Convergence in alcohol abuse in Brazilian capitals between genders , 2006 to 2019 : what population surveys show

REV BRAS EPIDEMIOL 2021; 24: E210022.SUPL.1 ABSTRACT: Objective: To analyze the temporal trend of the prevalence of alcohol abuse among adults in Brazilian capitals, between 2006 and 2019. Methods: Time series study, based on data from the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel), between 2006 and 2019. The population consisted of adults (≥ 18 years old) with landline telephone residing in Brazilian capitals. The trend analysis was performed by linear regression. Results: Between 2006 and 2019 there was a significant increase (p = 0.03) in the abusive consumption of alcoholic beverages in the total adult population, from 15.6 to 18.8%. Among men, there was a stability trend (p = 0.96), and among women, there was an increase from 7.7 to 13.3% (p < 0.001; β = 0.295). In the male gender stratified by capitals , from 2006 to 2019 there was a reduction in Belém, Fortaleza, João Pessoa, Macapá, Manaus, Natal, Recife, São Luis, and Teresina. On the other hand, there was growth in the Federal District. Among women, the trend was upward in: Aracaju, Belo Horizonte, Cuiabá, Curitiba, Florianópolis, Goiânia, Palmas, Porto Alegre, Rio de Janeiro, Salvador, São Paulo, Vitória, and the Federal District. Conclusion: The results indicate that more adult women are currently drinking in excess compared to previous years, suggesting an increased risk of alcohol-related harm in this portion of the population in Brazilian capitals, bringing about a convergence effect with the prevalence among men and women.


INTRODUCTION
The consumption of alcoholic beverages is an encouraged behavior in most cultures due to celebrations, socialization, religious ceremonies and other practices and social events 1,2 ; however, alcohol is a major public health issue 1-3 , since its chronic use can cause harm and dependence, resulting in mental, liver, heart diseases, neoplasm, among others. The problems coming from the episodic and acute use also constitute a significant risk factor for violence (aggression, homicide, suicide), traffic and work accidents etc. [3][4][5] . Besides, it leads to a global economic cost that surpasses 1% of the Gross Domestic Product (GDP) of middle and high income countries 6 .
The World Health Organization (WHO) estimates that, every year, there are approximately three million deaths associated with alcohol consumption, which represents 5.3% of all deaths 4 . Alcohol is the main risk factor for premature mortality and disability in the population aged between 15 and 49 years, causing 10% of all deaths in this age group 7,8 . In Brazil, alcohol consumption was the sixth risk factor for loss of disability-adjusted life years (DALYs) in 2019, leading to 3,716,649 million (5.69%) DALYs 7,8 .
The effects of alcohol in the body change according to the quantity and frequency of intake; they also depend on metabolism, genetic vulnerability, gender and life style. Once absorbed, it reaches all body parts and leads to reduced motor coordination and reflexes. The initial effect promotes a state of euphoria and disinhibition, but, if consumed in larger amounts, the opposite takes place, causing the depression of the nervous system 1, 9 . Studies show that alcohol abuse has increased around the world, with differences between genders, as well as disorders caused by alcohol intake and hospitalizations caused by this behavior [10][11][12][13][14] . The increasing alcohol use among women and the convergence between prevalence rates according to gender have been described in the literature 13,14 ; however, there are not many studies that investigate this phenomenon in Brazil.
Aiming at reducing the harmful intake of alcohol and its impact on health, the WHO and its member states defined the goal to reduce this consumption in 10% 15 . The theme was also included in the Sustainable Development Goals (SDGs), whose objective is to strengthen the prevention and treatment of substance abuse, including the abuse of narcotic drugs and the harmful consumption of alcohol 16 . However, it is still necessary to institute measures and public policies that promote advances, as well as establishing monitoring alcohol use systems and morbidity and mortality patterns.
Based on the exposed, the objective was to analyze the temporal trend of the prevalence in alcohol abuse among adults in Brazilian capitals, between 2006 and 2019.

STUDY DESIGN AND DATA COLLECTION
This is a time series study about the prevalence of alcohol abuse among adults living in Brazilian capitals.
We used data from the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel), from 2006 to 2019. Vigitel is a population-based telephone survey, performed by the Ministry of Health, which annually monitors the frequency and distribution of the main risk and protective factors for chronic non-communicable diseases (NCDs), such as alcohol consumption. Since 2006, a probability sample of adults aged 18 years or older, living in households with a landline telephone, in the 26 Brazilian capitals and the Federal District is interviewed. Approximately two thousand interviews are carried out in each city, accounting for 54 thousand per year.
The estimates made by Vigitel receive a sample weight due to the differences in coverage of landline telephones, so that they are representative of the total adult population in each city,. Therefore, a weight is attributed to each individual, aiming at correcting the differences in the probability of selection, and at equalizing the sociodemographic composition of the population served by household landlines to the total adult population of each city in each year of the survey, called post-stratification weight. Details about the sampling process and data collection are provided in the publications of Vigitel 17

DEFINITION OF INDICATORS
For this study, the following Vigitel questions were used 17 : • Do you usually consume alcohol? For those who answer yes, other questions are asked about frequency: how often do you consume alcohol? The alternatives are: one or two days a week; three or four days a week; five or six days a week; everyday; less than one day a week. The indicator of alcohol abuse per gender was assessed by the following questions: • For men: in the past 30 days, did you drink five or more doses of alcohol in a single occasion? Here, we consider those who answer yes; • For women: in the past 30 days, did you drink four or more doses of alcohol in a single occasion? Here, we consider those who answer yes.
The indicator analyzed in the study was the abusive consumption of alcohol ( binge drinking or heavy episodic use of alcohol), which constitutes an excessive amount of alcohol consumed in a short period of time, five or more doses of standard drinks (considering that one dose of alcohol or equivalent contains 12 g of pure alcohol, about 60 g) for men, and four or more doses for women (48 g) 2,17 .

ORGANIZATION AND DATA ANALYSIS
The indicator was stratified according to: gender (female and male); age group (18 to 24; 25 to 34; 35 to 44; 45 to 54; 55 to 64; and 65 or more); regions (North, Northeast, Center-West, Southeast and South); schooling (0 to 8; 9 to 11; and 12 years or more); and Brazilian capitals stratified by gender.
The percentage of adults who consumed alcohol in an abusive manner was calculated by the relation of the number of adults who reported alcohol abuse by the total of interviewees.
To identify the existence of a linear trend, we used a linear regression model, in which the dependent variable was the prevalence of alcohol abuse, and the explanatory variable was the year of the survey. The angular coefficient (β) of these models expressed the mean annual variation (increase or reduction) of the prevalence of alcohol abuse. A significant linear trend was considered when the β of the model was different than 0 and p value was lower than 0.05.
For data analysis, the post-stratification weights used in Vigitel were considered 17,18 . The analyses were performed using the software Stata (Stata Corp LP, College Station, Texas, United States), version 14.0.

ETHICAL ASPECTS
The Vigitel data are available for public access and use, and their collection was approved by the National Ethics and Human Research Commission of the Ministry of Health, report n. 355,590. An informed consent form was obtained orally, at the time of the telephone call.

RESULTS
Between 2006 and 2019, there was a significant increase (p = 0.03) in alcohol abuse for the total adult population, from 15.6 to 18.8%, with a growth rate of 0.157. Among men, the trend was stable (p = 0.96) and, among women, there was significant increase (p < 0.001), from 7.7 to 13.3% (β = 0,295). The prevalence among men was about three times higher than among women in 2006, and decreased to about two times higher in 2019, presenting tendency of convergence of the curves.

DISCUSSION
The study pointed to an upward trend in alcohol abuse in the total population and among women, maintaining stable among men. It was also possible to observe growth in alcohol abuse among those with higher schooling, the ones aged between 25 and 44 years and 55 to 64 years, as well as in the Center-West, Southeast and South regions of Brazil. Among men, there was increase only in the Federal District, and reduction in nine capitals. However, among women, there was an increasing trend in 13 capitals.
Abusive alcohol consumption (binge drinking) in a short period of time may result in severe events, such as violence, traffic accidents, accidents in general, alcohol poisoning, unsafe sex, unplanned pregnancy and sexually transmitted diseases 2, 19 .
The prevalence of binge drinking is higher among young individuals who participate in social events more often 19 , and in the American countries, including Brazil 2 . Studies have shown changes in the patterns of consumption according to age, decreasing among adolescents and adults aged up to 30 years, and increasing among those aged from 31 to 64 years 20,21 . These findings are similar to the ones in this study, which showed stability in the younger age groups (18 to 24 years), and increase among young adults (25 to 44 years) and the older population (55 to 64 years).
Regarding gender, the international literature shows changes in the pattern of alcohol consumption, increasing among women and stable among men 10,13,[21][22][23] , which is in accordance with the results of this study. Other analyses show increase in the prevalence of high risk alcohol use and mental disorders caused by alcohol among female individuals 10,13 .
Studies in the United States also revealed the slow narrowing of gender differences regarding alcohol abuse and chronic consumption/alcohol dependence 14,23,24 . The increasing alcohol use among women can be related to increasing autonomy, larger participation in the work market and education, which enables and encourages alcohol intake 25 . Other hypotheses observed in the American studies were changes in the rules about alcohol consumption and fewer social sanctions; more social tolerance, especially among people with higher schooling 24,26 ; changes in alcohol marketing, addressed to adult women 27 , with increasing number of products addressed to women and mothers 28 ; and the use of social media to increase consumption among women 29 .
The increasing alcohol abuse brings harmful consequences for women 14 , such as adverse effects in pregnancy and risk for the fetus 30 , higher chances of breast cancer 31 and heart disease 32 . Besides, women have lower rates of treatment and use of services for alcoholism 24 . Therefore, the increasing alcohol consumption among women translates into worse consequences for the health of this group.
There was an increase in alcohol abuse among adults. This consumption also tends to be higher among those with higher socioeconomic status. North-American studies from the National Alcohol Survey, using the binge drinking indicator, found increased risk of alcohol consumption among women with college education or higher 33 . There are also the effects of economic and political crisis in the health indicators 34 , since the reduction of income and REV BRAS EPIDEMIOL 2021; 24: E210022.SUPL.1 unemployment can reduce the expenses with alcohol, especially in the populations that are mostly affected economically 25,35,36 . On the other hand, the pathological suffering and the stress caused by reduced income and unemployment may lead to more alcohol consumption 35 . Therefore, the increasing stress resulting from the economic and political crisis in Brazil may also have contributed with the increasing alcohol consumption among Brazilian adults.
Such an increase shows that Brazil has not responded properly to the global goals for the reduction of alcohol abuse 15 . To stop the consumption from growing, it is important to invest in public surveillance policies, risk and damage control and health promotion. Therefore, understanding the sociodemographic characteristics related to groups with higher exposure to risk factors and behaviors contributes with the elaboration of equanimous and more efficient health policies and programs 40 .
In order to reduce alcohol abuse, several global and national initiatives were undertaken. In May, 2010, the World Health Assembly approved the Global Strategy to Reduce the Harmful use of Alcohol 1 , which defines guiding principles for the development and implementation of alcohol prevention policies. Besides, it exhorts a set of political options to national implementation. The strategy recommends ten points: leadership and effort in the subject; structure of health services for counselling and treatment; involvement of the community to identify the needs and solutions; establishment of policies to monitoring and control alcoholemy ; reduction in the availability of alcohol; regulation of alcohol commercialization; definition of a pricing policy; reduction of the negative consequences alcohol use and poisoning; reduction of illegal and informal alcohol impact on public health; and establishment of alcohol monitoring and surveillance. REV BRAS EPIDEMIOL 2021; 24: E210022.SUPL.1 Brazil adopted important public policies, such as Vida no Trânsito Program 41 and the prohibition of drinking and driving (Lei Seca -Law n. 11,705/2008; Nova Lei Seca -Law n. 12,760/2012), which already resulted in the reduction of alcohol use for drivers 42 . However, it is still necessary to make progress in regulating actions to increase taxes on products, to restrict access to alcohol, to forbid wide alcoholic beverages publicity, including the promotion and sponsorship , as well as the monitoring of the adopted measures 43 . The Brazilian legislation is flawed, and only forbids advertisements of beverages whose alcohol by volume is above 13 degrees Gay Lussac. Therefore, beer can be advertised freely. That is why it is important to advance in the improvement of law, including for beers 44 .
Among the study limitations, it is important to mention its cross-sectional design, with telephone interviews involving adults with a telephone landline, which may not represent the entire population. However, this issue is minimized by the use of data weighting factors. Besides, the Vigitel survey does not include all forms of alcohol consumption, such as chronic use.
The results show that there has been an increase in alcohol abuse among adult women in the Brazilian capitals, and show a convergence effect in the prevalence rates between men and women. The study highlights the increasing consumption among those aged from 25 to 44 years and 55 to 64 years, as well as individuals with high schooling. The surveillance of alcohol use and the related damage among women must be improved, in order to understand the causes the determine this phenomenon locally. Finally, the observed growth may affect the reach of national and global goals of reducing alcohol abuse.