Alcohol and Alcoholism Advance Access originally published online on November 18, 2005
Alcohol and Alcoholism 2006 41(1):99-106; doi:10.1093/alcalc/agh238
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WORLDWIDE ALCOHOL-RELATED RESEARCH AND THE DISEASE BURDEN
1 Nutritional Sciences Research Division, School of Life Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, London SE1 8WA, UK and 2 Department of Information Science, City University, London EC1V 0HB, UK
* Author to whom correspondence should be addressed at: Tel.: +44 (0)20 7040 0214; Fax: +44 (0)20 7040 8584; E-mail: g.lewison{at}soi.city.ac.uk
(Received 12 July 2005; first review notified 15 August 2005; in final revised form 19 September 2005; accepted 22 October 2005)
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ABSTRACT |
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Aims: The purpose of this study was to determine the international commitment to alcohol-related research relative to its global burden of disease, which is 4% of disability adjusted life years (DALYs). Methods: The worldwide literature indexed in the Science Citation Index® and the Social Sciences Citation Index® during 1992–2003 was analysed using advanced bibliometric techniques. Results: Biomedical research and the global disease burden due to alcohol both increased during 1992–2003, whilst the number of papers from alcohol-related research remained static and declined to <0.7% of all biomedical research literature. Nearly 58% of all alcohol-related research papers were from Canada and the United States, 30% from Western Europe, and 10% from Australia, New Zealand, or Japan. However, these regions suffer only 13% of the global burden of disease due to alcohol; meanwhile, the rest of the world contributed only 8% of the total research whilst suffering from 87% of the disease burden. The estimated annual expenditure on alcohol-related research in 2001 was $730 million, or about $12 per DALY due to alcohol. Conclusions: The global commitment to alcohol-related research is only one-sixth of that warranted by the burden of disease due to alcohol. Most such research is conducted in the developed world but is still less than that appropriate to the regional burden of disease. There is a need for more interest in alcohol-related research in the developing world, particularly in Latin America and Eastern Europe in view of their high burden of disease due to alcohol.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODOLOGY: BIBLIOMETRICSRESULTS: THE INTERNATIONAL...DISCUSSIONREFERENCES |
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After caffeine, ethanol is probably the most commonly used recreational drug worldwide. However, there is significant variation in the consumption of alcohol between individuals. Many enjoy the psycho-pharmacological effects of alcohol whilst others react quite badly, with flushing, nausea, and palpitations as a result of genetic variation in metabolism (Rajendram et al., 2005
). Alcohol is freely available throughout most of the world, although some communities prohibit its consumption on religious grounds.
The majority of people enjoy alcohol without harming themselves or others. Moderate alcohol consumption may even be beneficial in reducing the risk of ischaemic heart disease (Booyse and Parks 2001; Rehm et al. 2003c; Preedy and Watson 2005). However, excess alcohol intake may cause malnutrition or induce any of at least 60 different alcohol-related pathologies (Peters and Preedy 1999; Preedy and Watson 2005).
The World Health Organization (WHO, 2002) reported that in established market economies, 10.3% of the disease burden as quantified by disability-adjusted life years (DALYs) was attributable to alcohol in 2000. This is comparable to the disease burden caused by tobacco (11.7% of DALYs) but significantly more than that due to unprescribed drugs (2.3% of DALYs). However, these figures are conservative because they take into account the potential benefits of alcohol and focus on the effects of alcohol on health. The social problems due to alcohol misuse impose at least as much burden as the effects of alcohol on health. Alcohol misuse results in crime and anti-social behaviour, inefficiency in the workforce, and difficulties for the families of alcohol abusers. The social cost of alcohol misuse is significant and far greater than that from tobacco or drug abuse (Catalyst Health Consultants, 2001; Varney and Guest 2002; Fenoglio et al. 2003; Preedy and Watson 2005; Room et al. 2005).
Alcohol consumption and the associated burden of disease are rife throughout the modern world (Table 1). The global burden of disease (GBD) due to alcohol is increasing in terms of both mortality and disability. The GBD 2000 study revealed that 3.2% of global mortality was attributable to alcohol (WHO, 2002; Rehm et al., 2003b) whilst in the GBD 1990 study, 1.5% was attributable to alcohol (Murray and Lopez, 1997). The number of DALYs attributable to alcohol also increased, but not to the same degree. In 2000, alcohol accounted for 4.0% of the total number of DALYs worldwide (WHO, 2002; Rehm et al., 2003b; Room et al. 2005). However, there is international variation in the alcohol-related burden of disease, mainly in relation to the average per caput volume of consumption and patterns of drinking (WHO, 2002; Rehm et al., 2003a–c; Room et al. 2005).
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Alcohol-related research (ARR) is a multidisciplinary field which covers a wide spectrum including studies at the cellular level, clinical trials of treatment for patients, and epidemiological studies of international patterns of drinking. For the purposes of this study, we adopted the following definition:
The study of the causes, pathogenesis, and treatment of tissue perturbations, or changes in social and psychological harmony, induced by episodic or chronic ethanol ingestion. Ethanol is studied with regard to its use as a beverage, rather than as a pharmacological or chemical tool (such as when it is used to dissolve analytes). It encompasses not only the adverse effects but also the beneficial social (e.g. reducing inhibitions) and biomedical aspects (e.g. reducing cardiovascular disease).
However, the fundamental rationale for conducting research is to improve the well-being of the individual and society by either education or treatment. Previous investigations have suggested that the research grants from the US National Institutes of Health and the Medical Research Council of Canada correlate relatively well with the burden of disease in the USA and Canada (Gross et al., 1999; Lamarre-Cliché et al., 2001). We should, therefore, expect that the amount of ARR should reflect the GBD due to alcohol, and it is the objective of the current study to assess the worldwide commitment to ARR during 1992–2003 in relation to the GBD due to alcohol.
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METHODOLOGY: BIBLIOMETRICS |
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Identification of ARR
ARR papers published during the 12 year period from 1992 to 2003 were identified from the CD-ROM versions of the Science Citation Index® (SCI) and Social Sciences Citation Index® (SSCI) databases. Although some papers are published in specialist journals, such as Alcohol and Alcoholism, experience in other biomedical sub-fields (Lewison, 1996
) has shown that the majority of papers are in ‘general’ journals and can only be identified by means of keywords in their titles. Accordingly, a ‘filter’ was created based on keywords (often in combination) and on specialist, semi-specialist, and general journals. The former comprised five journals (Alcohol, Alcohol and Alcoholism, Alcohol Research & Health, Alcoholism: Clinical and Experimental Research, and Journal of Studies on Alcohol). The semi-specialist journals comprised a large number of journals on addiction such as Addiction, European Addiction Research, and Journal of Substance Abuse, provided that their article titles included (alcohol* or ethanol), [* represents any character(s) or none.] Articles in all other journals were included if their titles included words such as (alcoholism or drunkenness or hangover), or both, (acetaldehyde or alcohol or ethanol), and words such as (abuse* or crime or intoxicat* or misuse or problem* or rats or survey* or women). The filter was calibrated by inspection of the samples generated. The precision (specificity, p) and the recall (sensitivity, r) of the filter were 0.92 and 0.88, respectively. The calibration factor of the filter (i.e. the ratio of the true estimated total to that found) was, therefore, p/r = 1.045. Duplicate papers listed in both databases were removed. Papers that were not concerned with the effects of ethanol on humans or animals (mainly chemical and industrial research) were also excluded. The resulting file contained 22 370 papers of which 55% were only in the SCI, 19% only in the SSCI, and 25% in both databases. Approximately one in eight of the 2003 papers would have been missed because of delayed processing for the SCI and SSCI; allowance was made for this in the subsequent analysis.
The large majority of the papers (82%) were classified as being within the field of clinical medicine. The rest were mainly classified as biomedical research (8%) and psychology, or sociology (7%). The country or countries of origin of each paper were determined from the addresses of the authors, all of which are given in the SCI and the SSCI. The contributions of the 14 WHO regions stratified on the basis of geography and mortality were studied (Table 1; WHO, 2000). The contributions of the 15 countries that had published the most ARR during 1992–2003 were then analysed (Table 2). All 15 countries were located in one of three WHO regions [American region-A (AMR-A), European region-A (EUR-A), or Western Pacific region-A (WPR-A)]. The contributions of five leading countries outwith these regions were also assessed (Table 2). Integer counting was employed for these analyses. Thus, a paper from several centres in both Australia and the UK registered as one towards the respective totals for each country, and for the EUR-A and WPR-A regions.
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Relative commitment to ARR
In order to put ARR in context, the total number of publications from biomedical research worldwide, during 1992–2003, was determined from the SCI using a biomedical address keyword filter. This was then used to identify the contributions of the 14 WHO regions and the 20 countries listed in Table 2. This method of bibliometric analysis has been described previously (Lewison and Wilcox-Jay, 2003
). It is based on the principle that biomedical research, including that published in multidisciplinary journals such as Nature, can be identified from the presence of one or more of a long list of cognitive words in the address field (de Bruin and Moed, 1993). The relative percentage presence of a country, or region, in worldwide ARR (WARR) can then be compared with its presence in global biomedical research to show its relative commitment (RC) to the subject. For example, the UK publishes 
6% of WARR but just over 10% of all biomedical research, so the RC of the UK to ARR is 0.6. This measure largely compensates for the variable tendency of researchers in different countries to publish their papers in local non-English language journals not indexed in the SCI and SSCI databases. However, there is still some bias against non-English language clinical and social science research; this is discussed further below.
Calculation of research level to assess bias against non-English language research
The papers were classified by their research level (RL) on a scale from 1 = clinical to 4 = basic on the basis of the journal in which they were published. The value of RL was determined separately for the publication years in three quinquennia: 1990–94, 1995–99, and 2000–03 as a decimal number using the title words of papers in each journal (Lewison and Paraje, 2004). However, for a small number of papers (n = 486, or 2.2%), mainly those in sociology and professional fields (economics and law), such classifications were not possible and RL was assigned to zero. For each group of papers, it was then possible to determine both the mean value of RL and its distribution.
Calculation of global expenditure on alcohol related research
On the assumption that ARR is typical of biomedical research in general, global expenditure on ARR can be estimated on the basis of a mean cost per published paper. This was determined from the estimated worldwide biomedical expenditure in 2001 ($106 billion; Global Forum for Health Research, 2004) and the number of papers indexed in the SCI per year (277 000 at that time). These figures give an average cost per biomedical paper of $372 000 in 2001. This was used in conjunction with the total number of ARR papers published worldwide in 2001 (1924) to estimate the global expenditure on ARR in 2001.
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RESULTS: THE INTERNATIONAL COMMITMENT TO ARR |
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ARR papers from the 14 WHO mortality-stratified regions
WARR represents <0.7% of global biomedical research output (Table 3). The total numbers of both ARR papers and biomedical papers increased during 1992–2003. However, Fig. 1 and Table 3 illustrate the global decline in commitment to ARR over the same period (1992–95, 0.77%; 2000–03, 0.69%). The regional commitment to ARR as a percentage of their biomedical output varies from practically nothing (AMR-D) to just under 1% (0.94% AMR-A). The commitment to ARR declined in all of the WHO regions although in most regions the actual number of publications increased.
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Nearly 58% of all ARR papers originated from the AMR-A region (mainly Canada and the USA). A further 30% were from Western Europe (EUR-A) and 10% originated from the WPR-A region (mainly Australia and Japan). The rest of the world contributed to only 8% of all ARR papers.
Figure 2 compares the regional commitment to ARR (as a percentage of regional biomedical research published during 2000–03) to the percentage of the total regional burden of disease (RBD) attributable to alcohol in 2001. The world ratio of ARR (as a percentage of global biomedical research published during 2000–03) to the percentage of the GBD due to alcohol in 2001 was 0.17 (Table 3, Ratio RBDA). This suggests that WARR activity is only one-sixth of that appropriate to the GBD due to alcohol. Although the ratio was <1 in all of the 14 WHO regions, the discrepancy between ARR and burden of disease is of particular concern in Europe (EUR-A, ratio = 0.07; EUR-C, 0.04) and Latin America {AMR-B, 0.05; AMR-D, 0 [The AMR-D region (Bolivia, Ecuador, Guatemala, Haiti, Nicaragua and Peru) did not publish any ARR papers during 2000–2003 and so had a ratio of zero.]}. The ratio was highest in the predominantly Muslim low-income countries (Afghanistan, Egypt, Iraq, Morocco, Pakistan and Sudan) of the Middle East [Eastern Mediterranean region (EMR-D; 0.63)] where the disease burden due to alcohol is particularly low (0.3% of DALYs; WHO, 2002).
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The relative commitment to ARR in 20 countries
The ARR outputs of 20 countries were compared with their respective presence in biomedical research to determine their RC to ARR (Fig. 3). Given the finding that the AMR-A, EUR-A, and WPR-A regions together produce 92% of WARR papers, it was not surprising that the RCs of Canada, the USA, Australia, Sweden, Finland, and Spain were all greater than the world average. Of the 20 countries, Finland had much the highest RC to WARR. The percentage presence of Finnish centres in WARR papers (2.8%) is over double their percentage presence in biomedical publications overall (1.2%).
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The RL of ARR in 20 countries
The mean RLs of papers from the 20 countries listed in Table 2 are given in Table 4. The average worldwide RL is 2.05. A high RL probably indicates that only the basic science research from that country is fully covered by the databases. Thus a significant amount of clinical and sociological research from the seven countries with RL >2.3 (Russia, India, Brazil, Japan, Italy, China, and Spain) is probably published in national journals not indexed in the SCI or the SSCI. Their combined biomedical output is quite small, however, and even if a correction were made for this, the WARR output is unlikely to change significantly. Nevertheless, the effects on the regional analyses may be important. It is unlikely that the databases do not cover the basic research being performed by the five countries with the lowest RL (UK, Australia, Switzerland, Denmark, and South Africa). These countries are probably publishing more low RL, sociological, or clinical ARR (or relatively less high RL, basic ARR) in journals indexed in the SCI and SSCI than the global average. This is illustrated in Fig. 4, which shows the distribution of the RL of papers from six countries.
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Calculation of global expenditure on ARR
The annual worldwide expenditure on ARR was approximately $730 million in 2001 (assuming that ARR is typical of biomedical research in general. It is probably an overestimate as very little commercial development work takes place on relevant pharmaceutical drugs compared with the situation with other disease areas). This represented
0.7% of the annual global biomedical expenditure of $106 billion in 2001 (Global Forum for Health Research, 2004). As the WHO (2002) estimated that alcohol was responsible for 59 million DALYs in 2001, expenditure on WARR was approximately $12 per DALY. This is somewhat higher than that for malaria ($7 per DALY) and tuberculosis ($10.5 per DALY), but much less than expenditures on heart disease ($60 per DALY) and diabetes ($107 per DALY) (Lewison et al., 2004). |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODOLOGY: BIBLIOMETRICSRESULTS: THE INTERNATIONAL...DISCUSSIONREFERENCES |
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In the new millennium, society faces difficult choices in the allocation of scarce resources to research. The challenge is to maintain and improve life expectancy and the quality of life that was achieved for most of the world's population during the 20th century. Increases in the average volume of drinking and therefore increases in disease burden are predicted for the most densely populated countries of the developing world, including India and China (Rehm et al., 2003a
). The WHO estimated that 4% of the GBD in 2000 was due to alcohol (WHO, 2002; Rehm et al., 2003b). Since health research is designed to benefit the individual and society and WARR papers represented only 0.7% of all biomedical research publications during 1992–2003, and remained static while biomedical publications increased (Fig. 1), there is clearly an imbalance, with WARR amounting to only one-sixth of that appropriate to the magnitude of the problem. This is of particular concern given that over the same period the worldwide mortality attributable to alcohol doubled (Murray and Lopez, 1997, Rehm et al., 2003b). ARR is significantly below this level and declining in many parts of the world where alcohol is causing a major health burden. Regions of particular concern, where the burden of disease due to alcohol is high but interest in ARR is very low, include Latin America (AMR-B and AMR-D), Eastern Europe (EUR-C), and some of the WPR-B, see Fig. 2.
The estimated global expenditure on ARR represented not more than 0.7% of the estimated total expenditure on biomedical research in 2001, or about $730 million. This figure pales in comparison with the turnover of the alcoholic drinks industry. For example, the UK share of WARR expenditure (based on fractional counts of papers) is likely to be of the order of 5.1% x $730 million or $37 million (£21 million), whereas the alcoholic drinks market is worth over £30 billion ($54 billion) and generates £7 billion ($12.6 billion) for HM Treasury in revenues (The Prime Minister's Strategy Unit, 2003).
Of all the ARR papers listed in the SCI and SSCI, 92% originate from three of the WHO regions AMR-A (Canada and the US), EUR-A (Western Europe), and WPR-A (mainly Australia, New Zealand, and Japan). However, these regions suffer only 13% of the GBD due to alcohol. The rest of the world contributes only 8% of WARR whilst suffering from 87% of the GBD due to alcohol (Table 1). However, despite its major contribution to WARR, ARR activity in the AMR-A, EUR-A, and WPR-A regions is still significantly below that warranted by the proportion of regional burden of disease due to alcohol (Fig. 2). Thus, increased ARR in these developed regions is not only justifiable on humanitarian grounds but is also in the interest of people in these regions.
The ARR output from some countries may be artificially low because some papers (usually clinical and sociological) are published in local journals not indexed in the SCI or the SSCI. The relatively high RL of papers from Brazil and Russia (Table 4) suggests that this is more likely to bias ARR from Eastern Europe and Latin America than from Western Europe. The addition of papers in non-English language journals from these regions is unlikely to affect the analysis of WARR significantly as the biomedical outputs from these regions are relatively low. However, the effects on individual regional analyses might be more significant.
The ratio of percent of ARR to the proportion of regional disease burden caused by alcohol was highest in two mainly Muslim regions of the EMR-B and EMR-D, see Fig. 2. Islam prohibits consumption of alcohol and as a result the average consumption of alcohol (the equivalent of 0.6 l of 100% alcohol/year) and average consumption per drinker (6 l of 100% alcohol/year) in this region are the lowest in the world (Rehm et al., 2003a; Room et al. 2002). However, despite the low burden of disease (<1% of DALYs; WHO, 2002) the ARR activity is still somewhat below that warranted by the magnitude of the problem. Moreover, as previously suggested, the recorded burden of disease due to alcohol may be lower than the actual burden when social effects are included.
Research on how best to treat individuals with an alcohol problem has been remarkably successful in recent years (Mann et al., 2000; Berglund 2005). Thus brief interventions by family practitioners have been shown to be effective in reducing alcohol consumption and encouragement of participation in treatment programmes (Bien et al., 1993). The effectiveness of cognitive behaviour therapy, the Alcoholics Anonymous programme (12 step facilitation), and motivational enhancement therapy in inducing abstinence in alcoholics has been confirmed (Project MATCH Research Group, 1998). In addition, naltrexone and acamprosate have been found to reduce the relapse risk during early abstinence (O'Malley et al., 1996; Sass et al., 1996). However, many questions remain unanswered and even with an accompanying medical treatment many alcoholics relapse (Mann et al., 2000, 2005).
The effects of alcohol on society are both positive (e.g. on ischaemic heart disease, Rehm et al., 2003a–c) and negative, whereas the effects of tobacco are almost entirely negative. Moreover far more people drink (in most regions) than smoke so policies to control alcohol and its abuse need to be carefully designed in response to specific local cultural attitudes toward alcohol ingestion if they are to gain political acceptance. Substantial tobacco price increases and the prohibition of smoking in many public spaces have played a major role in the recent reduction of smoking in industrial countries, but corresponding policies with regard to alcohol would probably be unacceptable although both have been tried with some success (Chaloupka et al, 2002; Chikritzhs and Stockwell, 2002; Ragnarsdóttir et al. 2002); a range of policies, including raising the legal minimum drinking age in the USA, have also curbed the incidence of alcohol-related traffic accidents (Shults et al. 2001). Outright prohibition, except in Muslim societies, has usually failed, notably in the USA (Tyrrell, 1997). It may be better to promote light drinking, especially with meals. This is the area where ARR appears to be deficient, and where governments need help to ensure that their policies are firmly evidence-based (Room et al., 2005) and not influenced unduly by irresponsible advertising by the alcoholic drinks industry (Jernigan, 2001).
How might such research be supported? Increased international collaboration between the developed and developing world may increase ARR in those regions where the burden of disease is highest. In most countries, governments benefit significantly from taxes on alcohol and, therefore, bear the responsibility for using some of the proceeds in order to combat the medical and social harm caused by the product. There may also be scope for a constructive dialogue with the drinks industry whereby it is encouraged to research the promotion of moderate and responsible drinking in a country or region in return for some relaxation in the restrictions on advertising or sale of alcohol. This approach was used by the UK government in the 1980s with the tobacco industry and led to the setting up of the Health Promotion Research Trust and the Tobacco Products Research Trust by voluntary agreement. Direct funding by the drinks industry of independent research bodies such as the European Research Advisory Board, established in Brussels in 2003, may be another avenue. However, it is important to emphasize the need for independent scientific boards (i.e. free from government or industry influence) in the allocation of funds for ARR.
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ACKNOWLEDGEMENTS |
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We are grateful for the helpful comments of two anonymous referees. The authors report no conflict of interest.
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