Using the Pan American Health Organization digital conversational agent to educate the public on alcohol use and health: a preliminary analysis

BACKGROUND

Background: There is widespread misinformation about the effects of alcohol consumption on health, which were amplified during the COVID-19 pandemic through social media and internet channels. Chatbots and conversational agents became an important piece of the WHO response during the COVID-19 pandemic to quickly disseminate evidence-based information to the public, related to COVID-19 and tobacco. PAHO seized the opportunity to develop a conversational agent to talk about alcohol related topics and therefore complement traditional forms of health education which have been promoted in the past.

OBJECTIVE

Objective: To develop and deploy a digital conversational agent to interact to an unlimited number of users, 24 hours a day, anonymously, about alcohol topics, in several languages, including on ways to reduce risks from drinking, at no cost and accessible through various devices.

METHODS

Methods: The content development was based on the latest scientific evidence on alcohol impacts on health, social norms about drinking and data from the World Health Organization and PAHO. The agent itself was developed through a non-exclusive license agreement with a private company and included Google Digital Flow ES as the natural language processing software, and AWS for cloud services. Another company was contracted to program all the conversations, following the technical advice of PAHO staff.

RESULTS

Results: The conversational agent was named Pahola and it was deployed on November 19, 2021, through the PAHO website after a launch event with high publicity. No identifiable data were used and all interactions were anonymous, and therefore this was considered not research with human subjects. Pahola speaks in English, Spanish and Portuguese, interacts anonymously to a potential infinite number of users through various digital devices. Users were required to accept terms and conditions to enable access to their camera and microphone to interact with Pahola. Pahola attracted good attention from the media, reached 1.6 million people, leading to 236,000 clicks on its landing page, mostly through mobile devices. Only 1,532 users had a conversation after clicking to talk to Pahola. The average time users spent talking to Pahola was five minutes. Major dropouts were observed in different steps of the conversation flow. Some questions asked by users were not anticipated during programming and could not be answered.

CONCLUSIONS

Our findings showed several limitations to using a conversational agent for alcohol education to the general public. Improvements are needed to expand the content to make it more meaningful and engaging to the public. The potential of chatbots to educate the public on alcohol related topics seems enormous but requires a long-term investment of resources and research to be useful and reach many more people.

CLINICALTRIAL

Implementation fidelity of a Brazilian drug use prevention program and its effect among adolescents: a mixed-methods study

BACKGROUND

Based on the US DARE-kiR, a version of the Keepin' it REAL program, the Drug and Violence Resistance Educational Program (PROERD) is the most widely implemented Brazilian prevention program. It originates from the translation of the DARE-kiR, a version of the Keepin' it REAL program. Previous results suggest its inefficiency in preventing drug use among Brazilian adolescents. Since kiR fidelity can impact program outcomes, this mixed-methods study evaluates the PROERD implementation fidelity and its effects on preventing drug use among adolescents.

METHODS

Data from two cluster randomized controlled trials (cRCTs) with 4,030 students from 30 public schools in São Paulo (1,727 fifth graders and 2,303 seventh graders), assessed at two-time points, were analyzed quantitatively. After implementing each lesson during the cRCT, 19 PROERD instructors answered fidelity forms. The effect of PROERD fidelity on alcohol, cigarettes, marijuana, inhalant, and cocaine use (the last two only among seventh graders) in the six months prior to follow-up assessment was analyzed by logistic regressions for fifth grade and mixed effect models for seventh graders. For qualitative analysis, semi-structured interviews were conducted with PROERD instructors and investigated by thematic analysis.

RESULTS

Quantitative analysis showed that PROERD implementation fidelity had no impact on drug use among fifth and seventh graders. Conversely, the qualitative analysis revealed important aspects that may influence implementation fidelity and consequently program effectiveness, such as adaptations made by instructors, school infrastructure, among others, besides program application.

CONCLUSION

PROERD requires cultural adaptation to improve its implementation in Brazilian public schools.

The development of the Pan American Health Organization digital health specialist on alcohol use

Introduction

On 19 November 2021 the Pan American Health Organization (PAHO) developed and deployed the first-ever digital health worker dedicated to alcohol-related topics, named Pahola. This paper describes this developmental process and the first results of its uptake and interactions with the public.

Methods

PAHO secured a non-exclusive worldwide license with a technology company to use their Human OS ecosystem, which enables human-like interactions between digital people and users via an application. Google Digital flow ES was used to develop the conversations of Pahola on topics related to alcohol and health, screening of alcohol risk using the AUDIT and providing a quit/cut back plan to users, along with additional treatment services and resources in each country of the Americas. A communication campaign was also implemented from launching date until 31 December 2021.

Results

Pahola attracted good attention from the media, and potentially reached 1.6 million people, leading to 236,000 sessions on its landing page, mostly through mobile devices. The average time people effectively spent talking to Pahola was five minutes. Major dropouts were observed in different steps of the conversation flow.

Discussion

Pahola was quickly able to connect to a large worldwide population with reliable alcohol information. It could potentially increase the delivery of SBI and improve alcohol health literacy. However, its preliminary results pointed to much needed changes to its corpus and on its accessibility, which are being currently implemented.

The corporate capture of the nutrition profession in the USA: the case of the Academy of Nutrition and Dietetics

OBJECTIVE

The involvement of unhealthy commodity corporations in health policy and research has been identified as an important commercial determinant contributing to the rise of non-communicable diseases. In the USA, health professional associations have been subject to corporate influence. This study explores the interactions between corporations and the Academy of Nutrition and Dietetics (AND), and their implications for the profession in the USA and globally.

DESIGN

We conducted an inductive analysis of documents (2014-2020) obtained through freedom of information requests, to assess key AND actors' dealings with food, pharmaceutical and agribusiness corporations. We also triangulated this information with publicly available data.

SETTING

The USA.

PARTICIPANTS

Not applicable.

RESULTS

The AND, AND Foundation (ANDF) and its key leaders have ongoing interactions with corporations. These include AND's leaders holding key positions in multinational food, pharmaceutical or agribusiness corporations, and AND accepting corporate financial contributions. We found the AND has invested funds in corporations such as Nestlé, PepsiCo and pharmaceutical companies, has discussed internal policies to fit industry needs and has had public positions favouring corporations.

CONCLUSION

The documents reveal a symbiotic relationship between the AND, its Foundation and corporations. Corporations assist the AND and ANDF with financial contributions. AND acts as a pro-industry voice in some policy venues, and with public positions that clash with AND's mission to improve health globally.

Mobile technology and task shifting to improve access to alcohol treatment services in Mozambique

INTRODUCTION

Unhealthy alcohol use (UAU) is a major public health challenge, particularly in low- and middle-income countries. Mozambique is the fourth poorest country in the world where half of the population lives below the poverty line. UAU is frequent among drinkers in Mozambique; however, resources and infrastructure to treat UAU are very limited. This paper examines how task-shifting and a provider-facing mobile health application are being used to improve access to care. In this paper, the feasibility, acceptability and appropriateness of a provider-facing mobile health application being used under a task-shifting model to identify UAU and provide a four-session brief motivational interviewing intervention are described.

METHOD

The study used a sequential exploratory mixed-methods design with a QUAL → quan structure. First, 15 psychiatric technicians and primary care providers in Mozambique's Nampula Province participated in semi-structured interviews. These interviews were recorded and transcribed. Then, 45 providers completed a 12-item quantitative survey on tablets. Quantitative analysis used descriptive statistic calculation and qualitative analysis used thematic analysis.

RESULTS

Nonspecialized providers found the mobile health app to be acceptable, appropriate, and feasible when delivering a 4-session brief motivational intervention under a task-shifting model. Central benefits of the technology were enhanced standardization and efficiency of sessions as well as feelings of legitimacy when interacting with patients. Main concerns were feasibility of implementing the intervention due to time constraints of workload and internet connectivity issues.

CONCLUSIONS

Provider-facing technology shows promise in supporting task-shifting models that can expand alcohol intervention services and increase access to care in low- and middle-income countries. Providers without specialized training in behavioral health interventions can provide critical services to patients with UAU and provider-facing mobile health applications may help bring such models to scale.

Cannabis Industry Marketing Violations in Washington State, 2014-2019

OBJECTIVE

The purpose of this study was to describe marketing violations from the cannabis industry in Washington State.

METHOD

The study team obtained records of all Washington State cannabis marketing violations from October 2014 to September 2015, immediately following the legal cannabis market opening, and May 2017 to July 2019. A code book was developed based on the Washington State regulations related to marijuana advertising. Each marketing violation was coded according to ad characteristics including ad size, location, or type; content; business practices; and lack of mandatory health warnings.

RESULTS

A total of 328 violations were analyzed, from 183 different businesses. Marketing violations occurred most frequently in content posted online or directly in front of cannabis stores. Community members were as likely to identify violations as officers from the Washington State Liquor and Cannabis Board (WSLCB), the state agency in charge of regulation and enforcement of cannabis businesses. Very few violations were reported from competing members of the cannabis industry. Violations reported by the community were mostly related to content appealing to minors, whereas WSLCB officers were more likely to identify violations related to ad location in public spaces and ad size.

CONCLUSIONS

This study shows the conflict between prevention and profit in the nascent cannabis industry and the importance of community involvement in the regulation of cannabis marketing.

Alcohol industry, corporate social responsibility and country features in Latin America

INTRODUCTION AND AIMS

Research on corporate behaviour can contribute to the understanding of the possible adverse impacts of alcohol-industry corporate social responsibility (CSR) initiatives and their potential influence on policymaking. This study explores the association between alcohol-industry CSR activities and selected country features in Latin America and the Caribbean.

DESIGN AND METHODS

Nine health experts evaluated 148 CSR activities using a standardised protocol; activities were classified into the categories risk management CSR (rmCSR), that is, to avoid/rectify externalities (n = 67), and strategic CSR, that is, to fulfill philanthropic responsibilities (n = 81). We evaluated the associations, separately, between the number of rmCSR and of strategic CSR actions in each country with threats from public health measures (specifically, the level of research into alcohol consumption and harms, the existence of an alcohol surveillance system and the number of governmental alcohol policy actions) and per capita alcohol consumption; we adjusted by economic indices (country income level and the gross domestic product) and population size.

RESULTS

Multivariate analyses showed that the higher the level of alcohol research within a country and its per capita consumption, the more likely rmSCR activities were to occur, independently of the country's economic development or population.

DISCUSSION AND CONCLUSIONS

Results suggest rmSCR actions could be implemented as a way to preserve markets by counteracting scientific evidence about alcohol related harms. This evidence could serve as a starting point to future research, contributing to the understanding of alcohol industry behaviour and the advancement of effective public policies.

Gender Differences in Gambling Exposure and At-risk Gambling Behavior

This study aimed to evaluate the differences in gambling exposure and onset of gambling problems among male and female gamblers by comparing their demographic and behavioral profiles. This study utilized data from the gambling section of the First Brazilian National Alcohol Survey and Related Behaviors. Interviews were conducted with 3007 participants who were recruited after screening for at-risk gambling behaviors. Individuals who tested positive for at-risk gambling behaviors completed the Gambling Progression Questionnaire comprising items on games of chance, and were evaluated using the DSM-IV pathological gambling criteria. The participants' "lifetime gambling exposure" was 12.5%, with 4% having experienced gambling problems during their lifetime. Majority of the male at-risk gamblers (78%) reported that they began gambling in their 20 s and took approximately 3 years to start experiencing gambling-related problems. Contrastingly, female at-risk gamblers started gambling in their 30 s and they took about 12 years to start experiencing gambling-related problems. The present results show that men were 2.3 times more at risk of gambling exposure and 3.6 times more likely to experience gambling-related problems. Male at-risk male gamblers seemed to be lonelier and to have a low socioeconomic status, while women seemed to have lower income and social insertion. Considering these significant differences, more studies evaluating gender differences in gambling behavior are necessary.

Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion

Objective:

This study compared the rates of binge drinking (BD) and alcohol use disorder (AUD) reported for 2006 with those reported for 2012, exploring their associations with unprotected sex, early pregnancy, and abortion in a representative sample of women in Brazilian households.

Methods:

This was a descriptive analysis of data from a cross-sectional study involving randomized multistage cluster sampling of the population ≥ 14 years of age. Weighted prevalence rates and odds ratios were estimated, and serial mediation analysis was performed.

Results:

A total of 4,256 women were analyzed. The BD prevalence was 35.1% and 47.1% in 2006 and 2012, respectively, a significant increase, especially among women 40-59 years of age. There was no significant difference in AUD prevalence. BD (without AUD) was found to increase the odds of unprotected sex and abortion. The path analysis showed that early pregnancy was a mediator of the relationship between alcohol consumption and abortion.

Conclusion:

Among women in Brazil, the harmful use of alcohol is increasing, which has an impact on female reproductive health and exposure to risks. There is a need for specific prevention initiatives focusing on alcohol-related behaviors in women.

Is the alcohol industry doing well by 'doing good'? Findings from a content analysis of the alcohol industry's actions to reduce harmful drinking

OBJECTIVES

The aims of this study were to: (1) describe alcohol industry corporate social responsibility (CSR) actions conducted across six global geographic regions; (2) identify the benefits accruing to the industry ('doing well'); and (3) estimate the public health impact of the actions ('doing good').

SETTING

Actions from six global geographic regions.

PARTICIPANTS

A web-based compendium of 3551 industry actions, representing the efforts of the alcohol industry to reduce harmful alcohol use, was issued in 2012. The compendium consisted of short descriptions of each action, plus other information about the sponsorship, content and evaluation of the activities. Public health professionals (n=19) rated a sample (n=1046) of the actions using a reliable content rating procedure.

OUTCOME MEASURES

WHO Global strategy target area, estimated population reach, risk of harm, advertising potential, policy impact potential and other aspects of the activity.

RESULTS

The industry actions were conducted disproportionately in regions with high-income countries (Europe and North America), with lower proportions in Latin America, Africa and Asia. Only 27% conformed to recommended WHO target areas for global action to reduce the harmful use of alcohol. The overwhelming majority (96.8%) of industry actions lacked scientific support (p<0.01) and 11.0% had the potential for doing harm. The benefits accruing to the industry ('doing well') included brand marketing and the use of CSR to manage risk and achieve strategic goals.

CONCLUSION

Alcohol industry CSR activities are unlikely to reduce harmful alcohol use but they do provide commercial strategic advantage while at the same time appearing to have a public health purpose.

Armed conflict, alcohol misuse, decision-making, and intimate partner violence among women in Northeastern Uganda: a population level study

BACKGROUND

Relations among and interactions between exposure to armed conflict, alcohol misuse, low socioeconomic status, gender (in)equitable decision-making, and intimate partner violence (IPV) represent serious global health concerns. Our objective was to determine extent of exposure to these variables and test pathways between these indicators of interest.

METHODS

We surveyed 605 women aged 13 to 49 who were randomly selected via multistage sampling across three districts in Northeastern Uganda in 2016. We used Mplus 7.4 to estimate a moderated structural equation model of indirect pathways between armed conflict and intimate partner violence for currently partnered women (n = 558) to evaluate the strength of the relationships between the latent factors and determine the goodness-of-fit of the proposed model with the population data.

RESULTS

Most respondents (88.8%) experienced conflict-related violence. The lifetime/ past 12 month prevalence of experiencing intimate partner violence was 65.3%/ 50.9% (psychological) and 59.9%/ 43.8% (physical). One-third (30.7%) of women's partners reportedly consumed alcohol daily. The relative fit of the structural model was superior (CFI = 0.989; TLI = 0.989). The absolute fit (RMSEA = 0.029) closely matched the population data. The partner and joint decision-making groups significantly differed on the indirect effect through partner alcohol use (a1b1  = 0.209 [0.017: 0.467]).

CONCLUSIONS

This study demonstrates that male partner alcohol misuse is associated with exposure to armed conflict and intimate partner violence-a relationship moderated by healthcare decision-making. These findings encourage the extension of integrated alcohol misuse and intimate partner violence policy and emergency humanitarian programming to include exposure to armed conflict and gendered decision-making practices.

Alcohol consumption, masculinity, and alcohol-related violence and anti-social behaviour in sportspeople

OBJECTIVES

There is no research examining alcohol-related aggression and anti-social behaviour in UK or European sportspeople (athletes), and no research has examined relationships between masculinity, alcohol consumption, and alcohol-related aggression and antisocial behaviour in sportspeople (athletes). This study addresses this gap.

DESIGN

Cross-sectional.

METHODS

A sample (N=2048; women=892, 44%) of in season sportspeople enrolled at UK universities (response 83%), completed measures of masculinity, alcohol consumption, within-sport (on-field) violence, and having been the perpetrator and/or victim of alcohol-related violent/aggressive and antisocial behaviour (e.g., hit/assaulted, vandalism, sexual assault). Logistic regressions examined predictors of alcohol-related violence/aggression and anti-social behaviours.

RESULTS

Significant bivariate relationships between masculinity, within-sport violence, alcohol consumption, and alcohol-related aggression and anti-social behaviour were found for both men and women (p's<.001). Logistic regression adjusting for all variables showed that higher levels of masculinity and alcohol consumption in men and women were related to an increased odds of having conducted an aggressive, violent and/or anti-social act in the past 12 months when intoxicated. Odds ratios were largest for relationships between masculinity, alcohol consumption, within-sport violence, and interpersonal violence/aggression (p's<.001). A similar pattern of results was found for having been the victim of aggression and anti-social behaviour.

CONCLUSIONS

Alcohol-related aggression and anti-social behaviour appear to be problematic in UK university sportspeople, and is related to masculinity and excessive drinking. Interventions that reduce excessive alcohol consumption, masculine norms and associated within-sport violence, could be effective in reducing alcohol-related aggression and antisocial behaviour in UK sportspeople.

Introducing care management to Brazil's alcohol and substance use disorder population

Brazil has a sizable alcohol and substance use disorder (ASUD) population, yet there are considerable gaps in treatment access and retention. ASUD, a chronic medical condition, is highly comorbid with medical and behavioral health disorders. This indicates a need for more targeted interventions in order to achieve health care integration (a major goal of Brazil's health care system). Care management - that is, the organization of patient care by an institution - is a viable strategy to engage individuals with ASUD who might benefit from treatment but are not aware of or do not use the available resources, as well as to help maintain patients in treatment. Care management is considered an essential supplement to the treatment of chronic disease. The objective of this article is to discuss the applicability of care management for the treatment of ASUD within the public health care system in Brazil. We describe models of care management that have been adopted internationally and identify the feasibility and advantages for its adoption in Brazil.

Amphetamine-type stimulant use and conditional paths of consumption: data from the Second Brazilian National Alcohol and Drugs Survey

OBJECTIVE:

The aim of this study was to estimate nationally representative prevalence rates of amphetamine-type stimulant (ATS) use and to identify consumption-associated factors, proposing a conditional model of direct and indirect consumption paths.

METHOD:

Using data from the Second Brazilian National Alcohol and Drugs Survey, this cross-sectional study analyzed a subsample of 3,828 participants between 15 and 64 years old, gathering information on the use of psychoactive substances in a probabilistic sample of the Brazilian household population.

RESULTS:

Rates of lifetime and last-year ATS use were, respectively, 4.1 and 1.6%. Economically privileged individuals and users of other substances were more at risk for using ATS. The results suggest that higher education decreases the chances of ATS consumption. The conditional model showed that higher income increased ATS use, higher education lowered the odds of such an increase, and cocaine use cancelled that associative effect.

CONCLUSION:

Brazil presents high rates of ATS use. Prevention and treatment strategies should focus on the protective effect of higher education levels and should target polydrug use. Knowledge of ATS-associated factors and user profiles is the starting point for developing effective treatments and tailored prevention strategies.

Alcohol Industry Sponsorship of University Student Sports Clubs in Brazil

OBJECTIVE

The university sport environment represents an important target for alcohol industry marketing. This study investigated the nature of relationships between the alcohol industry and university student sports clubs (USSCs).

METHOD

Semi-structured interviews were conducted with board members from 60 active USSCs in the city of São Paulo, Brazil. Interviews were transcribed and subjected to content analysis using NVivo10.

RESULTS

All invited USSCs participated in the study. Most (n = 53; 88%) reported having signed contracts with the alcohol industry (breweries, in every case) to have their sports events and parties sponsored. The most common sponsorship arrangement involved the supply of discounted beer for sport and student events. T-shirts, beer freezers, and stereo systems were also frequently provided by the alcohol industry to support alcohol-related sports events. In addition, the alcohol industry event promoters helped market the events and products. In return, the USSCs agreed to exclusively sell the sponsors' brand of beer and/or order and sell a quota of beer at their events. Forty-nine interviewees (81%) reported agreements with alcohol companies whereby open bars (free alcohol events) would also be provided. Despite reporting a range of alcohol harms, participants did not perceive there to be a high risk of harm from the alcohol sponsorship arrangements.

CONCLUSIONS

Most USSCs in São Paulo, Brazil, have formalized contracts with the alcohol industry that promote the marketing, sale, and consumption of alcohol at parties and university games. A critical review of the impacts of these practices and university policies on alcohol industry sponsorship that can take account of the role of such arrangements in student drinking is warranted.

The marketing potential of corporate social responsibility activities: the case of the alcohol industry in Latin America and the Caribbean

AIMS

The aims were to: (1) identify, monitor and analyse the Corporate Social Responsibility (CSR) practices of the alcohol industry in Latin America and the Caribbean (LAC) and (2) examine whether the alcohol industry is using these actions to market their products and brands.

METHODS

Nine health experts from Argentina, Brazil and Uruguay conducted a content analysis of 218 CSR activities using a standardized protocol. A content rating procedure was used to evaluate the marketing potential of CSR activities as well as their probable population reach and effectiveness. The LEAD procedure (longitudinal, expert and all data) was applied to verify the accuracy of industry-reported descriptions.

RESULTS

A total of 55.8% of the actions were found to have a marketing potential, based on evidence that they are likely to promote brands and products. Actions with marketing potential were more likely to reach a larger audience than actions classified with no marketing potential. Most actions did not fit into any category recommended by the World Health Organization; 50% of the actions involving classroom and college education for young people were found to have marketing potential; 62.3% were classified as meeting the definition of risk management CSR.

CONCLUSION

Alcohol industry Corporate Social Responsibility activities in Latin America and the Caribbean appear to have a strategic marketing role beyond their stated philanthropic and public health purpose.

Intimate partner violence trends in Brazil: data from two waves of the Brazilian National Alcohol and Drugs Survey

OBJECTIVE

To compare intimate partner violence (IPV) prevalence rates in 2006 and 2012 in a nationally representative household sample in Brazil. The associations between IPV and substance use were also investigated.

METHODS

IPV was assessed using the Conflict Tactic Scale-R in two waves (2006/2012) of the Brazilian Alcohol and Drugs Survey. Weighted prevalence rates and adjusted logistic regression models were calculated.

RESULTS

Prevalence rates of IPV victimization decreased significantly, especially among women (8.8 to 6.3%). The rates of IPV perpetration also decreased significantly (10.6 to 8.4% for the overall sample and 9.2 to 6.1% in men), as well as the rates of bidirectional violence (by individuals who were simultaneously victims and perpetrators of violence) (3.2 to 2.4% for the overall sample). Alcohol increased the likelihood of being a victim (odds ratio [OR] = 1.6) and perpetrator (OR = 2.4) of IPV. Use of illicit drugs increased up to 4.5 times the likelihood of being a perpetrator.

CONCLUSIONS

In spite of the significant reduction in most types of IPV between 2006 and 2012, violence perpetrated by women was not significantly reduced, and the current national rates are still high. Further, this study suggests that use of alcohol and other psychoactive drugs plays a major role in IPV. Prevention initiatives must take drug misuse into consideration.

Opinions about Alcohol Control Policies Among Brazilians: The First National Alcohol Survey

Several general-population alcohol surveys have been conducted in Brazil in the past 25 years, none using probability sampling methodology. This article focuses on the results of the first alcohol national survey in Brazil, particularly as it concerns support for six alcohol policies. A total of 2,346 interviews were conducted with adults aged 18 and older. The interviews, averaging 53 minutes in length, were conducted face to face in the respondent's home by trained interviewers using a standardized questionnaire, with an overall response rate of 66.4%.

Overall at least half of the respondents supported the six alcohol policies analyzed. Gender, intensity of alcohol consumption and age were the main variables associated with approval of the alcohol policies. The relatively high level of support for the alcohol policies suggests that there is room for developing new measures in the area in Brazil.

Discrepant trends in income, drinking, and alcohol problems in an emergent economy: Brazil 2006 to 2012

BACKGROUND

To examine the association between increases in income and self-reported alcohol consumption, binge drinking, and alcohol problems in 2006 and 2012 in Brazil.

METHODS

Participants were interviewed as part of 2 multistage representative cluster samples of the Brazilian household population between November 2005 and April 2006 and between November 2011 and March 2012. The number of current drinkers during these 2 intervals (n = 1,379 and n = 1,907, respectively) comprised the sample analyzed. Four past-year outcome variables-standard drinks per week, binge drinking, presence of alcohol-related social/health problems, and DSM-5 alcohol use disorder (AUD)-were estimated across income, age, and gender groups. Regression models were estimated to evaluate these and other sociodemographic effects on drinking and problem outcomes and to test for possible wave by income interactions.

RESULTS

Response rates were 66.4% in 2006 and 77% in 2012. Income increases were seen in virtually all age-gender subgroups and were particularly pronounced for younger age groups and older women. Both genders reported increased drinks per week (men: 12.82, 2006; 15.78, 2012; p < 0.01; women: 4.89, 2006; 7.66, 2012; p < 0.001) and proportion binge drinking (men: 57%, 2006; 66%, 2012; p < 0.05; women: 39%, 2006; 48%, 2012; p < 0.05), although this was not seen in all gender and age groups. Social/health problem prevalence decreased among men (37%, 2006; 26%, 2012; p < 0.001) and remained the same among women (13%, 2006; 14%, 2012). DSM-5 AUD decreased among men (34%, 2006; 24%, 2012; p < 0.01) and remained stable among women (14%, 2006; 16%, 2012).

CONCLUSIONS

Brazilian economic development between 2006 and 2012 led to a rise in income in several gender and age groups. Although not always directly associated with an observed increase in alcohol consumption, the rise in income may have created a sense of optimism that inhibited a rise in alcohol-related problems.

Depressive symptoms and alcohol correlates among Brazilians aged 14 years and older: a cross-sectional study

Background

The associations between depressive symptoms and alcohol-related disorders, drinking patterns and other characteristics of alcohol use are important public health issues worldwide. This study aims to study these associations in an upper middle-income country, Brazil, and search for related socio-demographic correlations in men and women.

Methods

A cross-sectional study was conducted between November 2005 and April 2006. The sample of 3,007 participants, selected using a multistage probabilistic sampling method, represents the Brazilian population aged 14 and older. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale and alcohol dependence was assessed using the Composite International Diagnostic Interview. Associations assessed using bi-variate analysis were tested using Rao-Scott measures. Gender specific multinomial logistic regression models were developed.

Results

Among the participants with alcohol dependence, 46% had depressive symptoms (17.2% mild/moderate and 28.8% major/severe; p < 0.01); 35.8% (p = 0.08) of those with alcohol abuse and 23.9% (p < 0.01) of those with a binge-drinking pattern also had depressive symptoms. Alcohol abstainers and infrequent drinkers had the highest prevalence of major/severe depressive symptoms, whereas frequent heavy drinkers had the lowest prevalence of major/severe depressive symptoms. In women, alcohol dependence and the presence of one or more problems related to alcohol consumption were associated with higher risks of major/severe depressive symptoms. Among men, alcohol dependence and being ≥45 years old were associated with higher risks of major/severe depressive symptoms.

Conclusions

In Brazil, the prevalence of depressive symptoms is strongly related to alcohol dependence; the strongest association was between major/severe depressive symptoms and alcohol dependence in women. This survey supports the possible association of biopsychosocial distress, alcohol consumption and the prevalence of depressive symptoms in Brazil. Investing in education, social programs, and care for those with alcohol dependence and major/severe depressive symptoms, especially for such women, and the development of alcohol prevention policies may be components of a strategic plan to reduce the prevalence of depression and alcohol problems in Brazil. Such a plan may also promote the socio-economic development of Brazil and other middle-income countries.

Gambling onset and progression in a sample of at-risk gamblers from the general population

The goal of this study was to investigate gambling-related behavior, onset and progression in a sample of at-risk gamblers from the community. A national household survey was conducted in Brazil, covering individuals 14 years old or older. Subjects were screened for at-risk gambling, those testing positive answered a questionnaire about gambling progression, preferred games and DSM-IV pathological gambling criteria. Out of 3007 respondents, 118 were considered at-risk gamblers according to the Lie/Bet Questionnaire. According to the DSM-IV, 32.7% and 24.9% of those were considered problem and pathological gamblers, respectively. Early at-risk gamblers (onset prior to 20 years of age), were more likely to be male, to prefer non-commercially structured games, and to chase losses while gambling. Young pathological gamblers (under 35 years of age) progressed faster from regular to problem gambling (roughly 2 years) than mature pathological gamblers (12 years). Such findings had not been described before because previous reports focused mostly on clinical samples that lack young, male, early-onset gamblers. Gambling programs have not satisfactorily covered this segment of gamblers. Outreach strategies and early interventions should be provided to prevent these individuals from rapidly evolving into pathological gambling.

Binge drinking among Brazilians: Higher drinking frequency increases related problems

Abstract Aims: To correlate binge drinking (BD) with alcohol-related problems (ARP) in the Brazilian population. Methods: A representative cross-sectional survey was conducted in 143 Brazilian cities. Associations between the frequencies of BD and ARP were gathered using an ordered logit regression model. Results: Higher BD frequencies significantly increased the chance of injury in accidents, job loss, and involvement in intense arguments and assaults over the year. High frequency in BD increases the odds of all ARP. Conclusion: There is a dose-response association between the frequency BD and ARP and is therefore a possible target for public prevention policies.

How smokers may react to cigarette taxes and price increases in Brazil: data from a national survey

BACKGROUND

Despite being the third largest tobacco producer in the world, Brazil has developed a comprehensive tobacco control policy that includes a broad restriction on both advertising and smoking in indoor public places, compulsory pictorial warning labels, and a menthol cigarette ban. However, tax and pricing policies have been developed slowly and only very recently were stronger measures implemented. This study investigated the expected responses of smokers to hypothetical price increases in Brazil.

METHODS

We analyzed smokers' responses to hypothetical future price increases according to sociodemographic characteristics and smoking conditions in a multistage sample of Brazilian current cigarette smokers aged≥14 years (n=500). Logistic regression analysis was used to examine the relationship between possible responses and different predictors.

RESULTS

In most subgroups investigated, smokers most frequently said they would react to a hypothetical price increase by taking up alternatives that might have a positive impact on health, i.e., they would "try to stop smoking" (52.3%) or "smoke fewer cigarettes" (46.8%). However, a considerable percentage responded that they would use alternatives that would reduce the effect of price increases, such as the same brand with lower cost (48.1%). After controlling for sex age group (14-19, 20-39, 40-59, and ≥60 years), schooling level (≥9 versus ≤9 years), number of cigarettes per day (>20 versus ≤20), and stage of change for smoking cessation (precontemplation, contemplation, and preparation), lower levels of dependence were positively associated with the response "I would try to stop smoking" (odds ratio [OR], 2.19). Young age was associated with "I would decrease the number of cigarettes" (OR, 3.44). A low schooling level was strongly associated with all responses.

CONCLUSIONS

Taxes and prices increases have great potential to stimulate cessation or reduction of cigarette consumption further among two important vulnerable populations of smokers in Brazil: young smokers and those of low educational level. The results from the present study also suggest that seeking illegal products may reduce the impact of increased taxes, but does not eliminate it.

Higher prevalence of major depressive symptoms in Brazilians aged 14 and older

OBJECTIVE

Depression is a highly prevalent condition and is considered a major public health issue. The aim of the present study was to estimate the prevalence of depressive symptoms in the Brazilian population and establish their sociodemographic correlates.

METHOD

A cross-sectional study was conducted between November 2005 and April 2006. Data were collected in face-to-face interviews using a standardized questionnaire. The sample consisted of 3,007 interviews with individuals aged 14 years and older and followed a probabilistic design covering the Brazilian national territory. Depressive symptoms were assessed according to the Center for Epidemiologic Studies Depression Scale.

RESULTS

The observed prevalence of depressive symptoms was 28.3% (13% mild/moderate; 15.3% major/severe; p < 0.01). Increased depressive symptom rates were associated with being a female, being 45 years of age and older, having lower educational attainment, being single, having family income of up to 2.5 times minimum wage, and living in the northern region of Brazil (p < 0.05).

CONCLUSIONS

The prevalence of depressive symptoms in Brazil is high, with major depressive symptoms being the most frequent form of this symptomatology. Considering the biopsychosocial model of mental disorders, this survey points to the involvement of psychosocial factors in the prevalence of depressive symptoms in Brazil.

Religious beliefs and alcohol control policies: a Brazilian nationwide study

OBJECTIVE

The connection between lower alcohol use and religiousness has been extensively examined. Nevertheless, few studies have assessed how religion and religiousness influence public policies. The present study seeks to understand the influence of religious beliefs on attitudes toward alcohol use.

METHODS

A door-to-door, nationwide, multistage population-based survey was carried out. Self-reported religiousness, religious attendance, and attitudes toward use of alcohol policies (such as approval of public health interventions, attitudes about drinking and driving, and attitudes toward other alcohol problems and their harmful effects) were examined. Multiple logistic regression was used to control for confounders and to assess explanatory variables.

RESULTS

The sample was composed of 3,007 participants; 57.3% were female and mean age was 35.7 years. Religiousness was generally associated with more negative attitudes toward alcohol, such as limiting hours of sale (p , 0.01), not having alcohol available in corner shops (p , 0.01), prohibiting alcohol advertisements on TV (p , 0.01), raising the legal drinking age (p , 0.01), and raising taxes on alcohol (p , 0.05). Higher religious attendance was associated with less alcohol problems (OR: 0.61, 95%CI 0.40-0.91, p = 0.017), and self-reported religiousness was associated with less harmful effects of drinking (OR: 0.61, 95%CI 0.43-0.88, p = 0.009).

CONCLUSIONS

Those with high levels of religiousness support more restrictive alcohol policies. These findings corroborate previous studies showing that religious people consume less alcohol and have fewer alcohol-related problems.

Bridging the gap between science and public health: taking advantage of tobacco control experience in Brazil to inform policies to counter risk factors for non-communicable diseases

AIMS AND DESIGN

The historical and economic involvement of Brazil with tobacco, as a major producer and exporter, was considered an insurmountable obstacle to controlling the consumption of this product. Nevertheless, the country was able to achieve significant progress in implementing public policies and to take an international leadership position, meeting its constitutional commitment to protect public health. In this paper we provide a brief historical overview of tobacco control (TC) in Brazil, and analyse the factors that contributed to the major decline in tobacco consumption in the country over the last 20 years, as well as identify the challenges that had to be overcome and those still at play.

FINDINGS

The Brazilian case demonstrates how cross-sectorial collaborations among health-related groups that capitalize on their respective strengths and capacities can help to influence public policy and overcome industry and population resistance to change. Although Brazil still lags behind some leading TC nations, the country has an extensive collaborative TC network that was built over time and continues to focus upon this issue.

CONCLUSIONS

The tobacco experience can serve as an example for other fields, such as alcoholic beverages, of how networks can be formed to influence the legislative process and the development of public policies. Brazilian statistics show that problems related to non-communicable diseases are a pressing public health issue, and advocacy groups, policy-makers and government departments can benefit from tobacco control history to fashion their own strategies.

Drinking patterns and associated problems in Brazil

This paper describes patterns of alcohol consumption and associated problems in Brazil. Data came from a multicluster random sample of 2,346 Brazilians 18 years of age and older. The survey was conducted in 2005-2006 and had a response rate of 66.4%. About 35% of the men and 59% of the women did not drink in the past 12 months, while 39% of the men and 13% of the women consumed alcohol at least once a week. Further, 38% of the men and 17% of the women consumed 5 or more drinks "usually", and 40% of the men and 18% of the women reported binge drinking in the past 12 months. The prevalence of alcohol use disorders (DSM-4 abuse and/or dependence) was 19% among men and 4% among women. Although abstinence in Brazil is relatively high, binge drinking is frequent and, thus, alcohol problems and alcohol use disorders are also frequent.

The effect of the new traffic law on drinking and driving in São Paulo, Brazil

OBJECTIVE

To present data on drinking and driving in the city of São Paulo, Brazil, and the effects of the new traffic law (Law 11,705) introduced in 2008.

METHODS

A cross-sectional study was performed using a questionnaire and passive breath test data to study the prevalence of drinking and driving and the association of drinking and driving with background characteristics and drinking patterns on two separate occasions. The data were gathered from 2007 to 2009 through roadside surveys conducted on busy public roads. Four thousand two-hundred thirty-four (4234) drivers were approached, before and after prohibition, from the south, north, east, and west regions of the city of São Paulo, located in southeastern Brazil, including cars, motorcycles, and utility vehicles. A total of 3854 (91%) consented to participate in the survey and answered the questionnaire. Out of this group, 3229 (84%) agreed to take the passive breathalyzer test.

RESULTS

Logistic regression analyses controlling for gender and age was used to predict a positive breath test (above 0.2g/l) and the impact of the new law. These analyses indicated that, after the passage of the new traffic law, there was a 45% decrease in driver behavior with positive breathalyzer results. Having a pattern of alcohol consumption of at least once a week and the habit of drinking and driving are risks for a positive breathalyzer.

CONCLUSIONS

Despite the decline in the frequency of motorists driving under the influence of alcohol, traffic-related injuries and deaths, after the new law, other measures for a public policy related to alcohol should be considered based on scientific evidence, consistency of action, clear goals, community support, and greater reliability in the laws.

Drinking and driving in southeastern Brazil: results from a roadside survey study

OBJECTIVE

The objective of this study is to present data from a roadside survey study on drinking and driving and alcohol consumption in southeastern Brazil.

METHODS

A cross-sectional roadside survey study using a questionnaire and breathalyzer data is the method used to determine the prevalence of drinking and driving and to examine whether socio-demographic characteristics and drivers' behavior, attitude and alcohol consumption predicted positive blood alcohol content (BAC). The data were gathered from 2005 to 2007 through roadside surveys conducted on high volume public roads in four cities in southeastern Brazil. A total of 4182 randomly selected drivers took part in the research. Of these drivers, 3488 (83.4%) completed the questionnaire and agreed to take a breath test.

RESULTS

Overall, 24.6% of drivers had a detectable blood alcohol concentration (BAC) and 15.9% had a BAC above the legal limit (0.6g/l) at the time of the study. Logistic regression controlling for locale (city), sex, age and marital status was used to predict whether each driver would present a positive breath test. Socio-demographic characteristics, driving behaviors and attitudes, and alcohol consumption patterns were included as predictors. These analyses indicated that those who believed drinking and driving was a serious offense were about two-thirds as likely to have a positive breath test, and that drivers reporting a pattern of regular alcohol use were three times as likely to have a positive breath test.

CONCLUSIONS

These findings indicate that drinking and driving is relatively common in Brazil, and that it occurs considerably more frequently than similar surveys suggest, is the case in other countries.

Use of licit and illicit substances among adolescents in Brazil--a national survey

OBJECTIVE

We estimate the prevalence of alcohol, tobacco and illegal substance use in a national representative sample of adolescents. We also estimate how socio demographic characteristics, household environment and mental health are associated with substance misuse.

METHOD

This is a cross-sectional study using data from the first Brazilian National Alcohol Survey, which gathered information on the use of psychoactive substances in 761 participants aged 14 to 19 years old. Weighted logistic regression was used to calculate adjusted odds ratios.

RESULTS

More than half of the adolescents interviewed were regular alcohol users and one out of ten were abusers and/or dependents. Older male adolescents living in urban areas were more likely to present alcohol related disorders and to smoke. Age had an inverse association with illegal substance use. Smokers and those using illegal substances were more likely to report domestic violence while those with alcohol abuse/dependence were more likely to have depression.

CONCLUSIONS

The high prevalence of alcohol, tobacco and illicit substance consumption among Brazilian adolescents is staggering. Young males with mood disorders from urban areas are more at risk of developing alcohol disorders while illegal drug use is highly associated to household dysfunction in early life. Brazilian growing economy will possibly lead to increased levels of substance use among adolescents if new prevention measures are not implemented. The intensification of law enforcement strategies to reduce psychotropic substances access is required.

The distribution of alcohol consumption and the prevention paradox in Brazil

AIMS

To examine the proportion of self-reported alcohol consumed by different gender and age groups in Brazil over the past year, and to examine whether the 'prevention paradox' applies to Brazilian data on alcohol-related problems.

DESIGN

A multi-stage cluster sample, representative of the Brazilian household population.

SETTING

This study was conducted in Brazil between November 2005 and April 2006.

PARTICIPANTS

Respondents were aged ≥ 14 years (n = 3007).

MEASUREMENTS

Measures included past year estimates of (i) number of standard drinks, (ii) frequency of binge drinking, and (iii) alcohol-related problems.

FINDINGS

The survey response rate was 66.4%. The top 2.5% of the drinkers by volume consume 14.9%, the top 5% consume 27.4% and the top 10% consume 44.2% of all alcohol consumed in Brazil. Men consume 77.8% of the total alcohol, and 18-29-year-olds consume 40.3%. Individuals below risky drinking guidelines for weekly volumetric intake account for 49-50% of all problem drinkers and 45-47% of all problem types reported. Individuals who do not binge or who binge infrequently (1-3 times/year) account for 50-51% of all problem drinkers and 45-46% of all reported problem types. Most binge drinkers are low-volume drinkers.

CONCLUSIONS

Consistent with the prevention paradox literature, most drinking problems in Brazil are associated with low or moderate drinking. Binge drinking accounts more clearly for the distribution of alcohol problems than total volume consumed.