Public health thinking around alcohol-related harm: Why does per capita consumption matter? (2021)

OBJECTIVE: Alcohol per capita consumption (APC) is used for monitoring harmful alcohol exposure in populations and assessing progress with goals set internationally and nationally. Recently, the alcohol industry challenged the use of this indicator. Here, we assessed the validity of APC as an indicator for reducing alcohol-related harm.
METHOD: We conducted a narrative review of association between population-level drinking and harm rates, and the underlying mechanisms of this association.
RESULTS: A substantial literature demonstrates quite consistently close associations between APC and population harm levels for various types of health and social harms. Across populations with different total consumption, the distribution of consumption displays a fairly fixed shape, with no clear distinction between heavy drinkers and other drinkers. The mean consumption in a population is closely associated with the prevalence of heavy drinking; an increase in APC arises from a change in the whole distribution, heavy drinkers included. Although risk of harms from drinking increases with consumption, it seems that for many harm types the majority of drinkers, who do not drink heavily, account for a large proportion of harms from alcohol.
CONCLUSIONS: By reducing APC, decreases in drinking among heavy drinkers as well as among ordinary drinkers will lead to fewer alcohol-related harms. The evidence strongly suggests public health gains from universal policies targeting APC. Reducing APC is furthermore an investment in future public health, as it is likely an efficient way of preventing people from becoming very heavy drinkers, who may cause themselves and others severe health and social problems.