Female infanticide is the deliberate killing of newborn female
children. Female infanticide is prevalent in several nations around the
world. It has been argued that the low status in which women are viewed
in patriarchal societies creates a bias against females. The modern practice of sex-selective abortion is also used to regulate gender ratios.
In 1978, anthropologist Laila Williamson, in a summary of data she had collated on how widespread infanticide was, found that infanticide had occurred on every continent and was carried out by groups ranging from hunter gatherers to highly developed societies, and that, rather than this practice being an exception, it has been commonplace. The practice has been documented among the Indigenous peoples of Australia, Northern Alaska and South Asia, and Barbara Miller argues the practice to be "almost universal", even in the Western world.
Miller contends that female infanticide is commonplace in regions where
women are not employed in agriculture and regions in which dowries are the norm. In 1871, in The Descent of Man, and Selection in Relation to Sex, Charles Darwin wrote that the practice was commonplace among the aboriginal tribes of Australia.
Female infanticide is also closely linked to a lack of education and
high poverty rates, which explains why it is widely prevalent in
locations such as India, Pakistan, and West Africa.
In 1990, Amartya Sen writing in the New York Review of Books
estimated that there were 100 million fewer women in Asia than would be
expected, and that this number of "missing" women "tell[s] us, quietly,
a terrible story of inequality and neglect leading to the excess
mortality of women".
China has a history of female infanticide spanning 2,000 years.
With the arrival of Christian missionaries in the late sixteenth
century, the missionaries discovered female infanticide was being
practiced – newborns were seen thrown into rivers or onto rubbish piles.
In the seventeenth century, Matteo Ricci documented that the practice occurred in several of China's provinces and that the primary reason for the practice was poverty.
In 19th-century China, female infanticide was widespread. Readings from Qing texts show a prevalence of the term nì nǚ
("to drown girls"), and drowning was the common method used to kill
female children. Other methods used were suffocation and starvation.
Leaving a child exposed to the elements was another method of killing
an infant: the child would be placed in a basket which was then placed
in a tree. Buddhist
nunneries created "baby towers" for people to leave a child; it is
however unclear as to whether the child was being left for adoption or
if it had already died and was being left for burial. In 1845 in the
province of Jiangxi,
a missionary wrote that these children survived for up to two days
while exposed to the elements, and that those passing by would pay no
attention.
Chinese anti infanticide tract circa 1800.
The majority of China's provinces practiced female infanticide during the 19th century. In 1878, French Jesuit missionary Gabriel Palatre collected documents from 13 provinces, and the Annales de la Sainte-Enfance (Annals of the Holy Childhood) also found evidence of infanticide in Shanxi and Sichuan.
According to the information collected by Palatre, the practice was
more widely spread in the southeastern provinces and in the Lower Yangzi
River region.
In China, the practice of female infanticide was not wholly
condoned. Buddhism in particular was quite forceful in its condemnation
of it. Buddhists wrote that the killing of young girls would bring bad karma;
conversely, those who saved a young girl's life either through
intervening or through presents of money or food would earn good karma,
leading to a prosperous life, a long life and success for their sons.
However the Buddhist belief in reincarnation
meant that the death of an infant was not final, as the child would be
reborn; this belief eased the guilt felt over female infanticide.
The Confucian attitude towards female infanticide was conflicted. By placing value on age over youth, Confucian filial piety
lessened the value of children. The Confucian emphasis on the family
led to increasing dowries which in turn led to a girl being far more
expensive to raise than a boy, causing families to feel they could not
afford as many daughters. The Confucian custom of keeping the male
within the family meant that the money spent on a daughter's upbringing
along with the dowry would be lost when she married, and as such girls
were called "money-losing merchandise". Conversely the Confucian belief
of Ren
led Confucian intellectuals to support the idea that female infanticide
was wrong and that the practice would upset the balance between yin and yang.
A white paper published by the Chinese government in 1980 stated
that the practice of female infanticide was a "feudalistic evil". The state's official position on the practice is that it is a carryover from feudal times, and is not a result of the states one-child policy. Jing-Bao Nie argues however that it would be "inconceivable" to believe there is no link between the state's family planning policies and female infanticide.
The dowry system in India is one given reason for female infanticide;
over a time period spanning centuries it has become embedded within
Indian culture. Although the state has taken steps
to abolish the dowry system, the practice persists, and for poorer
families in rural regions female infanticide and gender selective
abortion is attributed to the fear of being unable to raise a suitable
dowry and then being socially ostracized.
In 1789, during British colonial rule in India the British discovered that female infanticide in Uttar Pradesh
was openly acknowledged. A letter from a magistrate who was stationed
in the North West of India during this period spoke of the fact that for
several hundred years no daughter had ever been raised in the
strongholds of the Rajahs of Mynpoorie. In 1845, however the ruler at
that time did keep a daughter alive after a district collector named
Unwin intervened.
A review of scholarship has shown that the majority of female
infanticides in India during the colonial period occurred for the most
part in the North West, and that although not all groups carried out
this practice, it was indeed widespread. In 1870, after an investigation
by the colonial authorities the practice was made illegal, with the Female Infanticide Prevention Act, 1870.
According to women's rights
activist Donna Fernandes, some practices are so deeply embedded within
Indian culture it is "almost impossible to do away with them", and she
has said that India is undergoing a type of "female genocide".
The United Nations has declared that India is the most deadly country
for female children, and that in 2012, female children aged between 1
and 5 were 75 percent more likely to die as opposed to boys. The children's rights group CRY has estimated that of the 12 million females born yearly in India, 1 million will have died within their first year of life. During British rule, the practice of female infanticide in the Indian state of Tamil Nadu among the Kallars and the Todas was reported. More recently in June 1986, it was reported by India Today in a cover story Born to Die that female infanticide was still in practice in Usilampatti in southern Tamil Nadu. The practice was mostly prevalent among the dominant caste of the region, Kallars.
Despite
this practice being punishable according to Islamic law, there have
been cases of female infanticide in Pakistan due to a few reasons, for
example, children being born out of wedlock and then killed to avoid the
stigma of illegitimacy. Pakistan is still a male-dominated nation and remains a patriarchal society. In addition, the boys in the family are given preferential treatment, receiving food and medical care before the girls do.
Having a child out of wedlock in Pakistan is culturally taboo. When
women give birth to their babies, they often kill them to escape the
shame or persecution. However, the ratio of female babies being killed
in these cases is much higher than the boys because boys are much more
valued. Infanticide is illegal in Pakistan. However, people do not
report these cases, making it impossible for police to investigate.
According to National Right to Live News, in 2017, only one case
was actually reported, but 345 babies were found dead in Pakistan's
capital between January 2017 and Spring of 2018.
Socio-economics
Eliminating
females poses an issue, as this reduces the number of females that will
be able to bear children. It also poses an issue with feelings of
female worth, as families wanting to eradicate female babies teach the
young girls in their society that they are inferior to the opposite sex,
making it more likely that they have problems of lacking
self-confidence and esteem.
The dowry system has an effect on the families and poverty line, as
some families struggle to pay a dowry while earning below the minimum
wage.
As of 2017, Pakistani women earn less than their male
counterparts, earning under a hundred rupees a month, and are often
unable to receive an education that would allow them to have better
working hours and pay. Some are also restricted to only working within the home, while men are allowed to do the majority of crop work and herding.
In many countries, female infanticide is associated with
socio-economic struggles. A study done in India found three
socio-economic reasons associated with female infanticide. The study
found that economic utility indicates that boys are valued more than
girls due to the fact that boys can work and bring in money to the
household. Due to the sociocultural utility factor of female
infanticide, for many cultures having a boy in the family is mandatory
in order to carry out the legacy of the family line. There is also a
religious factor in female infanticide. Many believe that men are the
only ones that can provide, and sons are viewed as mandatory in order to
kindle the funeral pyre of their late parents and to assist in the
soul's salvation.
Solutions and programs
Non-Government Developmental Organizations (NGDOs) have gender
awareness policies designed to prevent female discrimination all over
the world. These NGDOs approach corporations in an attempt to educate
those in the workforce on the pressing challenges women in society face.
Other than increasing education regarding this issue, another
noteworthy solution to female infanticide involves targeting the dowry system.
Many societies oppose female children because of the heavy cost of
dowry they would have to incur for a female. By reducing the financial
burden on families, the eradication of the dowry system could therefore potentially reduce the apparent preference of male children as well as female infanticide rates.
Another way of decreasing female infanticide rates is by
providing families with incentives to give birth to females. India's
Girl Child Protection Scheme[31]
is one such scheme that encourages female births by providing families
with financial support if they give birth to female children and
additional support to those families whose children receive an
education. This improves female literacy rates and increases female
participation in the workforce, reducing female foeticide rates in
underdeveloped countries.
Implementing gender education within schools and the workplace
will add to gender neutrality within society, increasing the value of
women. Sympathizing with women's suffrage in countries limiting women's
rights will add to the battle in which women fight for freedoms in their
home state. Building upon gender equality in education and teaching
women strategies to cope with their situations will help them grow
confidence and want to spread their knowledge and passions with their
female children. The issue with female infanticide is that women devalue
their own gender. When mothers give away their female children, it only
adds to the lesser image of women. Having women respect themselves and
their own children for who they are will increase the population, and it
will increase the value of women. It may take a long time to implement
these changes in society, but societal revision is a slow process.
Education, value in life, and passion for gender are all aspects of
decreasing female infanticide. Having locations to rid of a female
child, such as "The Girl Child Protection Scheme", appears as a step
toward change. This program only adds to the availability and
opportunity for female infanticide. Instrumentalizing gender education
and value of life will greatly inspire change in societies that
participate in such process of termination.
Consequences and reactions
As a result of large high female infanticide rates in countries, the population is often skewed with a larger proportion of males.
According to the United Nations, this surplus of men in society
coincides with increasing rates of child abuse, domestic violence, and bride trafficking/kidnapping,
presenting a grave threat to the security of women in the affected
areas. This also increases the likelihood of women becoming victims of
harmful sexually transmitted diseases, which further adversely affects their lives as well as population rates. Owing to these concerning issues, there is also a concerning boost in maternal mortality rates and an increase in mental health conditions among women in these locations.
The Geneva Centre for the Democratic Control of Armed Forces (DCAF) wrote in their 2005 report, Women in an Insecure World, that at a time when the number of casualties in war had fallen, a "secret genocide" was being carried out against women.
According to DCAF the demographic shortfall of women who have died for
gender related issues is in the same range as the 191 million estimated
dead from all conflicts in the twentieth century. In 2012, the documentary It's a Girl: The Three Deadliest Words in the World was released, and in one interview, an Indian woman claimed she had killed eight of her daughters.
The long-term effects of alcohol have been extensively researched. The health effects of long-term alcohol consumption vary depending on the amount consumed. Even light drinking poses health risks, but atypically small amounts of alcohol may have health benefits. Alcoholism causes severe health consequences which outweigh any potential benefits.
Conversely, light intake of alcohol may have some beneficial
effects. The association of alcohol intake with reduced cardiovascular
risk has been noted since 1904 and remains even after adjusting for known confounders. Light alcohol intake is also associated with reduced risk of type 2 diabetes, gastritis, and cholelithiasis. However, these are only observational studies and high-quality evidence for the beneficial effects of alcohol is nonexistent.
The developing adolescent brain is particularly vulnerable to the toxic effects of alcohol. In addition, the developing fetal brain is also vulnerable, and fetal alcohol spectrum disorders (FASDs) may result if pregnant mothers consume alcohol. Some nations have introduced alcohol packaging warning messages that inform consumers about alcohol and cancer, and about risk of fetal alcohol syndrome for women who drink while pregnant.
Alcohol does have psychosocial benefits such as stress reduction, mood elevation, increased sociability, and relaxation, but it is unclear if these outweigh the confirmed increase in the risk of cancer.
The level of ethanol consumption that minimizes the risk of disease, injury, and death is subject to some controversy. Several studies have found a J-shaped relationship between alcohol consumption and health,
meaning that risk is minimized at a certain (non-zero) consumption
level, and drinking below or above this level increases risk, with the
risk level of drinking a large amount of alcohol greater than the risk
level of abstinence. Other studies have found a dose-response relationship, with lifetime abstention from alcohol being the optimal strategy and more consumption incurring more risk.
The studies use different data sets and statistical techniques so
cannot be directly compared. Some older studies included former and
occasional drinkers in the "abstainers" category, which obscures the
benefits of lifetime abstention as former drinkers often are in poor
health. However, the J-curve was reconfirmed by studies that took the mentioned confounders into account.
Nonetheless, some authors remain suspicious that the apparent health
benefits of light alcohol use are in large part due to various selection biases and competing risks. Mendelian randomization
studies have been inconsistent regarding the risk curve, with three
studies finding linear dose-response risks overall and two studies
finding a J-shape for lipid profiles. The variance in alcohol consumption that is explained by genetics is small, requiring large sample sizes and potentially violating assumptions of the analysis.
As one reviewer noted, "Despite the wealth of observational data,
it is not absolutely clear that alcohol reduces risk, because no
randomized controlled trials have been performed." The National Institute on Alcohol Abuse and Alcoholism (NIAAA) announced a randomized controlled trial in 2017, but the National Institutes of Health (NIH) cancelled it in 2018 due to irregular interactions by the program staff with the alcohol industry.[29][30] A trial in Spain is expected to complete in 2028.
In 2013, Norwegian psychiatrist Hans Olav Fekjær compared the situation to those of hormone replacement therapy (HRT), vitamin E, and β-carotene;
similarly to alcohol, observational studies for each of these
treatments showed significantly reduced risk of coronary heart disease,
but initial randomized trials of these treatments failed to replicate
the effect. For HRT, pooling multiple randomized control trials and stratifying the data by age and time since menopause showed the benefits were limited to treatment soon after menopause.
For vitamin E, trials have shown that the benefits are limited to
certain populations such as those with diabetes and a specific genotype. For β-carotene, the randomized trials have shown that β-carotene increases cardiovascular disease risk when supplemented, with all beneficial effects due to other vitamins in foods providing β-carotene.
In light of the conflicting evidence, many have cautioned against
recommendations for the use of alcohol for health benefits. At a
symposium in 1997, Dr. Peter Anderson of the World Health Organization (WHO) labeled such alcohol promotion as "ridiculous and dangerous". It has been argued that the health benefits from alcohol have been exaggerated by the alcohol industry, with industry participation in the wording of messages and warnings.
The debate is not purely scientific, with groups such as the
International Scientific Forum on Alcohol Research (ISFAR) critiquing
anti-alcohol studies as distorting the evidence, scientists in turn accusing these groups of bias due to industry funding, and members of the groups responding that these are false and misleading assertions. Studies with industry funding find less risk of stroke,
and industry-linked systematic reviews consistently find
cardioprotective effects, compared to reviews with no associations being
54% positive.
Considered as a treatment for cardiovascular disease, alcohol is
addictive, has greater risk of adverse effects, and is less effective
than other interventions such as heart medications, exercise, or good nutrition.
The world
The
available evidence is in agreement that current drinking levels are too
high. The WHO has emphasized the need to revise alcohol control
policies worldwide in order to reduce overall alcohol consumption.
Globally, assuming the J-shaped curve is correct, the
age-standardised, both-sexes consumption that minimizes risk is about 5
grams of ethanol per day, and an average individual would cause
themselves harm by drinking more than 17 grams per day. However, the average intake among current drinkers in 2016 was approximately 40 grams of ethanol per day.
1.03 billion males (35.1% of the male population aged ≥15 years, ~2/3
of male drinkers) and 312 million females (10.5% of the female
population aged ≥15 years, ~1/3 of female drinkers) consumed harmful
amounts of alcohol.
The proportion of the population consuming harmful amounts of alcohol
has stayed at approximately the same level over the past three decades.
Estimates of the worldwide number of deaths per year caused by alcohol vary. The 2016 Global Burden of Disease (GBD) study estimated 2.8 million, while the 2020 GBD study estimated 1.78 million. The WHO estimates 3 million deaths per year from harmful use of alcohol, representing 5.3% of all deaths across the globe.
All of these numbers are net deaths, subtracting deaths prevented from
deaths caused. Professor Tim Stockwell, former director of the Canadian
Institute for Substance Use Research argues that alcohol may not prevent
any deaths and guesses that as many as 6 million deaths may be caused
by alcohol.
Besides this, the WHO attributes 5.1% of the global burden of disease
and injury to alcohol, as measured in disability-adjusted life years
(DALYs). The WHO does not list alcohol in its 2019 list of the top 20 leading causes of DALYs, but alcohol use disorder (AUD) would rank around #39, combining AUD with alcohol-related cirrhosis
and liver cancer would rank between malaria (#19) and refractive errors
(#20), and all alcohol-attributed DALYs would rank between stroke (#3)
and lower respiratory infections (#4).
Similarly the number of alcohol-attributed deaths would rank between
chronic obstructive pulmonary disease (#3) and lower respiratory
infections (#4).
Research of Western cultures has consistently shown increased survival associated with light to moderate alcohol consumption. Australasia and Europe are also the locations with the highest levels of harmful alcohol consumption. Researchers have investigated cultures with different alcohol consumption norms and found conflicting results.
The risks of alcohol consumption are age-dependent. Risk is greatest among males aged 15–39 years, due to binge drinking which may result in violence or traffic accidents.
It is less risky and potentially more beneficial for an older
individual to consume a given amount of alcohol, compared to a similar
younger individual, as they are less likely to develop cancer during
their remaining lifespan, less likely to be involved in accidents, and
more likely to benefit from alcohol's cardiovascular effects. Taking the
lower bound of the confidence intervals, the GBD 2020 study suggests
that people do not need to drink until age 25, and in many regions, the
study did not find any significant benefit for drinking over abstinence
even as late as ages 45 or 60. Other studies have found similar patterns.
India
A
study of 4,465 subjects in India confirmed the association of alcohol
consumption with coronary risk in men. Compared to lifetime abstainers,
alcohol users had higher blood sugar (2 mg/dl), blood pressure (2 mm Hg)
levels, and the high-density lipoprotein
cholesterol (HDL-C) levels (2 mg/dl) and significantly higher tobacco
use (63% vs. 21%). Indians who consume alcohol had a 60% higher risk of
heart attack, which was greater with local spirits (80%) than branded spirits (50%). The harm was observed in alcohol users classified as occasional as well as regular light, moderate, and heavy consumers.
Five percent of all cancers diagnosed in Indians in 2021 were
attributed to alcohol consumption, with cancers of the esophagus, liver,
and breast accounting for the most number of cases.
As of 2014, male life expectancy was lower in Russia than other
countries. For example, at 2005 mortality rates, only 7% of UK men but
37% of Russian men would die before the age of 55 years.
A study by Zaridze et al. in 2009 found that "excessive alcohol
consumption in Russia, particularly by men, has in recent years caused
more than half of all the deaths at ages 15–54 years." The study used 43,802 deaths linked to alcohol or tobacco but only 5475 other deaths as controls. Further studies have confirmed that heavy drinking and smoking are the main cause of high death rates in Russia as of 2014. The high consumption of vodka in the context of binge drinking is a significant factor.
For smokers aged 35-54, the 20-year risk of death was 35% for men who
had reported drinking three or more bottles of vodka a week and 16% for
men who had reported consuming less than one bottle a week.
South Asia
The
landmark INTERHEART Study has revealed that alcohol consumption in
South Asians was not protective against CAD in sharp contrast to other
populations who benefit from it.
United Kingdom
A
governmental report from Britain has found that "There were 8,724
alcohol-related deaths in 2007, lower than 2006, but more than double
the 4,144 recorded in 1991. The alcohol-related death rate was 13.3 per
100,000 population in 2007, compared with 6.9 per 100,000 population in
1991." In Scotland, the NHS estimate that in 2003 one in every 20 deaths could be attributed to alcohol.
A 2009 report noted that the death rate from alcohol-related disease
was 9,000, a number three times that of 25 years previously.
A UK report came to the result that the effects of
low-to-moderate alcohol consumption on mortality are age-dependent.
Low-to-moderate alcohol use increases the risk of death for individuals
aged 16–34 (due to increased risk of cancers, accidents, liver disease,
and other factors), but decreases the risk of death for individuals ages
55+ (due to decreased risk of ischemic heart disease).
A study in the United Kingdom found that alcohol causes about 4% of cancer cases in the UK (12,500 cases per year).
United States
Excessive alcohol use was the 3rd leading behavioral cause of death for people in the United States in the year 2000. In 2001, an estimated 75,766 deaths were attributable to alcohol.
From 2006 through 2010, there were approximately 87,798 deaths on
average attributable to alcohol occurred in the United States each year.
Alcohol-related deaths among Americans about doubled from 1999 to 2020.
In 2020, alcohol was linked to nearly 50,000 deaths among adults aged
25 to 85, a sharp rise from just under 20,000 in 1999. All age groups
experienced increases, with the most significant rise occurring in
individuals aged 25 to 34, where death rates nearly quadrupled during
this period. In 2025, the US Surgeon General advocated for cancer risk warnings on alcoholic beverages.
Alcohol has been found to have anticoagulant properties. Thrombosis is lower among moderate drinkers than abstainers.
A meta-analysis of randomized trials found that alcohol consumption in
moderation decreases serum levels of fibrinogen, a protein that promotes
clot formation, while it increases levels of tissue type plasminogen
activator, an enzyme that helps dissolve clots.
These changes were estimated to reduce coronary heart disease risk by
about 24%. Another meta-analysis in 2011 found favorable changes in HDL
cholesterol, adiponectin, and fibrinogen associated with moderate
alcohol consumption.
A systematic review based on 16,351 participants showed J-shaped curve
for the overall relationship between cardiovascular mortality and
alcohol intake. Maximal protective effect was shown with 5–10 g of
alcohol consumption per day and the effect was significant up to 26
g/day alcohol consumption.
Serum levels of C-reactive protein (CRP), a putative marker of
inflammation and predictor of CHD (coronary heart disease) risk, are
lower in moderate drinkers than in those who abstain from alcohol,
suggesting that alcohol consumption in moderation might have
anti-inflammatory effects.
Data from one prospective study suggest that, among men with initially
low alcohol consumption (</=1 drink per week), a subsequent moderate
increase in alcohol consumption may lower their CVD risk.
Peripheral arterial disease
A
prospective study published in 1997 found "moderate alcohol consumption
appears to decrease the risk of PAD in apparently healthy men."
In a large population-based study, moderate alcohol consumption was
inversely associated with peripheral arterial disease in women but not
in men. But when confounding by smoking was considered, the benefit
extended to men. The study concluded "an inverse association between
alcohol consumption and peripheral arterial disease was found in
nonsmoking men and women."
Intermittent claudication
A study found that moderate consumption of alcohol had a protective effect against intermittent claudication. The lowest risk was seen in men who drank 1 to 2 drinks per day and in women who drank half to 1 drink per day.
Heart attack and stroke
Drinking in moderation has been found to help those who have had a heart attack survive it. However, excessive alcohol consumption leads to an increased risk of heart failure.
At present there have been no randomised trials to confirm the evidence
which suggests a protective role of low doses of alcohol against heart
attacks. There is an increased risk of hypertriglyceridemia, cardiomyopathy, hypertension, and stroke if three or more standard drinks of alcohol are taken per day.
A systematic review reported that reducing alcohol intake lowers blood
pressure in a dose-dependent manner in heavy drinkers. There is no safe
amount of alcohol without having a negative effect on blood pressure.
Even individuals who consume only one drink per day show a link to
higher blood pressure.
Frequent drinking of alcoholic beverages is a major contributing factor in cases of elevated blood levels of triglycerides.
Cardiomyopathy
Large amounts of alcohol over the long term can lead to alcoholic cardiomyopathy. Alcoholic cardiomyopathy presents in a manner clinically identical to idiopathic dilated cardiomyopathy, involving hypertrophy of the musculature of the heart that can lead to congestive heart failure.
Alcohol consumption increases the risk of atrial fibrillation, a type of abnormal heart rhythm that increases the risk of stroke and heart failure. This remains true even at moderate levels of consumption.
Nervous system
Chronic heavy alcohol consumption impairs brain development, causes alcohol dementia, brain shrinkage, physical dependence, alcoholic polyneuropathy (also known as 'alcohol leg'), increases neuropsychiatric and cognitive disorders and causes distortion of the brain chemistry.
At present, due to poor study design and methodology, the literature is
inconclusive on whether moderate alcohol consumption increases the risk
of dementia or decreases it.
Evidence for a protective effect of low to moderate alcohol consumption
on age-related cognitive decline and dementia has been suggested by
some research; however, other research has not found a protective effect
of low to moderate alcohol consumption. Some evidence suggests that low to moderate alcohol consumption may speed up brain volume loss. Chronic consumption of alcohol may result in increased plasma levels of the toxic amino acid homocysteine; which may explain alcohol withdrawal seizures, alcohol-induced brain atrophy and alcohol-related cognitive disturbances. Alcohol's impact on the nervous system can also include disruptions of memory and learning (see Effects of alcohol on memory), such as resulting in a blackout phenomenon.
Strokes
Epidemiological
studies of middle-aged populations generally find the relationship
between alcohol intake and the risk of stroke to be either U- or
J-shaped.
There may be very different effects of alcohol based on the type of
stroke studied. The predominant form of stroke in Western cultures is
ischemic, whereas non-western cultures have more hemorrhagic stroke. In
contrast to the beneficial effect of alcohol on ischemic stroke,
consumption of more than two drinks per day increases the risk of
hemorrhagic stroke. The National Stroke Association estimates this
higher amount of alcohol increases stroke risk by 50%.
"For stroke, the observed relationship between alcohol consumption and
risk in a given population depends on the proportion of strokes that are
hemorrhagic. Light-to-moderate alcohol intake is associated with a
lower risk of ischemic stroke which is likely to be, in part, causal.
Hemorrhagic stroke, on the other hand, displays a log-linear relationship with alcohol intake."
Alcohol misuse is associated with widespread and significant brain lesions.
Alcohol related brain damage is not only due to the direct toxic
effects of alcohol; alcohol withdrawal, nutritional deficiency,
electrolyte disturbances, and liver damage are also believed to
contribute to alcohol-related brain damage.
Excessive alcohol intake is associated with impaired prospective memory.
This impaired cognitive ability leads to increased failure to carry out
an intended task at a later date, for example, forgetting to lock the
door or to post a letter on time. The higher the volume of alcohol
consumed and the longer consumed, the more severe the impairments.
One of the organs most sensitive to the toxic effects of chronic
alcohol consumption is the brain. In the United States approximately 20%
of admissions to mental health facilities are related to
alcohol-related cognitive impairment, most notably alcohol-related
dementia. Chronic excessive alcohol intake is also associated with
serious cognitive decline and a range of neuropsychiatric complications.
The elderly are the most sensitive to the toxic effects of alcohol on
the brain.
There is some inconclusive evidence that small amounts of alcohol taken
in earlier adult life is protective in later life against cognitive
decline and dementia.
However, a study concluded, "Our findings suggest that, despite
previous suggestions, moderate alcohol consumption does not protect
older people from cognitive decline."
Wernicke–Korsakoff syndrome is a manifestation of thiamine deficiency, usually as a secondary effect of alcohol misuse. The syndrome is a combined manifestation of two eponymous disorders, Korsakoff's Psychosis and Wernicke's encephalopathy. Wernicke's encephalopathy is the acute presentation of the syndrome and is characterised by a confusional state while Korsakoff's psychosis main symptoms are amnesia and executive dysfunction. "Banana bags",
intravenous fluid containers containing vitamins and minerals (bright
yellow due to the vitamins), can be used to mitigate these outcomes.
Essential tremor
Essential tremors—or,
in the case of essential tremors on a background of family history of
essential tremors, familial tremors—can be temporarily relieved in up to
two-thirds of patients by drinking small amounts of alcohol.
Ethanol is known to activate aminobutyric acid type A (GABAA) and
inhibit N-methyl-D-aspartate (NMDA) glutamate receptors, which are both
implicated in essential tremor pathology and could underlie the ameliorative effects.
Additionally, the effects of ethanol have been studied in different
animal essential tremor models. (For more details on this topic, see Essential tremor).
Chronic use of alcohol used to induce sleep can lead to insomnia: frequent moving between sleep stages occurs, with awakenings due to headaches and diaphoresis.
Stopping chronic alcohol misuse can also lead to profound disturbances
of sleep with vivid dreams. Chronic alcohol misuse is associated with NREM stage 3 and 4 sleep as well as suppression of REM sleep and REM sleep fragmentation. During withdrawal REM sleep is typically exaggerated as part of a rebound effect.
Mental health effects
High rates of major depressive disorder
occur in heavy drinkers. Whether it is more true that major depressive
disorder causes self-medicating alcohol use, or the increased incidence
of the disorder in people with an alcohol use disorder is caused by the
drinking, is not known though some evidence suggests drinking causes the
disorder. Alcohol misuse is associated with a number of mental health disorders and alcoholics have a very high suicide rate.
A study of people hospitalized for suicide attempts found that those
who were alcoholics were 75 times more likely to go on to successfully
commit suicide than non-alcoholic suicide attempts.
In the general alcoholic population the increased risk of suicide
compared to the general public is 5-20 times greater. About 15 percent
of alcoholics commit suicide, the most common methods being overdosing
and cutting/scratching. There are high rates of suicide attempts,
self-harm, suicidal ideation, and self-harm ideation in people with
substance dependence who have been hospitalized. Use of other illicit drugs is also associated with an increased risk of suicide. About 33 percent of suicides in the under 35s are correlated with alcohol or other substance misuse.
Social skills
are significantly impaired in people that have alcoholism due to the
neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area of the brain. The social skills that are impaired by alcohol use disorder include impairments in perceiving facial emotions, prosody perception problems and theory of mind deficits; the ability to understand humor is also impaired in people with an alcohol use disorder.
Studies have shown that alcohol dependence relates directly to cravings and irritability. Another study has shown that alcohol use is a significant predisposing factor towards antisocial behavior in children.
Depression, anxiety and panic disorder are disorders commonly reported
by alcohol dependent people. Alcoholism is associated with dampened
activation in brain networks responsible for emotional processing (e.g. the amygdala and hippocampus).
Evidence that the mental health disorders are often induced by alcohol
misuse via distortion of brain neurochemistry is indicated by the
improvement or disappearance of symptoms that occurs after prolonged
abstinence, although problems may worsen in early withdrawal and
recovery periods.
Psychosis is secondary to several alcohol-related conditions including
acute intoxication and withdrawal after significant exposure.
Chronic alcohol misuse can cause psychotic type symptoms to develop,
more so than with other illicit substances. Alcohol misuse has been
shown to cause an 800% increased risk of psychotic disorders
in men and a 300% increased risk of psychotic disorders in women which
are not related to pre-existing psychiatric disorders. This is
significantly higher than the increased risk of psychotic disorders seen
from cannabis use making alcohol misuse a very significant cause of
psychotic disorders.
Approximately 3 percent of people who are alcohol dependent experience
psychosis during acute intoxication or withdrawal. Alcohol-related
psychosis may manifest itself through a kindling mechanism. The mechanism of alcohol-related psychosis is due to distortions to neuronal membranes, gene expression, as well as thiamin
deficiency. It is possible in some cases that excessive alcohol use,
via a kindling mechanism, can cause the development of a chronic
substance-induced psychotic disorder, i.e. schizophrenia.
The effects of an alcohol-related psychosis include an increased risk
of depression and suicide as well as psychosocial impairments. However, moderate wine drinking has been shown to lower the risk for depression.
While alcohol
initially helps social phobia or panic symptoms, with longer term
alcohol misuse can often worsen social phobia symptoms and can cause
panic disorder to develop or worsen, during alcohol intoxication and
especially during the alcohol withdrawal syndrome.
This effect is not unique to alcohol but can also occur with long-term
use of drugs which have a similar mechanism of action to alcohol such as
the benzodiazepines, which are sometimes prescribed as tranquilizers to people with alcohol problems. Approximately half of patients attending mental health services for conditions including anxiety disorders such as panic disorder or social phobia have alcohol or benzodiazepine dependence.
It was noted that every individual has an individual sensitivity level
to alcohol or sedative hypnotic drugs and what one person can tolerate
without ill health another will have very ill health and that even
moderate drinking can cause rebound anxiety
syndromes and sleep disorders. A person who is experiencing the toxic
effects of alcohol will not benefit from other therapies or medications
as they do not address the root cause of the symptoms.
Addiction to alcohol, as with any addictive substance tested so far, has been correlated with an enduring reduction in the expression of GLT1 (EAAT2) in the nucleus accumbens
and is implicated in the drug-seeking behavior expressed nearly
universally across all documented addiction syndromes. This long-term
dysregulation of glutamate transmission is associated with an increase
in vulnerability to both relapse-events after re-exposure to drug-use
triggers as well as an overall increase in the likelihood of developing
addiction to other reinforcing drugs. Drugs which help to re-stabilize
the glutamate system such as N-acetylcysteine have been proposed for the treatment of addiction to cocaine, nicotine, and alcohol.
The effect on depression and returning to drinking among
individuals with alcohol dependence has always been controversial.
Studies show that after doing a study on men and women hospitalized for
alcohol dependence the likelihood of returning to drinking with
depression is extremely high. A diagnosis of major depression at entry
into an inpatient treatment for alcohol dependence showed shorter times
to first drink and also relapse in both women and men.
A
national survey (NHANES) conducted in the U.S. concluded, "Mild to
moderate alcohol consumption is associated with a lower prevalence of
the metabolic syndrome,
with a favorable influence on lipids, waist circumference, and fasting
insulin. This association was strongest among whites and among beer and
wine drinkers."
Similarly, a national survey conducted in Korea reported a J-curve
association between alcohol intake and metabolic syndrome: "The results
of the present study suggest that the metabolic syndrome is negatively
associated with light alcohol consumption (1–15 g alcohol/d) in Korean
adults," but risk increased at higher alcohol consumption.
Gallbladder effects
Research has found that drinking reduces the risk of developing gallstones.
Compared with alcohol abstainers, the relative risk of gallstone
disease, controlling for age, sex, education, smoking, and body mass
index, is 0.83 for occasional and regular moderate drinkers (< 25 ml
of ethanol per day), 0.67 for intermediate drinkers (25-50 ml per day),
and 0.58 for heavy drinkers. This inverse association was consistent
across strata of age, sex, and body mass index."
Frequency of drinking also appears to be a factor. "An increase in
frequency of alcohol consumption also was related to decreased risk.
Combining the reports of quantity and frequency of alcohol intake, a
consumption pattern that reflected frequent intake (5–7 days/week) of
any given amount of alcohol was associated with a decreased risk, as
compared with nondrinkers. In contrast, infrequent alcohol intake (1–2
days/week) showed no significant association with risk."
A large self-reported study published in 1998 found no
correlation between gallbladder disease and multiple factors including
smoking, alcohol consumption, hypertension, and coffee consumption. A retrospective study from 1997 found vitamin C (ascorbic acid)
supplement use in drinkers was associated with a lower prevalence of
gallbladder disease, but this association was not seen in non-drinkers.
During the metabolism of alcohol via the respective dehydrogenases, nicotinamide adenine dinucleotide
(NAD) is converted into reduced NAD. Normally, NAD is used to
metabolize fats in the liver, and as such alcohol competes with these
fats for the use of NAD. Prolonged exposure to alcohol means that fats
accumulate in the liver, leading to the term 'fatty liver'. Continued
consumption (such as in alcohol use disorder) then leads to cell death
in the hepatocytes as the fat stores reduce the function of the cell to
the point of death. These cells are then replaced with scar tissue,
leading to the condition called cirrhosis.
Alcoholic liver disease
is a major public health problem. For example, in the United States up
to two million people have alcohol-related liver disorders. Chronic heavy alcohol consumption can cause fatty liver, cirrhosis, and alcoholic hepatitis.
Treatment options are limited and consist of most importantly
discontinuing alcohol consumption. In cases of severe liver disease, the
only treatment option may be a liver transplant from alcohol abstinent donors. Research is being conducted into the effectiveness of anti-TNFs. Certain complementary medications, e.g., milk thistle and silymarin, appear to offer some benefit. Alcohol is a leading cause of liver cancer
in the Western world, accounting for 32-45% of hepatic cancers. Up to
half a million people in the United States develop alcohol-related liver
cancer.
Alcohol affects the nutritional state of chronic drinkers. It can
decrease food consumption and lead to malabsorption. It can also create
imbalances in skeletal muscle mass and cause muscle wasting. Chronic
consumption of alcohol can also increase the breakdown of important
proteins in the body which can affect gene expression.
Oral and dental implications
Oral cancer
The
consumption of alcohol alone is not associated with an increased risk
of oral squamous cell carcinoma (OSCC); however, the synergistic
consumption of alcohol and tobacco is positively associated with the
occurrence of (OSCC), and significantly increases an individual's risk.
Studies confirm that alcohol dissolves the lipid component of epithelium
and increases the permeability, amplifying the toxicity of carcinogenic
components of tobacco. Limiting the overall consumption of the two has
shown to reduce the risk of OSCC by three-fourth. The knowledge provided
is useful for better understanding the differences in the effect of the
combined consumption of alcohol and tobacco, in the development of
OSCC.
Alcohol consumption has frequently been associated with an
increased risk of oral cancer in current literature. Studies have found
that people that consume alcohol were two times more likely to develop
oral cancer in comparison to people who did not. The mechanisms in which
alcohol acts as a carcinogen within the oral cavity are currently not
fully understood. It is thought to be a multifactorial disease which
then gives rise to a cancerous lesion. Many theories have become
apparent in research, including alcohol being responsible for high
estrogen and androgen levels, specifically in women, which may
facilitate the alcohol-related immunodeficiency and/or immunosuppression
that causes carcinogenesis. Therefore, immediate cessation of the habit
of alcohol consumption can aid in decreasing the risk of oral cancer.
Alcohol-based mouthwashes used to be very common and can still be
purchased for use today. Correlation in the presence of alcohol in
mouthwashes with development of oral and pharyngeal cancer is unknown
due to lack of evidence. However, it has been suggested that
acetaldehyde, the first metabolite of ethanol, plays a role in the
carcinogenesis of alcohol in oral cancer. Acetaldehyde, has been found
to increase when in the salivary medium after an alcoholic beverage has
been consumed and could possibly occur with alcohol-based mouthwashes as
well, posing as a possible risk factor for oral cancer. However, more
research must be conducted regarding these theories.
Alcohol consumption is associated with a higher risk of
periodontitis, an inflammatory disease of the gums around the teeth.
There was also found to be a dose-response relationship in which the
risk of periodontitis increased by 0.4% for each additional gram of
daily alcohol consumption. Mechanisms explaining the relationship
between the two are still unclear; however, several explanations have
been suggested. One explanation is the weakening of neutrophil activity
by alcohol consumption which potentially leads to bacterial overgrowth
and increases bacterial penetration subsequently leading to periodontal
inflammation and periodontal disease. Characteristics of the disease
include shrinkage of gingival height and increased mobility of teeth
which may exfoliate if the disease continues to progress. A patient's
consumption of alcohol needs to be monitored to estimate the risk of
periodontitis, but further well-designed cohort studies are needed to
reaffirm theses results.
Other systems
Respiratory system
Chronic alcohol ingestion can impair multiple critical cellular functions in the lungs.
These cellular impairments can lead to increased susceptibility to
serious complications from lung disease. Recent research cites alcoholic lung disease as comparable to liver disease in alcohol-related mortality. Alcoholics have a higher risk of developing acute respiratory distress syndrome (ARDS) and experience higher rates of mortality from ARDS when compared to non-alcoholics. In contrast to these findings, a large prospective study has shown a protective effect of moderate alcohol consumption on respiratory mortality.
Kidney stones
Research indicates that drinking beer or wine is associated with a lower risk of developing kidney stones.
Low to moderate alcohol consumption is shown to have protective effect for men's erectile function. Several reviews and meta-analyses of existing literature show that low to moderate alcohol consumption significantly decrease erectile dysfunction risk.
Men's sexual behaviors can be affected dramatically by high
alcohol consumption. Both chronic and acute alcohol consumption have
been shown in most studies (but not all) to inhibit testosterone production in the testes. This is believed to be caused by the metabolism of alcohol reducing the NAD+/NADH ratio both in the liver and the testes; since the synthesis of testosterone requires NAD+, this tends to reduce testosterone production.
Long term excessive intake of alcohol can lead to damage to the central nervous system and the peripheral nervous system resulting in loss of sexual desire and impotence in men. This is caused by reduction of testosterone from ethanol-induced testicular atrophy, resulting in increased feminisation of males and is a clinical feature of alcohol abusing males who have cirrhosis of the liver.
Hormonal imbalance
Excessive alcohol intake can result in hyperoestrogenisation. It has been speculated that alcoholic beverages may contain estrogen-like compounds. In men, high levels of estrogen can lead to testicular failure and the development of feminine traits including development of male breasts, called gynecomastia. In women, increased levels of estrogen due to excessive alcohol intake have been related to an increased risk of breast cancer.
Alcohol and cortisol have a complex relationship. While cortisol is a
stress hormone, alcoholism can lead to increased cortisol levels in the
body over time. This can be problematic because cortisol can
temporarily shut down other bodily functions, potentially causing
physical damage.
Diabetes mellitus
A
meta-analysis determined the dose-response relationships by sex and end
point using lifetime abstainers as the reference group. A U-shaped
relationship was found for both sexes. Compared with lifetime
abstainers, the relative risk (RR) for type 2 diabetes among men was
most protective when consuming 22 g/day alcohol and became deleterious
at just over 60 g/day alcohol. Among women, consumption of 24 g/day
alcohol was most protective, and became deleterious at about 50 g/day
alcohol.
A systematic review on intervention studies in women also supported
this finding. It reported that alcohol consumption in moderation
improved insulin sensitivity among women.
The way in which alcohol is consumed (i.e., with meals or binge
drinking) affects various health outcomes. It may be the case that the
risk of diabetes associated with heavy alcohol consumption is due to
consumption mainly on the weekend as opposed to the same amount spread
over a week. In the United Kingdom "advice on weekly consumption is avoided".
A twenty-year twin study from Finland reported that moderate alcohol
consumption may reduce the risk of type 2 diabetes in men and women.
However, binge drinking and high alcohol consumption was found to
increase the risk of type 2 diabetes in women.
Rheumatoid arthritis
Regular consumption of alcohol is associated with an increased risk of gouty arthritis and a decreased risk of rheumatoid arthritis.
Two recent studies report that the more alcohol consumed, the lower the
risk of developing rheumatoid arthritis. Among those who drank
regularly, the one-quarter who drank the most were up to 50% less likely
to develop the disease compared to the half who drank the least.
The researchers noted that moderate alcohol consumption also
reduces the risk of other inflammatory processes such as cardiovascular
disease. Some of the biological mechanisms by which ethanol reduces the
risk of destructive arthritis and prevents the loss of bone mineral
density (BMD), which is part of the disease process.
A study concluded, "Alcohol either protects from RA or, subjects with RA curtail their drinking after the manifestation of RA".
Another study found, "Postmenopausal women who averaged more than 14
alcoholic drinks per week had a reduced risk of rheumatoid arthritis..."
Osteoporosis
Moderate alcohol consumption is associated with higher bone mineral density in postmenopausal women. "...Alcohol consumption significantly decreased the likelihood [of osteoporosis]." "Moderate alcohol intake was associated with higher BMD in postmenopausal elderly women." "Social drinking is associated with higher bone mineral density in men and women [over 45]." However, heavy alcohol use is associated with bone loss.
A 2010 study concluded, "Nonlight beer intake is associated with
an increased risk of developing psoriasis among women. Other alcoholic
beverages did not increase the risk of psoriasis in this study."
Immune system
Bacterial infection
Excessive alcohol consumption seen in people with an alcohol use disorder is a known risk factor for developing pneumonia.
Common cold
A
study on the common cold found that "Greater numbers of alcoholic
drinks (up to three or four per day) were associated with decreased risk
for developing colds because drinking was associated with decreased
illness following infection. However, the benefits of drinking occurred
only among nonsmokers. ... Although alcohol consumption did not
influence risk of clinical illness for smokers, moderate alcohol
consumption was associated with decreased risk for nonsmokers."
Another study concluded, "Findings suggest that wine intake,
especially red wine, may have a protective effect against common cold.
Beer, spirits, and total alcohol intakes do not seem to affect the
incidence of common cold."
It was estimated in 2006 that "3.6% of all cancer cases worldwide
are related to alcohol drinking, resulting in 3.5% of all cancer
deaths."
A European study from 2011 found that one in 10 of all cancers in men
and one in 33 in women were caused by past or current alcohol intake. The World Cancer Research Fund panel report Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective
finds the evidence "convincing" that alcoholic drinks increase the risk
of the following cancers: mouth, pharynx and larynx, oesophagus,
colorectum (men), breast (pre- and postmenopause).
Acetaldehyde is the major metabolite when one drinks alcohol, produced in the liver, and it is known to be carcinogenic. It is suspected that this metabolite is the main reason alcohol promotes cancer.
Typically the liver eliminates 99% of acetaldehyde produced. However,
liver disease and certain genetic enzyme deficiencies result in high
acetaldehyde levels. Heavy drinkers who are exposed to high acetaldehyde
levels due to a genetic defect in alcohol dehydrogenase have been found to be at greater risk of developing cancers of the upper gastrointestinal tract and liver.
A review in 2007 found "convincing evidence that acetaldehyde... is
responsible for the carcinogenic effect of ethanol... owing to its
multiple mutagenic effects on DNA."
Acetaldehyde can react with DNA to create DNA adducts including the
Cr-PdG adduct. This Cr-PdG adduct "is likely to play a central role in
the mechanism of alcoholic beverage related carcinogenesis."
Fetal alcohol syndrome or FAS is a birth defect that occurs in the offspring of women who drink alcohol during pregnancy. More risks than benefits according to a survey of current knowledge. Alcohol crosses the placental barrier and can stunt fetal growth or weight, create distinctive facial stigmata, damaged neurons and brain structures, and cause other physical, mental, or behavioural problems. Fetal alcohol exposure is the leading known cause of intellectual disability in the Western world. Alcohol consumption during pregnancy is associated with brain insulin and insulin-like growth factor resistance.
Effects of alcoholism on family and children
Children
raised in alcoholic families have the potential to suffer emotional
distress as they move into their own committed relationships. These
children are at a higher risk for divorce and separation, unstable
marital conditions and fractured families.
Feelings of depression and antisocial behaviors experienced in early
childhood frequently contribute to marital conflict and domestic
violence. Women are more likely than men to be victims of
alcohol-related domestic violence.
Children of alcoholics
often incorporate behaviors learned as children into their marital
relationships. These behaviors lead to poor parenting practices. For
example, adult children of alcoholics may simultaneously express love
and rejection toward a child or spouse. This is known as insecure attachment.
Insecure attachment contributes to trust and bonding issues with
intimate partners and offspring. In addition, prior parental emotional
unavailability contributes to poor conflict resolution skills in adult
relationships.
Evidence shows a correlation between alcoholic fathers who display
harsh and ineffective parenting practices with adolescent and adult
alcohol dependence.
Children of alcoholics are often unable to trust other adults due to fear of abandonment.
Further, because children learn their bonding behaviors from watching
their parents' interactions, daughters of alcoholic fathers may be
unable to interact appropriately with men when they reach adulthood.
Poor behavior modeling by alcoholic parents contributes to inadequate
understanding of how to engage in opposite gender interactions.
Sons of alcoholics are at risk for poor self-regulation that is
often displayed in the preschool years. This leads to blaming others for
behavioral problems and difficulties with impulse control. Poor
decision-making correlates to early alcohol use, especially in sons of
alcoholics. Sons often demonstrate thrill-seeking behavior, harm avoidance, and exhibit a low level of frustration tolerance.
Economic impact from long-term consumption of alcohol
There is currently no consistent approach to measuring the economic impact of alcohol consumption. The economic burden such as direct, indirect, and intangible cost of diseases can be estimated through cost-of-illness studies. Direct costs are estimated through prevalence and incidence studies, while indirect costs are estimated through the human capital method, the demographic method, and the friction cost method.
However, it is difficult to accurately measure the economic impact due
to differences in methodologies, cost items related to alcohol
consumption, and measurement techniques.
Alcohol dependence
has a far reaching impact on health outcomes. A study conducted in
Germany in 2016 found the economic burden for those dependent on alcohol
was 50% higher than those who were not.
In the study, over half of the economic cost was due to lost
productivity, and only 6% was due to alcohol treatment programs. The
economic cost was mostly borne by individuals between 30 and 49 years
old. In another study conducted with data from eight European countries,
77% of alcohol dependent patients had psychiatric and somatic
co-morbidity, which in turn increased systematic healthcare and economic
cost. Alcohol consumption can also affect the immune system and produce
complications in people with HIV, pneumonia, and tuberculosis.
Indirect costs due to alcohol dependence are significant. The
biggest indirect cost comes from lost productivity, followed by
premature mortality.
Men with alcohol dependence in the U.S. have lower labor force
participation by 2.5%, lower earnings by 5.0%, and higher absenteeism by
0.5–1.2 days. Female binge drinkers have higher absenteeism by 0.4–0.9
days. Premature mortality is another large contributor to indirect costs
of alcohol dependence.
In 2004, 3.8% of global deaths were attributable to alcohol (6.3% for
men and 1.1% for women). Those under 60 years old have much higher
prevalence in global deaths attributable to alcohol at 5.3%.
In general, indirect costs such as premature mortality due to
alcohol dependence, loss of productivity due to absenteeism and
presenteeism, and cost of property damage and enforcement, far exceed
the direct health care and law enforcement costs.
Aggregating the economic cost from all sources, the impact can range
from 0.45 to 5.44% of a country's gross domestic product (GDP).
The wide range is due to inconsistency in measurement of economic
burden, as researchers in some studies attributed possible positive
effects from long term alcohol consumption.
