Estimation of Unrecorded Alcohol Consumption in

Download PDF
0 downloads 0 Views 135KB Size Report
Comment
Jun 6, 2016 - Scott Foresman and Company, Glenview, IL. Forouzanfar .... L, Sandar L, Santos IS, Sapkota A, Satpathy M, Saunders JE, Sawhney. M, Saylan ...
ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH

Vol. 40, No. 6 June 2016

Estimation of Unrecorded Alcohol Consumption in Low-, Middle-, and High-Income Economies for 2010 €rgen Rehm, Elisabeth Larsen, Candace Lewis-Laietmark, Paul Gheorghe, Ju Vladimir Poznyak, Dag Rekve, and Alexandra Fleischmann

Background: Consumption of unrecorded alcohol is prevalent, especially in low-income countries (LIC). Monitoring and reduction of unrecorded consumption have been asked for in the World Health Organization (WHO) global strategy to reduce the harmful use of alcohol. To date, only a few countries have installed monitoring systems, however. Methods: As part of the WHO global monitoring, an expert survey using the nominal group technique, a variant of Delphi studies, was conducted to assess level and characteristics of unrecorded consumption in 46 member states. One hundred experts responded. Descriptive statistics and repeated analysis of covariance were used to analyze the data. Results: The study showed feasibility of the chosen methodology to elicit information of unrecorded consumption with experts responding for 74% of the countries. Response rate was lower for LIC. Compared to prior WHO estimates, experts tended to estimate higher unrecorded consumption for LIC, and lower unrecorded consumption for high-income countries. Unrecorded consumption was seen as a financial, public health, and social problem by the majority of experts. Homemade alcohol was the most prevalent subcategory of unrecorded consumption globally. Conclusions: The chosen methodology was feasible, and new information about consumption of unrecorded consumption could be gathered. There is still a need for increasing efforts of national monitoring, especially in LIC. Key Words: Alcohol, Unrecorded, Income Groupings, Nominal Group Technique, Monitoring.

A

LCOHOL USE IS one of the leading causes of death and injury worldwide (Forouzanfar et al., 2015; Lim et al., 2012, Rehm et al., 2009; World Health Organization, 2014). The 2014 Global Status Report on Alcohol and Health estimated that in 2012, approximately 5.1% of the global burden of disease equivalent to 139 million disabilityadjusted life years and 5.9% of the global mortality equivalent to 3.3 million deaths were accountable to this risk factor (World Health Organization, 2014). Total alcohol consumption is composed of 2 main parts, recorded and unrecorded consumption, where the latter makes up about one-fourth of total consumption (24.8%;

From the Centre for Addiction and Mental Health (CAMH) (JR, EL, CL-L, PG), Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute (JR), Toronto, Ontario, Canada; Institute of Medical Science (IMS) (JR), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Psychology and Psychotherapy (JR), Technische Universit€ at Dresden, Dresden, Germany; Department of Psychiatry (JR), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (JR), University of Toronto, Toronto, Ontario, Canada; and Department of Mental Health and Substance Abuse (VP, DR, AF), World Health Organization, Geneva, Switzerland. Received for publication February 1, 2016; accepted March 9, 2016. Reprint requests: J€ urgen Rehm, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Toronto, ON M5S 2S1, Canada; Tel.: +1-416-535-8501, ext. 36173; Fax: +1-416-595-6068; E-mail: [email protected] Copyright © 2016 by the Research Society on Alcoholism.

World Health Organization, 2014). Recorded alcohol is all alcohol consumption that can be measured and monitored through official statistics based on government regulation, such as tax, sales, production, and import/export data (Poznyak et al., 2013; Rehm et al., 2007). Unrecorded alcohol is a more heterogeneous category which consists of: legally produced alcohol usually for artisanal purposes such as homemade brews and wines; illegally produced artisanal alcohols such as moonshine; industrially produced illegal alcohol; smuggled alcohol; cross-border purchases or other alcohol recording in a different jurisdiction; and surrogate alcohols that are—at least officially—not intended for human consumption such as medicinal alcohol, eau de cologne, or industrial alcohol (Lachenmeier et al., 2013; Rehm et al., 2014). Based on current knowledge, the proportion of unrecorded alcohol consumption on total consumption appears to be linked to economic wealth. The World Health Organization (WHO) indicates that approximately 8.5% of alcohol consumed in high-income countries (HIC) is unrecorded, whereas 40% of alcohol consumed in low-income countries (LIC) is unrecorded (World Health Organization, 2014). The high proportion of unrecorded alcohol consumed in low- to mid-income countries is likely due to unrecorded alcohol being low cost, and thus affordable for low-income and marginalized populations (overviews: Lachenmeier et al., 2007; Rehm et al., 2014; for an example, see De Boni et al., 2014).

DOI: 10.1111/acer.13067 Alcohol Clin Exp Res, Vol 40, No 6, 2016: pp 1283–1289

1283

REHM ET AL.

1284

Given the above described global scope of unrecorded consumption and its specific association with vulnerable populations, it is important to have good estimates of the size of the phenomenon. Obviously, the above definition of alcohol outside of the usual governmental statistics makes effective monitoring difficult, and most countries do not make efforts to estimate this type of alcohol (Rehm and Poznyak, 2015). Thus, within the global monitoring of alcohol consumption as part of the global strategy to reduce the harmful effect of alcohol (World Health Organization, 2010), a new methodology was created to measure the size and composition of unrecorded consumption via a Delphi methodology, using nominal groups (and described below; Rehm and Gadenne, 1990). The main objectives of the study were as follows:

The full questionnaire of round 1 can be found in the appendix of Rehm and Poznyak (2015). In short, experts were asked their opinion about the level and pattern of unrecorded alcohol consumption within their respective country. The question about level was aided by providing the prior WHO estimate to anchor estimates, as taken from the Global Status Report (World Health Organization, 2011) in liters adult per capita and as a proportion. Additional questions included estimates for the proportion of types of unrecorded alcohol consumed (for categories see above); whether unrecorded alcohol consumption was generally perceived as a primary matter of concern; to describe social and demographic characteristics of typical consumers of unrecorded alcohol; and mechanisms implemented in their country to prevent unrecorded alcohol consumption. For each question, experts were advised to provide level of certainty that the estimates were correct and sources of evidence to support their responses, if available.

1. To test the feasibility to use Delphi methodology for assessing unrecorded alcohol consumption, especially for low- and middle-income countries. 2. To collect national estimates on unrecorded consumption, not available from the usual route of systematic reviews of the scientific literature (Rehm et al., 2014). 3. To improve prior WHO estimates, in part derived from commercial data providers. 4. To gain better insight into the subcategories of unrecorded consumption.

Data on income groups were derived from the 2010 World Bank Analytical Classifications (World Bank list of economies [July 2010]; http://www.preventionweb.net/english/hyogo/gar/ 2011/en/bgdocs/Annexes/GAR%2011%20Annex%201%20World %20Bank%20country%20classification.pdf). Descriptive statistics were used to give an overview on the main results with respect to the main objectives described above. Chi-squared and analyses of covariance (ANCOVAs), including repeated-measures ANCOVAs, were computed to determine the relationship between economic wealth and response rate, also in light of departures from the WHO estimates (Winer, 1962).

Data Analysis

RESULTS MATERIALS AND METHODS Participants Alcohol experts from 46 countries with knowledge of national unrecorded alcohol consumption were identified through WHO, Expertscape, PubMed, Web of Science, and Google web searches. Broadly, the panel comprised of individuals from health ministries or affiliated agencies (in their capacity as experts), the law enforcement sector, customs, and research organizations. Each participant was invited, via email, to provide a national perspective of unrecorded alcohol consumption for the year 2010 using a standardized questionnaire (see below and Rehm and Poznyak, 2015). The countries were selected based on the following criteria: proportion of unrecorded based on prior estimates, size of the country, and any known controversy about the size of unrecorded consumption from the prior Global Status Report on Alcohol and Health (World Health Organization, 2011). The countries selected covered 63% of the world’s population in 2010. Data Collection The survey on unrecorded consumption for the year 2010 was conducted by the Centre for Addiction and Mental Health (CAMH) and WHO by email or via the Internet (WHO portal) and took place from April 2013 to December 2013. Data collection of the WHO was restricted to official WHO counterparts in the Ministries of Health in the respective countries in their capacity as experts. As stipulated by the nominal group methodology (Delbecq et al., 1975; Linstone and Turoff, 1975; Van de Ven and Delbecq, 1974), there were 2 rounds: in the first round, each expert gave their estimates. In the second round, based on feedback of the CAMH about the results of round 1 (mean estimates from each country), a final estimate was given by participating experts.

Feasibility A total of 46 countries were approached to participate in the current study (21% of all WHO member states). Among countries approached, we received at least 1 response from 74% of the 46 countries. Responses were received from 7 HIC, 11 upper middle-income countries (UMIC), 11 lower middle-income countries (LMIC), and 5 LIC (see Table 1). Response rate was different significantly between income status of the countries (UMIC was highest, followed by HIC, LMIC, and LIC; overall difference in response rate: v2 = 8.58, df = 3, p < 0.036). The average number of responses (in round 1) also differed by income classification, where, in general, average number of responses declined with lower economic wealth. However, the differences in answers per country fail to reach significance (Table 1), F(3, 42) = 2.60, p = 0.064. Estimates for Unrecorded Alcohol Tables 2 and S1 summarize the relationship between the average percent estimate of unrecorded alcohol consumption by country and economic wealth. The proportion of unrecorded consumption was, overall, the greater, the lower the income level (i.e., countries with the lowest income level had the greatest proportion of unrecorded consumption, and countries with the highest income level the smallest proportion; overall differences: F(3, 136) = 22.06, p < 0.0001).

ESTIMATION OF UNRECORDED ALCOHOL CONSUMPTION

1285

While expert and prior WHO estimates did not differ overall on average, F(1, 136) < 1, p = 0.84, both their variance differed, and they differed for different levels of income, interaction between type of estimate and income level, F (3, 136) = 3.14, p = 0.027. For LIC, expert estimates were on average 6% higher than prior WHO estimates, where for HIC, the reverse was true (WHO estimates 4.4% higher). In the second round for selected countries with high number of experts responding in the first round, usually high agreement was achieved (in several countries, all experts agreed; see Table S1). The 2 countries with the highest variation were Poland and Russia, where there was a tradition of indirect estimation of unrecorded consumption (Razvodovsky, 2010; Rehm and Poznyak, 2015), but where experts disagreed about the relevance of such indirect estimates. As shown in Table 2, expert unrecorded alcohol estimates were highest for LIC (56%) and LMIC (37%), and lowest for UMIC (27%) and HIC (14%). This gradient was also present in prior WHO estimates given as anchor in the sur-

vey, albeit to a different degree (different between LIC and HIC by experts: 42%; in WHO estimates: 32%). Between countries (Table S1), Ethiopia (77%), Kenya (66%), Ghana (60%), and Ukraine (60%) were estimated with the highest average estimated proportion of unrecorded alcohol consumption. Azerbaijan (2%), Estonia (4%), Italy (4%), and Czech Republic (9%) had the lowest estimates for unrecorded alcohol consumption estimates; however, the estimates for Estonia are confounded, as the official statistics for recorded consumption contain the majority of unrecorded alcohol. Unrecorded Consumption Patterns High variability was observed among type of unrecorded alcohol consumption within the selected countries. Homeproduced alcohol was overall the most important category and made up nearly 50% of unrecorded consumption in LIC and UMIC. Illegally produced alcohol on industrial scale

Table 1. Number of Countries Answered and Responses by Income Group 2010 Income levela

Number of countries approached

% of countries approachedb

Number of countries answeredc

Response rate (%)d

Average number of responses round 1e

Average number of responses round 2f

11 15 11 9 46

28 27 22 13 21

5 11 11 7 34

45 73 100 78 74

0.9 2.1 3.0 2.9 2.2

0.0 4.3 1.9 3.0 2.7

LIC LMIC UMIC HIC Total

a World Bank country classifications for 2010, where LIC is low-income countries, LMIC is lower middle-income countries, UMIC is upper middle-income countries, and HIC is high-income countries. b Percent of countries approached out of all the countries (worldwide) within the respective income group. c Countries that provided at least 1 completed questionnaire. d Number of countries answered divided by total number of countries approached. e Total number of responses received within income group, divided by the total number of countries approached within income group in round 1. f Total number of responses received within income group, divided by the total number of countries approached within income group in round 2.

Table 2. Average Unrecorded Percent Estimates: Experts and WHO

Round

N answers experts (countries)

LIC

1 2

10 (5) 0 (0)

LMIC

1 2 1 2 1 2 1 2

31 (11) 13 (3) 33 (11) 13 (7) 26 (7) 15 (5) 100 (35) 41 (15)

2010 Income levela

UMIC HIC Total

b

Total consumption (in l ethanol) 4.5 n.a. 7.9 9.3 9.8 12.8 11.0 10.7 8.7 11.4

Unrecorded consumption estimates in % of all per capita consumption, mean (SD) Experts

WHO

Differencec

56.0 (17.8) 50.0 (13.2) 6.0 (11.5) No second round due (not sufficient data for any country in round 1) 36.7 (20.8) 36.7 (24.7) 0 (9.3) 23.3 (9.4) 22.5 (9.8) 0.8 (2.4) 26.5 (19.0) 26.5 (11.7) 0.1 (20.0) 28.4 (10.1) 24.8 (7.6) 3.5 (9.9) 13.8 (7.6) 18.2 (4.5) 4.3 (6.3) 12.1 (7.3) 18.0 (4.3) 5.9 (6.8) 29.3 (21.1) 29.9 (18.1) 0.6 (13.6) 20.8 (11.2) 21.6 (7.8) 0.8 (8.0)

a World Bank country classifications for 2010, where LIC is low-income countries, LMIC is lower middle-income countries, UMIC is upper middle-income countries, and HIC is high-income countries. b Adult per capita consumption from 2014 Global Status Report on Alcohol and Health (World Health Organization, 2014). c Difference between expert and WHO estimates. Italics refer to round 2 estimates.

REHM ET AL.

1286

was observed as a sizable problem, especially in LMIC. Cross-border seems to be mainly a phenomenon in HIC, with over 33% of unrecorded alcohol consumed within this category. Surrogate was overall relatively least important type of unrecorded consumption, but still had 13% of unrecorded in LIC (see Table S2). Perceptions of Unrecorded Alcohol Consumption as Problem Overall, the majority of experts considered unrecorded consumption a financial (74%), public health (71%), and social problem (66%). In all 3 categories examined, perception as financial, public health, or social problems, there were no differences by income category of the country (all 3 chisquared tests with p-values above 0.05). DISCUSSION The current study aimed to determine the feasibility of the Delphi method to assess global unrecorded alcohol consumption. Overall, the results indicated that the methodology was successful in estimating the proportion of unrecorded consumption, with responses for 76% of all countries approached, which is roughly equivalent to over half of the world’s population. This does not necessarily answer the question about validity of answers, which were surely also impacted by the anchors, that is prior WHO estimates, given (Chapman and Johnson, 2002; Tversky and Kahneman, 1974). We can only give 2 examples of independent validation: the estimate for Sweden was almost identical to the empirical estimate derived from the regular survey, where a representative sample is asked about their alcohol purchases in the past 30 days (22.4% in the survey vs. 23% in the feasibility study; data from the survey obtained by Monitor Study, Centralf€ orbundet f€ or alkohol- och narkotikaupplysning). Second, for Russia, the estimate was 43.3% which was higher than the estimates of the Global Status Report of 23.8%, based on the methodology of indirect estimation via male unintentional injury or violence deaths (Nemtsov, 2011; Neufeld and Rehm, 2013; Norstr€ om, 2011). It is not clear which estimates are better, as we lack a gold standard, and this underlines the necessity to do more research on unrecorded consumption in Russia. However, the exercise also led to many additional materials, small studies, and other information, which will be helpful in this research and further estimates of unrecorded consumption. Unfortunately, there was a gradient in response rate based on income group: the Delphi method was least feasible in LIC with a response rate of under 50% of the countries compared to rates between 70 and 100% (for the other income categories; see Table 1). The lower response could be due to lack of accessible national and regional studies on unrecorded consumption in developing countries (Rehm et al., 2010). Alternative methods should be considered for closing this knowledge gap, such as random walk sampling in quar-

ters with high unrecorded consumption (for an application, see Rehm and Hingson, 2013), or surveys among treatment facilities for alcohol use disorders, as unrecorded consumption is often the beverage type of choice for heavy consumers including people with alcohol use disorders because of the relatively low price (Lachenmeier et al., 2007; Rehm et al., 2014). Also, the WHO risk factor surveillance surveys offer a module to assess unrecorded consumption with a few questions (STEPwise approach to surveillance http:// www.who.int/chp/steps/en/). Relationships between unrecorded consumption and income status of a country were also observed. Consistent with the 2014 Global Status Report on Alcohol and Health, we found that the higher the relative proportion of unrecorded alcohol consumption, the lower the economic wealth of a country (World Health Organization, 2014). Countries with the highest unrecorded alcohol consumption estimates (50% or greater) were the least wealthy, with 13% estimated to be surrogate alcohol. Such gradient could be linked to the notion that unrecorded alcohols, namely surrogate alcohol, tend to be cheaper than industrially produced beverages, thus easier to obtain (World Health Organization, 2014). This study also highlights some of the nuances of unrecorded alcohol consumption patterns, by country and income group. Home-produced alcohol was by far the most popular type of unrecorded consumption globally. Although crossborder shopping has been previously noted as less prevalent throughout the world (Rehm et al., 2010), we found that cross-border consumption generally remains salient in highincome economies. Estimates for surrogate alcohol consumption were overall low, with its relative proportion being highest in LIC. This finding came as a surprise, as more than 50% of the countries in the WHO survey on alcohol and health indicated the presence of surrogate unrecorded alcohol (see Rehm et al., 2014; World Health Organization, 2011). It seems that while surrogate alcohol is present in many countries, it does not necessarily cover a large proportion of the unrecorded alcohol consumption. With respect to type of alcohol, spirits make up the biggest portion of unrecorded consumption. There are exceptions in several African countries, where traditional fermented beverages like sorghum beer or palm wine constitute the biggest portion of unrecorded consumption (according to our experts in Angola, Burkina Faso, C^ ote d’Ivoire, Ethiopia, Kenya, South Africa, and Zambia). For more details on traditional beverages that are often unrecorded can be found in an earlier Global Status Report on Alcohol (World Health Organization, 2004). With respect to the perception of unrecorded consumption, the majority of experts perceived it as a financial, public health, and social problem (see above), reiterating the points of the WHO global strategy, where it is explicitly listed among the 10 areas for national action (World Health Organization, 2010). Interestingly, the financial problems of unrecorded consumption to a country (such as lack of taxation) were highlighted the most by experts. This is in line with

ESTIMATION OF UNRECORDED ALCOHOL CONSUMPTION

the result of reviews that the main ingredient to cause health harm in unrecorded alcohol is ethanol (Rehm et al., 2010, 2014). While this study was the first systematic effort to estimate unrecorded alcohol consumption for the most populous countries in the world, it is not without limitations. The biggest limitation certainly is the lack of a gold standard for the answers. While there are indications that these revised estimates constitute an improvement, we cannot be sure, as long as we do not have more systematic studies on the amount of unrecorded consumption. Second, while the experts were selected based on their contribution to the literature in the respective countries, they are a convenience sample, and it is hard to estimate the potential bias of their estimates. Also, the selection criteria favored experts from countries of higher income categories, as there is still a marked gradient in publications between the richest and the poorest countries. CONCLUSION This study examined the feasibility of assessing unrecorded alcohol consumption and found overall quite positive results, albeit with some problems in finding experts for LIC. The main contributions consisted in finding additional empirical evidence for estimates, clearer information on patterns and subcategories of unrecorded consumption and some indications that prior WHO estimates may have systematically underestimated unrecorded in LIC and overestimated in HIC. Given that unrecorded was seen as a financial, public health, and social problem by most respondents, policy measures to deal with unrecorded alcohol consumption should be more widely implemented (Lachenmeier et al., 2011; World Health Organization, 2011). CONFLICT OF INTEREST The authors report no conflict of interest. REFERENCES Chapman GB, Johnson EJ (2002) Incorporating the irrelevant: anchors in judgments of belief and value, in Heuristics and Biases: The Psychology of Intuitive Judgement (Gilovich T, Griffin DW, Kahneman D eds), pp 120– 138. Cambridge University Press, New York, NY. De Boni RB, Bertoni N, Bastos LS, Bastos FI (2014) Unrecorded alcohol in Rio de Janeiro: assessing its misusers through Respondent Driven Sampling. Drug Alcohol Depend 1:169–173. Delbecq AL, Van de Ven AH, Gustafson DH (1975) Group Techniques for Program Planning: A Guide to Nominal Group and Delphi Processes. Scott Foresman and Company, Glenview, IL. Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, Burnett R, Casey D, Coates MM, Cohen A, Delwiche K, Estep K, Frostad JJ, Astha KC, Kyu HH, Moradi-Lakeh M, Ng M, Slepak EL, Thomas BA, Wagner J, Aasvang GM, Abbafati C, Abbasoglu Ozgoren A, Abd-Allah F, Abera SF, Aboyans V, Abraham B, Abraham JP, Abubakar I, Abu-Rmeileh NM, Aburto TC, Achoki T, Adelekan A, Adofo K, Adou AK, Adsuar JC, Afshin A, Agardh EE, Al Khabouri MJ, Al Lami FH, Alam SS, Alasfoor D, Albittar MI, Alegretti MA, Aleman AV,

1287

Alemu ZA, Alfonso-Cristancho R, Alhabib S, Ali R, Ali MK, Alla F, Allebeck P, Allen PJ, Alsharif U, Alvarez E, Alvis-Guzman N, Amankwaa AA, Amare AT, Ameh EA, Ameli O, Amini H, Ammar W, Anderson BO, Antonio CA, Anwari P, Argeseanu Cunningham S, Arnlov J, Arsenijevic VS, Artaman A, Asghar RJ, Assadi R, Atkins LS, Atkinson C, Avila MA, Awuah B, Badawi A, Bahit MC, Bakfalouni T, Balakrishnan K, Balalla S, Balu RK, Banerjee A, Barber RM, Barker-Collo SL, Barquera S, Barregard L, Barrero LH, Barrientos-Gutierrez T, Basto-Abreu AC, Basu A, Basu S, Basulaiman MO, Batis Ruvalcaba C, Beardsley J, Bedi N, Bekele T, Bell ML, Benjet C, Bennett DA, Benzian H, Bernabe E, Beyene TJ, Bhala N, Bhalla A, Bhutta ZA, Bikbov B, Bin Abdulhak AA, Blore JD, Blyth FM, Bohensky MA, Bora Basara B, Borges G, Bornstein NM, Bose D, Boufous S, Bourne RR, Brainin M, Brazinova A, Breitborde NJ, Brenner H, Briggs AD, Broday DM, Brooks PM, Bruce NG, Brugha TS, Brunekreef B, Buchbinder R, Bui LN, Bukhman G, Bulloch AG, Burch M, Burney PG, Campos-Nonato IR, Campuzano JC, Cantoral AJ, Caravanos J, Cardenas R, Cardis E, Carpenter DO, Caso V, CastanedaOrjuela CA, Castro RE, Catala-Lopez F, Cavalleri F, Cavlin A, Chadha VK, Chang JC, Charlson FJ, Chen H, Chen W, Chen Z, Chiang PP, Chimed-Ochir O, Chowdhury R, Christophi CA, Chuang TW, Chugh SS, Cirillo M, Classen TK, Colistro V, Colomar M, Colquhoun SM, Contreras AG, Cooper C, Cooperrider K, Cooper LT, Coresh J, Courville KJ, Criqui MH, Cuevas-Nasu L, Damsere-Derry J, Danawi H, Dandona L, Dandona R, Dargan PI, Davis A, Davitoiu DV, Dayama A, de Castro EF, De la Cruz-Gongora V, De Leo D, de Lima G, Degenhardt L, del Pozo-Cruz B, Dellavalle RP, Deribe K, Derrett S, Des Jarlais DC, Dessalegn M, deVeber GA, Devries KM, Dharmaratne SD, Dherani MK, Dicker D, Ding EL, Dokova K, Dorsey ER, Driscoll TR, Duan L, Durrani AM, Ebel BE, Ellenbogen RG, Elshrek YM, Endres M, Ermakov SP, Erskine HE, Eshrati B, Esteghamati A, Fahimi S, Faraon EJ, Farzadfar F, Fay DF, Feigin VL, Feigl AB, Fereshtehnejad SM, Ferrari AJ, Ferri CP, Flaxman AD, Fleming TD, Foigt N, Foreman KJ, Paleo UF, Franklin RC, Gabbe B, Gaffikin L, Gakidou E, Gamkrelidze A, Gankpe FG, Gansevoort RT, Garcia-Guerra FA, Gasana E, Geleijnse JM, Gessner BD, Gething P, Gibney KB, Gillum RF, Ginawi IA, Giroud M, Giussani G, Goenka S, Goginashvili K, Gomez Dantes H, Gona P, Gonzalez de Cosio T, Gonzalez-Castell D, Gotay CC, Goto A, Gouda HN, Guerrant RL, Gugnani HC, Guillemin F, Gunnell D, Gupta R, Gupta R, Gutierrez RA, Hafezi-Nejad N, Hagan H, Hagstromer M, Halasa YA, Hamadeh RR, Hammami M, Hankey GJ, Hao Y, Harb HL, Haregu TN, Haro JM, Havmoeller R, Hay SI, Hedayati MT, Heredia-Pi IB, Hernandez L, Heuton KR, Heydarpour P, Hijar M, Hoek HW, Hoffman HJ, Hornberger JC, Hosgood HD, Hoy DG, Hsairi M, Hu G, Hu H, Huang C, Huang JJ, Hubbell BJ, Huiart L, Husseini A, Iannarone ML, Iburg KM, Idrisov BT, Ikeda N, Innos K, Inoue M, Islami F, Ismayilova S, Jacobsen KH, Jansen HA, Jarvis DL, Jassal SK, Jauregui A, Jayaraman S, Jeemon P, Jensen PN, Jha V, Jiang F, Jiang G, Jiang Y, Jonas JB, Juel K, Kan H, Kany Roseline SS, Karam NE, Karch A, Karema CK, Karthikeyan G, Kaul A, Kawakami N, Kazi DS, Kemp AH, Kengne AP, Keren A, Khader YS, Khalifa SE, Khan EA, Khang YH, Khatibzadeh S, Khonelidze I, Kieling C, Kim D, Kim S, Kim Y, Kimokoti RW, Kinfu Y, Kinge JM, Kissela BM, Kivipelto M, Knibbs LD, Knudsen AK, Kokubo Y, Kose MR, Kosen S, Kraemer A, Kravchenko M, Krishnaswami S, Kromhout H, Ku T, Kuate Defo B, Kucuk Bicer B, Kuipers EJ, Kulkarni C, Kulkarni VS, Kumar GA, Kwan GF, Lai T, Lakshmana Balaji A, Lalloo R, Lallukka T, Lam H, Lan Q, Lansingh VC, Larson HJ, Larsson A, Laryea DO, Lavados PM, Lawrynowicz AE, Leasher JL, Lee JT, Leigh J, Leung R, Levi M, Li Y, Li Y, Liang J, Liang X, Lim SS, Lindsay MP, Lipshultz SE, Liu S, Liu Y, Lloyd BK, Logroscino G, London SJ, Lopez N, Lortet-Tieulent J, Lotufo PA, Lozano R, Lunevicius R, Ma J, Ma S, Machado VM, MacIntyre MF, Magis-Rodriguez C, Mahdi AA, Majdan M, Malekzadeh R, Mangalam S, Mapoma CC, Marape M, Marcenes W, Margolis DJ, Margono C, Marks GB, Martin RV, Marzan MB, Mashal MT, Masiye F, Mason-Jones AJ, Matsushita K, Matzopoulos R, Mayosi BM, Mazorodze TT, McKay AC, McKee M, McLain A, Meaney PA, Medina C, Mehndiratta MM, Mejia-Rodriguez F, Mekonnen W, Melaku YA, Meltzer M, Memish ZA, Mendoza W, Mensah GA, Meretoja A, Mhimbira

1288

FA, Micha R, Miller TR, Mills EJ, Misganaw A, Mishra S, Mohamed Ibrahim N, Mohammad KA, Mokdad AH, Mola GL, Monasta L, Montanez Hernandez JC, Montico M, Moore AR, Morawska L, Mori R, Moschandreas J, Moturi WN, Mozaffarian D, Mueller UO, Mukaigawara M, Mullany EC, Murthy KS, Naghavi M, Nahas Z, Naheed A, Naidoo KS, Naldi L, Nand D, Nangia V, Narayan KM, Nash D, Neal B, Nejjari C, Neupane SP, Newton CR, Ngalesoni FN, Ngirabega Jde D, Nguyen G, Nguyen NT, Nieuwenhuijsen MJ, Nisar MI, Nogueira JR, Nolla JM, Nolte S, Norheim OF, Norman RE, Norrving B, Nyakarahuka L, Oh IH, Ohkubo T, Olusanya BO, Omer SB, Opio JN, Orozco R, Pagcatipunan RS Jr, Pain AW, Pandian JD, Panelo CI, Papachristou C, Park EK, Parry CD, Paternina Caicedo AJ, Patten SB, Paul VK, Pavlin BI, Pearce N, Pedraza LS, Pedroza A, Pejin Stokic L, Pekericli A, Pereira DM, Perez-Padilla R, Perez-Ruiz F, Perico N, Perry SA, Pervaiz A, Pesudovs K, Peterson CB, Petzold M, Phillips MR, Phua HP, Plass D, Poenaru D, Polanczyk GV, Polinder S, Pond CD, Pope CA, Pope D, Popova S, Pourmalek F, Powles J, Prabhakaran D, Prasad NM, Qato DM, Quezada AD, Quistberg DA, Racape L, Rafay A, Rahimi K, Rahimi-Movaghar V, Rahman SU, Raju M, Rakovac I, Rana SM, Rao M, Razavi H, Reddy KS, Refaat AH, Rehm J, Remuzzi G, Ribeiro AL, Riccio PM, Richardson L, Riederer A, Robinson M, Roca A, Rodriguez A, Rojas-Rueda D, Romieu I, Ronfani L, Room R, Roy N, Ruhago GM, Rushton L, Sabin N, Sacco RL, Saha S, Sahathevan R, Sahraian MA, Salomon JA, Salvo D, Sampson UK, Sanabria JR, Sanchez LM, Sanchez-Pimienta TG, Sanchez-Riera L, Sandar L, Santos IS, Sapkota A, Satpathy M, Saunders JE, Sawhney M, Saylan MI, Scarborough P, Schmidt JC, Schneider IJ, Schottker B, Schwebel DC, Scott JG, Seedat S, Sepanlou SG, Serdar B, Servan-Mori EE, Shaddick G, Shahraz S, Levy TS, Shangguan S, She J, Sheikhbahaei S, Shibuya K, Shin HH, Shinohara Y, Shiri R, Shishani K, Shiue I, Sigfusdottir ID, Silberberg DH, Simard EP, Sindi S, Singh A, Singh GM, Singh JA, Skirbekk V, Sliwa K, Soljak M, Soneji S, Soreide K, Soshnikov S, Sposato LA, Sreeramareddy CT, Stapelberg NJ, Stathopoulou V, Steckling N, Stein DJ, Stein MB, Stephens N, Stockl H, Straif K, Stroumpoulis K, Sturua L, Sunguya BF, Swaminathan S, Swaroop M, Sykes BL, Tabb KM, Takahashi K, Talongwa RT, Tandon N, Tanne D, Tanner M, Tavakkoli M, Te Ao BJ, Teixeira CM, Tellez Rojo MM, Terkawi AS, Texcalac-Sangrador JL, Thackway SV, Thomson B, Thorne-Lyman AL, Thrift AG, Thurston GD, Tillmann T, Tobollik M, Tonelli M, Topouzis F, Towbin JA, Toyoshima H, Traebert J, Tran BX, Trasande L, Trillini M, Trujillo U, Dimbuene ZT, Tsilimbaris M, Tuzcu EM, Uchendu US, Ukwaja KN, Uzun SB, van de Vijver S, Van Dingenen R, van Gool CH, van Os J, Varakin YY, Vasankari TJ, Vasconcelos AM, Vavilala MS, Veerman LJ, Velasquez-Melendez G, Venketasubramanian N, Vijayakumar L, Villalpando S, Violante FS, Vlassov VV, Vollset SE, Wagner GR, Waller SG, Wallin MT, Wan X, Wang H, Wang J, Wang L, Wang W, Wang Y, Warouw TS, Watts CH, Weichenthal S, Weiderpass E, Weintraub RG, Werdecker A, Wessells KR, Westerman R, Whiteford HA, Wilkinson JD, Williams HC, Williams TN, Woldeyohannes SM, Wolfe CD, Wong JQ, Woolf AD, Wright JL, Wurtz B, Xu G, Yan LL, Yang G, Yano Y, Ye P, Yenesew M, Yentur GK, Yip P, Yonemoto N, Yoon SJ, Younis MZ, Younoussi Z, Yu C, Zaki ME, Zhao Y, Zheng Y, Zhou M, Zhu J, Zhu S, Zou X, Zunt JR, Lopez AD, Vos T, Murray CJ (2015) Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386:2287–2323. Lachenmeier DW, Gmel G, Rehm J (2013) Unrecorded alcohol consumption, in Alcohol: Science, Policy, and Public Health (Boyle P, Boffetta P, Lowenfels AB, Burns H, Brawley O, Zatonski W, Rehm J eds), pp 132– 142. Oxford University Press, Oxford, UK. Lachenmeier DW, Rehm J, Gmel G (2007) Surrogate alcohol: what do we know and where do we go? Alcohol Clin Exp Res 31:1613–1624. Lachenmeier DW, Taylor BJ, Rehm J (2011) Alcohol under the radar: do we have policy options regarding unrecorded alcohol? Int J Drug Policy 22:153–160. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, Amann M, Anderson HR, Andrews KG, Aryee M, Atkinson C, Bacchus

REHM ET AL.

LJ, Bahalim AN, Balakrishnan K, Balmes J, Barker-Collo S, Baxter A, Bell ML, Blore JD, Blyth F, Bonner C, Borges G, Bourne R, Boussinesq M, Brauer M, Brooks P, Bruce NG, Brunekreef B, Bryan-Hancock C, Bucello C, Buchbinder R, Bull F, Burnett RT, Byers TE, Calabria B, Carapetis J, Carnahan E, Chafe Z, Charlson F, Chen H, Chen JS, Cheng T-A, Child JC, Cohen A, Colson KE, Cowie BC, Darby S, Darling S, Davis A, Degenhardt L, Dentener F, Des Jarlais DC, Devries K, Dherani M, Ding EL, Dorsey ER, Driscoll T, Edmond K, Ali SE, Engell RE, Erwin PJ, Fahimi S, Falder G, Farzadfar F, Ferrari A, Finucane MM, Flaxman S, Fowkes FG, Freedman G, Freeman MK, Gakidou E, Ghosh S, Giovannucci E, Gmel G, Graham K, Grainger R, Grant B, Gunnell D, Gutierrez HR, Hall W, Hoek HW, Hogan A, Hosgood HD III, Hoy D, Hu H, Hubbell BJ, Hutchings SJ, Ibeanusi SE, Jacklyn GL, Jasrasaria R, Jonas JB, Kan H, Kanis JA, Kassenbaum N, Kawakami N, Khang Y-H, Khatibzadeh S, Khoo J-P, Kok C, Laden F, Lalloo R, Lan Q, Lathlean T, Leasher JL, Leigh J, Li Y, Lin JK, Lipshultz SE, London S, Lozano R, Lu Y, Mak J, Malekzadeh R, Mallinger L, Marcenes W, March L, Marks RE, Martin RE, McGale P, McGrath J, Mehta S, Mensah GA, Merriman TR, Micha R, Michaud C, Mishra V, Hanafiah KM, Mokdad AA, Morawska L, Mozaffarian D, Murphy T, Naghavi M, Neal B, Nelson PK, Nolla JM, Norman R, Olives C, Omer SB, Orchard J, Osborne Rh, Ostro B, Page A, Pandey KD, Parry CD, Passmore E, Patra J, Pearce N, Pelizarri PM, Petzold M, Phillips MR, Pope D, Pope CA III, Powles J, Rao M, Razavi H, Rehfuess EA, Rehm JT, Ritz B, Rivara FP, Roberts T, Robinson C, Rodriguez-Portales JA, Romieu I, Room R, Rosenfeld LC, Roy A, Rushton L, Salomon JA, Sampson U, Sanchez-Riera L, Sanman E, Sapkota A, Seedat S, Shi P, Shield KD, Shivakoti R, Singh GM, Sleet DA, Smith E, Smith KR, Stapelberg NJ, Steenland K, St€ ockl H, Stovner P, Straif K, Straney L, Thurston GD, Tran JH, Dingenen RV, Van Donkelaar A, Lennert Veerman J, Vijayakumar L, Weintraub R, Weissman MM, White RA, Whiteford H, Wiersma ST, Wilkinson JD, Williams HC, Williams W, Wilson N, Woolf AD, Yip P, Zielinski JM, Lopez AD, Murray CL, Ezzati M (2012) A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380:2224–2260. Linstone HA, Turoff M (1975) Delphi Method: Techniques and Applications. Addison-Wesley, Boston, MA. Nemtsov AV (2011) A Contemporary History of Alcohol in Russia. S€ odert€ orns h€ ogskola, Stockholm, Sweden. Neufeld M, Rehm J (2013) Alcohol consumption and mortality in Russia since 2000—are there any changes following the alcohol policy changes starting in 2006. Alcohol Alcohol 48:222–230. Norstr€ om T (2011) The role of alcohol in the Russian mortality crisis. Addiction 106:1957–1965. Poznyak V, Fleischmann A, Rekve D, Rylett M, Rehm J, Gmel G (2013) The World Health Organization’s global monitoring system on alcohol and health. Alcohol Res 35:244–249. Razvodovsky YE (2010) Unrecorded alcohol consumption: quantitative methods of estimation. Alcoholism 46:15–24. Rehm J, Gadenne V (1990) Intuitive predictions and professional forecasts. Cognitive processes and social consequences, in International Series in Experimental Social Psychology. Pergamon Press, Oxford. Rehm J, Hingson R (2013) Measuring the burden. Alcohol’s evolving impact on individuals, families, and society. Alcohol Res 35:117–118. Rehm J, Kailasapillai S, Larsen E, Rehm MX, Samokhvalov AV, Shield KD, Roerecke M, Lachenmeier DW (2014) A systematic review of the epidemiology of unrecorded alcohol consumption and the chemical composition of unrecorded alcohol. Addiction 109:880–893. Rehm J, Kanteres F, Lachenmeier DW (2010) Unrecorded consumption, quality of alcohol and health consequences. Drug Alcohol Rev 29:426–436. Rehm J, Klotsche J, Patra J (2007) Comparative quantification of alcohol exposure as risk factor for global burden of disease. Int J Methods Psychiatr Res 16:66–76. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J (2009) Global burden of disease and injury and economic cost attributable to alcohol use and alcohol use disorders. Lancet 373:2223–2233.

ESTIMATION OF UNRECORDED ALCOHOL CONSUMPTION

Rehm J, Poznyak V (2015) On monitoring unrecorded alcohol consumption. Alcohol Drug Addict 28:79–89. Tversky A, Kahneman D (1974) Judgement under uncertainty: heuristics and biases. Science 185:1124–1131. Van de Ven AH, Delbecq AL (1974) The effectiveness of nominal, delphi, and interacting group decision making processes. Acad Manage J 17:605–621. Winer BJ (1962) Statistical Principles in Experimental Design. 2nd ed. McGraw-Hill Inc., New York, NY. World Health Organization (2004) Global Status Report on Alcohol. World Health Organization, Geneva, Switzerland. World Health Organization (2010) Global Strategy to Reduce the Harmful Use of Alcohol. World Health Organization, Geneva, Switzerland. World Health Organization (2011) Global Status Report on Alcohol and Health. World Health Organization, Geneva, Switzerland.

1289

World Health Organization (2014) Global Status Report on Alcohol and Health. World Health Organization, Geneva, Switzerland.

SUPPORTING INFORMATION Additional Supporting Information may be found online in the supporting information tab for this article: Table S1. Mean percent of unrecorded alcohol consumption and number of responses, by country and income group (rounds 1 and 2). Table S2. Percent of unrecorded alcohol type by country and income group.