Implementation

Three steps should be considered to implement primary prevention for alcohol control nationally.

• Establish collaboration between the NCCP and others interested in alcohol control in the government and in NGOs.
• Perform a sampling survey to determine current alcohol consumption and pricing trends.
• Establish a primary prevention program against alcohol using the threefold strategy of education, legislation and national leadership as summarized on slide 8 and discussed in more detail below.

Importance of Alcohol

Heavy drinking of alcohol increases the risk of cancer of the oropharynx, larynx and esophagus, and the effect is exacerbated by smoking. Some studies have shown associations rectal cancer (beer drinking) ands with breast cancer (heavy alcohol consumption). Primary liver cancer is strongly associated with hepatic cirrhosis from either toxic or infectious agents. In developed countries cirrhosis relates principally to heavy alcohol consumption, However, there is little evidence that consumption of small amounts of alcohol increases the risk of cancer. In contrast, any degree of active or passive exposure to tobacco smoke is hazardous.

Alcohol and tobacco consumption show similarities. Both are toxic and can damage several body systems as well as cause cancer. Their use is seen especially among the disadvantaged in developed countries, and in developing countries experiencing economic advance. Both habits receive social encouragement like peer pressure, and are backed by strong commercial interests. Both are potentially addictive, producing physiological dependency. And both are "price elastic" with consumption falling off as the cost to the individual goes up.

Religious and cultural factors strongly influence alcohol consumption. The sale and consumption of alcohol are prohibited in Muslim countries. But in other countries wine with meals is a social norm. In yet other countries the use of strong alcoholic beverages has become widespread and may be heavy among some population subgroups. Because of this social complexity a specific program against alcohol is not usually part of a national cancer control program (NCCP). Rather the NCCP will collaborate with other government and public health initiatives that reduce excessive use of alcohol and that educate children especially about its adverse effects on health.

Alcohol Control

Preventive measures can include:

Health protection to limit the accessibility of alcohol using economic, physical, legal or other means. Economic measures might include price controls or differential taxation. Physical measures might control numbers, types and locations of outlets, their hours and days of sale through a government liquor control board or through licensing outlets. Legal measures might enforce a legal minimum drinking age. Negative lifestyle influences can be controlled and restrictions can be placed on advertising and marketing restrictions.

Health promotion seeks to promote a healthy lifestyle that includes less harmful use of alcohol. Through health and health policy awareness, for example, public education can be carried out. Another measure would be to target high risk groups such as young people or drivers with specialized preventive programs. To encourage less hazardous drinking one could substitute other beverages or reduce the alcohol content of alcoholic beverages.

Health services objectives would detect harmful consequences of alcohol early and intervene effectively. Identify individuals who show signs of alcohol misuse or dependency. Early detection efforts should be systematic, and measures for intervention could include counseling and referral, self-help techniques and periodic follow-up. Health professionals can intervene, and individuals who have experienced the same problems can provide support (12 step program, alcoholics anonymous, etc.)

Overall, reducing individual consumption is the most powerful strategy by introducing obstacles to alcohol use and by encouraging healthy lifestyle. The most effective government action is to raise prices by taxation. Other measures are limiting availability, raising the minimum age that alcohol can be purchased, and creating a government monopoly on the sale of alcohol.

Evaluation

For alcohol control, WHO (1995) recommends the following indicators as examples.

Process Measures

Over 80% of schoolchildren aged 10 years and over get education on the hazards of drinking alcohol.
Over half of adults get an anti-alcohol message yearly.
More than two anti-alcohol legislative measures are implemented.

Impact Measures

Over 80% of schoolchildren aged 10 years and over are aware of the hazards of drinking alcohol (population survey).
Over half of adults are aware of the link between alcohol and cancer (population survey).

Outcome Measures

Short term: More than a half of adults have reduced their consumption of alcohol
Medium term: Reduced incidence of cirrhosis.
Long term: Reduced incidence of cancers of the head and neck, esophagus and liver..

WHO (1995) National Cancer Control Programmes: Policies and managerial guidelines. World health Organization, Geneva.
Rankin JG & Ashley MJ (1985). Alcohol-related Health Problems and their Prevention. In: Last J (Ed) Public health and preventive medicine. Ed 12 pp1039-1073. Appleton-Century-Crofts, Norwalk
World Cancer Research Fund and American Institute for Cancer Research (1997). Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington, DC, ISBN 1-899533-05-2.
Greenwald P, Kramer BS & Weed DL (1995) Cancer prevention and control. Marcel Dekker, Inc. New York.
DeVita VT, Jr, Hellman S & Rosenberg SA (1997) (Ed). Cancer: Principles and practice of oncology. Ed 5 Lippincott-Raven, Philadelphia.

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