Service de Psychiatrie B, CHU de Clermont-Ferrand and
1 CLP Santé, 20 rue de Boulainvilliers, Paris, France
Received 10 May 2000; in revised form 28 June 2000; accepted 3 August 2000
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ABSTRACT |
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INTRODUCTION |
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France is notable for its high alcohol consumption, despite a constant decline over the last 30 years. In 1994, the French still consumed 11.7 l of pure alcohol per inhabitant, making them one of the highest consumers in the European Union; an intake which remained stable until 1996 (Baudier and Arenes, 1995; Baudier et al., 1996
; Got and Weill, 1998
).
Although alcohol use remains a major public health issue, no consistent overall information system is yet available concerning alcohol-related problems and their economic consequences. The French Ministry of Health created a mission, chaired by one of the authors, to assess treatment facilities for persons with difficulties due to alcohol consumption, and part of the work consisted of assessing the health costs of alcoholism. The total cost to the nation of an illness comprised health costs and social costs. Health costs due to alcohol for France in 1996 comprise the cost of general health care for related disorders plus the cost of the specialized health care for alcohol abusers (which is small and easy to evaluate as it is a specific budget item in public accounts). There are two methods by which this can be estimated (see Methods). Social costs are shared between private costs borne by the private sphere (consumers, enterprises, insurances, lost production due to the poorer health of alcohol abusers, crime, suicide, distress, etc.) and public costs mainly borne by administrations intervening in these domains. In the present paper, we provide estimates of these costs.
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METHODS |
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First method: based on the alcohol abuse factor
We determined the health disorders for which there is unequivocal epidemiological evidence of a link with alcohol abuse, and for which the costs can be identified (Williams, 1988; Guignon, 1994
; Rueff, 1995
; HCSP, 1996; Tellier, 1996
; Rumeau Rouquette et al., 1997
; Com-Ruelle, 1998
). For each disorder we computed the number of cases attributable to alcohol abuse, using the classical epidemiological measure of attributable risk (Morganstern et al., 1980
). Attributable risk is the additional incidence of the disease related to exposure to a definite risk factor, in this instance alcohol abuse, taking into account other possible causes:
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Second method: estimate based on the prevalence of alcohol abuse for in- and out-patients
Based on the hospital prevalence of alcohol problems in France (Allemand et al., 1990; Ramirez et al., 1990
; Balmès and Daurès, 1995
; Com-Ruelle and Dumesnil, 1997
; Reynaud et al., 1997
), we applied a percentage to in-patient hospital costs. This method allows only the hospitalizations directly linked to alcohol to be taken into account, as we have no attribution factor for hospitalizations due to health disorders for which alcohol abuse is only a risk factor. The same was done for out-patient care, by applying the alcohol abuse prevalence rates in out-patient departments to the total costs of consultations, examinations and prescriptions (ANAP, 1995). To this is added the cost of special facilities, the 158 Centres Ambulatoires de Soins Alcoologiques (CASA; Out-patient Alcohol Treatment Centres) funded by the state (budget item 4717), whose annual cost was US$ 23 million.
Sources
Epidemiological data.
Estimates of the prevalence of alcohol abuse rely on epidemiological surveys, especially the health survey of 19911992 (Tellier, 1996). Information on the prevalence of alcohol-related health disorders in France is limited to hospital statistics (Allemand et al., 1990
; Ramirez et al., 1990
; Balmès and Daurés, 1995
; Reynaud et al., 1997
; Com-Ruelle, 1998
), accident rates (traffic, work, and at home) [Haut Comité d'Etude et d'Information sur l'Alcoolisme (HCEIA; National Committee for Research and Information on Alcohol Abuse), 1985; Barrucand, 1988; Honkanen, 1993; Rueff, 1995; Rumeau Rouquette et al., 1997], and the results of some specific surveys among physicians (Huas et al., 1993
). Although the public welfare bodies have no national routine information on alcohol abuse (Rueff, 1995
), regional patterns of alcohol abuse are becoming better known through individual consumption surveys (Baudier and Arenes, 1995
; Rueff, 1995
; Baudier et al., 1996
), although uncertainties persist regarding the reliability of declared consumption, which may be distorted by social expectancies, and survey methods may be difficult to compare (Guignon, 1994
; Rueff, 1995
; Rumeau Rouquette et al., 1997
).
Data on relative risks.
These were extracted from French and international epidemiological studies based on varying alcohol abuse thresholds (Lewis et al., 1985; Chick et al., 1986
; Lang and Darne, 1990
; Johnson et al., 1995
; Longnecker, 1995
). We made a systematic study of these sources and retained only the significant relative risks.
Data on costs of health care. We used the following sources.
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RESULTS |
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Table 1 shows the AAF for an alcohol abuse prevalence of 10% (low-bound estimate). Most of these health disorders stem directly from alcohol abuse, i.e. AAF = 100%. These calculations were repeated for a prevalence of 15% (high estimate).
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In France, acute alcohol intoxication (blood alcohol >80 mg/dl) is noted in 3040% of fatal traffic accidents (Rueff, 1995) and 20% of suicides.
Costs.
In this first step of cost estimation, we have retained the out-patient and hospital costs of the various health disorders possibly linked to alcohol, without distinguishing what proportion of the cost is due to alcohol abuse. We have not allowed for injuries arising from accidents (accidents at work, accidents at home, and traffic accidents), because we could not estimate the medical costs of such injuries. Likewise, certain health disorders identified as being directly or indirectly linked to alcohol abuse could not be allowed for, either because we had no data for the relative risk, or because we had no representative data at the national level for out-patient and hospital care (e.g. for cortical atrophy or fetal-alcohol syndrome). The total direct costs of health disorders possibly associated with alcohol is thus estimated conservatively as US$ 10 800 million. Of this, only a fraction of the costs is attributable to alcohol abuse. This fraction is given by the AAF for each health disorder (see Table 1 and Table 2).
The share of alcohol abuse in the costs of each of the health disorders is calculated using the corresponding AAF values for two different prevalence rates. Alcohol-dependence syndrome and alcohol-induced psychosis are a heavy liability, accounting for about 30% of the total cost. The health disorders linked directly to alcohol abuse, i.e. alcohol dependency and alcohol-induced psychosis, cirrhosis of the liver and cancer of the mouth, throat, and oesophagus, imposed a hospital cost in 1996 of between US$ 1000 and 1100 million according to the prevalence figure selected. Their total cost amounted to between US$ 1100 and 1150 million. The health disorders for which alcohol is only a risk factor are estimated conservatively at US$ 1200 to 1500 million.
Summary. For a prevalence of 10% in the overall population, the low estimate of cost in 1996 was about US$ 2300 million; for a prevalence of 15% it was more than US$ 2700 million. This cost concerns only the health disorders linked directly or indirectly to alcohol abuse. It does not allow for injuries from accidents caused by alcohol intoxication.
Second method: estimate based on the prevalence of alcohol abuse among hospital in-patients and out-patients
As directly linked illness.
According to the CREDES study (Com-Ruelle, 1998), 3% of hospital patients are admitted for alcohol abuse. The cost of their hospitalization was estimated at US$ 1060 million for 1992, i.e. 2.4% of hospital expenditure. Some 85% of the costs were incurred in psychiatric (46%) and medical (39%) treatment. Re-evaluating these costs for 1996, assuming that they still accounted for 2.4% of hospital expenditure, gave a value of about US$ 1300 million. According to other authors (Niles and McCrady, 1991
; Umbricht-Schneiter et al., 1991
; Balmès and Daurès, 1995
; Reynaud et al., 1997
), 510% of patients are hospitalized for a problem directly linked to alcohol abuse. Assuming a prevalence of 5%, we obtained a cost of more than US$ 2100 million for 1995 if this rate is applied to the total hospital expenditure proposed by CREDES and re-evaluated by us (5% x 1300 million/3% = 2100 million). We can therefore conclude that, using this method, the costs directly attributable to alcohol abuse in hospital patients are between US$ 1300 and 2100 million, a likely value being about US$ 1600 million.
With alcohol as a risk factor.
According to the CREDES study (Com-Ruelle, 1998) 10% of hospitalized patients are at risk from alcohol abuse. According to other prevalence studies (Niles and McCrady, 1991
; Balmes and Daurès, 1995
; Reynaud et al., 1997
) about 15% of all hospital patients display alcohol use disorders. If this rate is applied to the total hospital expenditure, we obtain a cost of US$ 8300 million for 1995. However, this cost is clearly not wholly attributable to alcohol abuse, since this is only a risk factor. We do not know what coefficient needs to be applied to obtain the real cost.
Costs attributable to alcohol abuse in out-patient clinics.
According to studies conducted among out-patients (Bush et al., 1987; Simon et al., 1991
; Huas et al., 1993
), 20% of adult out-patients present a risk linked to alcohol consumption, or suffer already from an alcohol use disorder. If this rate is applied to the total out-patient expenditure, the cost for 1995 amounts to US$ 10 000 million. As above, this cost is not wholly attributable to alcohol abuse. According to Delande (1991), the cost of out-patient care for alcohol abusers can be estimated to be the same as their costs for in-patient care, because alcohol abusers are great consumers of out-patient care. Thus, if the hospital costs are at least US$ 1600 million for 1995, then, following Delande, the out-patient costs can be put at US$ 1600 million too.
Summary. This method indicates a total minimum estimate of about US$ 3300 million, with about US$ 1600 million for hospital care and about the same for out-patient care. This cost concerns only alcohol abuse declared as an illness. The costs of alcohol abuse as a risk factor cannot be evaluated by this method, because the coefficent that would need to be applied is not known.
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DISCUSSION |
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The recent study by Got and Weill (1998) lists the available data and also enables the missing data to be identified. The large amount of missing data has led us to construct only reserved hypotheses, which explains the wide range of possible values given.
The total impossibility of obtaining data that are more reliable and the absence of any information system for health problems linked to alcohol are evidence of the indifference in France concerning this issue.
Comparison of general health care costs of alcohol abuse calculated by the two methods of evaluation
Directly linked illnesses.
Using the approach based on the AAF, the hospital costs for 1996 amounted to between US$ 1000 million (prevalence 10%) and US$ 1100 million (prevalence 15%). This cost evaluates only health disorders directly linked to alcohol abuse, i.e., intoxication, dependency, cirrhosis, and cancer of the liver, mouth, throat and oesophagus. The costs for medium and long hospital stays are not included. By contrast, the approach based on the prevalence of alcohol abuse gives a total cost of about US$ 3200 million.
Results with the first approach (AAF) correspond to those from the CREDES survey (Com-Ruelle, 1998). This is the cost which can be the most clearly assessed. In the second approach (prevalence), the hospital costs were about US$ 1600 million in 1995, for all types of stay. The difference may thus partly derive from what types of hospital stay were included in the calculation of costs. However, this wide discrepancy may also be linked to the estimation of out-patient costs, which are grossly undervalued in the AAF approach: US$ 83 million against US$ 1600 million with the prevalence approach.
As a risk factor. The AAF approach estimates the cost of alcohol abuse as a risk factor at US$ 1250 to 1600 million minimum. Injuries from accidents caused by alcohol use are not included in this cost, which is therefore heavily underestimated. The prevalence method cannot evaluate this cost, which is accordingly ignored.
The cost of specialized health care for alcoholics. The CASA and the ANPA have a total budget of around US$ 38 million, allocated by the State under budget item 4717: the part which is directly allocated for treatment is US$ 23 million, used only in outpatient care, with the rest being allocated to various bodies and for preventive action. These derisory facilities are the State's alibi and disguise the almost complete absence of any health policy for persons in difficulty due to alcohol consumption.
Evaluation of social costs
Whereas direct costs, particularly medical costs, can be estimated, the indirect costs, especially the social costs, remain difficult to assess. In France, there are no reliable studies available concerning social expenditure or costs of the economic consequences of alcohol abuse, hence it is difficult to propose any sound values (Got and Weil, 1998). Even so, since it is reasonable to assume that the social costs of alcohol abuse (Bernard, 1980) make up most of its total cost, this issue can hardly be ignored. As no hard data are available for France, we refer to four studies recently conducted in other countries on this subject. These countries are Germany (Brecht et al., 1996
), Canada (Single et al., 1998
), the USA (Rice et al., 1991
; Heien and Pittman, 1993
), and New Zealand (Devlin et al., 1997
). A comparative analysis of the structure of the costs generated by alcohol abuse in these four countries helps us to assess the scale of the social costs.
Thus, comparing the studies in these four countries reveals that, although the monetary cost of alcohol abuse varies with the method of calculation used, and the country considered, the structure of the costs is remarkably constant. In Germany, some 74% of the total costs are indirect, i.e. absenteeism (26%), early retirement (22%) and premature death (52%), and most of these costs are borne invisibly by the entire population. The remaining costs, i.e. 26% of the total, are medical costs. In Canada, if the costs incurred by application of the law, which represent 18% of the total cost, are excluded, about 2025% of the cost derives from health care expenditure, and 7075% from lost production. Alcohol abuse costs 1.09% of gross national product (GNP). In the USA, the indirect costs of alcohol abuse are also high, compared with the direct costs; some authors propose a figure of 80% of the total cost. The cost total, in 1998, was US$ 85.5 million, i.e. 1.9% of GNP. In New Zealand, the direct costs make up less than 20% of the total cost estimated generously, or 33% of the total cost estimated conservatively. The total cost is between 1% and 1.57% of the GNP.
If we consider that the direct costs in France are at least US$ 3300 million, and that they represent 25% of the total cost of alcohol abuse (conservative assumption), the indirect costs will be at least about US$ 10 000 million. Based on the same assumptions, the total cost of alcohol abuse in France amounts to at least US$ 13 200 million, i.e. 1.04% of GNP.
There is no reliable French study on this subject. However, mention can be made of the study by the HCEIA, according to which the total cost was said to be between US$ 16 600 and 33 300 million in 1987, but for which the methodology was imprecise. Another survey was made with EDF-GDF (National Gas and Electricity Board) employees in 19841985 (Chevalier and Lambrozo, 1990), according to which the annual expenditure per person with an alcohol problem came to US$ 10 100 (including absence from work 74.8%, hospitalizations 23.5%, medical treatment 0.6% and medication 1.1%). If this result, obtained from a sample of the population, can be extrapolated to the population of France, then the cost of alcoholism comes to over US$ 9000 million a year, even if we consider only the population of 1.5 million alcohol dependants, i.e. leaving aside alcohol abusers.
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GENERAL CONCLUSIONS AND COMMENTS |
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Beyond the high cost of alcohol-related health problems, the work of our assessment mission highlights: (1) the inaccuracy of the currently available information system; (2) the weakness of the specialized facilities, and the lack of specialists inside and outside the hospitals; (3) the insufficient attention paid to alcohol problems, and the inadequate training of both general practice and hospital physicians; (4) the insufficient social concern for a proper policy to fight alcohol problems. This deplorable situation largely derives from the special status enjoyed by alcohol and wine in France, where they symbolize a certain French quality of life. This study, among others, has helped to weaken this special status, prompting the French government, despite strong lobbying from the alcohol trade, to include alcohol and tobacco in the scope of its interdepartmental mission against substance abuse and addiction (MILDT) on 15 July 1999. This step should favour the emergence of a consistent global policy, not only for illegal drugs, but also legal ones, such as alcohol.
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FOOTNOTES |
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