Unite for a Framework Convention for Alcohol Control
Authors: Shiu Lun Au Yeung, Tai Hing Lam
Journal: The Lancet (2019)

In the 2012 UN Political Declaration, when describing the main contributors to the four most prominent non-communicable diseases, the term harmful use is only used to describe alcohol use. Such a term implies that alcohol use can be safe and beneficial. This assumption could be partly driven by the findings of conventional epidemiology studies indicating moderate drinkers have a lower risk of cardiovascular disease than non-drinkers. Such conclusions have been the topic of debate for several decades because moderate drinkers might have other characteristics that are cardioprotective, rather than alcohol itself (ie, confounding). Wood and colleagues1Wood AM Kaptoge S Butterworth AS et al.Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies.Lancet. 2018; 391: 1513-1523Google Scholar reported that limits for alcohol use should be much lower than currently recommended. Recommendations from some researchers and health-care professionals, together with the alcohol industry's aggressive and uncontrolled promotion to drink for cardiovascular health, have added to the increasing epidemic of alcohol use. In a prospective cohort study in The Lancet, Iona Millwood and colleagues2Millwood IY Walters BG Mei XW et al.Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China.Lancet. 2019; (published online April 4.)http://dx.doi.org/10.1016/S0140-6736(18)31772-0Google Scholar showed that, at least for stroke, the apparently protective effects of moderate alcohol consumption were largely non-causal using mendelian randomisation, which is the optimal non-experimental design to minimise confounding. These findings, consistent with previous mendelian randomisation studies,3Au Yeung SL Jiang CQ Cheng KK et al.Moderate alcohol use and cardiovascular disease from mendelian randomization.PLoS One. 2013; 8: e68054Google Scholar, 4Holmes MV Dale CE Zuccolo L et al.Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data.BMJ. 2014; 349: g4164Google Scholar were based on a large Chinese sample using robust genetic analyses with verification of pleiotropy in women who had low alcohol consumption. Although randomised trials would yield the most definitive answer, the MACH15 trial (NCT03169530) of moderate drinking was terminated because of potential pro-industry bias. Considering that this study by Millwood and colleagues2Millwood IY Walters BG Mei XW et al.Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China.Lancet. 2019; (published online April 4.)http://dx.doi.org/10.1016/S0140-6736(18)31772-0Google Scholar and a previous analysis1Wood AM Kaptoge S Butterworth AS et al.Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies.Lancet. 2018; 391: 1513-1523Google Scholar cast doubts about the net protective effects of moderate drinking and the 2016 Global Burden of Disease Study5GBD 2016 Alcohol CollaboratorsAlcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2018; 392: 1015-1035Scopus (0) Google Scholar showed harms at all levels of alcohol use, further trials would be unethical. Conventional epidemiology studies have successfully shown the harms of smoking and supported tobacco control with the WHO Framework Convention on Tobacco Control (FCTC) before mendelian randomisation was feasible. However, conventional epidemiology results on the cardioprotective effect of alcohol, albeit confounded, will likely appear repeatedly,6Xi B Veeranki SP Zhao M Ma C Yan Y Mi J Relationship of alcohol consumption to all-cause, cardiovascular, and cancer-related mortality in U.S. adults.J Am Coll Cardiol. 2017; 70: 913-922Google Scholar generate confusion, and might be exploited by the alcohol industry to enable market expansion. Conventional epidemiology studies always lag behind the development of an epidemic of harmful exposure over several decades. Thus, the absolute and relative risks of the harms, such as smoking and drinking, will continuously be underestimated, and new harms caused by these factors will continue to be identified.7Lam TH Xu L Commentary: fundamental limitations of meta-analysis of cohort studies, epidemiological challenges and the stage of obesity epidemic.Int J Epidemiol. 2017; 46: 547-548Google Scholar These problems will apply to conventional epidemiology studies not only on alcohol use but also on tobacco use, unhealthy diet, physical inactivity, and obesity.7Lam TH Xu L Commentary: fundamental limitations of meta-analysis of cohort studies, epidemiological challenges and the stage of obesity epidemic.Int J Epidemiol. 2017; 46: 547-548Google Scholar The direct implication is that the burden of diseases attributable to these factors will also be underestimated. Future conventional epidemiology studies of alcohol consumption and abstinence need to analyse the time-varying nature of alcohol use throughout the life course, with long-term follow-up to capture the cumulative effect of prolonged alcohol use and use trajectories.7Lam TH Xu L Commentary: fundamental limitations of meta-analysis of cohort studies, epidemiological challenges and the stage of obesity epidemic.Int J Epidemiol. 2017; 46: 547-548Google Scholar Triangulating evidence from different study designs is needed.8Braillon A Alcohol: cardiovascular disease and cancer.J Am Coll Cardiol. 2018; 71: 582-583Google Scholar, 9Lawlor DA Tilling K Davey Smith G Triangulation in aetiological epidemiology.Int J Epidemiol. 2016; 45: 1866-1886Google Scholar Randomised trials on quitting alcohol at different levels will be ethical, informative, and warranted. Braillon8Braillon A Alcohol: cardiovascular disease and cancer.J Am Coll Cardiol. 2018; 71: 582-583Google Scholar proposed the term moderate alcohol use should be replaced with low risk of drinking, where appropriate, to show that there is a health risk associated with drinking at any level. We further advocate that the term harmful use should no longer be used. The WHO voluntary global non-communicable diseases target for 2025 of a 10% reduction in harmful alcohol use (which is ill-defined) is unachievable with current approaches. Alcohol control is complex and stronger policies are required. The alcohol industry is thriving and should be regulated in a similar way to the tobacco industry.10Yoon S Lam TH The illusion of righteousness: corporate social responsibility practices of the alcohol industry.BMC Public Health. 2013; 13: 630Google Scholar, 11Casswell S Thamarangsi T Reducing harm from alcohol: call to action.Lancet. 2009; 373: 2247-2257Google Scholar Since the WHO FCTC has been successful, we advocate for a Framework Convention for Alcohol Control (FCAC)10Yoon S Lam TH The illusion of righteousness: corporate social responsibility practices of the alcohol industry.BMC Public Health. 2013; 13: 630Google Scholar, 11Casswell S Thamarangsi T Reducing harm from alcohol: call to action.Lancet. 2009; 373: 2247-2257Google Scholar and urge WHO to start the process as soon as possible. We also propose a stage of alcohol epidemic model (SAEM) with reference to the stage of tobacco epidemic model and the stage of obesity epidemic model.12Xu L Lam TH Stage of obesity epidemic model: Learning from tobacco control and advocacy for a framework convention on obesity control.J Diabetes. 2018; 10: 564-571Google Scholar At present, alcohol use is increasing in all countries. The SAEM forewarns that alcohol-attributable diseases will continue to increase, even when alcohol prevalence has reached the peak (ie, 0% increase) and begins to decline. The lag between the peak of alcohol prevalence and alcohol-induced diseases, which could be several decades, might confuse policy makers, and be used by the alcohol industry and related interests to argue against more stringent control measures by claiming that moderate drinkers should not be deprived of the supposed health benefits. We need to learn from tobacco control and unite to advocate for a FCAC. We declare no competing interests. Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in ChinaGenetic epidemiology shows that the apparently protective effects of moderate alcohol intake against stroke are largely non-causal. Alcohol consumption uniformly increases blood pressure and stroke risk, and appears in this one study to have little net effect on the risk of myocardial infarction. Full-Text PDF Open Access