Title: Alcohol Use: Global Public Health Impact

Camila Magalhães Silveira, MD

Department of Psychiatry - Institute of Psychiatry

University of São Paulo

Alcohol Medical Scholars Program (Slide 1)

I.        Introduction

A.      Relationship between alcohol and health is important and complex 1 (Slide 2)

                                                             1.      Global alcohol use:

a.       2 billion worldwide drink 2

b.      Moderate use associated with health benefits (e.g., ↓ heart attack)

c.       Harmful use of alcohol—global public health problem

d.      76 million in world have alcohol use disorders (AUD) 2

e.      AUD related to 60 diseases and injuries 3

                                                             2.      3 dimensions related to alcohol consumption: (Slide 3)

a.        The individual

1’ Per capita consumption (average volume per person, per year)

2’ Drinking patterns like heavy episodic drinking (HED)

3’ Type of alcoholic beverage

b.       Societal factors (e.g., drinking culture, country differences)

c.       Population group (e.g., gender, age, poverty)

B.      This lecture will cover: (Slide 4)

                                                             1.      Measures and health impact

                                                             2.      Geographical and cultural differences

                                                             3.      Gender and demographic differences

                                                             4.      Health care implications

                                                             5.      Prevention of harmful use

 

II.      Different ways to measure alcohol consumption 4/health impact (Slide 5)

A.      Exposure to alcohol (per capita consumption) (Slide 6) :

                                                             1.      Useful to monitor magnitude of consumption + trends in problems 5

                                                             2.      Definition of abstainers: no alcoholic intake in the preceding 12 months

                                                             3.      Definition: sum of alcohol per person

a.       Imports

b.      Production

c.       Exports

                                                             4.      Limitations:

a.       Doesn’t count unrecorded consumption

1'       Illegal

2'       Tourist

3'       Stockpiling

4'       Waste

5'       Smuggling

6'       Duty-free

b.      Doesn’t consider abstainers, drinking habits, quantities, frequencies, etc.

 

B.      Drinking patterns (Slide 7): 

                                                             1.      Standard drinking definition (USA and Brazil = 10-12g ethanol) (Slide 8)

a.       12 oz beer

b.      4 oz wine

c.       1.5 oz whisky

                                                             2.      Moderate (1–2 drinks/occasion) (Slide 9)

a.       Healthy (Slide 10)

1'       ↓ heart attacks 1

2'       ↓ stroke 1

3'       ↓ cognitive impairment 6

4'       ↓ gall stones

5'       ↓ diabetes mellitus 7

b.      ~7% in this range have problems:

1'       ↑ sleep disruption 8

2'       ↑ liver diseases in susceptible people 9

c.       Some should not drink even in moderation (Slide 11):

1'       Children and adolescents (< 18 y) (↑ possible brain effects)

2'       Women who may become pregnant or are pregnant (danger to child)

3'       Drivers, etc.

4'       Those on medications that can interact with alcohol

                                                                                                                                    a'       ’Benzodiazepines (diazepam/Valium)

                                                                                                                                   b'       Pain pills

5'       Individuals with certain medical conditions: 

                                                                                                                                    a'       HIV (alcohol ↓ immune Fx)

                                                                                                                                   b'       Cancer (alcohol ↑ recurrence)

                                                                                                                                    c'       Liver diseases

                                                                                                                                   d'       Those in alcohol recovery

               

                                                             3.      High Risk Drinking (HRD): danger ↑ as intake ↑ 10:

a.       Definition (Slide 12):

1'       Men:    

                                                                                                                                    a'       → 14 drinks/week

                                                                                                                                   b'       → 4 drinks/day

2'       Women:

                                                                                                                                    a'       more than 7 drinks in a typical week

                                                                                                                                   b'       more than 3 drinks on any day

b.      Health Risks (Slide 13):

1'       3x↑laryngeal cancer

2'       3x ↑ blood pressure

3'       4x ↑ fatty liver

4'       4x ↑pancreatic cancer 11

5'       ↑ infections and other immune effects

                                                             4.      Heavy Episodic Drinking  (HED=Binge)12:

a.       Definition: Blood alcohol conc. (BAC) > 0.08 gm% equivalent to: (Slide 14)

1'        5+ drinks/session

2'       4+ drinks/session

b.      HED leading risks for variety of health and social problems (Slide 15):

1'       Vehicle craches/ violence

2'       risky sex

3'       unintended pregnancy

4'       heart disease

5'       problems with family, work

6'       psychiatric symptoms (anxiety, sadness, etc.)

C.      Comparative Risk Analysis (CRA) 13 (Slide 16):

                                                             1.      Complex and represents the evolution for previous measures presented

                                                             2.       CRA based on heavy drinking aspects (Slide 17):

a.       Drinking occasions

1'       High usual quantity/occasion

2'       Frequency of festive drinking (fiestas/community celebrations)

3'       Proportion of drinking occasions/getting drunk

4'       Drinking daily or nearly daily

b.      Drinking in public places (e.g. requires transportation ->linked traffic accide.

c.       Not drinking with meals (e.g. drinking with meals less detrimental)

                                                             3.      Range from 1(OK) to 4 (problem)

D.      Alcohol use disorders as measured (Slide 18)

                                                             1.      Alcohol abuse: 1+ recurrent in same 12 mos.; (Slide 19)

a.       ↓Ability to fulfill role obligations

b.      Use in physically hazardous situations

c.       Legal problems

d.      Social or interpersonal probs.

e.      Never dependent

                                                             2.      Alcohol dependence: 3+ recurrent in same 12 mos.;

a.       Tolerance (need more for effects)

b.      Withdrawal (symptoms opposite of intake)

c.       Use heavier or longer than intended

d.      Desire and inability to cut down

e.      Activities aborted

f.        Much time spent in alcohol-related activities

g.       Ongoing use despite consequences

E.       Global burden of disease and deaths attributable to alcohol 4, 13, 14  (Slide 20):

                                                             1.      Deaths (Slide 21)

                                                             2.      DALY definition—Disability-Adjusted Life Years

a.       Years of life lost due to premature death

b.       Years of “healthy” life lost through poor health or disability

 

                                                             3.      World: 2.5 million deaths/yr alcohol related (~4% of total; 6% vs. 1% ) (Slide 22)

a.        ~50% acute causes :

1'       ~34% accidents while intoxicated

                                                                                                                                    a'       Motor-vehicle accidents

                                                                                                                                   b'       Falls

                                                                                                                                    c'       Drowning

                                                                                                                                   d'       Burns and firearm injuries

2'       ~15% intentional injuries (e.g., homicide, suicide, etc.)

                                                                                                                                    a'       Violence

                                                                                                                                   b'       child maltreatment

                                                                                                                                    c'        homicide

                                                                                                                                   d'       suicide

b.      Chronic causes

1'       ~20% heart disease

2'       ~15% cancer

3'       ~10% liver cirrhosis

4'       ~5% depression, etc

                                                             4.      World: 69 million alcohol-attributable DALYs (~5% of all DALYS; ~8% vs. 1% )

a.       Alcohol: 3rd leading DALY risk factor (world) (Slide 23)

1'       1st – childhood underweight (malnutrition/ underfeeding)

2'       2nd – unsafe sex

b.      Alcohol: 1st  leading risk factor cause of DALYs in middle income countries (7.6% of all DALYS)4

c.       Increasing morbidity:

1'       alcohol-attributable DALYs ~4% in 2000, and 4th leading risk factor

2'       1st – childhood underweight

3'       2nd – unsafe sex

4'       3rd – hypertension

                                                             5.      Alcohol-associated burden of disease

a.       Psychiatric conditions (mainly AUD) — ~40% 

b.      Unintentional injuries — ~30%

c.       Intentional injuries — ~11%

d.      Liver cirrhosis  — ~8%

e.      Cardiovascular diseases — ~7%

f.        Malignant neoplasms — ~6%

 

III.    Geographic/cultural differences (Slide 24)

A.      Now will apply different measures across regions/ countries (Slide 25):

B.      Using per capita consumption (Slide 26)

                                                             1.      Countries with 12–25 L of pure alcohol (defined as 100% ethanol/ adult/yr)

a.          = ~5 drinks (10g)/d/person

b.      E Europe

c.       W Europe

                                                             2.      6–12 L of pure alcohol

a.       =~3 drinks/d/person

b.      N America

c.       Latin America

                                                             3.      3–6L of pure alcohol

a.       = ~1 drink/d/person

b.      Africa

c.       E Asia

                                                             4.      0–3L of pure alcohol

a.       = <1/2 drink/d/person

b.      E Mediterranean

c.       SE Asia

                                                             5.      So: wide variation around overall average = 6.2 L per yr/per person (1,5 drinks/d):

a.       Better-off developing reg. (e.g., America, Asia, Pacific region): ↑ recent yrs

b.      ↑economy development → ↑consumption

c.       Islamic states stay low

C.      Using Proportion of abstainers: picture a bit different (Slide 27)

                                                             1.      E Europe à 0-20%

                                                             2.      W Europe à 0-20%%

                                                             3.      L America à 20-40%

                                                             4.      N. Americaà 20-60%

                                                             5.      E Asia à 40-60%

                                                             6.      Africa à 60-100%

                                                             7.      SE Asiaà 80-100% 

                                                             8.      E Mediterranean à  80-100%

D.      Using CRA of 1(OK) to 4 (problem): Are different from ratings per cap (Slide 28)

                                                             1.      3.5–4.0 countries: E Europe

                                                             2.      2.5–3.5 countries

a.       Latin America 

b.      Africa

c.       SE Asia

                                                             3.      2–2.5 countries

a.       N America

b.      E Asia

c.       E Mediterranean

                                                             4.      1–2 countries: W Europe

                                                             5.      Overall:

a.       Southern European “wine cultures” (score: 1)

b.      Intoxication: main goal of drinking in developing world (score: 4)

E.       Rates of alcohol use disorders (AUD/ 12 month prev.) 15, 16 (World ~3.6%; 6.5% ♂ vs. 1% ♀) (Slide 29)

                                                             1.      E Europe à ~10% (19% ♂, 3% )

                                                             2.      W Europe à ~6% (9% ♂, 2% )

                                                             3.      N America à ~5% (8% ♂, 2% )

                                                             4.      L America17 à ~4% (6% , 1%)

                                                             5.      E Asia à ~4% (8% , 0.3 ♀)

                                                             6.      SE Asiaà ~3% (5% ♂, 0.5% )

                                                             7.      Africa à ~1% (2% , 0.2% ♀)

                                                             8.      E Mediterranean à ~0.3% (1% , 0.1% ♀)

                                                             9.      Note: the worse AUD the worse DALY

F.       Using Disability Adjusted Life Years (DALY) (e.g. Years of “healthy” life lost through disability) 18

                                                             1.      E Europe à ~12% (developed country, Former socialist: low mortality)

                                                             2.      N. Americaà ~7%   (developed country/ very low mortality)

                                                             3.      W Europe à ~7%  (developed country/ very low mortality)

                                                             4.      L America à ~6%  (better-off developing countries/ low mortality)

                                                             5.      E Asia à ~6%   (better-off developing countries/ low mortality)

                                                             6.      Africa à ~2%  (very high mortality; low consumption)

                                                             7.      SE Asiaà ~1.5% (very high mortality; lowest consumption)

                                                             8.      E Mediterranean à ~1% (very high mortality; lowest consumption)

                                                             9.      So: ↑economy development → ↑consumption → ↑AUD →↑alcohol burden dis. 18

G.     In summary Regarding drinking patterns - CRA (Slide 30):

                                                             1.      E Europe worst all measures

                                                             2.      Developing countries near top on CRA (middle PCC, abstinence)

                                                             3.      E Med and Africa near top on CRA (↓PCC↑ abstinence)

                                                             4.      W Europe lowest CRA (↑ PCC ↓ abstinence)

IV.    Gender and demographic differences (Slide 31)

A.      Gender differences regarding rates in Section III

                                                             1.      Women have ↑ blood alcohol (BAC)/drink (Slide 32)

a.       ↓ muscle →↓ body water to dilute alcohol

b.      ↓ activity of alcohol dehydrogenase in stomach so ↓ metabolize alc

                                                             2.      Alcohol interfere hormonal balance and reproduction  19

a.       Directly: activating or inhibiting the neurohormonal axis

1'       Progesterone suppression: impair fertility

2'       ↓ pituitary LH secretion: anovulation

3'       ↑ estradiol: cycle disruption

b.      Consequences:

1'       Menstrual irregularities

2'       infertility

3'       Direct harm to fetus (discussed below)

4'       spontaneous abortion

                                                             3.      Women some unique risks20

a.       ↑breast cancer:

1'       alcohol ↑estrogen/androgen levels

2'        mammary gland susceptibility to carcinogens

3'        metastatic potential of breast cancer cells

b.      Harm to developing fetus

1'       Alcohol pass from mother’s to fetus blood

2'       Affect growth of fetus cells

3'       Affect brain and spinal cord cells

                                                             4.      Gender re: HED

a.       More abstention among women in 35 countries21

b.       HED men 2–3x > women

c.       ↑ convergence between genders in recent years 22

B.      Other demographic/social/cultural characteristics (Slide 33 )

                                                             1.      Age

a.       18–24 most common HED

1'       e.g. 42% HED in USA

2'       e.g.  29% in Brazil

b.      Earlier onset HED à risk of AUD 12, 23

                                                             2.      Ethnicity vs education24

a.        White non hispacics ↑educ: ↓ drinks per HED episode

b.      Other than white + ↓ educ: ↑drinks per HED episode 

                                                             3.      Marital status and HED25, 26: single > married

                                                             4.      Beverage type (Slide 34)

a.       USA adolescents and young adults

1'       Beer>spirits>wine

2'       Alcohol-pops concern, but few studies27 

b.      USA adults HED24

1'       74% beer

2'       20% spirits

3'       10% wine

c.       Europe adults28

1'       ↑ HED beer/spirits (North/Eastern Europe)

2'       ↓ HED if wine with meals (e.g., W Europe)

                                                             5.      College 12 mo prevalence 29 (Slide 35)

a.       HED

1'       USA: 44% (50% , 39% ) 12

2'       Brazil: 35% (45% ♂, 42% )

b.      Alc problems USA

1'       ~600,000 injuries (falls/motor vehicle accidents)

2'       ~700,000 assaults

3'       ~100,000 victims of sexual assault

4'       ~3.4 million drove under influence

5'       ~25% negative academic consequences

                                                             6.      Remember: demography and social/cultural overlap’

a.       Male: more accepted drinks and have problems

b.      Geographic overlaps with religions (e.g., Islam)

c.       Public laws/policies impact on race, gender, etc.

 

V.      Health care implications (Slide 36)

A.      Around 45% with HED see MD 30,31 (Slide 37)

B.      Doc needs to ask each patient regarding drinking pattern:

                                                             1.      Usual and max past yr quantity

                                                             2.      Frequency drink and HED

                                                             3.      Age onset regular drinking: earlier= ↑ likely have problems

C.      Doc needs to remember:

                                                             1.      HED most frequent at age 18–24/ other sociodemog. aspects

                                                             2.      Drinking pattern is:

a.       Lower in Muslim countries and Asia

b.      Worse in Latin countries:“fiesta drinking”

c.       Higher in N America and W Europe

d.      Worse in E Europe

D.      Docs should use alcohol screen questionnaires re: problems (Q’aires don’t Dx)32

                                                             1.      Alcohol Use Disorders Identification Test

a.       10 questions

b.      Score > 8 = Heavy /AUD

c.       Sensitivity = 50–90%

d.      Specificity = 80%

                                                             2.      CAGE (Slide 38)

a.       4 questions (Cut-down, Annoyed, Guilty, Eye-opener)

b.      Score >2 = problems

c.       Sensitivity = 53%

d.      Specificity = >80%

E.       Treatment depends on drinking pattern + problems. If (Slide 39):

                                                             1.      Abstinent:  don’t encourage to start

                                                             2.       Moderate drinkers: continue drinking in this way, but explain risks

                                                             3.      Hazardous drinkers: brief intervention (Slide 40)

a.       Target: primary care physicians

b.      Effective: non alcohol dependent subjects

c.       Goal: moderate drinking not abstinence

d.      4 sessions or fewer (just a few minutes).

e.      Steps involved - FACT

1'       Feedback: drinking habits/ physical and lab. findings.

2'       Advice to reduce drinking. Education about moderate drinking/goals.

3'       Commitment: patient’s responsibility/opportunity to change.

4'       Tracking: Follow up (phone calls, visits and laboratory tests). 

                                                             4.      Criteria of Abuse/dependence: refer to specialist

 

VI.    Prevention of harmful use (Slide 41)

A.      HED problematic worldwide

B.      Challenges in global strategy to ↓ harmful use of alcohol33

                                                             1.      Policies adjusted for national, religious, culture

                                                             2.      9 target areas (Slide 42):

a.       Leadership, awareness and commitment to ↓ HED etc.

b.      Health services need to

1'       Support screen/ brief interv. for HED in primary care

2'       Establish system to record alcohol morbidity/mortality

c.       Community action

1'       Prevent selling/ consumption by under-age

2'       Develop alcohol-free environments

3'       Develop community programs risk groups (young, unemployed)

d.       Drink–driving policies and countermeasures 33, 34

1'       Upper limit for BAC

2'       Lower limits are needed for young drivers

3'       Sobriety check points and random breath-testing

4'       Administrative suspension of driving licenses

5'       Driver-education, counseling, Rx programmes

6'       Alternative transportation after drinking places close

7'       Mass media campaign

e.       Availability of alcohol

1'       Regulate retail sales

2'       Create minimum age for buy/consume

3'       Prevent sales to intoxicated

f.        Marketing of alcoholic beverages

1'       Restrict promotions targeting young people

2'       Regulate new forms of alcohol marketing

g.       Pricing policies

1'       Regular review prices re level of inflation and income

2'       Restrict price promotions

3'       Establish minimum prices

4'       Price incentives for non-alcoholic beverages

h.      ↓ negative alcohol consequences

1'       Regulate drinking context to ↓ violence

2'       Enforce laws against serving to intoxication

3'       ↓% alcohol in beverage

i.         ↓ public health impact of illicit alcohol

1'       Quality control re: production/ distribution

2'       Tax home brew/illicit alcohol

C.      Special steps for colleges35, 36 (Slide 43)

                                                             1.       Campus-based

a.       Eliminate keg parties

b.      Create alcohol-free dormitories

c.       Control alcohol at sports events

d.      Ban alcohol on campus

                                                             2.      Education efforts

a.       Expanded alcohol-free late night student activities

b.      Improve/educate resident counselors

                                                             3.      Treat students who have HED, etc.

a.       Use brief interventions (discussed in different lecture)

b.      ↑ knowledge re accurate rates of HED

c.       Use regular follow-up

d.      Teach safer drink limits

e.      Cognitive-behavioral skills + norms clarification/motivational interventions 

                                                             4.      Parent-based intervention (PBI)37

 

VII.   Summary of major points of lecture (Slide 44)

A.      Are many different measures of alc use/problems

B.      Countries differ on problem rates

                                                             1.      Burden: large and increasing

                                                             2.      E Europe high

                                                             3.      USA moderate high

                                                             4.      W Europe best drinking pattern – minor quantities regularly

                                                             5.      Better-off developing reg. (e.g., America, Asia, Pacific region): ↑ recent yrs, culture of intoxication

                                                             6.      E Mediterranean/ E Asia lower although among people drink, they drink in the heavy patter

C.      Higher rates problems

                                                             1.      Males

                                                             2.      18–24

D.      Global problems need global interventions

                                                             1.      Act globally

                                                             2.      Interventions: effective but underused

                                                             3.      Health systems: transform to meet new challenges


References

1.            Rehm J, Baliunas D, Borges GL, Graham K, Irving H, Kehoe T, Parry CD, Patra J, Popova S, Poznyak V, Roerecke M, Room R, Samokhvalov AV, Taylor B. The relation between different dimensions of alcohol consumption and burden of disease: an overview. Addiction. 2010;105(5):817-43.

2.            WHO. Global status report on alcohol 2004. Geneva: World Health Organization2004.

3.            Rehm J, Rehn N, Room R, Monteiro M, Gmel G, Jernigan D, Frick U. The global distribution of average volume of alcohol consumption and patterns of drinking. Eur Addict Res. 2003;9(4):147-56.

4.            WHO. Global Health Risks - Mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization2009.

5.            OMS. Global burden of disease: 2004 update. Geneva: Organização Mundial da Saúde2008.

6.            Virta JJ, Jarvenpaa T, Heikkila K, Perola M, Koskenvuo M, Raiha I, Rinne JO, Kaprio J. Midlife Alcohol Consumption and Later Risk of Cognitive Impairment: A Twin Follow-up Study. J Alzheimers Dis. 2010.

7.            Joosten MM, Chiuve SE, Mukamal KJ, Hu FB, Hendriks HF, Rimm EB. Changes in alcohol consumption and subsequent risk of type 2 diabetes in men. Diabetes. 2010.

8.            Reinberg A, Touitou Y, Lewy H, Mechkouri M. Habitual moderate alcohol consumption desynchronizes circadian physiologic rhythms and affects reaction-time performance. Chronobiol Int. 2010;27(9-10):1930-42.

9.            Szabo G. Moderate drinking, inflammation and liver disease. Ann Epidemiol. 2007;17(supl):49-54.

10.          Szabo G, Mandrekar P. A recent perspective on alcohol, immunity, and host defense. Alcohol Clin Exp Res. 2009;33(2):220-32.

11.          Michaud DS, Vrieling A, Jiao L, Mendelsohn JB, Steplowski E, Lynch SM, Wactawski-Wende J, Arslan AA, Bas Bueno-de-Mesquita H, Fuchs CS, Gross M, Helzlsouer K, Jacobs EJ, Lacroix A, Petersen G, Zheng W, Allen N, Ammundadottir L, Bergmann MM, Boffetta P, Buring JE, Canzian F, Chanock SJ, Clavel-Chapelon F, Clipp S, Freiberg MS, Michael Gaziano J, Giovannucci EL, Hankinson S, Hartge P, Hoover RN, Allan Hubbell F, Hunter DJ, Hutchinson A, Jacobs K, Kooperberg C, Kraft P, Manjer J, Navarro C, Peeters PH, Shu XO, Stevens V, Thomas G, Tjonneland A, Tobias GS, Trichopoulos D, Tumino R, Vineis P, Virtamo J, Wallace R, Wolpin BM, Yu K, Zeleniuch-Jacquotte A, Stolzenberg-Solomon RZ. Alcohol intake and pancreatic cancer: a pooled analysis from the pancreatic cancer cohort consortium (PanScan). Cancer Causes Control. 2010;21(8):1213-25.

12.          Wechsler H, Dowdall GW, Davenport A, Rimm EB. A gender-specific measure of binge drinking among college students. Am J Public Health. 1995;85(7):982-5.

13.          Rehm J, Klotsche J, Patra J. Comparative quantification of alcohol exposure as risk factor for global burden of disease. Int J Methods Psychiatr Res. 2007;16(2):66-76.

14.          WHO. Global burden of disease: 2004 update. Geneva: World Health Organization2008.

15.          Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009;373(9682):2223-33.

16.          Bromet EJ, Gluzman SF, Paniotto VI, Webb CP, Tintle NL, Zakhozha V, Havenaar JM, Gutkovich Z, Kostyuchenko S, Schwartz JE. Epidemiology of psychiatric and alcohol disorders in Ukraine: findings from the Ukraine World Mental Health survey. Soc Psychiatry Psychiatr Epidemiol. 2005;40(9):681-90.

17.          Silveira CM, Viana MC, Siu ER, Andrade AG, Anthony JC, Andrade LH. Socio-demographic correlates of transitions from alcohol use to disorders and remission in the São Paulo Megacity Mental Health Survey, Brazil. Alcohol Alcohol in press

18.          Room R, Babor T, Rehm J. Alcohol and public health. Lancet. 2005;365(9458):519-30.

19.          Augustynska B, Ziolkowski M, Odrowaz-Sypniewska G, Kielpinski A, Gruszka M, Kosmowski W. Menstrual cycle in women addicted to alcohol during the first week following drinking cessation--changes of sex hormones levels in relation to selected clinical features. Alcohol Alcohol. 2007;42(2):80-3.

20.          Nolen-Hoeksema S, Hilt L. Possible contributors to the gender differences in alcohol use and problems. J Gen Psychol. 2006;133(4):357-74.

21.          Wilsnack RW, Wilsnack SC, Kristjanson AF, Vogeltanz-Holm ND, Gmel G. Gender and alcohol consumption: patterns from the multinational GENACIS project. Addiction. 2009;104(9):1487-500.

22.          Wilsnack RW, Vogeltanz ND, Wilsnack SC, Harris TR, Ahlstrom S, Bondy S, Csemy L, Ferrence R, Ferris J, Fleming J, Graham K, Greenfield T, Guyon L, Haavio-Mannila E, Kellner F, Knibbe R, Kubicka L, Loukomskaia M, Mustonen H, Nadeau L, Narusk A, Neve R, Rahav G, Spak F, Teichman M, Trocki K, Webster I, Weiss S. Gender differences in alcohol consumption and adverse drinking consequences: cross-cultural patterns. Addiction. 2000;95(2):251-65.

23.          Weitzman ER, Nelson TF, Wechsler H. Taking up binge drinking in college: the influences of person, social group, and environment. J Adolesc Health. 2003;32(1):26-35.

24.          Naimi TS, Nelson DE, Brewer RD. The intensity of binge alcohol consumption among U.S. adults. Am J Prev Med. 2010;38(2):201-7.

25.          Naimi TS, Brewer RD, Mokdad A, Denny C, Serdula MK, Marks JS. Binge drinking among US adults. Jama. 2003;289(1):70-5.

26.          Kerr-Correa F, Hegedus AM, Sanches AF, Trinca LA, Kerr-Pontes LRS, Tucci AM, Floripes TM. Differences in drinking patterns between men and women in Brazil. Geneva: World Health Organization. Department of Mental Health and Substance Abuse2005.

27.          Metzner C, Kraus L. The impact of alcopops on adolescent drinking: a literature review. Alcohol Alcohol. 2008;43(2):230-9.

28.          Popova S, Rehm J, Patra J, Zatonski W. Comparing alcohol consumption in central and eastern Europe to other European countries. Alcohol Alcohol. 2007;42(5):465-73.

29.          Hingson RW, Zha W, Weitzman ER. Magnitude of and trends in alcohol-related mortality and morbidity among U.S. college students ages 18-24, 1998-2005. J Stud Alcohol Drugs Suppl. 2009;(16):12-20.

30.          Edlund MJ, Booth BM, Tang L. Percentage of hazardous drinkers who might be treated in primary care. Psychiatr Serv. 2010;61(11):1163.

31.          Chan AW, Pristach EA, Welte JW. Detection by the CAGE of alcoholism or heavy drinking in primary care outpatients and the general population. J Subst Abuse. 1994;6(2):123-35.

32.          Schuckit MA. Alcohol-use disorders. Lancet. 2009;373(9662):492-501.

33.          WHO. Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization2010.

34.          WHO. Drinking and Driving - A road safety manual for decision-makers and practitioners. Geneva: World Health Organization2007.

35.          Dejong W. Finding common ground for effective campus-based prevention. Psychol Addict Behav. 2001;15(4):292-6.

36.          Dejong W, Towvim LG, Schneider SK. Support for alcohol-control policies and enforcement strategies among US college students at 4-year institutions. J Am Coll Health. 2007;56(3):231-6.

37.          Ichiyama MA, Fairlie AM, Wood MD, Turrisi R, Francis DP, Ray AE, Stanger LA. A randomized trial of a parent-based intervention on drinking behavior among incoming college freshmen. J Stud Alcohol Drugs Suppl. 2009;(16):67-76.