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INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References

In Mexico, a distributor of alcohol opposes new regulations that prohibit the bulk selling of alcohol and the wholesale of 96° proof alcohol that has not been rendered undrinkable, based on the argument that the government health sector has no interest in these issues. Bar owners alert their customers to the locations of breathalyzer checkpoints. Members of a local association appeal for the dismissal of the President of a municipality because he is imposing fines on bars that infringe the law by selling alcohol to underage youth. Parents are overwhelmed by the number of adolescents who become drunk at their daughters' traditional 15th birthday parties when they buy alcohol in amounts more suitable for an adult gathering and then allow their young guests to leave intoxicated.

This absence of public awareness occurs in spite of the role that alcohol plays in the burden of disease. Alcohol abuse occupies first place among risk factors for premature death and days lost to disease in Latin American developing countries such as Mexico [1]. Despite research conducted systematically in the country since the mid-1970s, knowledge of the reasons behind this high burden has scarcely increased.

The role of alcohol in health and social problems is denied by drinkers; by families who experience guilt and shame and hide the problem [2]; and by society as a whole, which condones drunkenness and by policy makers. In the health system, alcohol dependence is not regarded as a chronic disease with the right to treatment, while population-based approaches that reduce the burden by altering the drinking environment and the availability of alcohol are limited.

Historically, commercial and economic interests have been more important than public safety: a problem such as this, embedded in globalization, requires strategies that go beyond national borders. The prestige and influence of the World Health Organization in Mexico and other developing societies could help to shift the balance.

THE CONTEXT OF DRINKING

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References

When the Spaniards arrived in Mexico in 1519, the maguey (agave from which a local fermented beverage known as pulque is produced) had been cultivated for over 8000 years. During pre-Colonial times, the most widespread pattern of use was communal drinking in rituals associated mainly with agriculture, and major life events such as birth, marriage and death. Pulque was used for religious purposes, producing a ritual inebriation accepted by society. It was also the popular secular beverage for restricted use. Inebriation was allowed during some festivities for males and females, both young and old. There was an element of fatality: people born under the astrological sign of the rabbit would, it was thought, be inevitably inclined towards drinking [3].

Indian norms seem to have focused on the occasions when alcohol could be used and by whom, rather than on how much was drunk [3]. According to Corcuera de Mancera [4], violation of the norms was punished severely, the price for momentary loss of individual control being isolation. Although the severity of the punishment could vary it was effective, because it was always applied immediately with no opportunity to appeal.

The Spanish conquest modified the indigenous patterns of use which changed from occasional use, linked to certain festivities, to indiscriminate non-religious use. The number of drinking occasions was augmented by the adoption of numerous Catholic festivals and this, along with the reduced rigor of the Indian authorities to punish wrongdoing because they had lost their political power, led to an increase in abuse. The Catholic religion shared the normative discourse of the old religions but lacked an effective means of enforcement [4].

Nowadays, social norms continue to be oriented towards determining who may drink rather than towards moderation. The absence of norms encouraging moderation is perhaps linked to the lack of a temperance tradition. Household surveys conducted in the 1980s showed a consensus among the population that it was acceptable for males to drink and become drunk, but not for females. Only 22% of the interviewees thought males and females had the same right to drink, or become drunk. Changes in women's position in society have led to an increase in intake among this group. Nevertheless, cultural norms continue to restrict consumption among females, and social problems in women are higher when compared to males with similar drinking habits.

The introduction of population-based interventions, which restrict drinking occasions and levels of alcohol intake, would need to be accompanied by efforts to modify cultural beliefs to gain public support and thereby increase the probability of enforcement.

PER CAPITA CONSUMPTION

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References

Per capita consumption based on reported sales of alcohol has shown variations over the past 30 years. A significant increase in consumption levels has been observed, with per capita consumption for people aged 15 years and overbeing 3.82 litres in 1970, rising to 4.5 litres in 2004. It has been estimated that 40% of the distilled beverages consumed come from informal production or smuggling, which may account for an additional litre in the per capita intake of the population aged 15 years and over.

Like any other commodity, alcohol consumption rates reflect economic development, with major increases being observed during periods of major economic growth. It is also consumed more extensively among the wealthy, although abuse rates are higher among the poorer sectors of the population who spend a proportionately higher percentage of their salaries on alcohol.

Beer is the most popular beverage (accounting for 75% of per capita consumption), followed by spirits (20%) and, to a lesser extent, wine (1%) and other beverages targeting the youth market. Per capita use of grape wine has shown an increasing trend from 0.02 litres in 1970 to 0.06 litres in 2000, mainly among women, and prepared beverages such as coolers, from 0.56 litres in 1979 to 0.127 litres in 2000 reported mainly by the youth population. Fermented beverages, notably pulque, are still consumed; in the nation as a whole, 3% of male drinkers consume this beverage: higher rates are observed in the rural producing areas, although among younger age groups pulque has largely been replaced by beer.

PATTERNS OF DRINKING

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References

Per capita consumption in Mexico is lower than in North America and Europe yet the burden on society seems high, perhaps because of the manner in which alcohol is consumed. As described earlier, major transitions have occurred since the time of regulated intake prevalent during the pre-Colombian era in the 15th century. The country switched to a pattern often described as ‘fiesta drinking’, with a low frequency of drinking but high levels of intake per drinking occasion. There was frequent inebriation, mainly by middle-aged males in their 40s, and abstention or light drinking among females. Daily drinking was rare, being reported by less than 2% of the population, remaining at a stable rate over the years.

In the late 20th century there was a significant decrease in the rate of female abstainers. This was most noticeable in the age cohort born in the 1950s, a generation of women who joined the labour force for the first time, yet maintained low drinking rates. During this period there was also a significant decrease in the peak age of drinking and of heavy drinking among males: in 1988, the peak drinking age for men was between 30 and 49, whereas by 1998 it had fallen to 18–29 years. Younger men began to drink more heavily [5,6]. In 1988 the heaviest intake was observed among those aged between 40 and 49 years, whereas 10 years later this was observed in the group aged between 30 and 39 years.

By the beginning of the new millennium the proportion of adult females drinking high quantities had increased, and there was indiscriminate abuse among teenagers of both genders. The number of teetotalers among females aged 12–17 years fell significantly over a 4-year period and the proportion with abuse or dependence in both sexes rose [7]. Men in rural communities display lower levels of consumption but higher levels of abuse and dependence, compared with those living in urban areas; this is also the case among those with lower educational attainment [7].

Mexico has precisely the conditions that increase the risk of problems. There is a high percentage of teetotalers, daily consumption is uncommon and drinking is not associated with meals, people drink infrequently but consume large quantities when they do so, and drinking often occurs outside the home.

THE BURDEN OF ALCOHOL ON SOCIETY

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References

In common with other countries with high rates of teetotalism, Mexico has a high rate of problems commonly associated with drunkenness such as accidents, and high mortality rates due to chronic diseases, particularly liver cirrhosis. It has been estimated that alcohol abuse alone accounts for 9% of the total burden of illness in Mexico. The ailments associated with alcohol consumption that cause the loss of most years of healthy life include liver cirrhosis (39%), injuries from motor vehicle accidents (15%), alcohol dependence (18%) and homicides (10%) [8].

Alcohol dependence or abuse has been estimated at 12% for males and 1% for females, but only one-fifth of those with three or more symptoms of dependence defined following the criteria of the International Classification of Disease (ICD-10) seek treatment. General hospitals and other health facilities are the places where most alcoholics receive treatment, followed by self-help groups.

Data from surveys [9] suggest that drinking and problems start at an early age and those problems go untreated, increasing their impact on the quality of family life. Often, the health service provides care for the consequences of alcohol intake but not for the dependence itself. Despite the fact that several models for medical advice, such as brief interventions and relapse prevention, have been tested in the country [10], they have not been included in health delivery systems. Not surprisingly, Mexico is one of the countries in the world with the greatest number of Alcoholics Anonymous groups registered. Any government health policy should consider the inclusion of alcohol disorders in the general health agenda.

GOVERNMENT POLICIES PAST AND PRESENT

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References

A long tradition of alcohol use has been accompanied by a lengthy tradition of state control policies. Shortly after the Conquest, policy was oriented towards the control of public disorder. Thus, on feast days, pulque could be sold only before midday, a rule that was constantly broken. By the mid-16th century, regulations included prohibiting the addition of roots and other products to pulque to increase its potency. According to historical descriptions, roots such as ocpatli or cuapatle known as aderezo del vino (wine dressing; wine was the Spanish word used by Indians to define all alcoholic beverages) were added to increase their potency along with other substances such as quicklime, apple peel, lemon and chili [11]. More recently, a crystal of potassium sulphate and alum (alumbre) has reportedly been used for the same purpose. This crystal has the property of precipitating suspended particles, which might explain the fortifying effects of alcohol from clarified pulque once the proteins and other solids precipitate, resulting in faster absorption and metabolism. This practice has been found nowadays in pulque-producing Indian communities [12].

A local beverage known as chinguirito, made from sugar cane, which was a forerunner of rum, was prohibited and only spirits imported from Spain were permitted. Because local demand could not be satisfied by imports, illegal production of this beverage became common practice. Illegal distilleries were established near sugar plantations, sometimes in caves and other places out of sight of the authorities. There is also evidence of distilleries being located in people's homes, with temporary installations that could be moved according to the producers' needs [11].

Measures designed to reduce consumption were also observed, such as the one implemented in the early 17th century to regulate the number of establishments per inhabitant. In 1771 pulque taxes were raised considerably, to dissuade excessive consumption. According to Viqueira [13], pulque consumption did not increase at all during the second half of the 18th century. During this period, drunkenness in the public thoroughfare was penalized.

The Constitution of 1917 included the obligation to develop a Program against Alcoholism and stated that vagrancy and habitual drunkenness would lead to the loss of one's civic rights.

In the 1950s, the sale of alcohol was prohibited in Mexico City. This measure gave rise to what was called the ‘vice belt’, where establishments were set up on the outskirts of the city to satisfy demand; it was abolished shortly afterwards.

This was followed by laws regulating the proximity of establishments selling alcohol to schools and work-places, the legal age for purchasing alcohol and entering establishments where alcohol was sold and the alcohol levels permitted in the blood when driving. These measures unfortunately failed to include strategies to guarantee their enforcement. Urban growth has led to non-compliance with the measures determining the location of establishments selling alcohol. Efforts to control public disorder include prohibiting the sale of alcohol on special days such as elections or civic holidays.

In 1986 a National Program against Alcoholism and the Abuse of Alcoholic Beverages was formulated on the basis of an obligation stated in the 1985 National Health Law following a public health conceptual framework. The program was drafted and submitted for the consideration of more than 100 representatives from the public, social and private sectors divided into five working parties concerned with legislation, prevention, treatment, human resource training and research. The National Board against Addictions (alcohol, tobacco and drugs) was created, followed by boards at State and Municipal levels. Since then, the programs have been updated without modifying the underlying conceptual framework.

The alcohol industry exerted pressure during the elaboration of the National Programs. The project for the National Program of 1986 included measures for controlling prices (to keep them the same as or higher than those of the basic products included in the retail price index) and limited the number of licenses granted to establishments selling alcohol. These measures were questioned by the industry, which cited the dangers of increasing the illegal market. The final Program was reformulated by introducing a clause that indicated the need to study the effects of controlling the availability of alcohol.

The pressure of the alcohol industry is partly responsible for the lack of stronger taxation policies as a means of reducing availability, in spite of the fact that alcohol consumption is acutely sensitive to prices. In Mexico, to be effective, any policy would have to include beer as it is the main product consumed. The lack of measures to control availability, as opposed to what is observed in market oriented economies, has resulted in an increase of alcohol use in Mexico, with international alcohol firms using sophisticated forms of marketing and political action.

Moreover, despite the policy recommendations included in the above-mentioned National Program against Alcohol Abuse endorsed by the Ministry of Health in 1986, a gradual loss of government control over alcohol production has been observed. The state had a monopoly over sugar cane production and was therefore able to supervise the commercialization of sugar cane to produce alcohol, but this monopoly was dissolved. The Ministry of Finance modified the tax policy, so that it was no longer applied at the original production stage but rather at first commercialization. The inspection of premises was discontinued, so that it became more difficult to detect unregistered premises. International agreements made alcohol produced in other countries more available. The prohibition of the retail sale of 96° proof alcohol and the sale of alcohol in bulk was not introduced until 2004. There are no regulations to enforce the destruction of containers of registered beverages. Consequently these containers are re-used, with minimal modifications to the labels, to sell unregistered alcohol, in both licensed and unlicensed premises. In a country where the informal economy occupies such a salient position, special attention must be paid to the control of the unregulated market in order to reduce the risk to consumers of products produced outside the hygiene regulations, and to counter smuggling, which undermines tax revenues.

Evidence of the important role played by alcohol in accidents has led the authorities to support campaigns to detect drunk drivers. In Mexico City, for example, these programs led to a 44% reduction in mortality rates [14]. Despite this, not all the states have drink driving regulations.

CONCLUSIONS

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References

In present-day Mexico, consumption patterns and public policies are a combination of traditions from both before and after the Colonial period, with no integrated policy permitting effective action. It is clear that neither evidence of the scope of the problem nor the measures implemented to reduce it, have proved sufficient.

This means, therefore, that the next step must be taken in research to permit the shift from information to policy, and to obtain support from international organizations that will counteract popular denial of the problem and pressure from the economic interests of both the industry and the state, in order to strike a balance and a sustainable policy that will result in the reduction of alcohol-related problems.

DECLARATION OF INTEREST

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References

Maria Elena Medina-Mora received a seed grant from the pharmaceutical industry for a household survey on psychiatric epidemiology and support for participating in two academic conferences. In her view, this support does not represent conflict in this paper.

References

  1. Top of page
  2. INTRODUCTION
  3. THE CONTEXT OF DRINKING
  4. PER CAPITA CONSUMPTION
  5. PATTERNS OF DRINKING
  6. THE BURDEN OF ALCOHOL ON SOCIETY
  7. GOVERNMENT POLICIES PAST AND PRESENT
  8. CONCLUSIONS
  9. DECLARATION OF INTEREST
  10. References
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    García Andrade C., Medina-Mora M. E., Natera N., Juárez J., Kershenobich D. Consumo de Alcohol en una Comunidad Ñahñu del Valle del Mezquital [Alcohol consumption in a Ñahñu community in the Mezquital Valley]. In: Consejo Nacional Contra las Adicciones (editor) Retos Para la Atención Del Alcoholismo En Pueblos Indígenas [Challenges for the treatment of alcoholism in Indian nations]. México: CONADIC; 2005, p. 3642.
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    Secretaría de Seguridad Pública del Distrito Federal [Ministry for Public Security of the Federal District]. 2004. Available at: http://portal.ssp.df.gob.mx/portal/comunicacionsocial/boletines/b12392006.htm (accessed 26 September 2006).