One of the most important products of global addiction demand is an alcoholic beverage. In developing countries like India, alcohol consumption tends to be a major problem because of the various socio‑cultural practices across the nation, different alcohol policies and practices across the various states, lack of awareness of alcohol‑related problems among the community, false mass media propaganda about alcohol use, various alcohol drinking patterns among the alcohol consumers and the emergence of social drinking as a habit because of the widespread urbanization across the country. Stringent alcohol policies are needed across the various states to reduce alcohol consumption, and alcohol consumers have to be educated about the various harmful effects of alcohol consumption and the effects it can have on their minds, body, and soul.
The term alcohol refers to ‘ethyl alcohol’. It is consumed as an alcoholic beverage in diluted concentrations of absolute (i.e., 100%) ethyl alcohol. There are various types of alcoholic beverages that are consumed around the world. One standard alcoholic beverage corresponds to 10 g of absolute alcohol. The quantity differs among the types of alcoholic beverages. The most commonly used alcoholic beverages are beer, wine, whiskey, rum, vodka, gin, and brandy and locally brewed beverages like arrack and toddy. Alcohol consumption becomes a problem when the individual engages in a problematic drinking pattern that puts him at the risk of developing adverse health events.
According to recent data published by the World Health Organization (WHO), the total per capita consumption of alcohol by individuals above 15 years of age is 6.2 L of pure alcohol per year, which equals 13.5 g of pure alcohol per day. However, there is a wide variation between the WHO regions and member states. Nearly 5.1% of the global burden of disease is attributable to alcohol consumption, and it causes nearly 3.3 million deaths every year.
The 12‑month prevalence of AUDs in India in the year 2010 was 2.6% and that of alcohol dependence was 2.1%. In 2012, 33.1% of all road traffic accident deaths were attributable to drunk and driving. The National Mental Health Survey of India 2015–16 found the prevalence of AUDs to be 9% in adult men. In India, the alcohol‑attributable fraction (AAF) of all-cause deaths were found to be 5.4%. Around 62.9% of all the deaths due to liver cirrhosis were attributable to alcohol use.
When alcoholic beverages are consumed, alcohol gets absorbed from the stomach and small intestine. It is distributed through blood circulation to every organ in the body. The alcohol gets absorbed by the liver at a rapid pace and excreted through the kidneys, which accounts for 95% to 98% of the alcohol consumed. In a study done by Gururaj et al., it was concluded that, because of the increase in the alcohol consumption occurring all over the country, the hospital admission rates because of alcohol consumption were also increasing with 20% to 30% of admissions because of direct or indirect problems caused because of alcohol consumption.
The various medical complications because of alcohol consumption are:
- Gastrointestinal (GI) complications: The direct effect of alcohol on the lining of the stomach can lead to acute gastritis and present as vomiting, usually associated with heavy drinking. Repeated damage can lead to hyperacidity leading to peptic ulcer disease. Alcohol is one of the most important reasons for hemorrhagic gastritis. The most common complication of long‑term alcohol is alcoholic liver disease (ALD).
- Cancer: Drinking as few as 1.5 drinks per day increases a woman’s risk of breast cancer 1.4‑ For both genders, four drinks per day increase the risk for oral and esophageal cancers by approximately three‑fold and rectal cancers by 1.5 fold. In a study done by Bangardi et al., it was found that alcohol most strongly increased the risk of cancers of the pharynx, oral cavity, esophagus, and larynx.
- Changes in the genitourinary system: Acutely, modest doses of ethanol can not only increase sexual drive but can also lead to a decrease in the erectile capacity in men. Even in the absence of liver impairment, a significant minority of chronic alcoholic men show irreversible testicular atrophy with shrinkage of seminiferous tubules, resulting in a decrease in ejaculate volume and a low sperm count. In a study done by Chandra et al., it was found that there was a disproportionately high association of alcohol abuse with high‑risk sexual behavior and HIV infection.
- Muscular changes: Between one‑half and two‑thirds of alcoholics can have skeletal muscle weakness caused by acute alcoholic myopathy, which may improve with abstinence, but it is not fully cured. Effects of alcohol consumption on the skeletal system can include lower bone density. In a study done by Venkat et al., it was found that those who suffer from chronic alcoholism suffered from avascular necrosis of the femoral head and reduced bone density.
- Neurological complications: The short‑term effects of alcohol consumption that can get relieved after stopping alcohol consumption include blackouts, blurred vision, impaired memory, and slower reaction times. In a study done by Peng et al., it was found that chronic alcohol use can lead to the development of alcoholic tremors, myopathy, Wernicke’s encephalopathy, and cerebellar degeneration.
- Psychiatric complications: Consuming alcoholic beverages to overcome depression and anxiety has been a common practice. Though alcohol can relieve those conditions to some extent initially, it starts to deplete the neurotransmitter serotonin in the brain, causing depression and anxiety, and the need to consume more alcohol to medicate depression arises. This chronic use can lead to increased risk for suicide, personality disorders, and risk‑taking behaviors. Problems related to alcohol consumption made up 17.6% of psychiatric emergencies in hospitals. In a case‑control study of completed suicides in Bangalore done by Gururaj, it was found that alcohol consumption was a major risk factor for suicide with nearly a 25 times increase among alcohol users. Suicide rates among women increased by nearly six times who were a spouse of alcohol abusers. A study done by Vijayakumar et al., in Chennai, found that suicide rates were higher among alcohol users as compared with non‑users.
Social consequences of alcohol use
Alcohol consumption not only affects the individuals but also his family members get affected in one way or the other. The person in an intoxicated state may indulge in domestic violence with his family members; may exhaust the savings of the family, which can negatively affect the education of his children, and the children of alcoholic fathers will have strained relationship with their family members, which can affect their psychological wellbeing. In a study done by Gururaj et al., in Bangalore, it was found that emotionally abusing the spouse was found to be 2.5 times more common among persons who consume alcohol, 23.3% of the users physically abused their spouse and 7.8% of them physically abused their spouse resulting in injuries. In a study done by Markowitz et al., domestic violence was reported by 20% of women, and husband’s practice of alcohol consumption was reported by them as the most significant cause for domestic violence
Impact of alcohol use on economic and family finances
The economic impact of alcohol consumption plays a major role in families belonging to lower socio‑economic strata. In a study done by Bonu et al., it was found that there was an empirical association found between the use of alcohol and tobacco and impoverishment through borrowing and selling off assets in distress because of hospitalization a study was done by Benegal et al., it was found that alcohol‑dependent persons spent more money than they earned, they were forced to take loans to spend for their expenses related to alcohol consumption, on an average, 12.2 working days were lost to the habit and around 60% of the families were financially supported by the income from other family members. In a study done by Ramanan et al., half of the persons who consume alcoholic beverages had strained relations with their family members especially their spouse and children.
Road traffic accidents
One of the major problems of alcohol consumption is road traffic accidents which occur due to driving vehicles under the influence of alcoholic beverages. Both developing and developed countries report high rates of road traffic accidents because of alcohol consumption. In a study conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) in 12 major hospitals of Bangalore city, it was found that nearly 28% of injuries because of road traffic accidents were directly attributable to alcohol. The roadside survey revealed that nearly up to 40% of the drivers were under the influence of alcohol. In a study done by Aditya et al., it was found that 20% of the fatal road traffic accidents were because of alcohol use. The blood alcohol concentration (BAC) of 38% of those alcohol users was above the permissible limits. In a study done by Gururaj, it was found that alcohol abuse was reported in over 20% of traumatic brain injuries. According to the latest data released by the National Crime Records Bureau (2015), Tamil Nadu recorded the highest number of drunk and driving accidents in the country. In a study done by Korlakunta et al., high‑risk behavior was more common among alcohol‑dependent individuals with road traffic accidents being the most frequently observed.
Legal problems because of alcohol consumption
Another important area where complications arise because of alcohol abuse is legal problems. Crimes that are committed following alcohol intoxication include sexual/physical assault, rape, exploitation of women in commercial sex work, and homicide. According to the National Crime Records Bureau of India, the different crimes that are related to alcohol consumption fall under four major acts namely, the Prohibition Act, Gambling Act, Psychotropic Substance Act, and Excise Act. However, the major reason which the public nuisance created because of alcohol abuse goes unnoticed is that those crimes are classified under petty crime and they largely go unrecognized or they may get overlooked.
Alcohol policy in India
Although the prohibition of alcohol use is encouraged in the constitution of India, alcohol policy is a state subject. States are having full control of alcohol‑related legislation, excise rates, and the production, distribution, and sale of alcohol. Newly independent India, which was born post‑independence, retained alcohol prohibition until the mid‑1960s, and by 1970, only the state of Gujarat had a complete alcohol prohibition policy. In Bihar, there is a complete prohibition of alcohol use since 4 April 2016. However, following a year after the ban, trade of illicit liquor flourished along the borders, as the neighboring states have no prohibition on alcohol. In addition, there seems to be illicit trade of narcotic drugs as people have begun to look for other substances for addiction Government is now looking to remove the prohibition act, as illicit liquor use, deaths because of methanol poisoning, and substance abuse are on the rise. The major reason states experience fluctuation on the alcohol prohibition at the policy level is that it generates nearly 15% to 20% of their revenue from alcohol taxation, contributing a significant amount to the state treasury. In states like Gujarat, where complete prohibition is in force, the rich have continued access to alcoholic beverages and the lower class and poor people resort to illegal brewing of alcohol with an increase in deaths because of methanol poisoning. In countries like the United States of America (USA) increased taxation on alcoholic beverages has been used to reduce alcohol consumption. In India, those measures will not work, as alcohol consumers have easy access to illicit liquor and substances. Other laws related to the regulation of alcohol use like hours of sale, drunken driving, and sale to minors are regularly breached.
Drunken driving (Motor Vehicle Act)
When a person consumes an alcoholic beverage, there is a rise in BAC because of which there is a gradual and progressive loss of driving ability because of an increase in the reaction time, overconfidence, degraded muscle coordination, impaired concentration, and decreased auditory and visual acuity. This is known as drunken driving. There are laws to govern drunken driving in India. The BAC limits are fixed at 0.03%. As per the Motor Vehicle Act, any person whose BAC values are found to be more than this limit are booked under the first offense and may be fined about INR 2,000 to 10,000 and/or he or she may face a maximum of 6 months to 4 years imprisonment.
As per the Cable Television Network (Regulation) Amendment Bill, the advertising of alcoholic beverages was banned in India. Still, private channels are often permitting alcohol companies to advertise using surrogate means like using brand names for soda or water or music. However, as the target audience is moving from watching television to mobile phones, liquor companies have now begun to invest in online video marketing.
Primary care intervention for alcohol‑related problems
In developing countries like India, primary care physicians are the first contact of patients with the healthcare system. It is a major platform for screening to identify at‑risk individuals and diagnose AUDs. As recommended by the WHO, the AUDs Identification Test (AUDIT), for use in a primary care setting, is a validated screening tool. It can be used to identify alcohol consumers who are harmful/hazardous drinkers and alcohol‑dependent individuals. Systematic reviews and randomized controlled trials (RCTs) have demonstrated that brief intervention in a primary care setting by one‑to‑one counseling can help at‑risk drinkers and those with mild alcohol‑related problems. Based on the evidence, primary care management of alcohol‑related problems include three core steps, namely, counseling the patient on the ill effects of alcohol and, if necessary, prescribing medications like disulfiram and connecting with the patients by organizing treatment programs and forming support groups. If necessary, they have to refer the patient to higher centers for further care and management.
Alcohol consumption is emerging as a major public health problem in India. Multi‑centric scientific community‑based research studies have to be conducted in various individual states to understand the problem better. Various policymakers, media, professionals, and society have to be educated about the consequences of chronic alcohol through sensitization programs and health education campaigns. There is a direct need for a rational alcohol control policy with specific objectives like alcohol taxation, production, and promotion policy.