Commercial Determinants of Tobacco PDF

Tobacco epidemiology 1.1 billion smokers worldwide, including about 850 million men and 250 million women 1/3 of the world population over 15 smoke rates are higher in younger people there is a clear gradient according to education status and social class responsible for 10% of all deaths and 30% of...

Tobacco epidemiology 1.1 billion smokers worldwide, including about 850 million men and 250 million women 1/3 of the world population over 15 smoke rates are higher in younger people there is a clear gradient according to education status and social class responsible for 10% of all deaths and 30% of cancer deaths there is one death every six seconds from a smoking-related disease globally, tobacco is responsible for 16% of deaths among men and 7% of deaths among women 600,000 individuals die annually from second hand smoke, and 75% of these deaths are among women and children projections prevalence is falling in high income countries and rising in low income countries by 2030, tobacco is expected to be the biggest killer worldwide (10 million deaths annually) by the end of the 21st century estimated 1 billion will die from tobacco use (ten times the total number who died in the 20th century) smoking-related costs in Ireland 2009 cost of treatment per smoker: €7700 smoking-related health expenditure: €500million costs due to premature mortality: €3500million revenue: €1216million Commercial Determinants Page 1 harmful effects of smoking in 1951, Doll and Hill's case control study found that 99.5% of men with lung cancer were smokers cancers lung (20x risk), pharyngo-oesophageal, lip, oral, pancreatic, renal, bladder, breast, cervical cardiovascular atherosclerosis, angina, MI, stroke, hypertension peripheral vascular carotid stenosis, gangrene, abdominal aortic aneurysm, PVD resp pneumonia, bronchiectasis, bronchiolitis, emphysema GIT peptic ulcer disease MSK osteoporosis ophthalmological macular degeneration, cataracts skin collagen breakdown genitourinary erectile dysfunction teratogenic prematurity, IUGR, perinatal mortality passive smoking SIDS, lung ca. in spouse (15% increase risk) passive smoking ETS = environmental tobacco smoke (37% in nightclubs) mix of exhaled mainstream smoke and sidestream smoke complex mixtures of >4000 compounds >50 known or suspected carcinogens including benzene, nickel, 2-napthylamine, formaldehyde, polycyclic aromatic hydrocarbons lung cancer - 15% increase in spouse of smoker foetus: small for dates, perinatal mortality child: sudden infant death, resp. infections Big Tobacco in 2010 the combined profits of the six leading tobacco companies was $35 billion (5.9 trillion cigarettes sold) Commercial Determinants Page 2 in 2010 the combined profits of the six leading tobacco companies was $35 billion (5.9 trillion cigarettes sold) this was equal to the combined profits of Coca Cola, Microsoft and McDonald’s that year the China National Tobacco Corporation produces more tobacco than the other top nine tobacco producing countries combined estimates of revenues from the global tobacco industry vary widely but are likely approaching half a trillion dollars annually although tobacco is ultimately a financial burden on the governments and health care systems of countries, it is also a source of government revenue, through tobacco taxes and additional profit for those countries with state owned tobacco companies each year the tobacco industry in China contributes over 7% of the central government’s total revenue if Big Tobacco were a country, it would have a gross domestic product (GDP) similar to that of Poland and Sweden helping smokers to quit 1/3 of smokers in Ireland who saw their GP in 2017 had discussed ways of giving up smoking (source: Healthy Ireland) 3/4 of smokers admitted hospital wanted to quit, but only 23% were referred to Smoking Advice Service main factors associated with quitting following hospital admission: male cardiovascular admission lower passive smoking exposure after discharge abstained from smoking during admission medical advice after discharge to stop smoking Commercial Determinants Page 3 nicotine replacement therapy should be offered to patients who want to stop patients in hospital experiencing withdrawal symptoms route of admin can be patch / gum / nasal spray / inhaler a course of any treatment to support smoking cessation (10–12 weeks) costs approximately €150 treatment should be stopped if the attempt fails and should not usually be repeated within 6 months, unless exceptional circumstances have interrupted the attempt psychological and behavioural aspects of smoking addiction must also be addressed Fagerstrom test for nicotine dependence alternatives to NRT varenicline (Champix) 2nd line Rx when NRT has failed partial nicotinic receptor agonist reduces withdrawal symptoms and rewarding effects of smoking by preventing binding of nicotine to receptors safety concerns re neuropsychiatric side effects evidence mixed bupropion noradrenergic and dopaminergic reuptake inhibitor (NDRI) increases concentrations of noradrenaline and dopamine in the synaptic cleft by inhibiting reuptake exact mechanism underlying its benefits in smoking cessation are not fully understood E-cigarettes Electronic Nicotine Delivery Systems (ENDS) not regulated specifically other than general product safety little reliable evidence Commercial Determinants Page 4 PUBLIC HEALTH INTERVENTIONS the health benefits of comprehensive tobacco control policies outweigh the negative economic effects of lost employment revenue in 1991 World Bank adopted a policy not to lend, invest in or provide loans for tobacco production, processing or marketing in 1999 the World Bank and WHO produced a report on economics of tobacco control provided evidence for tobacco control policies with an emphasis on low and middle income countries, where most smokers live what is effective? improvements in the quality and extent of information comprehensive bans on tobacco advertising and promotion restrictions on smoking in public places prominent warning labels increased access to nicotine replacement treatments reducing the supply of tobacco is NOT effective in reducing tobacco consumption taxation tax increases are the single most effective intervention to reduce demand for tobacco raising the real price of cigarettes by 10% reduces smoking by about 4% in HICs and by 8% in LMICs tax comprises about two thirds of retail price of cigarettes in most HICs but less than half of the total price on average in LMICs harmful effects of taxation spending on tobacco reduces money available for food, linked to increased risk of malnutrition in the family in a country where poor people are likely to smoke, tobacco taxes can be regressive but if increasing taxation results in smokers quitting, then tax increases will reduce the family’s overall tax burden impact of tobacco control in LMICs countries will need support to change from tobacco to another type of farming there will be job losses among tobacco farmers but economic losses are offset by gains from improved health at household and national level smuggling increased taxes lead to increased cost of tobacco and increased risk of smuggling countries that are able to control crime are able to keep smuggling low Commercial Determinants Page 5 WHO Framework Convention on Tobacco Control (WHO FCTC) adopted by the World Health Assembly on 21 May 2003 and entered into force on 27 February 2005 the FCTC is the first ever global public health treaty one of the most rapidly and widely embraced treaties in United Nations history it obligates ratifying countries to broad, comprehensive tobacco control policies developed in response to the globalization of the tobacco epidemic tackles a variety of complex factors with cross border effects, such as; taxation (recommends at least 70% of the cost of cigarettes should be tax) trade liberalisation direct foreign investment global marketing transnational tobacco advertising promotion and sponsorship the international movement of contraband and counterfeit cigarettes non-price measures protection from exposure to tobacco smoke regulation of the contents of tobacco products regulation of tobacco product disclosures packaging and labelling of tobacco products education, communication, training and public awareness tobacco advertising, promotion and sponsorship demand reduction measures concerning tobacco dependence and cessation progress 2017 WHO report on the global tobacco epidemic about 4.7 billion people 63% of the world’s population are covered by at least one comprehensive tobacco control measure this has quadrupled since 2007 when only 1 billion people and 15% of the world’s population were covered. Commercial Determinants Page 6 WHO MPOWER: six components 1. monitor tobacco use & prevention policies 2. protect people from tobacco smoke 3. offer help to quit 4. warn about dangers 5. enforce bans on advertising, promotion, sponsorship 6. raise taxes public health policy measures (Ireland) 2001: age limit raised from 16 to 18 2002: Public Health (Tobacco) Act 1. preliminary and general 2. office of tobacco control 3. regulation and control of sale, marketing and smoking of tobacco products 2004: ban on smoking in the workplace ban on all in-store or retail advertising graphic health warning on packaging retails outlets required to register to sell tobacco use of descriptors 'light', 'low tar', 'mild' etc. prohibited taxes (80% of the €12 cost goes to revenue) 2016: smoking ban in cars w/ children 2018: plain packaging smoking ban in hospitals HSE adopted Tobacco Control Framework All hospital campuses smoke free by December 2015 pre-ban surveys showed that: patients who abstain during admission are 3x more likely to quit after discharge 42% of smokers did not smoke in hospital, 47% smoked less than usual main reason for not smoking/reducing was difficulty finding a place to smoke (47%) 90% do not find it difficult to abstain in a place where smoking is not allowed Commercial Determinants Page 7 further recommendations remove VAT on nicotine replacement therapy smoke free schools / universities Commercial Determinants Page 8 Tobacco Control Framework Convention on Tobacco Control The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) was developed by countries in response to the globalization of the tobacco epidemic. The framework was ratified in February 2005 (90 days after it had been acceded to, rat ified, accepted, or approved by 40 States). There were 180 parties to the convention in 2015 (WHO 2015). This is the first global public heath treaty and addresses issues pertaining to tobacco including; trade liberalization and d irect foreign investment, tobacco advertising, promotion and sponsorship beyond national borders, and illicit trade in tobacco products (WH O 2015). Legislative Changes aimed at reducing smoking Tobacco-Free Ireland The Tobacco-Free Ireland (TFI) Policy document was developed by the Department of Health in 2013. This government strategy (2013 - 2025) has a number of cross-governmental actions which are based on the six national standards based on the WHO report on the Global Tobacco Epidemic 2008. This report outlines the MPOWER package i.e. six of the most important, effective and evidenced-based tobacco policies which are listed below. Monitoring of tobacco use and prevention policies Protecting people from second-hand smoke Offering help to people who want to quit Warning of the dangers of tobacco Enforcing bans on advertising, promotion and sponsorship Raising taxes on tobacco While some of these actions are health promoting, many are specific to legislation and therefore health protection e.g. smoking ban, legislation regarding sales and increasing taxes. Commercial Determinants Page 9 Effect of Anti-Smoking Legislative Approaches The Figures below clearly shows the remarkable progress in tobacco control in terms of tobacco consumption rates in the United States over the past century. These figures give a snapshot how effective tobacco control strategies mirror tobacco consumption rates – almost demonstrating immediate benefits. Commercial Determinants Page 10 Commercial Determinants Page 11 Tobacco Control & Public Health What if we had a vaccine that could prevent 1 in 10 deaths worldwide? We already do... TOBACCO CONTROL Tobacco control dates back to the 1500's, when the first ban on smoking and snuff was issued by Pope Urban VII in 1590. Below are few of the earliest examples of tobacco control. 1590 Pope Urban VII issues the first smoking ban in holy places, threatening excommunication for anyone that "took tobacco in the porchway of or inside a church, whether it be by chewing it, smoking it with a pipe or sniffing it in powdered form through the nose". 1614 Mongolian Emperor makes the death penalty the punishment for using tobacco. 1701 Dr. Nicholas Andry de Boisregard warns that young people taking too much tobacco have trembling, unsteady hands, staggering feet and suffer a withering of "their noble parts." 1761 John Hill (London Physician) performs perhaps the first clinical study of tobacco effects; warns snuff users they are vulnerable to cancers of the nose. Arguments for Protecting People from Tobacco Smoke: Clean air is a basic human right Second hand smoke exposure is deadly Only 100% smoke-free environments protect health (Do Not Allow Exemptions) Smoke-free laws are popular Smoke-free laws do not hurt business Smoke-free laws protect worker's health Smoke-free laws help smokers quit Smoke-free laws lead to smoke free homes Why Is Smoking and Tobacco Use Still So Prevalent? Despite widespread knowledge about the dangers of tobacco, global tobacco control remains underfunded. In much of the world, smoking rates have declined, while in developing countries rates have not fallen and in few countries rates of smoking have actually increased. New York as an example of progress in tobacco control. In 2001, Michael Bloomberg, former smoker, was elected mayor of New York City. Once elected, Bloomberg made tobacco control a top priority. Bloomberg's administration partnered with the city’s Department of Public Health and the CDC to educate about the dangers of smoking and using other tobacco products and to lower the rate of tobacco use in the city. As a result, the number of smokers in New York has sharply declined Commercial Determinants Page 12 Tobacco Taxation Raising taxes on tobacco has proven to be a highly effective tobacco control measure in cities and countries around the world. New York City saw a 20% decline in smoking between 2002 - 2006 after raising taxes. Data from South Africa demonstrates a clear inverse correlation between tax rate and consumption. Arguments for Raising Taxes on Tobacco When tobacco prices go up (by 10%), consumption goes down (by 4%) on average Tobacco taxes help protect the poor and the young Revenue from tobacco taxes can be utilised to pay for better healthcare Successful Tobacco Taxations Strategies will: Have a simple and effective tax structure Increase taxes on tobacco regularly Avoid product substitution Implement measures to combat tax evasion and smuggling. Possible smuggling of illegal cigarettes is one argument used by the tobacco industry against raising taxes on cigarettes and other tobacco products. However, evidence suggest that the supply of illicit tobacco, rather than its price, is a key factor contributing to tax evasion. WHO Framework Convention on Tobacco Control (2003) Commercial Determinants Page 13 WHO Framework Convention on Tobacco Control (2003) The (FCTC) was the world's first legally binding public health treaty. "The WHO FCTC was developed in response to the globalization of the tobacco epidemic. The spread of the tobacco epidemic is facilitated through a variety of complex factors with cross-border effects, including trade liberalization and direct foreign investment. Other factors such as global marketing, transnational tobacco advertising, promotion and sponsorship, and the international movement of contraband and counterfeit cigarettes have also contributed to the explosive increase in tobacco use." (WHO, 2003) The WHO FCTC demands: Tobacco reduction strategies Price and tax measures to reduce the demand for tobacco Stricter laws on packaging and labelling of tobacco products World No Tobacco Day In 1987, The WHO's World Health Assembly established World No Tobacco Day (WNTD), a 24 hour period of abstinence from tobacco products. Each year since that time, WNTD has been celebrated near the end of May. Each year, The WHO selects a new theme for WNTD, and produces educational materials to raise awareness about the theme: 2000: Tobacco kills, don’t be duped 2001: Second-hand smoke kills 2002: Tobacco-free sports 2004: Tobacco and poverty, a vicious circle 2005: Health professionals against tobacco 2006: Tobacco: deadly in any form or disguise 2007: Smoke-free inside 2008: Tobacco-free youth 2009: Tobacco health warnings 2010: Gender and tobacco with an emphasis on marketing to women 2011: The WHO Framework Convention Tobacco Control 2012: Tobacco Industry Interference 2013: Ban tobacco advertising, promotion, and sponsorship 2014: Raise taxes on tobacco 2015: Stop illicit trade of tobacco products 2016: Get ready for plain packaging The ultimate goal of World No Tobacco Day is to help protect present and future generations not only from the devastating health consequences due to tobacco, but also from the social, environmental and economic scourges of tobacco use and exposure to tobacco smoke Commercial Determinants Page 14 MPOWER 6 policies for tobacco control, shown to be the most cost-effective public health interventions for reducing tobacco consumption Monitor tobacco use and prevention policies. Good monitoring systems must track several indicators, including prevalence of tobacco use; impact of policy interventions; and tobacco industry marketing, promotion and lobbying. Protect people from tobacco smoke. Research clearly shows that there is no safe level of exposure to second-hand smoke. The overwhelming success and popularity of smoke-free legislation in countries that have adopted it contradict false claims by the tobacco industry that these laws are unworkable and costly to businesses. Offer help to quit tobacco use. People who are addicted to nicotine are victims of the tobacco epidemic. Among smokers who are aware of the dangers of tobacco, three out of four want to quit. Three types of treatment should be included in any tobacco prevention effort: tobacco cessation advice incorporated into primary health-care services; easily accessible and free quit lines; access to low-cost pharmacological therapy. Warn about the dangers of tobacco. Some people are unaware that even the smallest level of tobacco use is dangerous, in part because this is not the case with other behavioural health risks. Health warnings on the packaging of all tobacco products are guaranteed to reach all users and cost governments nothing to implement. Enforce bans on tobacco advertising, promotion and sponsorship. Tobacco manufacturers are some of the best marketers in the world. A ban on marketing and promotion is a powerful weapon against the tobacco epidemic. Raise taxes on tobacco. Commercial Determinants Page 15 Raise taxes on tobacco. Increasing the price of tobacco through higher taxes is the single most effective way to decrease consumption and encourage tobacco users to quit. A 70% increase in the price of tobacco could prevent up to a quarter of all smoking-related deaths worldwide. Plain Packaging/Pictorial Warning Labels Plain packaging is the future in enforcing anti-tobacco advertising bans with evidence suggesting that plain packaging is associated with lower smoking appeal. Australia led the way in plain packaging in December 2012. Since then, all tobacco products must be sold in standardized drab, dark brown packaging with large graphic health warnings. Tobacco manufacturers have always used packaging as a platform to reinforce brand loyalty and users’ perceived self-image, particularly among young people. Pack warnings reduce this marketing effect. Evidence suggests that the greater impact of the pictorial warning label compared to the text-only warning is consistent across diverse racial/ethnic and socioeconomic populations. Given their great reach, pictorial health warning labels may be one of the few tobacco control policies that have the potential to reduce communication inequalities across groups. Policies that establish strong pictorial warning labels on tobacco packaging may be instrumental in reducing the toll of the tobacco epidemic, particularly within vulnerable communities. Bans on Tobacco Advertising, Promotion and Sponsorship From the graph shown, there was a 9% decrease in cigarette consumption in countries with a ban on advertising, compared to a 1% decrease in countries without a ban. Commercial Determinants Page 16 Tobacco Control in Ireland Smoke Free Policies In March 2004, Ireland became the first country in the world to create and enjoy smoke-free indoor workplaces and public places, including restaurants, bars and pubs. Within three months, Norway's smoke-free legislation entered into force. Since then, these examples have been followed by many countries including Italy, Uruguay, Poland and Spain, along with many cities across the globe. Most people in Canada, Australia and the United States are protected by state or local smoke-free legislation. Advertising ban Cinema, billboards and print - 2004 International sponsorship and indirect advertising - 2005 Internet advertising - 2008 Point of sale advertising - 2009 Health warnings Both in English and Irish - 2008 International sponsorship and indirect advertising - 2005 Size increased to 32% in front - 2008 Size increased to 45% in rear - 2008 Graphic pictorial warnings - 2012 Latest policies Standardized packaging - 2016 Smoking ban in private vehicles - 2016 Media Campaigns and Health Warnings (Past versus Present) Much of the tobacco advertising of the past has been replaced with anti-tobacco campaigns. Advertising bans on tobacco have been a successful component of tobacco control programs. Commercial Determinants Page 17 Commercial Determinants Page 18 Global Burden of Tobacco: A Call to Action The Deadly Toll of Tobacco According to the WHO, tobacco use is responsible for the deaths of 6 million people worldwide each year (1 in 10 adults). Despite the progress that has been made in the fight for tobacco control, there are still more than 1 billion smokers in the world today. Although there have been sharp declines in smoking in many parts of the world, tobacco related deaths have nearly tripled in the past decade. If trends continue, 1 billion people will reportedly die from tobacco use and exposure during the 21st century - 1 person every six seconds. One in two long-term smokers are killed by their addiction. Half of deaths are in middle age (35-69). It is the single most important cause of preventable deaths in the world. The Cost of Smoking in Ireland It is estimated that, in 2013, 5,950 premature deaths can be attributed to smoking and exposure to second-hand smoke, along with over 200,000 hospital episodes. The total cost to the health service is estimated to be over €460 million. Tobacco's Deadly Toll in The U.S. and Europe According to the CDC smoking is responsible for more than 480,000 deaths per year (including deaths from secondhand smoke) in the United States. In Europe more than 600,000 deaths per year are attributed to smoking. Second hand smoke causes approximately 7,330 deaths from lung cancer and nearly 34,000 deaths from heart disease each year. Commercial Determinants Page 19 Hazards of Action Smoking Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general. Some examples include: multiple cancers, chronic lung disease cardiovascular disease bone loss cataracts low birth weight asthma pneumonia, bronchitis sudden infant death syndrome Commercial Determinants Page 20 Biology of Nicotine Addiction Smoking Behaviour With repeated exposure, tolerance develops to many of the rewarding effects of nicotine, thereby reducing its primary reinforcing effects such as mood regulation, and inducing physical dependence (i.e., withdrawal symptoms in the absence of nicotine). Metabolism Those who metabolize nicotine rapidly take in more cigarette smoke per day than those who metabolize nicotine slowly. For example, on average, women metabolize nicotine more quickly than men, which may contribute to their increased susceptibility to nicotine addiction and may help to explain why, among smokers, it is more difficult for women to quit. Nicotinic cholinergic Nicotine sustains tobacco addiction by acting on nicotinic cholinergic receptors in the brain to trigger the release receptor of dopamine and other neurotransmitters Neurotransmitter Stimulation of nicotinic cholinergic receptors releases a variety of neurotransmitters in the brain. One of them, release dopamine, signals a pleasurable experience and is critical for the reinforcing effects Commercial Determinants Page 21 Second-Hand Smoke Exposure Two main sources of childhood second-hand smoke exposure: 1. Domestic settings 2. Vehicular transport Approximately 45% children are exposed to second hand smoke at home in Ireland. 20% of pregnant women smoke during pregnancy in Ireland vs. 7% in Massachusetts. 14% of Irish school children are exposed to second hand smoke while traveling by car. A ban on smoking in cars where children are present was signed into law in Ireland in December 2015 under the Protection of Children’s Health. From January 1st 2016 it is an offense for anyone to smoke a tobacco product in a vehicle where a child is present, or to allow someone else to smoke in the vehicle. The offense is enforced by the Gardaí and carries a fixed penalty of €100 with the option of tougher penalties of up to €1,000 for failing to stop or providing inaccurate details. Commercial Determinants Page 22 Shift in Tobacco-Related Death To LMICs Proportion of tobacco consumption and mortality have decreased in HICs but increased in LMICs Commercial Determinants Page 23 Alcohol epidemiology third leading cause of death and disability in developed countries mortality resulting from alcohol consumption is higher than that caused by diseases such as TB, HIV/AIDS & diabetes 2.3 billion people worldwide are current drinkers 18.2% of the global population partook in heavy episodic drinking in 2016 in 2016, the harmful use of alcohol resulted in 132.6 million DALYs (5.1% of all DALYs) 3 million deaths (5.3% of all deaths) men > women alcohol-related disease burden highest in Africa problem drinkers: physical/social/mental well-being is harmed as consequence of alcohol acute problems - intoxication, binge drinking (6+ units in one session) chronic problems - regular heavy drinking binge drinking is higher among youth alcohol consumption limits units of alcohol = litres x percentage alcohol 1 unit = 8g 1 standard drink = 10g (1/2 pint / small glass wine / small measure spirit) M: 28 units per week F: 21 units per week binge drinking is defined as > 5 units in one session 30% of men and 22% of women in Ireland consume more than the recommended weekly limit alcohol in Ireland > 50% of Irish drinkers have 'harmful patterns' (70% men, 40% women) Commercial Determinants Page 24 > 50% of Irish drinkers have 'harmful patterns' (70% men, 40% women) problem drinkers: physical/social/mental well-being is harmed as consequence of alcohol health consequences 88 alcohol-related deaths per month contributes to 50% of suicides involved in 25% of A&E visits societal consequences accidents e.g. drink driving (3/10 crash deaths), fires, drowning crime: contributing factor in 97% of public order offences) economics: loss of productivity, high insurance premiums, healthcare costs family: violence, marriage breakdown costs to the health service €1.2 billion - illness €500 million - acute facilities €500 million - GP services €100 million - mental health occupation is a risk factor for alcohol abuse absence from home unemployment social pressure at work medical professionals involvement in manufacture & sale of booze harmful effects of alcoholism obesity high in calories liver alcoholic liver disease, fatty liver disease, steatosis, hepatocellular carcinoma, cirrhosis cancer mouth, pharynx, larynx, oesophagus, liver, breast, bowel respiratory aspiration pneumonia reproductiv testicular atrophy, erectile dysfunction e pregnancy miscarriage, fetal alcohol syndrome GIT gastritis, pancreatitis, sialadenitis CVS hypertension, cardiomyopathy, heart failure, arrhythmia neurological peripheral neuropathy, dementia, cerebellar degeneration, Wernicke's-Korsakoff syndrome, blackouts, withdrawals, seizures withdrawal delirium tremens, anxiety, nausea, fatigue benefits of alcohol minimal in men 10 units/ day over previous 10 days aims: manage withdrawal symptoms, & reduce the risk of seizures & DT’s inpatient vs. outpatient chlordiazepoxide (Librium) is the benzodiazepine of choice example of detox regimen: Day 1 - 20mg QDS Day 2 - 15mg QDS Day 3 - 10mg QDS Day 4 - 5mg QDS Day 5 - 5mg BD + PRN withdrawal symptoms can be assessed using various rating scales e.g. CIWA-Ar others thiamine 100mg TDS for those at risk of developing Wernicke-Korsakoff syndrome prophylactic parenteral B vitamins 3-5 days haloperidol consider in treating delirium tremens NB reduces seizure threshold prevention of alcoholism primary: prevent occurrence legislation e.g. minimum pricing, drink-driving laws education e.g. schools, public campaigns Commercial Determinants Page 26 education e.g. schools, public campaigns secondary: early detection & treatment screening CAGE questionnaire tertiary: management & prevention of reoccurrence rehabilitation e.g. AA pharmacological: aversive (Disulfiram), anti-craving (acamprosate, naltrexone) psychological: motivational interviewing, CBT treat co-morbid mental disorders address social problems brief intervention minimal intervention lasting a few minutes or less which involves structured advice well suited to primary care due to their feasibility Feedback - provide feedback on risk for alcohol problems Responsibility - to highlight that person is responsible for change Advice - to reduce or change Menu - provide options for change Empathy - be warm, reflective and understanding in approach Self-efficacy - encourage belief about changing behaviour Commercial Determinants Page 27 Commercial Determinants Page 28 Public Health Response to Alcohol In 2012, about 3.3 million deaths, or 5.9% of all global deaths, were attributable to alcohol consumption. This is greater than, for example, the proportion of deaths from HIV/AIDS (2.8%), violence (0.9%) or tuberculosis (1.7%). Alcohol misuse or abuse is associated with an increased risk of chronic illness such as cancer, diabetes, depressive disorders and cardiovascular disease. It is also associated with intentional and unintentional injuries and harm to both the drinker and people other than the drinker. This includes reduced job performance and absenteeism, family deprivation, violence, suicide, homicide, crime and fatalities caused by driving while under the influence of alcohol, while it is also a factor for risky sexual behaviour. In 2012, 139 million DALYs (disability- adjusted life years), or 5.1% of the global burden of disease and injury, were attributable to alcohol consumption. Harmful Drinking in Ireland Over half of all Irish drinkers have a harmful pattern of drinking, that’s 4 in 10 women and 7 in 10 men who drink, which equ ates to 1.35 million harmful drinkers. 75% of all alcohol consumed in Ireland in 2013 was done so as part of a binge drinking session. 88 deaths every month in Ireland are directly attributable to alcohol. 1 in 11 children in Ireland say parental alcohol use has a negative effect on their lives. Economic Burden of Alcohol in Ireland Global Perspective There are 3.3 million alcohol-related deaths annually Almost half the global population has never consumed alcohol The most destructive drinking patterns in the world are in Eastern Europe Commercial Determinants Page 29 The most destructive drinking patterns in the world are in Eastern Europe 25% of Russian men die before age 55, usually due to alcohol excess 78% of people in LMICs who are alcohol-dependent receive no treatment In South Africa, 52% of male traffic deaths are alcohol-related, compared to 4% in Italy In Estonia, there are 195 stores selling hard alcohol per 100,000 people, compared to 3.5 per 100,000 people in Sweden Population Health Interventions - Fiscal Measures 1. Legal drinking/Purchasing age Ireland: It is illegal for minors to buy alcohol and for adults to buy it for minors, or to consume alcohol in a public space in Ireland. Germany: Fermented alcoholic beverages may be consumed by minors at the age of 14 in public in presence of a legal guardian; drinking in private is not regulated by a specific legal restriction. United States: The National Minimum Drinking Age Act of 1984 withholds revenue from states that allow the purchase of alcohol by anyone under the age of 21. 2. Marketing Restrictions Phase out drinks industry sponsorship of sport and other large public events. Reduce the volume, content and placement of all advertising in all media. Introduce a 9pm watershed for alcohol advertising on radio and television. Ban outdoor advertising of alcohol. 3. Opening Hours Alcohol can be sold in stores in Ireland only between 10:30 and 22:00 on weekdays and Saturdays or 12:30 and 22:00 on Sundays. 4. Minimum Unit Pricing Minimum pricing is a "floor price" beneath which alcohol cannot be sold and is based on the amount of alcohol in a product, m easured in units or grams. It is a targeted measure, designed to stop strong alcohol from being sold at pocket -money prices in the off-trade, particularly supermarkets. Minimum unit pricing policies are under consideration in many countries across the globe. Population Health Interventions - Non-Fiscal Measures 1. Improving The Built Environment Regulating new licenses: An Australian report noted an association between "the density of liquor outlets and alcohol -related harms". Limiting the number of outlets that sell alcohol may limit alcohol related harm. Restricting opening hours: Hahn et al 2010 reported a systematic review on restricting opening hours for alcohol sales and re ported "policies decreasing hours of sale by 2 hours or more at on- premises alcohol outlets may be an effective strategy for preventing alcohol-related harms". Commercial Determinants Page 30  alcohol-related harms". 2. Public Awareness Campaigns Drink Aware: Drink Aware is sponsored by the drinks industry in Ireland. "The overall aim of the initiative is to promote the responsible use of alcohol, while at the same time challenging anti-social drinking behaviours". The Drinkaware Trust is an independent UK based charity that aims to help people make better choices about their drinking by providing impartial, evidence based information, advice and practical resources. In 2014, Drinkaware ran a campaign to tackle underage drinking, focusing on parents and encouraging well-informed conversations about alcohol between them and their children. This ‘Talk’ Campaign comprised of an online film, social media, website articles, media coverage and supermarket posters directing parents to info rmation and advice available on the Drinkaware website. In a survey of parents who visited the site, 74% said they were likely to spe ak to their child about the risks of alcohol following their visit to the site. (Drinkaware Annual Report, 2014). Alcohol Action Ireland: Alcohol Action Ireland is the national charity for alcohol - related issues. "Our work involves providing information on alcohol-related issues, creating awareness of alcohol- related harm and offering policy solutions with the potential to reduce that harm, with a particular emphasis on the implementation of the recommendations of the Steering Group report on the National Substance Misuse Strategy". 3. Community Interventions Off the booze, on the ball: Driven by the GAA's Alcohol and Substance Abuse Prevention (ASAP) programme, a partnership with t he HSE, 'The Challenge' offers participants the opportunity to press pause on alcohol consumption following the hectic Christmas per iod. It invites participants to abstain from alcohol for four weeks in order to give their New Year a healthy kick -start. (Gaelic Athletic Association, 2013) Commercial Determinants Page 31