Epidemiology, pattern and prevalence of alcohol consumption in India: need for public health action

INTRODUCTION

Liquor has been in use in human communities since time immemorial. Alcoholic beverages were processed and devoured in almost all parts of the globe even before the british colonial expansion that has changed the cultural position of alcohol nearly far and wide.¹ Multiple advanced forms of liquor were made current, and a commodity made at a domiciliary and community level was progressively transformed into an industrial product available round the clock with omnipresence. As part of the present day of globalisation, this course continues in a rising trend in developing nations. In the context of India, alcoholic beverages were known from ancient Vedic period, being used for adoration purposes, siddha and ayurvedic preparations, and generally taken as a tranquilizer.² Universally, harmful use of alcohol leads on to a mortality of around 3.3 million deaths per annum (5.9% of all causes of mortality), and 5.1% of the global burden of disease is strongly related to liquor consumption.³ Meanwhile accelerated globalization and economic liberalization are changing the social fabric and organizational structure of the Indian society and thus have a high impact on drinking patterns and cultures in the state as well. This article reviews literature on alcohol use in India and the need for public health plan, action or intervention in multiple dimensions.

PATTERN AND PREVALENCE OF ALCOHOL ABUSE AND RELATED ILLNESS

India is a diverse nation with hefty variation in climate, vegetation, natural resources, culture and traditions. This variegation is also echoed in the types of alcoholic beverages prepared, procured and used up with assorted cultural meaning associated with liquor use. The most common forms of alcoholic beverages available are arrack (fermentation of rice/paddy or wheat), toddy (wine from palm), country liquor (arrack), illicit liquor, Indian made foreign liquor (IMFL), beer and imported liquor.⁴ According to WHO, traditional alcoholic beverages viz., arrack, toddy, country liquor contain about 20 to 40% of alcohol, whereas it is as high as 56% in illicit liquor thus making the latter a big menace to the country’s health. Ingredients used in illicit liquor production are akin to those used in country liquor manufacture; yet, illicit liquor is more often adulterated with industrial methylated spirit and other adulterants posing huge detrimental effects on health. Adding on to the fire, illicit liquor is relatively cheaper than the licensed country liquor and thus more rampant among urban and rural poor community making them more vulnerable.⁵

In South-east Asian region, an increase in per capita pure alcohol consumption by over 50% between 1980 and 2000 was reported. Not surprisingly, per capita pure-alcohol consumption has escalated in an alarming way by 106.7% between 1970-1972 and 1994-1996 in India. Travelling in the same trend, comprehensive global burden of disease and injury attributable to alcohol abuse in terms of disability adjusted life years (DALYs) has reached 5.1%. Global information system on alcohol and health (GISAH) reports approximately 3.3 million deaths (5.9% of all deaths) annually attributable to the harmful use of alcohol.^6,7 The following data of WHO indicates the rising crisis of alcohol use or abuse in India in the past decade (Table 2-3).^8-35

CONSEQUENCES OF ALCOHOL ABUSE

The issue of alcohol abuse in India is deeply rooted and has continued to affect not only health but also the social and economic well being of the youthful population and thus circumloculatorily the whole nation’s productivity. In view of WHO factsheet, roughly 200 diseases and injury conditions have shown causal relationship with harmful use of alcohol, not all cases detrimentally.³⁶ Not only quantity of liquor intake, but also patterns and trends of alcohol consumption, especially irregular heavy drinking, have been shown to be a deciding factor in multiple disorders. In almost all alcohol related disorders, a dose-response relationship to volume of alcohol consumption with risk of the disease increasing with increasing quantity of alcohol consumed has been evident in multiple studies with few exceptions viz., cardio-vascular arena of disorders, notably coronary artery heart disease (CAHD) and cerebro-vascular accidents/CVA (stroke), type-2 diabetes mellitus, and unintentional injuries, wherein other dimensions of consumption than average quantity of consumption play a deciding role in determining outcome.³⁷

ALCOHOL HARM PARADOX

In common understanding, economically weaker sections consume relatively less alcohol in quantity overall but pose a significantly elevated levels of liquor-attributable risks the wealthier counterparts. This has been termed the ‘alcohol harm paradox’.³⁸

ALCOHOL AND LIVER

Chronic liver diseases of any origin always have a poor outcome worldwide in terms of both morbidity and mortality. Keeping in view of the global demographic transition towards life style disorders, India being its epicentre of change, started a silent epidemic of Alcohol related liver disorders and non-alcoholic fatty liver diseases (NASH).³⁸ More worrisome is to find that, a stabilization for the past two to three decades in pure alcohol intake in economically developed nations, wherein a highly inimical tendency is being proclaimed from the struggling Asian and African nations (most chances of being underestimated because of poor reporting and surveillance systems). This is evident in a hospital based multi-centric study done in the peninsular India by Mukherjee PS et al on the pattern of chronic liver diseases (n=13014), showed about 30.4% of cases were alcohol related, followed by infective causes and NASH.

In 2012, global alcohol report of WHO proclaimed that, age standardised death rates (ASDR) of 39.5 per 1 lakh population and 19.6 per one lakh population were owing to alcohol related liver diseases (cirrhosis of liver). In view of of negligent national data on transplantation and their causal skeleton, extrapolation from series from multiple transplant centres all over the country revealed, hepatitis C and alcoholic cirrhosis as the major indications for the same posing both health and economic burdens on the community and the country.³

ALCOHOL AND ADDICTIVE BEHAVIOUR

Pattern of abusive and addictive nature of alcohol and other substances have a very notorious behaviour to change with time. With a handful of states flagging prohibition on liquor, the free-flowing alcohol shops around the tiniest streets pose a great danger for the younger generations to fall prey for dependence and subsequently addiction. There is paucity for national policy on alcohol addiction and not surprisingly a country wide data on alcohol related mental illnesses though the prevalence ballooning day by day. In an interview based cross-sectional study conducted by Chavan et al in Chandigarh (N=59470) found about 69 per 1000 population was either drug or alcohol dependant in nature.³⁹

A similar study conducted at Bengaluru, by Gururaj et al recorded a prevalence of 320 per 1000 alcohol users (N=28,507) which escalated from 90 per 1000 population by the same investigator at the same region two years back.⁴⁰ Though the alcohol consumption rate has come down in a meagre quantity as per the National family health survey data of 2005-06 and 2015-16, sill miles to go in getting away with alcohol dependence. In a bird’s eye view, It is evident that over 2006 to 2016, consumption of alcohol among men has fallen sharply in central and Northern states viz., Madhya Pradesh, Bihar, Uttarakhand, Haryana, West Bengal leaving peninsular India far behind in a bad shape.⁴¹

OTHER SEQUELAE OF ALCOHOL

Alcohol-related injuries have always been worrisome in India alike the western counterparts, where in the effective tackling and treatment of traumatic injuries is relatively not appreciable owing to the lacunae in skilled man power, basic infrastructure, efficient imposition of laws, and ill-fitting public health policies. In the sub-continent, alcohol abuse has a disproportionately high correlation with (RTA) road traffic accidents and intentional self-harm and implicating as high as 20 per cent of traumatic brain injuries.⁴² A systematic review by Das A et al reiterated the aforesaid finding that a significant proportion of injured or killed road users in India had used alcohol before the accident.⁴³ Esser MB et al (2015) found about 83% of the study participants proclaimed to have had at least a single alcohol-related violence from a heavy drinker in their lives either from the spouse or father for that matter concerned, and not surprising, 50% of the victims reported either emotional (verbal) violence or neglect and 25% and 6% proclaimed to have experienced physical violence and sexual violence respectively.^44,45 A study from Eastern India encompassing Jharkhand, Odisha and West Bengal found that women with alcoholic husbands experienced 5-13 times higher risk of domestic violence, varying by risk for physical, psychological and sexual dimensions.⁴⁵ Similarly multiple studies from India have found domestic intentional injuries and violence to be ranging from 18% to 70% with variation in the study methodology and tools applied.^46,47 A steep fall in ‘ever-married women who have ever experienced spousal violence’ in National family health survey 2015-16 to 28.8% from 37.2% (of 2005-06 NFHS-3 data) is to be elated.⁴¹

Another notable factor that requires special mention is about the ‘country liquor’ or adulteration of methanol with ethanol (in view of cheapness of methanol and its ability to give early euphoria or kick to chronic drinkers). India is a perennial landscape for toxic methanol poisoning, a recent incident that cost about 102 deaths in Malwani, Mumbai city, Maharashtra and 2017 Ramgopalpur incident in West Bengal with at least six citizens kicking the bucket due to spurious liquor.⁴⁸ The campus of interest in all these cases is that the major cause of fatalities in almost every Methanol poisoning is due lack of awareness amongst the habitual drinkers and late arrival at the hospital after full blown development of metabolic acidosis, dyselectrolemia and even coma.⁴⁹

In a meta-analysis on alcohol related suicidal ideation by Darvishi et al, at a global level including India based studies, recorded a significant association between suicidal ideation and alcohol use disorder with OR of 1.86 (CI: 1.38-2.35) and suicide attempt (OR=3.13; 95% CI: 2.45, 3.81); and completed suicide (OR=2.59; 95% CI: 1.95, 3.23).^48,49 In a countrywide survey by Pandey et al, to find the correlation of alcohol use with sexually transmitted infection amongst country men found a blanket prevalence of about 2.5% with 26% amidst them using alcohol. The men who consumed alcohol had higher prevalence of STI (3.6%; 95% CI: 2.9–5.1) than those who did not consume alcohol (2.1%; 95% CI: 1.5–2.6). This statistical information is reinforced by a similar research by Saggurti et al in 2010 in Mumbai, putting daily alcohol drinkers four times more likely than those not consuming alcohol in the last month to have gonorrhoea (NG) and chlamydia (CT) infection and three times more likely to have had a past history of exposure to herpes simplex virus-2 (HSV-2) and/or syphilis as determined by biological testing.⁵⁰

CONCLUSION

Does India need an alcohol ban? Adding on to the way ahead of an alcohol-free state, apex court of India ruled (December 15, 2016) a ban on State and Union Territories from granting licences for the sale of alcohol alongside the national and state highways county-wide, noting that drunken driving was the main culprit behind a large number of road traffic accidents (RTA) in the country is indeed on a ‘res extra commercium’ basis is heartwelcoming. Holding drug de-addiction programme (DDAP) of ministry of health and family welfare resulting in establishment of National drug dependence treatment centre (NDDTC) at AIIMS, New Delhi and similar centres for de-addiction is warranting to overcome this menace. Multicentric studies have established that heavy alcohol consumption increases the risk of blood pressure, cerebro-vascular accident (stroke) and cirrhosis of liver as discussed in the article earlier. It gains more attraction especially in terms of a developing nation like India, wherein people tend to drink so heavily. In this scenario, alcohol dependence/addiction tends to have both adverse health and socio-economic corollary, evading the vital resources away from basic necessities such as nutrition/food, shelter, clothing and schooling of the off springs. It also affects the welfare of other household members, especially the children and women dependant on the domiciliary head for the preceding. It is a well-known fact that the momentum of progress of a reserved who are dependent on the surplus it generates. Being an alcoholic rich nation, it is hard for the country to prosper both in economic affairs and in world health platform too. It is clear that a non pendular balance to be achieved in recreational use and renaissance of the public health and well-being.

ACKNOWLEDGEMENTS

Authors are thankful and appreciate the Centre for Community Medicine (CCM), All India Institute of Medical Sciences, New Delhi for guidance.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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