Tuesday, 5 June 2012

Essay: A call for Sobriety

Original Article by Y. Peppas for Passive Observers

From Mesopotamia and Ancient Greece to the Middle Ages and modern Europe, the consumption of alcohol-containing beverages is evident throughout the history of our civilization. The explosion of financial corporatism, which has gained its momentum by instilling consumerism in the core of human behaviour, has transformed alcohol from a home- or locally-made product into a highly profitable commodity and a symbol of the subculture called Western Lifestyle. In this way, we have reached an era where alcohol accounts for 5% of the global disease burden and is responsible for more than 4% of deaths worldwide [Beaglehole et al 2009]. This tragic realization has
triggered substantial efforts to build effective public health policies in order to fight the modern alcohol epidemic. Unfortunately, every genuine initiative towards this direction is counterbalanced by the inadequacy of governments to safeguard public interest and to resist pressure from the alcohol industry and its procurer, the World Trade Organization (WTO) [Baumberg et al. 2008] As a result, contemporary policies mainly focus on advocating individual-based strategies, which are absolutely necessary but insufficient per se to yield a pragmatic treatment of the disease [Room et al. 2005].

Alcohol consumption has been linked to more than 60 diseases. in most cases exhibiting a linear dose-response relationship (Figure 1). Alcohol abuse has been consistently associated with heart disease1, gastrointestinal disease, cancer, maternal and fetal disorders, epilsepsy and psychiatric disorders. The role of alcohol in violence-related and accidental injuries is also well known, with recent advancements in our understanding of the pathophysiological alterations2. Rehm et al. (2009) conclude that alcohol consumption is one of the greatest avoidable risk factors for disease worldwide.
Room and colleugues (2009) believe that recent advances in our understanding of the neuroscience of addiction have little relation to public policy making. Personally, I believe that this could be a dire mistake. Edward Bernays, using the insight that his uncle Sigmund Freud bequeathed3, formed the foundations of our modern consumeristic societies by systematically exploiting the power of the human subconscious 4. He was the mind behind the women's smoking campaign in the 1920s, a form of sinister propaganda that resulted in the symbolization of cigarettes as “torches of freedom” and the consolidation of female smoking as an act of liberalisation (Givel, 2007). The various forms of psychosomatic addiction to instant gratifications (nicotine, alcohol, food, illicit or prescribed drugs, shopping, sex) that have been cultivated throughout the last century share common underlying neurobiological mechanisms [Koob et al 2010][Dagher, 2011]. Given that lobbyists traditionally use specific techniques to seduce the public mind (discussed below), I believe that it is pivotal to comprehend the organic substrates of addictive behaviour and to utilize this knowledge in order to optimise treatment and preventive strategies both at the level of the individual, as well as the population as a whole [Welberg, 2011] In addition, the thorough understanding of the pathophysiology of addiction is the only way of providing solid evidence that would allow us to effectively regulate corporate giants such as the alcohol industry, which still manage to evade international justice by discrediting current scientific knowledge [Bond et al. 2010].

Individualized medical management of alcohol abuse constitutes an absolutely necessary intervention. Room et al (2009) advocate management strategies based on the Alcohol Use Disorders Identification Test (AUDIT), a 10-question test developed by the World Health Organization (WHO) [Barbor et al. 2001]5 The authors emphasize the paramount importance of early identification of individuals at risk in the primary care setting. Depending on their AUDIT score, individuals can be managed by brief (prevenive) intervention, additional regular monitoring, or proper diagnostic assessment (Figure 2). In the presence of physical addiction different treatment modalities can be employed, both in the outpatient and inpatient settings. These may range from social rehabilitation and group therapy (AA) to pharmacological detoxification with benzodiazepines, alcohol-sensitizers (e.g. Disulfaram) or naltrexone (Room, 2005). Unfortunately, the efficacy of different interventions remains a controversial issue and none of them can substitute the need for primary prevention through effective public policy making.

Anderson et al (2009) reviewed the effectiveness and cost-effectiveness of conventional public policies aimed at reducing the harm caused by alcohol. The authors concluded that the most effective policies employed so far include taxation, reducing alcohol availability, banning advertisement and drink-driving legislation, while educaitonal programmes were found to have minor or no effect at all (Figure 3). Although these measures have been applied sporadically in various countries (and in varying degrees), they have failed to consistently tackle the alcohol epidemic. In my opinion, the mentality of hoping to control alcohol abuse through price and availability measures is flawed in its roots, despite its merits. The situation in Britain is quite characteristic. The pressure of increasing alcohol tax is exerted on the indivudual, rather than the industry, and may in fact exacerbate the problem. In a world where value is equated to money (or vice versa), increasing the effective price of alcohol to high but still affordable levels, does nothing more than to reinforce the mental schema that alcohol consumption has an intrinsic value. In the same way, restricting alcohol availability by increasing the legal age of purchase or by introducing state-owned retail sale, does nothing more than to imply to minors that alcohol consumption comprises a “mature” human behaviour and to appoint to alcohol an attractive nature of rarity, respectively. Alcohol in Greece is much cheaper than in Britain and in reality can be purchased by 10 year old children ( e.g. for their parents' consumption) and still Greece has one of the lowest rates of alcoholism in Europe (Karabetsos, 2008).

The six policy approaches suggested by Anderson et al (2009).
1. Minimum tax rates for all alcoholic beverages, at least proportional to alcoholic
content, should be introduced and increased regularly in line with infl ation. In
countries with high levels of unrecorded production and consumption, initial focus
should be to increase the proportion of unrecorded alcohol that is taxed, rather than
to increase overall alcohol taxes.
2 Government monopolies for the retail sale of alcohol should be introduced or
maintained with a minimum age of purchase of 18–21 years. When government
monopolies are not feasible, a licensing system should be introduced with restrictions on
outlet density and days and hours of sale to manage the level of alcohol-related harm.
3 A ban on direct and indirect alcohol advertising.

4 Legal concentrations of alcohol in the blood for drivers should be introduced, with a
phased reduction to 0·5 g/L and eventually to 0·2 g/L, with visible enforcement
through random and systematic checks.

5 Widespread simple help for hazardous and harmful alcohol consumption should be
made available through primary-care facilities, supported by more intensive help for
alcohol dependence.

6 Educational programmes should not be implemented in isolation as an alcohol policy
measure, or with the sole purpose of reducing the harm caused by alcohol, but rather
as a measure to reinforce awareness of the problems created by alcohol and to prepare
the ground for specifi c interventions and policy changes.

The Reality

Beaglehole et al. (2009) suggest that “the alcohol industry will continue to affect public policy making by encouraging ineffective policies”. This is a view shared by many other public health experts [Cassweel et al 2009][Stenius & Babor 2009]. The studies by Bond and colleugues have drawn shocking parallels between the smoking and alcohol industries, through their work on the Tobacco Document Archive [Bond et al, 2009, 2010]. They revealed the joined lobbying of the two industries, their intermingled financial interests (e.g. Philip Morris owns the Miller Brewing company), as well as their mutually funded ventures of jeopardising the efficiacy of public health policies targeted against their products [ibid]. The hypocrisy of the WTO and its crude blackmail against governments is unprecedented. Baumberg et al. (2008) ingeniously pinpoint several loopholes in WTO agreements, including the relativism of what constitutes “necessary to protect human health”. The WTO proclaims that current policies are sufficient to protect human health, and thus dictates governments to transfer this responsibility to their citizens. The same strategy is applied by the IMF/World bank against economically weak countries that have been systematically looted by the unregulated banking sector. The WTO has consistently sunk every initiative of the WHO to create bilateral public policy aggreements (Stenius & Babor, 2009). Agreements such as the old GATT and the contemporary GATS (General Agreement on Trade in Services) effectively dismantle every effort of governments to preserve national sovereignity by labelling them protectionistic. Finally, organizations such as the International Centre for Alcohol Policies (ICAP) invest heavily in research, in order to create platforms that allow them to regulate public policy making (Casswell, 2009). The WTO openly finances propagandists to safeguard its interests in WHO forums [Bond, 2012]

Obviously, citizents could be heald responsible if they had the liberty of freedom of choice. We live in a world of manufacturing consent where the individual is considered to have the capacity to make informed choices. On the other hand, the function of the entire system is focused on seducing citizens in order to enslave their rationality to dopaminergic neurotransmitter deficits, which eventually make them the perfect pray for the corparate hienas. Alcohol companies try so hard to protect their sales. Are we doing our best to protect our fellow citizens health?

Anderson, P; Chishold, D; et al. (2009) Effectiveness and cost-effectiveness of programmes and policies to reduce harm caused by alcohol. Lancet, 373: 2234-2246

Barbor et al. (2001) , AUDIT- the alcohol use disorders identification test: guidelines for use in primary care. WHO

Baumberg, B; Anderson (2008) P, Trade and Health: how Worlt Trade Oragnization (WTO) law affects alcohol and public health. Addiction:103, 1952-1958

Beaglehole, R; Bonita, R (20090 Alcohol: a global health priority. Lancet: 373, 2173-2175

Bond, L; Daube, M; Chikritzhs, T (2010) Selling addictions: similarities in approaches between Big Tobacco and Big Booze. AMJ, 6: 325-343

Casswell et al (2009). Reducing harm from alcohol: call to action. Lancet, 373: 2247-2257

Dagher, A (2009) The neurobiology of appetite: Hunger as addiction. Int J Obesiry, 33: S30-33

Fillmore, KM; Stockwell, T, et al. (2007), Moderate alcohol use and reduced mortality risk: systematic errors in prospective studies and new hypothesis. En Epidem, 17: S16-23

Koob, GF (2010) Volkow, ND, Neuroscircuitry of Addiction. Addiction 113, 1845-1848

Room, R; Babor, T; Rehm, J (2008) Alcohol and public health. Lancet, 365: 519-530

Rehm, J; Mathers, C et al. (2009) Global burden of disease and injury and economic cost
attributable to alcohol use and alcohol-use disorders. Lancet, 373: 2223-33

Skog, OJ (1996) Public Health consequences of the J-curve hypothesis of alcohol problems. Addiction, 91: 323-327

Stenius, K; Babor, TF (2009) The alcohol industry andpublic interest science. Addiction, 105: 191-198

Welberg, L (2011) Addiction: from mechanisms to treatment, 2011. Nat Rev Neurosci, 12: 62-633

1. The popularization of the theoretical J-shaped relationship of alcohol and coronary heart disease (CHD) has had disturbing implications for public health policies[Skog et al. 1996]. Confounding factors may underlie the observed negative association between low to-moderate alcohol consumption and CHD [Fillmore et al. 2007]
2 Bushman BJ. Effects of alcohol on human aggression: validity of proposed mechanisms. In: Galanter M, ed. Recent developments in alcoholism. New York: Plenum, 1997; 13: 227–44)
3Sigmund Freud, a man who dedicated his life in trying to elucidate the nature of Ego, never managed to satisfy his own Ego. Because the Austrian and,subsequently, the British soceities of the early 20th Century were not mature enough to accept his psychoanalysis theory, he granted permission to his nephew (Edward Bernays) to deliver his work to the more liberal United States.
4For more information, see The centrury of self (2002), an award-winning british documentary by Adam Curtis. (http://video.google.com/videoplay?docid=9167657690296627941)

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