetime NMPOU, respectively when compared to students in the lowest quintile of mental health impairment. A significant interaction between mental health impairment and school environment indicated relatively lower risks of NMPOU in students from schools that provide more mental health services and have stricter substance use policies. Mental health impairment increased the risk of NMPOU, but the associations were moderated by the school environment. These findings underscore the importance of mental health services and substance use regulations in schools.

Fewer Cancer Cases in 4 Countries of the WHO European Region in 2018 through Increased Alcohol Excise Taxation: A Modelling Study

INTRODUCTION

Prevention of cancer has been identified as a major public health priority for Europe, and alcohol is a leading risk factor for various types of cancer. This contribution estimates the number of cancer cases that could have potentially been averted in 2018 in 4 European countries if an increase in alcohol excise taxation had been applied.

METHODS

Current country and beverage-specific excise taxation of 4 member states of the WHO European Region (Germany, Italy, Kazakhstan, and Sweden) was used as a baseline, and the potential impacts of increases of 20, 50, and 100% to current excise duties were modelled. A sensitivity analysis was performed, replacing the current tax rates in the 4 countries by those levied in Finland. The resulting increase in tax was assumed to be fully incorporated into the consumer price, and beverage-specific price elasticities of demand were obtained from meta-analyses, assuming less elasticity for heavy drinkers. Model estimates were applied to cancer incidence rates for the year 2018.

RESULTS

In the 4 countries, >35,000 cancer cases in 2018 were caused by alcohol consumption, with the highest rate of alcohol-attributable cancers recorded in Germany and the lowest in Sweden. An increase in excise duties on alcohol would have significantly reduced these numbers, with between 3 and 7% of all alcohol-attributable cancer cases being averted if taxation had been increased by 100%. If the 4 countries were to adopt an excise taxation level equivalent to the one currently imposed in Finland, an even higher proportion of alcohol-attributable cancers could be avoided, with Germany alone experiencing 1,600 fewer cancer cases in 1 year.

DISCUSSION/CONCLUSION

Increasing excise duties can markedly reduce cancer incidence in European countries.

Modifiable Factors and Colon Cancer Risk in Thai Population

To demonstrate the possible impact of modifiable factors on colon cancer development in Thai population, we conducted this case-control study from June 2016 until June 2017. The study was conducted in 11 Thai provincial hospitals. The hospitals in this study were selected by stratification by regions. Patients included 504 ones who were newly diagnosed with colon cancer within 1 month. In the control group, 997 health individuals were enrolled. Both case and control were adjusted by age. The results of this study showed that age and socioeconomic factors were associated with colon cancer risk. In addition, it was found that family history of colon cancer had very high association with colon cancer risk. Behavioral factors, including smoking, inadequate physical exercise, and salty food consumption were associated with colon cancer. We detected no association between obesity, alcohol consumption, and colon cancer. The results suggested that colon cancer might have higher association with genetic factors than behavioral factors among Thai patients. Based on the results of this study, stop smoking and promote adequate physical activity are suggested to reduce the incidence of colon cancrr among Thai patients.

Protection motivation theory to predict intention of healthy eating and sufficient physical activity to prevent Diabetes Mellitus in Thai population: A path analysis

BACKGROUND AND AIMS

Diabetes mellitus is a global health problem causing premature death and economic burden. The study aimed to investigate an application of the protection motivation theory (PMT) model to explain the intention of healthy eating behaviors and physical activity among healthy Thais.

METHODS

This study was a part of a large case control focused only on the control group without noncommunicable diseases. Nine hundred ninety-seven subjects were drawn from eleven provinces of Thailand. A self-administered questionnaire was constructed based on the PMT model to gather information on predictive factors on eating behaviors and physical activity. Path analysis was used to determine whether the empirical data fit the PMT structure as well as to assess the strength of association among PMT constructed factors predicting behavioral intention.

RESULTS

The findings demonstrated that empirical data of eating behaviors (CMIN χ2 p-value = 0.462; CMIN/df = 0.901; NFI = 0.997; CFI = 1; RMSEA <0.001) and physical activity (CMIN χ2 p-value = 0.053; CMIN/df = 2.187; NFI = 0.987; CFI = 0.993; RMSEA = 0.035) fit the PMT. The strongest predictive factor of behavioral intention on eating behaviors was response efficacy (β = 0.146), while self-efficacy was found to be the strongest factor for physical activity (β = 0.11). Knowledge had the only indirect effect on behavior intention through perceived susceptibility and perceived severity.

CONCLUSION

In conclusion, information on susceptibility and severity should be incorporated in intervention strategies to enhance response efficacy and self-efficacy to prevent diabetes.

Strategies used to initiate the first alcohol control law in Thailand: Lessons learned for other low- and middle-income countries

Thailand enacted its first-ever alcohol control law in February of 2008. The process, from its inception to enactment, took a total of two years and eight months. Using an historical analysis approach, the authors describe the policy advocates' activities aimed at gaining acceptance for the alcohol control policy, and provide advice for policy advocates attempting to pass similar laws in other countries. The advocacy process went through three distinct stages: an agenda-setting stage, followed by a policy-formulation stage and a legitimization stage. The agenda-setting stage involved educating the public about the harmful use of alcohol and its effect on society; during the second stage, an appropriate policy response was drafted and, lastly, during the legitimization phase, policy advocates navigated the political landscape in order to win final approval for the proposed policy. A tri-party coalition strategy (known as the 'triangle that moves the mountain' strategy) was employed which synchronized the work of three forces, each representing one of the three points of a triangle-of policy, knowledge, and civic expertise-coupled with media advocacy activities in order to increase the public and government acceptance of the proposed law. The public's view of the proposed law was critical to influence politicians to favour its adoption. While the knowledge and civic forces play a larger role during the agenda-setting and policy-formulation stages, the policy force was more active during the legitimization stage. Lastly, having a funding agency in place, such as Thai Health in this example, to provide a sustained source of funds for health promotion initiatives was critically important for policy advocates. Economic growth is an important determinant of increased consumption of alcohol per capita, and Thailand's experience of passing its first alcohol control law may serve as a useful guide for other low- or middle-income countries wishing to put a national alcohol control law in place.

Alcohol consumption and attributable harm in middle-income South-East Asian countries: Epidemiology and policy options

Background Factors and policies which potentially explain the changes in alcohol consumption and related harms from 2010 to 2017 in 11 middle-income countries in the South-East Asian region (Cambodia, Lao PDR, Indonesia, the Philippines, Malaysia, Maldives, Myanmar, Sri Lanka, Thailand, Timor-Leste, and Vietnam) were examined. Methods Using secondary data from UN agencies, we analyzed trends in alcohol consumption, alcohol-attributable deaths and the burden of disease. Results Starting from a level of consumption significantly below the global average-especially among the Muslim-majority countries (Maldives, Indonesia, and Malaysia)-the majority of the countries in this region had markedly increased their alcohol consumption along with the economic development they experienced between 2010 and 2017. In fact, five middle-income countries in this region (Vietnam, Lao PDR, Cambodia, Myanmar, and Timor-Leste) were in the top 12 countries globally based on absolute increases in adult alcohol per capita consumption (APC). The Philippines and Malaysia were the exceptions, as they had reduced their APC over this period. The majority of South-East Asian countries had parallel increasing trends in the age-standardized alcohol-attributable deaths and DALYs since 2010, in contrast to global trends. While all countries put some alcohol control policies in place, there were differences in the number and strength of the policies applied, commensurate with trends in consumption. In particular, three of the countries which were most successful in reducing consumption and harm (Malaysia, Philippines, and Sri Lanka) applied more effective tax methods based on specific taxation alone or in combination with another taxation method, applying higher taxation rates and regularly increasing them over time. Conclusion To achieve the global target and the Sustainable Development Goal in reducing alcohol consumption worldwide, middle-income countries, especially lower-middle-income countries, should employ stricter alcohol control policies, and apply an appropriate excise tax on alcohol products with regular increases to reflect inflation.

Alcohol use and injury risk in Thailand: A case-crossover emergency department study

INTRODUCTION AND AIMS

While injuries and alcohol contribute to a large proportion of the disease burden in Thailand, no well-designed underlying study has yet been published. This study aims to evaluate the relationship between acute alcohol consumption and injury risk in Thailand.

DESIGN AND METHODS

Using the case-crossover design, this study examined 520 injured patients aged 18 years and older from two emergency departments in Meuang District, Chiang-Mai Province, Thailand, from June to August of 2016. The case period was defined as 6 h prior to injury, the two control periods as the same 6-h period at 1 day and 7 days prior to injury. Alcohol exposure and the amount consumed were measured for these periods.

RESULTS

Twenty percent of injured patients consumed alcohol within the 6 h prior to injury, averaging 6.9 drinks during that time. The odds of injury for those individuals consuming alcoholic beverages was 5.0 (95% confidence interval 3.0, 8.2) times greater compared to non-exposure individuals; every additional drink consumed increased the odds of injury by 1.3 (95% confidence interval 1.2, 1.4). Alcohol use significantly increased the odds of sustaining an unintentional injury, intentional injury inflicted by someone else or experiencing a road traffic injury (among drivers). The dose-response analysis indicated alcohol use significantly increased the risks of unintentional injury and road traffic injuries (among drivers).

DISCUSSION AND CONCLUSIONS

Exposure to alcohol increased the odds of injury in a dose-dependent fashion; hence, comprehensive, cost-effective strategies should be implemented in Thailand to reduce alcohol exposure, binge drinking and drunk driving.

Regulatory Policies for Alcohol, other Psychoactive Substances and Addictive Behaviours: The Role of Level of Use and Potency. A Systematic Review

The object of this contribution based on a systematic review of the literature is to examine to what degree the level of use and potency play a role in regulatory policies for alcohol, other psychoactive substances and gambling, and whether there is an evidence base for this role. Level of use is usually defined around a behavioural pattern of the user (for example, cigarettes smoked per day, or average ethanol use in grams per day), while potency is defined as a property or characteristic of the substance. For all substances examined (alcohol, tobacco, opioids, cannabis) and gambling, both dimensions were taken into consideration in the formulation of most regulatory policies. However, the associations between both dimensions and regulatory policies were not systematic, and not always based on evidence. Future improvements are suggested.

Can pricing deter adolescents and young adults from starting to drink: An analysis of the effect of alcohol taxation on drinking initiation among Thai adolescents and young adults

The objective of this study is to assess the relationship between alcohol taxation changes and drinking initiation among adolescents and young adults (collectively "youth") in Thailand (a middle-income country). Using a survey panel, this study undertook an age-period-cohort analysis using four large-scale national cross-sectional surveys of alcohol consumption performed in Thailand in 2001, 2004, 2007 and 2011 (n=87,176 Thai youth, 15-24 years of age) to test the hypothesis that changes in the inflation-adjusted alcohol taxation rates are associated with drinking initiation. Regression analyses were used to examine the association between inflation-adjusted taxation increases and the prevalence of lifetime drinkers. After adjusting for potential confounders, clear cohort and age effects were observed. Furthermore, a 10% increase of the inflation-adjusted taxation rate of the total alcohol market was significantly associated with a 4.3% reduction in the prevalence of lifetime drinking among Thai youth. In conclusion, tax rate changes in Thailand from 2001 to 2011 were associated with drinking initiation among youth. Accordingly, increases in taxation may prevent drinking initiation among youth in countries with a high prevalence of abstainers and may reduce the harms caused by alcohol.

Assessing Patterns of Alcohol Taxes Produced by Various Types of Excise Tax Methods--A Simulation Study

AIM

To examine patterns of tax burdens produced by specific, ad valorem, and various types of combination taxations.

METHOD

One hundred unique hypothetical alcoholic beverages were mathematically simulated based on the amount of ethanol and perceived-qualities contained. Second, beverages were assigned values of various costs and tax rates, and third, patterns of tax burden were assessed per unit of ethanol produced by each type of tax method.

RESULT

Different tax methods produced different tax burdens per unit of ethanol for different alcoholic beverages. The tax burden produced by the ad valorem tax resulted in a lower tax burden for low perceived-quality alcoholic beverages. The specific tax method showed the same tax burden for both low and high perceived-quality alcoholic beverages. However, high perceived-quality beverages benefited from a lower tax burden per beverage price. Lastly, the combination tax method resulted in a lower tax burden for medium perceived-quality alcoholic beverages.

CONCLUSION

Under the oligopoly market, ad valorem taxation encourages consumption of low perceived-quality beverages; specific taxation encourages consumption of high perceived-quality beverages; and combination tax methods encourage consumption of medium perceived-quality beverages.

Alcohol taxation policy in Thailand: implications for other low- to middle-income countries

AIM

  Prevention of drinking initiation is a significant challenge in low- and middle-income countries that have a high prevalence of abstainers, including life-time abstainers. This paper aims to encourage a debate on an alternative alcohol taxation approach used currently in Thailand, which aims specifically to prevent drinking initiation in addition to reduce alcohol-attributable harms.

METHODS

  Theoretical evaluation, simulation and empirical analysis.

RESULT

  The taxation method of Thailand, 'Two-Chosen-One' (2C1) combines specific taxation (as a function of the alcohol content) and ad valorem taxation (as a function of the price), resulting in an effective tax rate that puts a higher tax both on beverages which are preferred by heavy drinkers and on beverages which are preferred by potential alcohol consumption neophytes, compared to either taxation system alone. As a result of these unique properties of the 2C1 taxation system, our simulations indicate that 2C1 taxation leads to a lower overall consumption than ad valorem or specific taxation alone. In addition, it puts a relatively high tax on beverages attractive to young people, the majority of whom are currently abstaining. Currently, the abstention rates in Thailand are higher than expected based on its economic wealth, which could be taken as an indication that the taxation strategy is successful.

CONCLUSION

  'Two-chosen-one' (2C1) taxation has the potential to simultaneously reduce alcohol consumption and prevent drinking initiation among youth; however, additional empirical evidence is needed to assess its effectiveness in terms of the public health impact in low- and middle-income countries.

Global and Country Specific Adult per capita Consumption of Alcohol, 2008

Aims: Alcohol is a substantial risk factor for mortality and the burden of disease globally. In accordance with the World Health Organization’s (WHO) global strategy to reduce the harmful use of alcohol, we estimated recorded, unrecorded, tourist, and total adult per capita consumption by country and WHO sub-region for 2008, and characterized the association between per capita consumption of alcohol and gross domestic product (GDP-PPP) per capita. Methods: Using data from the Global Information System on Alcohol and Health database ( World Health Organization, 2010 a) and the 2005 Global Burden of Disease study ( Institute for Health Metrics and Evaluation, 2010 ) on adult per capita consumption of alcohol, we estimated recorded adult per capita consumption for 2008 through time series analyses for 189 countries within WHO sub-regions, and then from these estimates calculated recorded adult per capita consumption estimates for each of the WHO sub-regions. Estimates for populations were obtained for 2008 from the United Nations Populations Division. 2008 GDP-PPP data by country (N = 178) were obtained from the International Monetary Fund. Results: Adult per capita consumption of alcohol in 2008 is estimated to have been 6.04 litres (95 % CI: 4.43 to 7.65). This can be broken down into 4.39 l (95 % CI: 3.72 to 4.86) of recorded per capita consumption of alcohol, 1.75 l (95 %CI: 0.25 to 3.25) of unrecorded per capita consumption of alcohol, and 0.00 l (95 %CI: 0.00 to 0.129) per capita consumption of alcohol consumed by tourists. Adult per capita consumption was highest for the European regions and lowest for the Eastern Mediterranean region. Total adult per capita consumption of alcohol showed an increase as GDP-PPP increased until approximately 15,000 international dollars of GDP-PPP per capita. Recorded consumption showed a general increase with GDP-PPP. Unrecorded consumption showed a U-shaped association with GDP-PPP per capita, with countries with the lowest and highest GDP-PPPs per capita having the lowest unrecorded adult per capita consumption of alcohol. Conclusions: In accordance with the WHO’s global strategy to reduce the harmful use of alcohol, we present estimates of the recorded, unrecorded, tourist, and total adult per capita alcohol consumption for 189 countries and the 14 WHO sub-regions. Accurate and up-to-date estimates of alcohol consumption are imperative for monitoring and developing effective strategies to control the large and increasing global alcohol-attributable burden of disease and injury.