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After the party, the hangover

One out of every four Brazilians drinks to the point of risking physical, psychological and social problems

MIGUEL BOYAYANA few weeks ago a phone call rendered psychiatrist Ronaldo Laranjeira speechless. On the other side of the line, a cousin that he had not talked to in a long time told him about the ordeal his father, who had been alcohol-dependent for years, had gone through a short time before. Upon feeling unwell on a Friday evening, he experienced the treatment given to the 10% of the population that is unable to free itself from alcohol and cannot spend more than one day without beer or cachaça (sugarcane spirits). He was taken to a São Paulo municipal hospital where the doctor in attendance apparently failed to grasp the situation, disliked what he saw and dismissed him, but not before scolding the family and inquiring why they had taken a drunk to hospital. The following day, Laranjeira”s uncle died.

This news arrived at a point in time when Laranjeira had just taken a major step toward understanding how the roots of alcohol dependence develop among Brazil”s population. After 30 years at Unifesp (the Federal University of São Paulo) doing research into the problems caused by the consumption of alcohol and other drugs, Laranjeira was preparing to publish the first national survey showing how much, how and what is drunk in this country, as presented in August at the Planalto Palace (official residence of the president of Brazil). From November 2005 to April 2006, researchers trained by him and his team interviewed 3,007 people aged over 13 in urban and rural areas in 147 towns across five regions of Brazil.

The result is the broadest picture of alcohol consumption in Brazil, which, together with other research studies, may provide guidance for the implementation of measures set forth in the National Alcoholic Beverages Policy. Sanctioned in May by President Lula, the objective of this law is to reduce the consumption of alcohol and the damage it causes, such as traffic accidents and the development of cancer, besides emotional losses.

What does this study show? A great deal, regarding issues only vaguely known about, generally drawn from studies based on a narrower sample or research conducted abroad. From its very start, the work coordinated by Laranjeira and financed by Senad, the National Anti-drug Bureau, which answers to the Presidency of the Republic, showed a more complex alcohol consumption pattern than originally envisaged and toppled the myth that almost all Brazilians drink in moderation, just the occasional mug of beer or glass of wine from time to time.

Now we know that roughly half of the adult population, more specifically 48% of people over 18, consists of teetotalers: they consume no alcoholic beverages or do so, on average, less than once a year, a piece of information that the Unifesp group is still unable to fully explain. According to Laranjeira, this figure is higher than expected and may, at least in part, be justified by religious reasons, since one out of every four people interviewed declared they were evangelical or protestant, religions that generally frown upon alcohol consumption and encourage abstinence.

What concerns researchers the most, however, is what happens to the other 52% of Brazilians. Out of these, roughly half enjoys a chilled beer or a glass of wine infrequently: one to three times a month. The problem is the other half, or 25% of the adult population, equal to some 30 million Brazilians, who consume alcohol more than once a week. One out of every six of these, classified as frequent drinkers, consumes amounts of alcohol regarded as bad for health, as they raise the risk of getting involved in fights, falling or having unprotected sex. On most of the occasions when these people sit at a bar, they have at least five shots of alcohol? one shot contains approximately 12 grams of pure alcohol and is equivalent to a can of beer, 45 milliliters of whisky or sugarcane spirits, one glass of wine or a small bottle of an “ice” type of drink.

EDUARDO CESARThis consumption pattern is different from the European one. In Mediterranean countries, one generally has wine quite often and in small quantities, during meals, whereas in Nordic countries and in Eastern Europe it is more common to consume lots and lots of whisky or vodka. The Brazilian consumption pattern is more varied. Many drink a little and a few drink a lot, which puts us among medium-sized consumers in the Americas, according to data from an unprecedented survey conducted by the Pan-American Health Organization. “We don”t drink any more than the Canadians, the Americans or the people from other countries in Europe, but we consume alcohol in a more harmful manner”, explains psychiatrist Florence Kerr-Corrêa, from Unesp, the Paulista State University at Botucatu, who studied differences in the consumption patterns of men vs. women.

Another characteristic of Brazilian consumption is the consumption of high levels of alcohol for a longer period of time over the course of a lifetime. As in several other countries, it is young people who drink the most. However, in Brazil, one continues to drink heavily until the age of 45 or 50, whereas in the USA the consumption of alcoholic beverages decreases after the third decade in life. “These data suggest that probably there will be more problems involving alcohol abuse and alcohol dependence among people of a productive age, during a stage in life in which they have generally acquired a family already”, explains Brazilian epidemiologist and psychiatrist Raul Caetano, a University of Texas professor and the author of the study”s questionnaire and the strategy.

There, people drink more heavily in the Northeastern and Midwestern regions, where 38% of people do not stop before the fifth glass. In the South and the Southeast, consumption is more moderate but frequent: half the population does not have more than two drinks at a time. Almost always it is the men who drink the most, whereas women, who are more sensitive to the effects of alcohol, generally limit themselves to one or two glasses. In all the regions, the most consumed beverage is beer, although there are variations in the North and in the Northeast, where sugarcane spirits rank second, ahead of wine. Another difference is that people of a higher social class (A and B) consume alcohol differently from those from class E. “The former drink during meals, in bars, together with tidbits, or alone, at home”, explains Laranjeira. “As for poorer people, it is the men who drink; they meet at a cheap bar and drink sugarcane spirits standing up, eating nothing with it.”

Once the calculations were completed, it appeared that these so-called frequent or heavy drinkers accounted for no less than 10% of adult Brazilians or 12 million people. This is equal to the population of a major city such as São Paulo. And once a week, it fills tens of thousands of restaurants, bars, and snack and drink outlets throughout the country and consumes at least five glasses of beer or several shots of sugarcane spirits. One can even imagine that five shots, which is what lots of people are capable of having when they go out to chat with their friends, are virtually nothing. But is that true?

Minutes after the first swig out of a glass of draft beer – or, as is more often the case among the inhabitants of the state of Rio Grande do Sul, the first glass of wine – alcohol reaches the stomach, where half is digested. What is not broken down chemically in the stomach goes through its walls and the small intestine, rapidly reaching the bloodstream. Comprised of one carbon atom, six hydrogen atoms and one oxygen atom, the ethanol molecule – the alcohol found in vodka, cognac and all alcoholic beverages – is easily diluted in blood. A small part is filtered by the kidneys and accumulates in the bladder, which is what causes the frequent and generally urgent need to urinate. The rest accumulates in water-rich tissues and organs, such as the muscles and the brain, besides being transported to the liver, where it undergoes two transformation stages in which a compound is generated that is less toxic for cells: acetic acid. Part of the alcohol, however, only goes through a partial transformation, generating a highly toxic compound, aldehyde, that damages cells and brings on a hangover, the characteristic “day-after” headache.

EDUARDO CESAR

This degrading process is rather slow. It is calculated that the body takes about one hour to degrade the alcohol in a single portion of drink. In a 70-kg adult, the 12 grams of pure alcohol found in can of beer or in a glass of whisky in just a few minutes reach a concentration of 0.2 g/l of blood. Just a little more than this is already enough to relax the body and make the person less shy and far more talkative; this is the euphoria stage, which is what is sought by everyone who is having a drink to get over a bad day or to feel more self confident in order to chat to the girl at the next table.

Excitement and self-assurance, however, do not last long. If in less than one hour another two cans of beer are consumed, one easily exceeds the concentration of 0.6 g/l of blood, the upper limit for driving, according to the Brazilian Traffic Code. When this happens, it is best to leave the car in the parking lot and get a ride with someone that is sober or to take a taxi home. This is when another type of alcohol effect starts appearing; one that interferes with the activity of the chemical messengers dopamine, gamma-aminobutyric acid and noradrenaline, thereby reducing the operation of different areas of the brain. After the fifth shot, thought processes become sluggish, wording is chosen more uninhibitedly, vision becomes more blurred and one”s reaction capabilities are impaired. Consumed in even greater amounts in the course of a few hours – teenage drunkenness in clubs – alcohol can lead to coma and even death, by hampering the workings of the centers in the brain that coordinate breathing.

Exaggerated consumption, if infrequent, does not usually cause any more damage to the drinker than an acute intoxication that lasts for one day and that makes the head spin, while churning the stomach and leaving a bitter taste in the mouth. If this behavior becomes habitual, however, irreversible damage can arise in organs such as the heart, the brain and the liver. It also increases the risk of developing depression and certain types of cancer. At this consumption level, the damage exceeds, by far, the benefits that the quantities of alcohol considered safe by the World Health Organization – two doses a day for men and one for women – can provide to the cardiovascular system. “Even at the safe level, alcohol only brings cardiovascular benefits to men over 40. In terms of health, younger men get nothing from drink”, says Caetano.

Another consequence of frequent consumption of high or low doses of beer, whisky and even wine is an increased risk of dependence, which generates problems for drinkers, their family and their friends. This psychiatric disturbance, which accounts for 90% of hospitalizations connected to drugs in this country, affects approximately one out of every ten Brazilians, a ratio five times higher than the world average. Furthermore, there are signs that this figure is rising in medium-sized and large cities: it climbed from 11.25 in 2001 to 12.3% in 2005 among people aged 12 to 65 living in towns with more than 200 thousand inhabitants, according to studies carried out by the team from Cebrid, the Brazilian Center of Information on Psychotropic Drugs, from Unifesp.

More easily recognizable, dependence and the illnesses that affect different organs are not the only problems brought on by alcohol consumption. There is another type of damage that is just as important and that until a few years ago had remained invisible: the so-called social damage, which is the price paid by the entire community, as a result of reduced productivity at work, wounds caused by fights, illnesses that weaken the patient from the physical and psychological standpoint, and treatment in public hospitals. World Health Organization data indicate that alcohol, directly or indirectly, accounts for 3% of deaths and 4% of all diseases. This ratio is higher in developing countries such as Brazil, where alcohol is linked to roughly 10% of deaths and illnesses as well, according to an estimate of Laranjeira and José Ninio Meloni, published in 2004 in Revista Brasileira de Psiquiatria (the Brazilian Journal of Psychiatry).

MIGUEL BOYAYAN

Although the exact figures remain unknown, it is believed that the cause of most of these deaths consists of traffic accidents involving drivers who insist upon driving home even after they have had several glasses of draft beer. Every year, about 20,000 people die in car accidents in Brazil, according to data released by the National Traffic Department. This is almost half the number of automobile-related accidents in the United States, a country whose vehicle fleet is almost six times larger than Brazil”s; over there, some 240 million automobiles are on the road, vs. about 38 million over here.

In the national survey, Laranjeira found that 10% of people who drink had driven at least once after consuming alcohol in the 12 months that preceded the interview. “It”s a very high ratio”, he commented. “In the United States, authorities become alarmed when this figure reaches three or four percent of drivers”, he says. Roughly three times more common among Brazilians than among North Americans, this habit may be even more common in large cities.

In another recent study, Laranjeira and physician Sérgio Duailibi decided to visit the streets of five Brazilian cities (São Paulo, Diadema, Santos, Belo Horizonte and Vitória) to check whether drivers drove after drinking alcohol. From 10 p.m. to 3 a.m. over several Fridays and Saturdays, they stopped 5,600 drivers and asked them to breath into a breath analyzer. On average, one out of every three drivers had been drinking before taking to the wheel – a ratio that ranged from 21% in Diadema, in the Greater São Paulo Area, to 41% in Vitória, capital of the state of Espírito Santo. In all the cities, one fifth of the drivers should not have been behind a steering wheel, since their blood alcohol levels exceeded the legal limit.

If low doses were sufficient to put at risk the safety of the driver – and of those who are nearby – it is easy to imagine what actually happens on the streets of our cities, where consumption is high, especially among young people. Almost half of the interviewees in the national survey had consumed alcohol compulsively (more than five shots among men and four among women in just a few hours) at least once during the previous year, while half of them drink like that at least once a month.The Brazilian Traffic Code allows one to drive provided one”s blood alcohol concentration does not exceed 0.6 grams of alcohol per liter of blood. However, even this level may not be safe. In July, Quatro Rodas (a leading car magazine in Brazil) published the results of an informal, but fairly illustrative, test of what can happen in traffic. Under the supervision of physicians, nine youngsters consumed successive doses of alcoholic beverages before driving over a short distance in which plastic cones simulated curves and obstacles. Even before reaching the legal limit, most of them ran over the cones and started speeding. There were also some who braked at green lights or got confused parking in their garage.

This type of consumption, which doctors call “binge drinking”, is more common among young men, particularly those aged up to 42. That, however, does not exclude the other gender: single or divorced women aged 18 to 44 who have completed high school or are at university also tend to go overboard as much as men where drinking is concerned, according to a study conducted by psychiatrists Laura Andrade, Camila Magalhães Silveira and Arthur Guerra Andrade, from the University of São Paulo (USP).

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They evaluated the alcohol consumption patterns of 1,464 people aged 18 and over in two middle-class and upper middle-class districts in the city of São Paulo: the elegant Jardim América and the bohemian Vila Madalena, where many streets are lined with bars. They found that one out of every ten interviewees had drunk excessively at least once in the previous year. Most consumed that much alcohol more than once a week, as described by the USP team in an article in the Journal of Studies on Alcohol and Drugs.

“The earlier people start drinking, the greater the risk of developing this consumption pattern”, says Camila. Moreover, the more they drink, the greater the problems they face. Laura asked how often the interviewees had one or more problems of a physical, emotional or social nature – covering a range of 24 different types. She then compared the results with the number of times they consumed alcohol a week and the amount of alcohol consumed every time they sat down to drink. As the consumption of alcohol increased, so did the problems, especially among the men, who tended to get into fights more often and became the target of their friends” or partners” complaints. However, the women who drank a large amount of alcohol faced the same proportion of problems as the men. Furthermore, they suffered from what physicians call the telescope effect. “Those who started drinking early move on to frequent alcohol consumption faster and also become alcohol-dependent sooner”, explains Laura.

Florence Kerr-Corrêa ascribed high alcohol consumption among women to their changing role within society. She compared how people drink in Botucatu and in Rubião Junior, a smaller town with a lower socioeconomic and cultural level. She found that alcohol consumption – whether in small or large doses – was more common among the female inhabitants of Botucatu, who had access to education and paid work.

One of the results of the national survey that drew the attention of Laranjeira”s team the most was the consumption of alcohol by adolescents. Of the 3,007 interviewees, 661 were aged 14 to 17 and should not have been able to purchase any alcohol at all, according to Brazilian law. Nevertheless, 24% of them said that they consumed alcohol more than once a month. Almost half of the adolescents who drink generally have more than three shots, and a similar ratio consumes alcohol compulsively at least once a month. More importantly, this study”s data suggest that people are starting to have beer, wine and other beverages at an increasingly younger age, comments Ilana Pinsky, a psychologist from Unifesp and co-author of the national study. People who at the time of the interviews were minors had had alcohol for the first time before they turned 14 and six months later they were already drinking regularly, whereas those aged 18 to 25 had only tried alcohol around the age of 15 and started drinking two years later, after they were 17. “Adolescents in general drink to relax, to have fun and to become part of the group”, explains Ilana; “the problem is that they are more susceptible to the effects of alcohol.”

“Adolescence is a period in which people naturally try new experiences”, recognizes Laranjeira. “But chemical experimentation also carries risks in its wake.” Studies conducted in Brazil and abroad show that the earlier one starts drinking, the greater the risk of becoming dependent. It also increases the likelihood of accidents, fights, falls and unprotected sex. However, the complications do not stop here. From the physiological point of view, adolescence is a stage in life when the brain is still developing and this can be jeopardized by alcohol. “There is no alcohol consumption level considered safe for adolescents. The longer drinking is delayed, the smaller the problems”, states Camila, who, together with Arthur Guerra Andrade, is part of Cisa, the Center of Information about Health and Alcohol, an NGO that is sponsored, among other organizations, by AmBev, the country”s largest beer manufacturer.

Given this outlook, the following question arises: what can one do to reduce alcohol consumption in the country and what are the losses connected with drinking” The answer to this problem, which only started drawing the attention of the Brazilian authorities recently and that, worldwide, is more serious than illicit drug abuse, is manifold and not always consensual. Among Brazilian experts, there are some who state that education is the way out, since alcohol consumption is a habit that has been with humankind for millennia, and possibly ever since someone tried fermented fruit or grain, long before agriculture began.

EDUARDO CESAR“Alcohol is pleasurable and agreeable for most people. One must learn that this is a habit that can be maintained in a suitable manner, in the right places”, explains psychopharmacologist Elisaldo Carlini, Cebrid coordinator, who until March was a member of the UN”s International Narcotic Control Board, which monitors the production and distribution of narcotics worldwide. “The country lacks intensive, ongoing and intelligent projects that teach the dangers of drug abuse”, he states.

However, education alone cannot solve the problem. Reducing the TV time slots in which alcoholic beverage advertising can be aired, which the minister of health, José Gomes Temporão, has been fighting for, might yield results, especially among young people. It is also necessary to truly enforce the country”s laws, such as the one that prohibits selling alcoholic beverages to people under 18 or the one that establishes that those who are caught drunk driving will lose their driving license. “In Brazil, we are lenient where failure to comply with regulations is concerned. We accept certain types of transgression better than US society”, says Caetano. “There is a feeling of impunity in the country, which is real. The law is not enforced and people know that.”

Laranjeira advocates higher taxes on alcoholic beverages and an increase in price. According to Caetano, federal, state and even municipal measures are also required, such as controlling bars” opening hours. Not to speak, of course, of providing access to suitable treatment for those who are alcohol-dependent. According to Pedro Gabriel Delgado, the Ministry of Health”s Mental Health coordinator, up to 2002, the public healthcare system offered no specialized care options and alcohol-related problems were treated by philanthropic organizations or groups such as Alcoholic Anonymous. There were only a few outpatient facilities and inefficient in-patient treatment in psychiatric hospitals. Currently, the country has 160 community centers and healthcare services that focus on treating alcohol-dependents. It is still too little. “The solutions to this problem involve regulating the market”, states Laranjeira, who is accused of advocating radical proposals against the excess consumption of alcohol. “Without this, industry will continue to turn a profit and society to pay the bill.”

The Projects
1.
National survey on alcohol consumption patterns in Brazilian society (08/57714-7); Coordinator: Ronaldo Laranjeira – Unifesp; Investment: R$ 1,000,000.00 (Senad).
2. Epidemiological study of psychiatric disturbances in the Greater São Paulo Area (03/00204-3); Coordinator: Laura Helena Guerra Andrade – USP; Investment: R$ 1,040,825.00 (FAPESP).
3. Gender, culture and alcohol-related problems: a study in the state of São Paulo and abroad (04/11729-2); Coordinator: Florence Kerr-Corrêa – Unesp; Investment: R$ 187,393.75 (FAPESP).

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