India: alcohol and public health
PREVALENCE OF ALCOHOL USE
India is generally regarded as a traditional ‘dry’ or ‘abstaining’ culture . A recent National Household Survey of Drug Use in the country , the only systematic effort to document the nation-wide prevalence of drug use, recorded alcohol use in the past year in only 21% of adult males. Expectedly, this figure cannot mirror accurately the wide variation that obtains in a large and complex country such as India. The prevalence of current use of alcohol ranged from a low of 7% in the western state of Gujarat (officially under Prohibition) to 75% in the North-eastern state of Arunachal Pradesh. There is also an extreme gender difference. Prevalence among women has consistently been estimated at less than 5%[3–5] but is much higher in the North-eastern states. Significantly higher use has been recorded among tribal, rural and lower socio-economic urban sections [6,7,25].
The per capita consumption is 2 l/adult/year (calculated from official 2003 sales and population figures). After adjusting for undocumented consumption (illicit beverages as well as tax-evaded products), which accounts for 45–50% of total consumption [8,9], this is likely to be around 4 l, but still low compared to that in wet nations. Spirits, i.e. government-licensed country liquor (rectified spirit mixed with water at 33.3% v/v), Indian-made foreign liquors such as whisky, rum, vodka and gin (42.8% v/v) and illicitly distilled spirits (of indeterminate composition) constitute more than 95% of the beverages drunk by both men and women. Beer accounts for less than 5% of consumption (70% of beer sales is dominated by strong beers at strengths over 8% v/v). Wine is a nascent but growing market.
THE HISTORICAL CONSTRUCTION OF AN AMBIVALENT DRINKING CULTURE
This apparent tradition of abstinence may, however, be a construct of relatively recent origin. The extensive records of diverse fermented and distilled beverages produced from fruits, grains and flowers , archaeological evidence of distillation in ancient India [c. 200 BCE], the elaborate sets of rules governing production, sales, taxation and public intoxication , lyrical descriptions of ritual fiesta drinking by both sexes in secular literature , the early recognition of the medical consequences of excess  and the frequent admonitions against the use of alcohol by the priestly elite  do not support the notion of a long-standing dry culture. The period of rapid social change during the colonial era transformed a society which, barring a segment of the brahminical (priestly class) elite, had until then what appears to be a relatively relaxed attitude to drink [16,17]. The emergence of an urban middle class, participating in the rapid industrial development of the 19th century, led to socio-economic empowerment of the lower rungs of the caste hierarchy. Changes in dietary practices were one of the means adopted by the lower strata to acquire higher social status. As a result of this phenomenon of Sanskritization , the growing middle classes embraced upper-caste norms of vegetarianism and abstinence from alcohol .
In parallel, the abkari (excise) policies of the colonial government, restricting manufacture of alcoholic beverages to licensed government distilleries, led to the rapid replacement of traditional alcoholic beverages by mass-produced factory-made products, with greater alcohol content and less variety, which were progressively more expensive due to ever-increasing taxation . The enormous increase in the number of distilleries and the practice of auctioning rights to distill and sell unlimited amounts of beverage alcohol led to increased consumption, drunkenness and crime . This was increasingly viewed as an unpopular imposition of English rule and drinking acquired the stature of a peculiarly English vice [22,23]. Alcohol use came to be regarded by the power elite as an atavistic trait of the primitive and the poor (tribals and socially backward drinking to transcend their miserable existence) or a licentious affectation of the upper classes [7,24–27].
Side by side, Gandhi and the nationalist movement harnessed the temperance aspirations of the middle classes into mass movements against drinking as a symbol of colonial oppression. Fired by the belief that the Indian nation should be ritually pure, they evolved a demand for total prohibition. The Constituent Assembly of independent India included prohibition as one of the Directive Principles of state policy .
In practice, alcohol policy devolved to individual states to formulate their own regulations and levy their own taxes. Most states derive 15–20% of their revenue from taxation on alcohol, which is the second largest source of the states’ exchequers after sales tax . This has created an ‘ambivalent’ drinking culture—neither dry nor wet. Alcohol use attracts social opprobrium at the same time that governments and alcohol manufacturers promote alcohol sales in pursuit of profit . In several states renewal of retail licenses are contingent upon meeting stiff sales quotas which are revised upwardly from time to time. The alcoholic beverage industry visibly influences the political process , with contributions to political parties and in the form of inducements to voters during elections. A few years ago, the Prime Minister designate of the country flew in for his investiture ceremony in the private aeroplane of a prominent liquor manufacturer. Nevertheless, alcohol use for the majority is still stigmatized .
THE SOCIAL COST OF AN AMBIVALENT DRINKING CULTURE
Expectedly, in such a situation where traditional social regulation of drinking has been supplanted by centuries of temperance or prohibitionist controls, no prescribed patterns of behavior exist to regulate drinking behaviours. This is known to predispose to deviant, unacceptable and asocial behaviour, as well as chronic disabling alcoholism . Repeated observations have documented that more than 50% of all drinkers satisfy criteria for hazardous drinking. The signature pattern is one of heavy drinking, typically more than five standard drinks on a typical occasions [31,33,34]. There is surprisingly little difference between amounts drunk by men and women. Although a large proportion of drinkers of both genders drink daily or almost daily, the frequency is significantly higher in men. Under-socialized, solitary drinking of mainly spirits, drinking to intoxication and expectancies of drink-related disinhibition and violence add to the hazardous patterns [35,36].
Needless to say, this translates into significant alcohol-related morbidity. Alcohol-related problems account for over a fifth of hospital admissions [37,38] but are under-recognized by primary care physicians. Alcohol misuse has been implicated in over 20% of traumatic brain injuries  and 60% of all injuries reporting to emergency rooms . It has a disproportionately high association with deliberate self-harm , high-risk sexual behaviour, HIV infection , tuberculosis , oesophageal cancer , liver disease and duodenal ulcer [45,46].
Alcohol misuse wreaks a high social cost [47,48]. A study from the state of Karnataka in South India estimated that monetizable direct and indirect costs attributable to people with alcohol dependence alone was more than three times the profits from alcohol taxation and several times more than the annual health budget of that state .
All these studies on morbidity are regional estimates, but given the ubiquitous presence of hazardous drinking patterns  should be generalizable across the country. However, there is inadequate recognition that alcohol misuse is a major public health problem in India.
ECONOMIC LIBERALIZATION, SOCIAL CHANGE AND CHANGES IN DRINKING PATTERNS
Indian society is currently undergoing another tectonic shift in its socio-economic fabric. The impact of globalization and economic liberalization (exposure to satellite television, rapid socio-economic transition and growing disposable incomes) appears to have influenced a widespread attitudinal shift to greater normalization of alcohol use.
There has been a significant lowering of age at initiation of drinking. Data from Karnataka showed a drop from a mean of 28 years to 20 years between the birth cohorts of 1920–30 and 1980–90 . Alcohol sales have registered a steady growth rate of 7–8% in the past 3 years. The largest expansion is seen in southern India, which has been driving most of this economic growth. It is visibly focused on the non-traditional segment of urban women  and young people, with a noticeable upward shift in rates of drinking among urban middle and upper socio-economic sections. The country liquor and whisky segment that earlier accounted for over 95% of documented consumption  has seen stagnation; the growth is in the non-traditional sectors of beer, white spirits and wine. A new segment of consumers is forming and a novel, convivial pattern is supplanting older drinking norms.
The local alcohol industry, quick to seize upon this emerging market, has introduced new products such as flavoured and mild alcoholic products, aimed to recruit non-drinkers, targeted primarily at women and young men . The industry circumvents bans on advertising by surrogate advertising, and the subject of alcohol advertising (surrogate and point-of-purchase) has changed from voluptuous pin-ups (targeting the traditional market of middle-aged male consumers) to life-style advertisements promoting the connection with good times, aimed clearly at women and youth. Multi-national alcohol beverage companies redeploying from shrinking markets in the developed world have identified India, with its growing consumer base, vast unexploited markets and commitments to the World Trade Organization to reduce quantitative restrictions on alcohol imports, as one of the most attractive markets for investment . In recent times the trade papers have reported a spate of buy-outs of local beverage companies by multi-national corporations. The revenue aims of state governments are at odds with their health and welfare aims as they push sales by imposing annually incremental quotas on production and sales.
As the rising prevalence converges on the signature pattern of frequent heavy drinking, the burden of health attributable to alcohol will mount dramatically. It is often assumed that non-communicable diseases affect higher social classes disproportionately, as mortality levels fall and national incomes increase. In low-income countries such as India the prevalence of alcohol and tobacco use is higher among the poor, which increases the risk of cardiovascular disease, cancer, liver disease and injuries among the poor relative to the better-off . There is also a strong association between use of tobacco and alcohol, and impoverishment through borrowing and distress-selling of assets due to costs of hospitalization .
THE OFFICIAL RESPONSE TO THE ALCOHOL PROBLEM
Unfortunately, the official response remains focused on the visible tip of the alcohol problem—people with alcohol dependence (around 4% of the adult male population)—instead of on the emerging crisis due to hazardous drinking in more than 20% of the adult population. This is reflected in the approach to alcohol control policies at federal and state levels. The focus is exclusively on supply reduction (prohibition-centric) and tertiary prevention.
Every attempt by individual state governments to prevent misuse through prohibition has been hastily reversed in the face of mounting revenue deficits, costs of policing smuggling from neighboring states and resulting underground alcohol economies, notwithstanding evidence of decreased consumption [3,36] and improved indices of economic wellbeing (personal communication, Excise Commissioner, Andhra Pradesh). In fact, most state governments have publicly recanted the official commitment to prohibition, although it remains enshrined in the constitution. Increased taxation has been used in other countries, to reduce consumption. In India, the impact of such measures is weak as consumers have easy access to undocumented (illicit and excise-evaded) alcohol, beyond the purview of taxation. There is also concern that alcohol as a commodity is relatively price-inelastic and therefore an increase in its price would simply increase the expense of alcohol consumers aggravating the economic hardship of their family members, without necessarily reducing any of the other negative impacts [26,30]. Regulatory laws pertaining to hours of sale, sale to minors and drunken driving are observed in the breach. The Indian Motor Vehicles Act specifies a blood alcohol cut-off of 30 mg% for drivers, which is arguably one of the strictest in the world. However, a recent study in Bangalore city across a calendar month found that 40% of drivers were over the legal limit .
The Government of India has funded 483 detoxification and 90 counselling centres country-wide under the auspices of the National Drug Deaddiction Programme to treat people with substance abuse disorders; 45% of people seeking treatment in these centres are for alcohol dependence. Most of these centres are defunct as they received a one-time grant. Paradoxically, the rates of help-seeking in these centres are the lowest in states with the highest prevalence of alcohol use , and the overall efficacy of treatment programmes provided is low .
The evidence from India is substantial that the direction for policy is to focus on macro-environments and make them more conducive to promoting health behaviours than bank on individual behavioural change . Nevertheless, that is hardly likely as state governments publicly recant their beliefs in prohibition and alcohol control, and try to extricate themselves from public funding of health care. Private expenditure already accounts for 82% of the total expenditure on health.
Public awareness of the alcohol problem
The popular media favour lurid descriptions of alcohol related violence and heroic accounts of sporadic, short-lived anti-alcohol agitations by women's groups . These, paradoxically, serve to marginalize the issue further and detract from a balanced public discourse. Because the subject is of low priority funding for research is low; there is little by way of a body of published literature, which can inform public policy, by projecting the socio-economic impact of alcohol misuse on a national scale. Social aspect organizations of the major liquor companies advocating safe drinking and sections of the mainstream English language media extolling the health benefits of alcohol have invaded that space. In the absence of evidence that the sensible or safe drinking paradigms can be universally applicable, there is apprehension that such moves may be counter-productive or even be interpreted as invitations to drink among an abstinent population . Hopefully, the impetus for a rational public health approach to alcohol policy will stem from the efforts of non-governmental organizations, which are waking up to the sizeable negative impact that harmful alcohol use has on the delivery of their health and development programmes.
AN ALCOHOL POLICY FOR THE 21ST CENTURY
A combination of (a) a population-based approach reducing overall consumption and (b) a high-risk approach targeting high-risk behaviours is essential to reduce the impact of the signature pattern of hazardous alcohol use in the country.
This requires an urgent shift to a public health paradigm in the approach to alcohol use. Health systems, especially at primary care levels, must be geared to play a greater role in the early detection and prevention of alcohol-related harm, perhaps through brief, cost-effective interventions that have been demonstrated to be useful . The social welfare system and the criminal justice system, often the first to come into contact with alcohol-related problems, can be sensitized in identifying and assisting individuals and families at risk from heavy drinking and acting as early referral systems. Extensive opportunities exist to lessen alcohol problems through community education and the prevention of drink driving, domestic violence, public disorder, unintentional injuries and criminal damage .
Community programmes supporting healthier life-styles, mass media campaigns that present the advantages of reduced consumption rather than the dangers of heavy alcohol and community development in general (job creation, skills development and upgrading infrastructure or recreational facilities in communities with high levels of alcohol abuse) should be utilized to encourage alternatives to drinking among the young and disadvantaged. Community action can also serve to shape attitudes, values and norms about drinking. Recently, several effective temperance campaigns have been led by heads of certain Hindu religious orders, although the impact has been limited to their immediate followers.
Existing legislation relating to controls on availability and marketing, restrictions on advertising, and especially minimum drinking age, need to be enforced rigorously. Simulations have demonstrated that implementing a nation-wide legal drinking age of 21 years can achieve about 50–60% of the alcohol consumption reducing effects of prohibition . Each year that drinking is delayed significantly reduces the likelihood of developing alcoholism and the life-time risk of alcohol abuse .
Dialogue and a degree of consensus between the health and revenue arms of government (i.e. federal and state agencies who are virtually opposing players) are crucial to reduce the mutually antagonistic directions of profit and welfare. A proportion of the considerable revenue from alcohol should be ploughed back into treatment and research. The priority for alcohol researchers in India is surely to focus on the public health dimensions of alcohol misuse and to focus on appropriate interventions. It is equally important for research findings to be published and publicized.
Hopefully, the imminent centralized system of value-added taxation will reduce the inequities in alcohol taxes between states, and thus diminish interstate smuggling, which nullifies the potential benefits of increasing alcohol prices to reduce consumption. Volume-based taxation (wherein a litre of beer is taxed equally as a litre of spirits) that promotes excess consumption of spirits requires rationalization and stricter control on the entry of illicit (often toxic) alcoholic beverages into circulation is essential. There is also a need to consider public health interests in issues relating to trade agreements. Investment in alcohol production and distribution by trans-national companies in India and the removal of tariff barriers is likely to increase availability and consumption and limit the effect of prevention programmes.
For all this to happen, a vital first step is for health planners and other stakeholders to debate and draft an explicit and rational alcohol policy appropriate for India  as it marches into the uncertain future of the 21st century.