The role of alcohol (and particularly heavy alcohol use and having an alcohol use disorder) in NCDs has been given increasing recognition. For example, alcohol was mentioned along with tobacco, diet and lack of exercise, as one of four major common risk factors for NCD in the recent status report of the World Health Organization [38
]and by the Lancet NCD action group [39
]. It has also been discussed at the recent NGO conference in Melbourne on health and the Millenium Development Goals (MDGs) during a session on NCDs, along with tobacco, diet and lack of exercise, alcohol was recognised as one of four major common risk factors [3
]. In terms of NCDs, alcohol has been particularly linked to cancer, cardiovascular diseases and liver disease. Preliminary estimates on the impact of alcohol on these diseases support the inclusion of alcohol consumption as one of four major risk factors globally.
Before discussing further implications we would like to lay open limitations of our approach. The CRA as well as the GBD are estimates based on best available data and modelling techniques. With respect to alcohol, even though the underlying data overall has relatively good reliability and validity, the estimates of alcohol exposure in countries with high level of unrecorded consumption confer a higher level of uncertainty [40
]. However, as the impact of unrecorded alcohol consumption was modelled the same as the impact of recorded consumption, overall its impact was probably underestimated (for health effects of unrecorded consumptions see [41
]). The second potential bias results from basing risk relationships on meta-analyses mainly stemming from cohort studies in high income countries. While the so derived risks may contain bias, especially for disease categories which are highly related to social determinants, the direction of this bias is also towards underestimations, as many research studies have shown that conditions like undernutrition or lack of sanitation which are more prevalent in low and mid income countries, increase the effect of alcohol [10
]. Also, the modelling of ischemic heart disease used in the 2000 CRA is based on a meta-analysis for high income regions(see above), overestimating the beneficial effect, as several of the underlying studies did not differentiate between lifetime abstainers and former drinkers(e.g., [42
]). For other regions, the modelling of the effects of alcohol on ischemic heart disease is based on multi-level analyses of aggregate data, and there is no overestimation of the protective effect because of misclassification of abstention in this type of analysis. Together with the lack of inclusion of NCD categories in the underlying GBD where alcohol has a detrimental effect (see above), overall the presented figures should be considered as conservative estimates; i.e. the net detrimental impact of alcohol consumption is underestimated.
As part of national efforts to address NCDs countries need to give priority to implementing the Global Strategy to Reduce the Harmful Use of Alcohol
approved by the WHA in Geneva in May 2010 [43
]. Particular attention should be given to implementing evidence-based strategies that have the potential to reduce the occurrence of heavy drinking episodes and the prevalence of alcohol use disorders that impact on NCDs. Such strategies are likely to include regulating the availability, price and marketing of alcohol, and improving the capacity of health services to support initiatives to screen for risk and conduct brief interventions for hazardous and harmful drinking at primary health care and other settings [6
]. While there is less evidence to support the efficacy of health education on its own, it nonetheless does seem appropriate that alcohol consumers should be made aware of the risk associated with different levels of drinking and NCDs. Consumers should, for example, be informed that stopping or reducing alcohol consumption will reduce cancer risks, albeit slowly over time[46
At a global level, support should be given to the WHO to enable it to carry out its mandate in terms of the Global Strategy to Reduce Harmful Use of Alcohol
and allied WHO resolutions, in particular with regard to providing technical assistance to low-and middle-income countries to develop and implement policies to reduce the burden of alcohol-related problems; seeing that public health interests regarding alcohol issues are taken into account in global trade agreements, the settlement of trade disputes, and decisions by international development agencies; and ensuring that transnational marketing or major international event marketing does not act against national policies with regard to alcohol advertising and promotion. For further information on evidenced based strategies that are likely to directly or indirectly impact on NCDs readers are referred to resources supported by WHO/PAHO [6
Addressing NCDs in countries at all levels of development is now seen as important in ensuring the achievement of MDGs [47
]. The way forward is to take concerted and inclusive actions to address the common causes of the most prevalent NCDs. Given the overwhelming evidence that alcohol is a major risk factor for NCDs, attention must now be directed towards addressing the drivers of alcohol use, especially of heavy use, and particularly those drivers operating at the social and environmental level using strategies that have been shown to have a high probability of having an impact.