Br. J. clin. Pharmac. (1975), 2, 195-196

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ALCOHOLISM: PREVENTION BETTER THAN CURE Since early times (Moses, 1450 B.C.) alcohol has been recognized as responsible for a number of adverse effects. It has been said that alcoholism follows only cancer and cardiovascular disease in its tally of victims in many countries. While its very nature makes precise comparison difficult there is no doubt that the problem is very serious (W.H.O., 1974). Many past conferences on alcoholism have been remarkable, in contrast say to conferences on tuberculosis, for the lack of prominence, the absence or only scant attention given to prevention. This has been surprising as in no other condition is the adage 'prevention is better than cure' more true. The recent publication of the twentieth report by the W.H.O. Expert Committee on Drug Dependence (1974) however draws attention to the relationship between alcohol consumption and alcoholism and suggests some preventive measures. The report cites the work of Popham, Schmidt & de Lint (1975) who pointed out the steady rise of alcohol consumption in the province of Ontario from 2.81 litres alcohol per capita in 1928 to 8.91 in 1967, a three-fold increase. Although it is conceivable other factors were involved, this was paralleled by a three-fold increase in death rate from cirrhosis of the liver, 4.4/100,000 population aged 20 years and over in 1928 to 13.2 in 1967. At the same time it is interesting to note that there was a three-fold decrease in the relative price of alcoholic beverages. The relative price index was obtained by dividing the average cost of 10 litres of alcohol by the personal disposable income; it fell from 0.102 in 1928 to 0.035 in 1967. Of all the fates of alcoholics, death from cirrhosis is a relatively clearly measurable end point and the W.H.O. report (1974), by taking national figures of 1966, shows how those countries with a high alcohol consumption have a high death rate from cirrhosis of the liver. France is at athe top of the list with an average consumption of 24.66 litres absolute alcohol consumption per capita and an annual death rate of 51.7/100,000 from cirrhosis of the liver. The figures for the U.K. are 7.66 litres and 4.1 deaths from cirrhosis per 100,000 of the population. While the correlation between alcohol consumption and cirrhosis was highly significant, whether alcohol was taken as a wine or spirits appeared irrelevant (W.H.O., 1974). The rise in incidence of alcoholism and death from cirrhosis with increasing consumption of alcohol has been

observed before. Jolliffe & Jellinek (1941) demonstrated the relationship between cirrhosis and alcohol consumption in forty-five American States in 1939. This was also shown by figures from Western Europe comparing different countries, and also from studying the levels of consumption and incidence of cirrhosis in France (Pequignot & Cyrulnik, 1970). Other evidence of the relationship of alcohol consumption and cirrhosis is afforded when special measures have been taken to suddenly reduce alcohol intake. For instance before prohibition in the U.S.A., the annual death rate from cirrhosis was 11-15/100,000, whereas with prohibition (1916) the rate dropped in 4 years to 7-8/100,000 where it remained until the end of prohibition. After the end of prohibition it gradually climbed back to a level of 11/100,000 (Klatskin, 1961). With the much higher levels of alcohol consumption in France much more dramatic effect was seen with wine rationing in Paris during the war. Consumption of alcohol fell from 30-35 litres to 3-5 litres absolute alcohol/year, mortality rate from cirrhosis fell from 35 to 6/100,000. The end of rationing has seen a gradual return to previous death rates (Pequignot & Cyrulnik, 1970). While the available figures relate chiefly to one manifestation of alcoholism, i.e. cirrhosis, there is little doubt that the incidence of alcoholism is related to the level of consumption of alcohol, not an unexpected finding. The time seems overdue for society to take a more consistent attitude to drug addiction. Quite rightly society uses all measures to minimize opiate addiction. It does not for instance allow a multi-million advertising campaign to encourage its use - whereas it allows tens of millions to be spent annually in persuading people to take alcohol which is responsible for far more addicts. It seems difficult to hold the view that advertising solely has the effect of persuading people to switch from one brand to another. It is not possible to identify those particularly susceptible to alcoholism in advance and perhaps society owes them a freer choice than they have at present, i.e. without them being bombarded with advertising particularly in their own home. As the W.H.O. report (1974) recommends, mass media advertising of alcoholic beverages should be eliminated as far as possible. Pricing policies can regulate the consumption of most commodities and a second way of reducing death from

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alcoholism is to make alcohol more expensive. The decline in cost of alcohol with an increase in alcoholism in Ontario was cited above. It is also noteworthy that France with the highest incidence of alcoholism has the cheapest alcoholic beverages, 3.5 times cheaper than the U.K. (W.H.O. Report, 1974). There are of course other useful measures available. Any society should expect an increase in addiction from a drug with addictive properties when it becomes more readily available, such as starting to sell it in supermarkets. Perhaps wide availability is the single most important factor in France. Although alcohol is 3.5 times as cheap in France as the U.K. (see above), the incidence of cirrhosis is not 3.5 times as great but 12 times the U.K. level. Finally the small but useful educational bodies in this field must be mentioned, but they have an uphill task against the enormous volume of negative education in paid and gratuitous advertising in the mass media. Maybe our legislators are at present too busy

grappling with economic problems to look at these four approaches but it is high time this health scandal was taken more seriously. In any case it is not irrelevant to the economic state. I have not attempted to review the many other consequences of alcohol and alcoholism, but recent work has shown that there is a large loss to industry, and the total cost of alcohol problems may more than offset government revenue from taxation in some countries (W.H.O. Report, 1974). Finally to use a fall in taxation income as an argument for keeping alcohol consumption at its present level seems not only immoral, but facile. Governments are never short of ideas for extracting taxes.

B.N.C. PRICHARD Department of Clinical Pharmacology, University College Hospital Medical School, University Street, London W.C]1

References JOLLIFFE, N. & JELLINEK, E.M. (1941). Vitamin deficiencies and liver cirrhosis in alcoholism. VII. Cirrhosis of the liver. Quarterly Journal Studies on Alcohol, 2, 544-583. KLATSKIN, G. (1961). Alcohol and its relation to liver damage. Gastroenterology, 41, 443451. MOSES (c. 1450 B.C.). Genesis, 9, 21. PEQUIGNOT, G. & CYRULNIK, C. (1970). Chronic diseases due to over-indulgence in alcoholic drinks. International Encyclopedia of Pharmacology & Therapeutics, Section 20, 2, 375412.

POPHAM, R.E., SCHMIDT, W. & de LINT, J. (1975). The

prevention of alcoholism: epidemiological studies of the effect of government control measures. In Drinking, Ed. Ewing, J.A. Chicago: Nelson-Hill (in press). WORLD HEALTH ORGANISATION. (1974). Expert Committee on Drug Dependence. Twentieth Report. Geneva: W.H.O.

Alcoholism: prevention better than cure.

Br. J. clin. Pharmac. (1975), 2, 195-196 EDITORIALS 195 ALCOHOLISM: PREVENTION BETTER THAN CURE Since early times (Moses, 1450 B.C.) alcohol has be...
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