Introduction

Alcohol is one of the most important risk factors for premature mortality and disability. Premature mortality disproportionately affects low- and middle-income countries (LMICs) (WHO 2011a); more than 85 percent of all deaths attributable to alcohol occur in these nations (Room and others 2013; WHO 2011a). This chapter updates the chapter on alcohol in Disease Control Priorities in Developing Countries, 2nd ed. (DCP2) (Rehm and others 2006), with new scientific evidence for interventions based on population, community, and individuals, with an emphasis on evidence from LMICs.

Alcoholic beverages vary with respect to their raw material, method of production, alcohol content, and presentation. Beverages are usually classified as fermented or distilled. In addition to the alcohol that appears in official statistics, many countries have a substantial amount of unrecorded alcohol, which may include illegally produced or smuggled alcohol products, but also surrogate alcohol (nonbeverage alcohol not officially intended for human consumption) and legal but unrecorded alcohol products (Lachenmeier, Sarash, and Rehm 2009).

Alcohol-Related Disorders

Choice of Interventions

The interventions in this chapter were identified with reference to a standardized matrix developed at a meeting of the volume editors and lead authors. The matrix divides interventions into three main groups:

• Population platform interventions, including universal prevention (IOM 1998)
• Community platform interventions
• Health care platform interventions.

This mapping exercise updates the DCP2 chapter on alcohol (Rehm and others 2006) and draws on three key previous exercises that reviewed the existing evidence (Babor and others 2010; Room, Jernigan, Carlini, Gmel, and others 2013; Room, Jernigan, Carlini, Gureje, and others 2002; WHO 2008, 2011b).

The search process consisted of an electronic review of the following databases: Medline (1994–2013), Embase (1994–2013), PsycINFO (1966–2013), Ovid (1970–2013), National Institute on Drug Abuse Database, SciELO (1994–2013), EBSCO (1994–2013), ISI Web of Knowledge (1994–2013), National Institute for Health and Care Excellence evidence search, Global Information System on Alcohol and Health, CINAHL, and Mental Health Gap Action Programme (mhGAP). The review resulted in identifying 42 articles; 21 additional records were identified through other sources. Of the 63 articles screened, 18 were excluded because they did not use a robust design; 45 were selected and assessed for eligibility, but three were excluded because of methodological limitations (Moher and others 2009).

Population-based interventions are usually evaluated by before-and-after population surveys, analyses of archival and official statistics, time-series analyses, qualitative research, and quasi-experimental studies. Quasi-experimental studies involve before-and-after measurements of communities or jurisdictions exposed to the intervention, compared with similar communities or jurisdictions where the intervention has not been implemented.

Natural experiments take advantage of the implementation of a new policy to test the effects; accordingly, they lack the random assignment of communities to the interventions being tested and so provide a lower level of evidence. Randomized controlled trials (RCTs), considered the gold standard for evaluating the effect of health interventions, are rarely used to test population-based interventions (Babor and others 2010). Although individual-based interventions are more suitable for RCTs, they must meet rigid standards to be considered robust (Guyatt and others 2011).

Interventions at a populationwide level that do not use experimental methodology were assessed using less stringent criteria, so quasi-experiments and natural experiments were rated as very good (+++) or good (++), depending on the strategies for data analysis. Time-series analysis or statistical modeling were considered to have a very good level of evidence. Other strategies, such as key informants or reports where information was lacking, were rated as limited + and not included in the analysis.

Community and health and social care interventions were assessed using primarily the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Using these, RCTs are regarded as having high quality (very good +++). When only some criteria included in the GRADE guidelines were used, the rank was lower (good ++). Studies with limitations in the methods (the sample size or follow-up period assessment), inconsistencies (low reliability due to low variable control), lack of directedness (use of surrogate variables), or imprecision (confidence intervals not reported) were ranked as having a lower level of evidence (limited +). Only articles rated as very good or good were included in this review.

Population Platform Interventions

Reducing the Availability of Alcohol

To control the physical availability of alcohol, governments need to be able to control its production, distribution, and sale. This control can be achieved by prohibition, monopolization, or other measures grouped in three clusters:

• Limiting the availability by means of taxes and minimum prices
• Limiting advertising and promotion
• Constraining access by licensing producers and wholesalers and retailers: when and where beverages can be available, to whom can they be sold, and how they can be sold.

Licensing systems facilitate the enforcement of regulations, the assessment of the origin of the alcohol, the determination of whether it has been legally produced and sold, and the collection of taxes. Settings in which unrecorded alcohol is highly available require additional controls. The following section describes evidence for these measures by region; tables 7.1, 7.2, and 7.3 provide additional information.

Table 7.1

Population-Based Interventions to Reduce Alcohol Availability.

Table 7.2

Restrictions on Alcohol Sale and Advertising: Density, Hours, Days, and Locations.

Table 7.3

Law Enforcement Measures to Reduce Impaired Driving.

Prohibition, Rationing, and Partial Bans

Bans on sales, when effectively enforced, have proved effective in reducing consumption and harm. However, evidence suggests that these measures encourage the black market, which is difficult and expensive to eliminate (Lachenmeier, Taylor, and Rehm 2011). Several experiments on prohibitions and bans have been conducted in recent years, showing a reduction in use, followed by an increase when controls were abolished (Room, Jernigan, Carlini, Gmel, and others 2013; Room, Jernigan, Carlini, Gureje, and others 2002).

Indigenous Communities

Margolis and others (2011) studied four remote Australian Indigenous communities; three implemented prohibition, and the fourth allowed low-alcohol beer within licensed premises. Serious injury rates declined in all four communities. Similar results were observed in the First Nation Communities in Canada (Gliksman, Rylett, and Douglas 2007). The remoteness of the communities studied is likely to have enhanced the effectiveness of the intervention.

Latin America and the Caribbean

The impact of partial bans on alcohol consumption on traffic accidents and injuries was evaluated in República Bolivariana de Venezuela during one week of national holidays (Herrera and others 2009). During the week the law was in effect, alcohol use was reduced and fewer accidents were reported.

Alternative solutions to prohibition include measures to regulate the alcohol market. Evidence has shown that alcohol consumption and related problems decrease when accessibility is diminished (for example, by pricing alcohol higher than other products) and consumption is more difficult (for example, by limiting the hours of sale). Alcohol prices may be increased through taxes, curbing consumption problems while increasing government revenues. Evidence has shown that this measure impacts heavy drinkers (defined as an average of more than 20 grams of pure alcohol per day for women and more than 40 grams for men) and light to moderate drinkers (less than 20 grams for women and less than 40 grams men), as well as younger and older drinkers (underage and legal age) (Babor and others 2010).

Taxation

The effects of taxation can be measured by price elasticity, which reflects the change in consumption in relation to the size of the price increase (percentage of change in quantity purchased/percentage change in price); an elasticity of less than −1.0 indicates that demand is relatively responsive to changes in price or is “elastic.” Elasticities between −1.0 and 0 indicate that the demand is less responsive to prices or is “inelastic” (NIAAA 2000). An inelastic response to a tax increase may still have positive public health effects.

Evidence, mostly from HICs, shows a range of elasticities from −0.3 for the beverage ranked first in the target population’s preferences to –1.5 for the one ranked last (Rehm and others 2003). Accordingly, an elasticity of –0.3 with respect to a tax on alcohol means that consumption will be reduced 3 percent by a 10 percent tax increase, while the alcohol tax revenue for the government will rise by 6.7 percent.

Latin America and the Caribbean

In Mexico, the price elasticity of demand was near –0.2 (Galindo, Robles, and Medina-Mora 2012); in República Bolivariana de Venezuela, the price elasticity was quite low, between –0.074 and –0.058 (Herrera and others 2009).

East Asia and Pacific

In China, using data from the China Health and Nutrition Surveys for 1993, 1997, 2000, 2004, and 2006 in nine provinces in China, the price elasticity was virtually zero for beer and only –0.12 for liquor (Tian and Liu 2011). A previous estimate derived from household surveys conducted in 1993 and 1998 in three main cities and one province of China found elasticities of –0.51 for wine coolers, –0.85 for beer, and –1.39 for wine (Pan, Fang, and Malaga 2006). Using time-series data for consumption and retail prices in Taiwan, China, the price elasticity for alcohol was –0.771 (Lee and others 2010).

A study conducted in Thailand showed the effectiveness of two taxation approaches (Sornpaisarn, Shield, and Rehm 2012). One tax schedule is based on alcohol content, aimed at discouraging harmful patterns by promoting beverages with low alcohol content, suitable for contexts with a high prevalence of current drinkers. The other tax scheme is estimated as a function of price, which increases taxes on beverages consumed by heavy drinkers and potential new drinkers. Since the first scheme has the potential risk of promoting consumption in abstainers who are a large segment of the population in LMICs (WHO 2013a), a combination of both measures is proposed, together with interventions designed to control the promotion of alcoholic beverages.

East Asia and Pacific, South Asia, and Sub-Saharan Africa

In a systematic literature review and meta-analysis, Sornpaisarn and others (2013) found 12 studies with evidence of the link between alcohol prices or taxation and consumption in LMICs (China, India, Kenya, Tanzania, Thailand, and Turkey), although unrecorded alcohol was not considered. Elasticity estimates were –0.64 (95% confidence interval [CI]: –0.80 to –0.48) for total alcohol consumption, –0.50 (95% CI: –0.78 to –0.21) for beer consumption, and –0.79 (95% CI: –1.09 to –0.49) for consumption of other alcoholic beverages. They concluded that the price elasticity of demand for alcohol in LMICs is similar to that in HICs, and suggested more research was needed on the association between alcohol price or taxation and alcohol-related harm and drinking initiation in LMICs.

Control of the Unrecorded Market

Quantitative studies of the effects of policy options for controlling the unrecorded market are scarce. The main concern for controling unrecorded alcohol is that it can undercut the effects of regulatory measures by offering people an alternative. Some successful control examples include the centuries-old requirement of official sealing labels over corks or stoppers; this measure has been widely used, and the attendant threat to withdraw the liquor license of any place caught using untaxed alcohol has been effective (Lachenmeier, Rehm, and Gmel 2007).

Another concern about unrecorded alcohol is its potential toxic effects. Although according to Lachenmeier, Rehm, and Gmel (2007) the contribution of these effects to mortality is still unclear, because of their public health importance some measures to reduce harm can be included in policies. For example, such measures could include abolishing denatured alcohol; abolishing the use of methanol, which is a simple form of alcohol closely related to ethanol and found in unregistered alcoholic beverages, but more toxic (Pincock and ABC Health & Wellbeing 2013); or treating products not intended for human consumption with bittering agents to prevent people from using them (Lachenmeier, Rehm, and Gmel 2007). For example, recently in Mexico, after an increase in the number of seizures of unrecorded alcohol, a new regulation was issued requiring that all ethyl alcohol and methanol produced in the country be mapped to the primary manufacturing process. This regulation prevents diversions to informal channels, where unrecorded alcohol can be mixed with alcoholic beverages. The regulation prohibits the sale of alcohol in bulk and the incorporation of methanol as a raw product in beverages (CSG 2014).

Following a review of policy options for regulating unrecorded alcohol, Lachenmeier, Taylor, and Rehm (2011) classified policies in:

• Reducing health risks: prohibiting the toxic compounds that are used to denature alcohol and substituting them with substances with acceptable toxic profiles, for example, via the use of bittering agents, to prevent accidental deaths
• Reducing cross-border shopping: narrowing tax differences between unrecorded and recorded beverages or introducing stricter controls
• Limiting illegal trade and counterfeiting: implementing tax stamps and electronic surveillance systems for the alcohol trade.

These authors also suggested that the introduction of education campaigns could increase awareness of the risks associated with drinking illegal alcohol. They concluded that the most problematic category was the control of home and small-scale artisanal production; the most promising option was to offer financial incentives to producers to ensure registration and quality control. There is a need for further research in countries with different cultures and traditions (Lachenmeier, Taylor, and Rehm 2011).

Minimum Prices and Bans on Discounts and Promotions

Evidence in HICs suggests that price discounts—such as happy hours and grocery store promotions—increase consumption and that higher prices for distilled spirits shift consumption to beverages with lower alcohol content, resulting in lower total intake. Enforcing minimum prices for a standard unit of alcohol is one of the most effective ways to reduce alcohol-related problems (Babor and others 2010). No evidence is available for LMICs.

Restrictions on Density, Hours, Days, Locations of Sale, and Advertising

Control of the physical availability of alcohol through measures such as restricting the hours, days, and locations of sale; limiting the density of concentration of retail drinking establishments and off-sales stores (shops licensed to sell alcoholic beverages for consumption off the premises); and establishing a minimum legal purchase age have diminished alcohol use and related problems in HICs (Babor and others 2010).

Although such measures have also been implemented in LMICs, only a few impact studies have been identified in these settings.

Latin America and the Caribbean

A significant reduction in violence was reported in Brazil following the implementation of a municipal law preventing the sale of alcohol after 11 p.m. Enactment of this law was followed by a public information campaign, the law was strictly enforced, and the measure was assessed by an interrupted time-series analysis. The results suggest that the law prevented an estimated 319 homicides over three years (Duailibi and others 2007). Similar results have been observed through restrictions on alcohol service hours in cities in Colombia (Sánchez and others 2011) and Peru (Málaga and others 2012).

Indigenous Communities

Some studies are available for indigenous groups within HICs. A study conducted in Tennant Creek in the Northern Territory, Australia, assessed the effectiveness of interventions and community attitudes toward increased restrictions on the availability of alcohol that included constraints on the days, hours, and amounts of different beverages allowed for sale. After two years, annual per capita consumption of pure alcohol declined by 19.4 percent, accompanied by declines in hospital admissions (Gray and others 2000).

In HICs that have banned advertising, an econometric analysis showed that these measures had only a modest effect on alcohol use (Rehm and others 2006). However, other research indicates that banning advertising, accompanied by taxation and availability restriction, combine to constitute the best buy in reducing alcohol-related problems (WHO 2014a). Research on restrictions on advertising has not been replicated in LMICs. However, research from Taiwan, China, has replicated findings from HICs showing that exposure to alcohol marketing is associated with greater likelihood of initiation and persistence of drinking among youth (Chang and others 2014).

Countermeasures to Alcohol-Impaired Driving

The harmful consequences of alcohol can be curbed by risk-reducing measures, such as drinking and impaired driving countermeasures. Impaired driving laws, when accompanied by strategies for reinforcing them, such as regular random breath testing of drivers, have been shown to reduce the number of fatal and nonfatal traffic injuries. These strategies modify the drinking practices of high-risk alcohol users and protect other members of the population, such as passengers, other drivers, and pedestrians.

• Various blood alcohol concentration (BAC) limits are in place globally. Setting and enforcing legislation on BAC limits of 0.05 grams per deciliter (g/dL) can lead to significant reductions in alcohol-related crashes (Babor and others 2010). Setting lower BAC limits (0.02 g/dL or less) or zero tolerance is recommended for inexperienced drivers and young adults as an effective means of reducing crashes related to impaired driving; HICs are more likely to have these laws in place than LMICs. These laws are more effective when random breath testing for all drivers is conducted, and when drivers perceive a high likelihood of being arrested if they break the law (WHO 2013b).
• Rehm and others (2006) estimated that random breath testing could reduce fatalities between 6 and 10 percent if partially implemented, and up to 18 percent if implementation were extended. For nonfatal injuries, they calculated a reduction of 15 percent. However, these estimates are based on information obtained from HICs, where road infrastructure and driving patterns may significantly differ from those in LMICs.
• A related measure—sobriety checkpoints—has a high level of research support, with a robust, although lower, level of evidence of effectiveness in HICs (Babor and others 2010).
• Administrative license suspension for driving under the effects of alcohol, allowing licensing authorities to suspend a driver’s license without a court hearing at the time of the offense or shortly after, has a good level of evidence; when punishment is swift, effectiveness is increased, particularly in countries where it is consistently applied (Babor and others 2010). Evidence in LMICs is scarce.

East Asia and Pacific

Studies conducted in China found that random breath tests and the perceived potential legal consequences of conviction reduced impaired driving rates (Kim and others 2013). The arrest of intoxicated drivers on BAC limits and enforcement were associated with a reduction of fatal accidents involving impaired driving in Taiwan, China (Chang and Yeh 2004).

Latin America and the Caribbean

In Brazil, low BAC rates reduced traffic injuries and deaths (Andreuccetti and others 2011).

Community Platform Interventions

The impact of this measure is generally evaluated in terms of knowledge and attitudes. The most common target group is young drinkers; school-based interventions are one of several education and persuasion initiatives tested.

Mass Media Campaigns

Awareness initiatives include mass media campaigns. When combined with policies and regulatory controls, awareness campaigns can help to increase public support for policy measures and compliance with laws and regulations. Warning labels related to drinking during pregnancy have been introduced in HICs and LMICs. A review of published literature testing the effectiveness of alcohol warning levels in the prevention of FASD in Canada, France, New Zealand, and the United States showed that although alcohol warning labels are popular, their effectiveness in changing behavior is limited (Thomas and others 2014). FASD, whether complete or incomplete, is a growing problem that warrants further attention. There is insufficient evidence, even in HICs; however, studies show that warning labels, when delivered through channels that are perceived to be useful, can be beneficial and can influence behavior if they are part of a comprehensive strategy (Wilkinson and Room 2009).

The mhGAP (WHO 2008) recommends advising women who are pregnant, breastfeeding, or planning to become pregnant to avoid alcohol completely, and offering social support services for those who require additional assistance (WHO 2014b). Treatment in some cases could be helpful.

Studies in South Africa show that treatment using case management interventions to reduce alcohol intake among high-risk pregnant women had positive effects. The effects included stopping drinking, changing drinking behavior reflected in reduced Alcohol Use Disorders Identification Test scores, and reducing problem drinking (Maraisa and others 2011) (table 7.4).

Table 7.4

Community-Based Interventions: School and Family Interventions and Media Campaigns.

Health Care Platform Interventions

Screening and Brief Interventions

Key elements of brief interventions include feedback, responsibility, advice, strategies, empathy, and self-efficacy. Strong evidence supports clinically significant effects on drinking behavior and related problems (Diaz and others 2011; Nagel and others 2009). The mhGAP Intervention Guide (WHO 2011b) identifies three levels of interventions with individual problematic drinkers:

• Screening and brief interventions by trained primary health care professionals
• Early identification and treatment of AUDs in primary health care
• Referral and supervisory support by specialists.

The WHO mhGAP action plan promotes scaling up services for mental, neurological, and substance use disorders, with more cases treated at the first level of care (WHO 2008). The program is based on a review and evaluation of the strength of the evidence to submit recommendations for action. Psychosocial support was found to be more effective than no treatment, while motivational interviewing and motivation enhancement were possibly more effective than standard psychosocial treatment involving families and friends (mainly spouses), or no treatment, or individual counseling.

Evidence in LMICs is widespread and consistent, showing positive results (table 7.5).

Table 7.5

Screening and Brief Interventions in Low- and Middle-Income Countries.

Medical and Social Detoxification, Treatment, Follow-Up, and Referral

The recent evidence for LMICs is consistent with what had previously been reported (Patel and others 2007) (table 7.6).

Table 7.6

Medical and Social Detoxification, Treatment, Follow-Up, and Referral.

The mhGAP recommends referral from first-level care and supervisory support by specialists for patients with established alcohol dependence. The recommended actions include the planning of cessation of alcohol consumption and detoxification; if necessary, the treatment of withdrawal symptoms with diazepam; the use of medications to prevent relapses, such as naltrexone, acamprosate, or disulfuram; and the assessment and treatment of comorbidity and possible referral to self-help groups (WHO 2008).

Self-Help and Support Groups

Mutual help and self-help organizations for those interested in reducing or ceasing drinking have been an important part of the social response to alcohol in many societies. Given that many religions forbid or discourage drinking, adherence to a religious congregation or group often carries with it an expectation of mutual help to stop drinking. In many social groups in Latin America and the Caribbean, joining a Protestant sect has often been a way out of sociocultural expectations of heavy drinking, particularly for men (Butler 2006; Eber 2001). Many mutual help groups that are not affiliated with particular religions or that are entirely secular have formed in different countries (Room, Jernigan, Carlini, Gmel, and others 2013; Room, Jernigan, Carlini, Gureje, and others 2002). The most well-known and widespread is Alcoholics Anonymous, which has proved adaptable to many cultural settings (Eisenbach-Stangl and Rosenqvist 1998; Mäkelä 1991).

Affiliation with Alcoholics Anonymous and similar groups is not considered a form of formal treatment—although some groups have affiliations with treatment institutions—and incorporating mutual help groups into a treatment system is likely to undercut their effectiveness. The principles of voluntary mutual help organizations often do not allow random-assignment clinical trials to test their effectiveness; consequently, not much research has been conducted on the impact of these groups (Ferri, Amato, and Davoli 2006; Terra and others 2007). However, survey results support the important role of these groups; 71 percent of the countries included in WHO’s Atlas on Substance Use (2010) reported the presence of Alcoholics Anonymous.

Latin America and the Caribbean

In Mexico according to a National Household Survey (Medina-Mora and others 2012), 44 percent of persons in treatment for alcohol problems reported being affiliated with self-help groups, while only 35 percent received professional treatment. A study conducted in a nonprobabilistic sample of 192 members of Alcoholics Anonymous found that the level of affiliation or involvement with the organization was negatively related to relapse; with more involvement, mean participation time was higher, and activities related to service were more frequent. Most of the nonrelapsed subjects were sponsors helping newcomers, practiced the 12 steps more often, and reported spiritual awakening experiences more frequently (Gutiérrez and others 2007; Gutiérrez and others 2009).

The WHO (2011b) makes a standard recommendation—that indicates that it can be offered to the majority of patients but might not be applicable to all cases—for nonspecialist health care workers to be encouraged to familiarize themselves with locally available self-help groups. These groups should offer services at no cost to patients, and they should provide support for recovery and new social connections unrelated to drinking. Relatives of patients with alcohol dependence should be encouraged to participate in appropriate self-help groups for families, so that they can better understand their relatives’ conditions and support their recovery.

Cost-Effectiveness of Interventions

The addition of a cost component or economic dimension to health impact assessment introduces the opportunity to identify alcohol prevention and control strategies that have better or worse value for money. For example, devoting scarce resources to interventions that do not discernibly reduce ill-health caused by the consumption of alcohol—as is the case for information and education—is a clear case of investing in interventions that are not cost-effective. At the other end of the spectrum, in contrast, imposition and enforcement of taxation policies offers an example of a highly cost-effective public health intervention that costs relatively little to implement but reaps substantial health returns.

The available body of economic evidence to inform decisions around these alcohol control measures in LMICs remains modest and is based on a modeling approach that relies on data from higher-income settings for some of its inputs. Rehm and others (2006) reported on the comparative cost-effectiveness of a group of interventions—enactment of legislation on drinking and driving, random breath testing, taxation of alcoholic beverages, reduced hours of sale, and advertising bans—in East Asia and Pacific, Latin America and the Caribbean, South Asia, and Sub-Saharan Africa. Increased taxation was the most cost-effective strategy, although it may have a regressive impact on the incidence of alcohol consumption if accompanied by a rise in an already high level of unrecorded consumption. The authors found reductions from 2 to 4 percent in the incidence of high-risk alcohol use, depending on regional drinking patterns. The strategy of reducing the hours of sale produced a modest reduction of 1.5–3.0 percent in the incidence of high-risk drinking, together with a 1.5–4.0 percent reduction in alcohol-related traffic fatalities.

The overall conclusion from this study was that countries with a high prevalence of high-risk drinking should begin with taxation, because in such contexts it appears to have the largest impact for the fewest resources. In settings where high-risk drinking is less of a public health burden, other strategies that restrict the supply or promotion of alcoholic beverages appear to be promising and relatively cost-effective mechanisms, although there is a clear need for greater empirical support of their efficacy. In Mexico, a combination of interventions yielded the best results, with higher taxation (by 50 percent) ranked first (Medina-Mora and others 2010). Tax increases were also the measure recommended in India (Mahal 2000). Banning advertising, in conjunction with taxation and restrictions on availability, is considered the best combination of measures (WHO 2014b).

In terms of individual-level measures, trial-based economic evaluations have been conducted in HICs, the results of which have been used to model expected costs and health gains in LMICs (Chisholm and others 2004; Rehm and others 2006). Although found to be the most costly intervention to implement, brief interventions also lead to a large health gain in the population as a result of an estimated 13–34 percent reduction in consumption among high-risk drinkers, making it a relatively cost-effective measure.

The relative cost-effectiveness of these alcohol control and prevention measures is further discussed and reviewed in chapter 12 in this volume (Levin and Chisholm 2015).

Challenges and Opportunities

Conclusions

LMICs have a high burden of disease derived from alcohol use, medium-to-low levels of policy implementation for reducing alcohol use and consequences, insufficient evidence of the impact of measures to reduce the burden, and a paucity of research. The combination of these factors constitutes a compelling argument that more decisive action is needed by national and international organizations to reduce the burden derived from alcohol use, which is a preventable cause of death and disability. This chapter documents the urgent need to increase research support to assemble evidence, monitor progress, and reduce the gap between evidence, its application in communities, and its inclusion in policies (Barnes 2000).

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Footnotes

World Bank Income Classifications as of July 2014 are as follows, based on estimates of gross national income (GNI) per capita for 2013:

• Low-income countries (LICs) = US$1,045 or less
• Middle-income countries (MICs) are subdivided:
  a) Lower-middle-income = US$1,046 to US$4,125
  b) Upper-middle-income (UMICs) = US$4,126 to US$12,745
• High-income countries (HICs) = US$12,746 or more.