Understanding the prevalence of lifetime abstinence from alcohol: An ecological study

doi:10.1016/j.drugalcdep.2017.05.008

Drug and Alcohol Dependence

Volume 178, 1 September 2017, Pages 126-129

https://doi.org/10.1016/j.drugalcdep.2017.05.008 Get rights and content

Highlights

•
Lifetime abstinence (LA) from alcohol is associated with gross domestic product (GDP).
•
This negative association applies predominantly to countries with a lower GDP.
•
The proportion of Muslims is positively associated with the prevalence of LA.
•
This applies predominantly to countries with a Muslim majority.

Abstract

Background

The level of alcohol consumption and related burden in a country are strongly impacted by the prevalence of abstinence from alcohol use. The objective of this study was to characterize the association of lifetime abstinence from alcohol use with economic wealth (as measured in the gross domestic product [GDP]) and Muslim religion on a country level.

Methods

An ecological study was performed using aggregate data of 183 countries for the year 2010. Lifetime abstinence among men and women was predicted using fractional response regression models with the natural logarithm of GDP-PPP (purchasing power parity) and the proportion of Muslim population as predictors. The models were further adjusted by the country’s median age and World Health Organization region. Precision of prediction was investigated.

Results

Descriptive analyses showed a strong negative association between GDP-PPP and lifetime abstinence in countries without a Muslim majority and a GDP-PPP up to 20,000 international dollars. Regression models confirmed the negative association with GDP-PPP and showed a strong positive association between lifetime abstinence and the proportion of Muslim population. Stratified sensitivity analyses showed that in countries without a Muslim majority only GDP-PPP showed a statistically significant association whereas in Muslim majority countries only the proportion of Muslims was associated with the prevalence of lifetime abstinence.

Conclusions

Particularly in countries with a lower GDP and without Muslim majority the prevalence of lifetime abstinence from alcohol use is strongly negatively associated with GDP-PPP. Future research should analyze the accordance in trends of GDP and lifetime abstinence over time.

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 r_s = 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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Adolescent substance use is a multifactorial social issue that leads to detrimental outcomes. The aim of this study is to understand the association of a lifetime history of substance abuse or dependence with family functioning, childhood victimisation, and depression, among adolescent male inmates in a juvenile detention centre in Malaysia.
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Data on economic development as measured by per capita gross-domestic product adjusted for purchase power parity were obtained from the World Bank (World Bank, 2017). In terms of other potential underlying reasons (for influencing factors on alcohol consumption, see Probst, Manthey & Rehm, 2017), the following data sources were used: alcohol control policy data were derived from the WHO Global Status Reports of 2014 and 2018 (World Health Organization, 2014, 2018), which are based on surveys completed by all member states in 2010 and 2016, respectively (for a description of methodology, see Poznyak et al., 2013). Target countries’ policy-related gray literature published in English was also reviewed.
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Methods Using secondary data from UN agencies, we analyzed trends in alcohol consumption, alcohol-attributable deaths and the burden of disease.
Results Starting from a level of consumption significantly below the global average—especially among the Muslim-majority countries (Maldives, Indonesia, and Malaysia)—the majority of the countries in this region had markedly increased their alcohol consumption along with the economic development they experienced between 2010 and 2017. In fact, five middle-income countries in this region (Vietnam, Lao PDR, Cambodia, Myanmar, and Timor-Leste) were in the top 12 countries globally based on absolute increases in adult alcohol per capita consumption (APC). The Philippines and Malaysia were the exceptions, as they had reduced their APC over this period. The majority of South-East Asian countries had parallel increasing trends in the age-standardized alcohol-attributable deaths and DALYs since 2010, in contrast to global trends. While all countries put some alcohol control policies in place, there were differences in the number and strength of the policies applied, commensurate with trends in consumption. In particular, three of the countries which were most successful in reducing consumption and harm (Malaysia, Philippines, and Sri Lanka) applied more effective tax methods based on specific taxation alone or in combination with another taxation method, applying higher taxation rates and regularly increasing them over time.
Conclusion To achieve the global target and the Sustainable Development Goal in reducing alcohol consumption worldwide, middle-income countries, especially lower-middle-income countries, should employ stricter alcohol control policies, and apply an appropriate excise tax on alcohol products with regular increases to reflect inflation.
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In response to the COVID-19 pandemic, as with other countries across the world, the Central and State Governments of India initiated several measures to slow down the spread of the virus and to ‘flatten the curve’. One such measure was a ‘total lockdown’ for several weeks across the country. A complex and unexpected outcome of the lockdown which has medical, ethical, economic, and social dimensions is related to alcohol consumption. The lockdown and consequent acute non-availability of alcohol resulted in people with alcohol dependence going into withdrawals, black marketing of alcohol, and in extreme cases suicide resulting from the alleged frustration of not having access to alcohol. The health dilemmas around this situation are biological (e.g. pushing people into risky situations-potentially fatal alcohol withdrawal, consumption of illicit or other non-consumable alcohol) and psychosocial (e.g. isolation increasing the risk of relapses, loss of control over the decision to abstain which can be detrimental to recovery, restriction of access to services for alcohol problems). The legal and rights-related dilemmas are centred around whether States have the right to impinge on individual autonomy on the grounds of public health, the capacity of the health systems to provide appropriate services to cope with those who will struggle with the unavailability of alcohol, the constitutionality of the Central government's impinging on jurisdiction of states under the guise of a health emergency caused by the pandemic, and the ability of the State to make unbiased decisions about this issue when it is highly dependent on the revenue from the sale of alcohol and associated industries. The way forward could be a pragmatic and utilitarian approach involving continued access to alcohol, while observing all physical distancing norms necessary during the pandemic, for those who want to continue drinking; and implementing innovative measures such as tele-counselling for those who wish not to return back to drinking.
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Citation Excerpt :
Economic wealth is strongly associated with alcohol per-capita consumption up to a certain amount of wealth, after which no further increases in consumption are observed.29 In low-income countries, most people simply do not have sufficient income to buy alcohol, and consequently levels of lifetime abstention are high,30 with alcohol use mainly restricted to the more affluent members of the population.28 This changes when the population has more disposable income, as is the case in middle-income countries.
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Centre for Addiction and Mental Health and the WHO Collaborating Center for Addiction and Mental Health at the Centre for Addiction and Mental Health.
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2023, Drug and Alcohol Review
Burden of diseases and injuries attributable to alcohol consumption in the Middle East and North Africa region, 1990–2019
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Short communicationUnderstanding the prevalence of lifetime abstinence from alcohol: An ecological study

Highlights

Abstract

Background

Methods

Results

Conclusions

Graphical abstract

Introduction

Section snippets

Design and data sources

Descriptive statistics

Modeling

Discussion

Conclusion

Conflict of interest

Role of funding source

Contributors

Acknowledgements

Lancet

Extent of alcohol prohibition in civil policy in Muslim majority countries: the impact of globalization

Addiction

Religious beliefs and practice, and alcohol use in Thai men

Alcohol Alcohol.

World Factbook Download 2010 Median Age

The Great Escape: Health, Wealth, and the Origins of Inequality

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Lancet

Economic and social implications of aging societies

Science

Changes in alcohol-related mortality and its socioeconomic differences after a large reduction in alcohol prices: a natural experiment based on register data

Am. J. Epidemiol.

Comparing alcohol affordability in 65 cities worldwide

Drug Alcohol Rev.

The Future Global Muslim Population – Projections for 2010–2030

Short communication
Understanding the prevalence of lifetime abstinence from alcohol: An ecological study