Short communicationUnderstanding the prevalence of lifetime abstinence from alcohol: An ecological study
Graphical abstract
Introduction
Alcohol is one of the top ten most important risk factors for burden of disease globally, accounting for about 5% of the global burden of disease in 2015 (Forouzanfar et al., 2016, World Health Organization, 2014). However, alcohol-attributable burden varies strongly across geographies: in North Africa and the Middle East alcohol use accounted for less than two percent of the total disease burden and ranked outside the top ten risk factors, while in Eastern Europe it was the fifth most important risk factor, accounting for over 13% of the total burden of disease (Forouzanfar et al., 2016).
Prior studies have shown that the levels of consumption are relatively similar between drinkers across different countries, so that the discrepancy in alcohol-attributable burden is strongly linked to the prevalence of abstinence from alcohol use (Room et al., 2005). There is great variation in the prevalence of abstinence across countries, which is seemingly linked to the gross domestic product (GDP) of the country (Shield et al., 2011, World Health Organization, 2014). While in low-income countries about 18% of the adult population were current drinkers in 2010, about 70% of the adult population were current drinkers in high-income countries (Schmidt et al., 2010, Shield et al., 2011, World Health Organization, 2014). The underlying causes for the apparent association have not been explored in much detail yet. A possible contributor is the affordability of alcohol. In most low- and middle-income countries, alcohol can be considered a luxury product available predominantly to the more prosperous layers of society. As an example, a study found that in Zurich, Switzerland or in Brussels, Belgium less than a quarter of the median daily income of low earning occupations was required to buy 700 ml of low-priced Scotch whisky (chosen as benchmark for comparison based on a high correlation with the prices of other alcoholic beverages). In Jakarta, Indonesia or Mumbai, India over five times the median daily income of a low earning occupation were required to afford the same amount and type of alcohol (Kan and Lau, 2013). Further, positive associations between changes in the affordability of alcohol and alcohol consumption as well as alcohol-attributable mortality were found in European countries (Herttua et al., 2008, Rabinovich et al., 2009). Overall, in most high-income countries, alcohol is highly affordable and affordability is overall lower in middle- and low-income countries (Kan and Lau, 2013), which matches with the crude pattern of prevalence of abstinence.
Another important factor that might impact the prevalence of lifetime abstinence from alcohol use in a country is the predominant religion. The Quran prohibits alcohol use and in 15 of the about 50 Muslim majority countries (where over 50% of the population are Muslim) alcohol use is either banned completely or prohibited with concessions, e.g., for non-Muslims or tourists (Al-Ansari et al., 2016). While there is some evidence relating Buddhist beliefs to alcohol use in Thailand (Assanangkornchai et al., 2002), as well as restrictions of alcohol use based on Hindu traditions for certain casts (Sharma et al., 2010) neither of these examples apply to a larger number of countries or consistently relate to national alcohol policies.
Based on the variation of drinking patterns across the life span (World Health Organization, 2014), the prevalence of lifetime alcohol use in a country might also depend on the age of initiation and the age-distribution (characterized by the median age in the total population) in a country (Wilsnack et al., 2009). It should be noted, however, that median age and GDP of a country are positively associated (Harper, 2014). Finally, countries in geographical proximity (e.g., within the same World Health Organization (WHO) region) might share relevant characteristics above and beyond the religion, economic development, and age-distribution.
In sum, prevalence of lifetime abstinence from alcohol use is a core factor for alcohol-attributable burden in a country and the investigation of related factors would improve the understanding of its global distribution. Thus, the objective of this study was to investigate GDP and the proportion of Muslim population as explanatory variables for the prevalence of lifetime abstinence in an ecological study. Specifically, the following hypotheses were investigated:
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A higher GDP is associated with a lower prevalence of lifetime abstinence from alcohol use.
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A higher proportion of Muslim population is associated with a higher prevalence of lifetime abstinence from alcohol use.
Section snippets
Design and data sources
Data on the prevalence of lifetime abstinence from alcohol use came from the Global Information System on Alcohol and Health (World Health Organization, 2013). For more methodological details to derive these data see (Poznyak et al., 2014).
The prevalence referred to the adult population (15+) in the year 2010. Data on the GDP at purchasing power parity per capita (GDP-PPP) in 2010 were retrieved from the World Bank (2016). The proportion of the population of Muslim faith in 2010 was obtained
Descriptive statistics
Complete data were available for a total of 183 countries. Descriptive analyses showed that the prevalence of lifetime abstinence declined steeply with increasing GDP-PPP up to about 20,000 International Dollars per capita (Fig. 1). However, this seemingly did not apply to Muslim majority countries. GDP-PPP and median age showed a high positive correlation (Spearman’s correlation coefficient rs = 0.78, p < 0.001).
Modeling
The results of the fractional response models are shown in Table 1. As expected
Discussion
This ecological study showed a strong association between the prevalence of lifetime abstinence from alcohol and the GDP-PPP as well as the proportion of Muslim population in a country. GDP seemed to be relevant particularly in the lower range up to about 20,000 international dollars per capita. The association with GDP-PPP did not apply in the same way in countries with a Muslim majority. In these countries the proportion of Muslims showed a strong negative association with the prevalence of
Conclusion
Future research should investigate if the observed associations hold true for trends in GDP over time. Based on developments over the past few decades (Deaton, 2013), a continuing increase of GDP a in low- and middle-income countries can be expected. Further, a gradual but small increase of alcohol use in the Eastern Mediterranean region (Rehm et al., under review) was observed over the past 25 years. These developments set the framework for investigations of the relationship between GDP-PPP
Conflict of interest
No conflict declared.
Role of funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Contributors
All authors conceptualized the study and data analysis. CP retrieved the data and performed the data analysis with support of JM. CP wrote the first draft of the manuscript and all authors contributed to the writing and revision of the manuscript and approved of the final version of the manuscript.
Acknowledgements
Charlotte Probst was supported by the Centre for Addiction and Mental Health, and the German Academic Scholarship Foundation.
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