# 2. Trends and patterns in alcohol consumption

Sabine Vuik
Jane Cheatley

Alcohol consumption is a causal factor for more than 200 disease and injury conditions (WHO, 2018[1]). The diseases include alcohol dependence, liver cirrhosis, and some cancers and cardiovascular diseases. Moreover, alcohol use can cause harm to others, as it can contribute to injuries resulting from violence, road traffic accidents and foetal alcohol spectrum disorders (i.e. a range of adverse effects in a child that results from alcohol exposure during pregnancy – see additional information in Box 4.3 in Chapter 4 of this report).

In addition to its impact on population health, harmful alcohol use also carries considerable economic and societal costs. As described in Chapters 4 and 5 of this report, diseases caused by harmful alcohol consumption increase health care costs, decrease labour force output, depress gross domestic product (GDP) and affect the formation of human capital through its effects on educational outcomes in children.

However, the impact of alcohol on health and the economy is complex. While overall volume of consumption is an important determinant of health outcomes, the pattern of consumption (frequency, quantity and heavy episodic drinking) also plays a role (WHO, 2018[1]). Moreover, alcohol consumption differs across sex, age and social group. It is therefore important to understand the trends and patterns.

People in OECD countries drank on average 10.0 litres of pure alcohol in 2018 (Figure 2.1) (see Box 2.1 for more details on definitions and data sources of alcohol consumption). This is roughly equivalent to two bottles of wine, or nearly 4 litres of beer, per week. In G20 countries the average is lower, at 7.9 litres per capita. This is driven by a number of very low-consumption countries, including Saudi Arabia, Indonesia, India and Turkey (which is also an OECD member country). On the other hand, the EU27 average is higher at 11.3 litres per capita, as many European countries have relatively high consumption levels. Men consume more alcohol than women in all countries, with around a three-fold gender gap.

The per capita alcohol consumption of a country depends on the total consumption of alcohol in the country and the size of the population (those aged 15 and over in the OECD and WHO statistics). The per-drinker alcohol consumption depends on how many people drink and how much they drink. In OECD countries, drinkers consume on average 15.4 litres of alcohol per year per consumer (Annex Figure 2.A.1), compared to the population average of 10.0 litres per capita. While the average consumption in G20 countries is lower, the per-drinker consumption is equal to the OECD at 15.4 litres per year per consumer. This is due to a number of countries (including South Africa, Turkey, the Russian Federation, and Brazil) where the number of drinkers is relatively low, but where those who do drink consume quantities that are relatively large compared to other countries.

These countries have a larger prevalence of abstainers – defined as people who did not consume alcohol in the preceding 12 months. On average in OECD countries, 32% of the population had abstained from alcohol consumption in the past year in 2016 (Figure 2.4). In G20 countries this figure is 47%, driven by countries such as Saudi Arabia and Turkey, where abstainers make up over 90% of the population. In all countries analysed, more women than men are abstainers: on average 42% of women in OECD countries abstain, compared to 21% of men. In the Russian Federation, the gap between men and women is notably small, but considerable differences between sexes are seen when it comes to other drinking behaviours. Men are much more likely to drink heavily and to binge drink; this is driven by traditional gender roles (Bobrova et al., 2010[6]).

On average in OECD countries, 42% of alcohol is consumed in the form of beer, 29% as wine and 23% as spirits1 (Figure 2.5). In 34 out of 52 countries, beer is the most consumed alcoholic beverage, as measured by alcohol volume. Latin American countries in particular see a high proportion of beer consumption – with the exception of Argentina and Chile. In eight countries – including other major wine-producing countries such as France, Italy and Portugal – wine accounts for the largest proportion of alcohol consumption. While spirits are often the second most consumed alcoholic beverage type, they rank first in eight countries, including some Central and Eastern European countries like the Slovak Republic, Estonia and Bulgaria. Fermented wheat and fermented rice wines – such as soju and sake, which are popular in Korea and Japan – increase the “other” category in those countries (OECD, 2020[7]).

On average in OECD countries, about 1.4 litres of unrecorded alcohol were consumed per capita per year over 2016 to 2018 (WHO, 2020[2]), corresponding to 14% of total annual consumption. (See Box 2.1 for more details on definitions and data sources of alcohol consumption, and see also Figure 8.2 in Chapter 8.) The G20 average is slightly lower at 1.2 litres per capita, while the EU27 average is higher at 1.5 litres. Countries with relatively high consumption of unrecorded alcohol are Greece (4.2 litres), the Russian Federation (3.5 litres) and India (2.6 litres). On average across the 52 countries studied, unrecorded consumption represents 18% of total alcohol consumption, ranging from 3% in Austria to nearly 50% in India and Saudi Arabia, and up to 83% in Indonesia. Unrecorded alcohol can include homemade or informally produced alcohol, smuggled alcohol, surrogate alcohol (alcohol not intended for human consumption) or alcohol obtained through cross-border shopping (WHO, 2020[8]).

Between 2010 and 2018, alcohol consumption changed little for the OECD on average: total per capita consumption decreased by 0.17 litres, dropping from 10.18 litres in 2010 to 10.01 litres in 2018. In the EU27 it decreased by 0.20 litres, while in G20 countries consumption dropped by 0.37 litres. However, at the country level different trends can be observed. Some countries have seen great decreases, including the Russian Federation (-7.4 litres in men; -2.4 in women), Estonia (-5.2 in men; -1.5 in women) Lithuania (-3.3 in men and -1.0 in women) and Romania (-3.2 in men; -1.3 in women) (Figure 2.6). On the other hand, about half of the countries analysed saw alcohol consumption increase. This increase in consumption was highest in Spain (+4.4 in men; +1.2 in women), Iceland (+2.5 litres in men; +0.8 in women), Bulgaria (+2.2 in men; +0.6 in women) and Malta (+2.1 litres in men; +0.6 in women). While the magnitude of the change was generally greater in men, in almost all cases the direction of the trend for men and women was the same (i.e. both sexes saw an increase, or both sexes saw a decrease).

While consuming large quantities of alcohol carries significant public health risks, heavy episodic drinking – drinking a large amount in a single sitting – poses health threats that go beyond the impact on overall consumption (Box 2.2). On average, 30% of adults in OECD countries engage in heavy episodic drinking at least once within 30 days (Figure 2.7). Many Central and Eastern European countries have relatively high rates: 49% of the population in Lithuania engages in heavy episodic drinking at least once within 30 days. In all countries, the rate of heavy episodic drinking in men is considerably higher than in women.

A large proportion of alcohol is consumed by people who drink at high levels. An Australian study found that the top 10% of the population with the highest alcohol consumption accounted for more than half (54.4%) of all alcohol consumed (Livingston and Callinan, 2019[12]). Similar results were found in France, where the top 10% of the population with the highest alcohol consumption drank 58% of all alcohol (Richard et al., 2019[13]). In the United States, it was found that the top 10% of current drinkers (as opposed to the top 10% of the entire population) accounted for 55.3% of total alcohol consumption (Kerr and Greenfield, 2007[14]). In the United Kingdom, 77% of alcohol units were consumed by people drinking more than the drinking guidelines (Bhattacharya et al., 2018[15]).

Heavy drinkers (men and women consuming more than 40 or 20 grammes of pure alcohol per day, respectively; see Box 2.3) consume a disproportionate amount of alcohol. Across six OECD countries, heavy drinkers make up only 4% to 14% of the population, but they consume between a third and half of all alcohol (Figure 2.8). As these calculations are based on self-reported alcohol consumption – which is known to be considerably underestimated, especially in heavy drinkers (Boniface, Kneale and Shelton, 2014[16]) – the actual proportion of alcohol consumed by heavy drinkers is likely to be even higher. Looking at the 20% of drinkers who drink the most, the analysis shows that they account for 65% to 87% of all alcohol consumed (Annex Figure 2.A.2).

Repeated or continuous use of alcohol can result in alcohol dependence. In OECD countries, 3.7% of the population is alcohol dependent (Figure 2.9), which represents about 50 million people. While the EU27 average is similar, the average for G20 countries is lower, at 2.9%. In all countries, as for heavy episodic drinking, prevalence is greater in men than in women. Prevalence is relatively high in some Central and Eastern European countries, including Latvia, Hungary, the Russian Federation, Slovenia, the Slovak Republic and Estonia. This is primarily driven by high prevalence rates for men, as the prevalence of alcohol dependence in women is more in line with other countries.

Drinking patterns change with age, with older age groups more likely to drink frequently and younger age groups more likely to engage in binge drinking (Chaiyasong et al., 2018[20]). In many countries analysed for this report, weekly alcohol consumption is most common around middle age, peaking between the ages 45 and 74 (Figure 2.10). On average across 25 OECD countries, weekly drinking is most common between the ages 45 and 59 in both men and women. However, in a number of Central and Eastern European countries (including Estonia, Latvia, Lithuania and Poland), weekly alcohol consumption is most prevalent in people aged 30 to 44. Other notable exceptions are Malta and the United States, where the prevalence of weekly alcohol consumption decreases with age. Other studies have found a similar pattern for the United States (Delker, Brown and Hasin, 2016[21]; Moore et al., 2005[22]).

The age distribution of binge drinking looks quite different: on average across OECD countries, monthly binge drinking is most common in the two youngest age groups, after which it becomes less prevalent with increasing age (Figure 2.11). The pattern is different for men in Bulgaria, Cyprus and the United Kingdom, and for both sexes in Romania, where those between the ages of 45 and 59 are more likely to engage in monthly binge drinking than any other age group. One study from the United Kingdom found that binge drinking was more common in men aged 45-54 than in those aged 35-44, but that it was still more common in those under the age of 35 (Castillo, Jivraj and Ng Fat, 2017[23]).

In 2017-18, about one in five teenagers aged 15 attending school had experienced drunkenness at least twice in life, according to the Health Behaviour in School-aged Children (HBSC) survey (Inchley et al., 2020[24]). This is despite the fact that the legal drinking age is 18 in most countries (WHO Regional Office for Europe, 2019[25]).

Younger generations are less likely to experience drunkenness at age 15 than a decade ago; if they have been drunk, it has been at an older age, although the differences are small. The proportion of 15-year-old boys who experienced drunkenness decreased from 40% in 2001-02 to 23% in 2017-18 (the proportion of girls decreased from 33% to 20%) on average in OECD countries (Figure 2.12). This pattern is observed in most countries, albeit with a few exceptions. For example, boys in Austria, Denmark and Germany, and girls in Austria and Italy reported an increase in the proportion of those who experienced drunkenness in 2014-18, while boys in Malta reported such an increase in 2006-18.

Sex differences in the proportion of those who experienced drunkenness vary across countries. The proportion of boys who experienced drunkenness exceeds by 3 percentage points or more the proportion of girls in 17 countries in 2017-18, whereas three countries show the reverse pattern.

Over 2001-14, the average age of first drunkenness increased slightly from 13.7 to 14.0 years in boys and from 13.9 to 14.2 years in girls across 21 OECD countries.2

The picture of drinking initiation is quite similar to that of drunkenness. There was a small decline in lifetime alcohol use among adolescents between 2014 and 2018, from 64% to 62% among boys and from 64% to 63% among girls on average across OECD countries (Inchley et al., 2020[24]). The proportion of 15-year-olds who have started to drink alcohol has decreased since 2014 in a majority of countries. The largest reductions (greater than 11 percentage points in both boys and girls) are observed in Estonia, the Russian Federation and Sweden. On the other hand, the proportion of boys who have ever drunk alcohol increased by 3-4 percentage points in France, Germany and Spain, and for girls it increased by 5-8 percentage points in France, Denmark and Ireland (Annex Figure 2.A.5).

Several reasons have been proposed to explain declining rates of youth drinking (Kraus et al., 2019[26]; Törrönen et al., 2019[27]; IAS, 2016[28]). While there may be a change following reinforced policy actions or a change in the social perception of alcohol as a social reaction to the negative effects of alcohol, other explanations include changes in technology, social norms, family relationships and gender identity, as well as trends in health, fitness, well-being and lifestyle behaviour (Kraus et al., 2019[26]). The increasing use of new technology and social media may contribute to reductions in drinking in youth, since nowadays young people mainly exchange virtual communications (e.g. via smartphones and social media), which may create fewer occasions for drinking. Social norms may also play a role: first, there is less peer pressure to drink; second, young people may wish to control their drinking to avoid the public diffusion of disreputable images of extreme drinking (occurring in private circumstances) through social media and networks. Family relationships may also contribute to declining youth drinking – in particular, with parents taking a stricter line on alcohol. Finally, changes in gender identity may be associated with less drinking in young men, as masculinity is less attached to heavy drinking than in the past (Törrönen et al., 2019[27]).

Several studies have found that early drinking is associated with drinking later on in life (Zucker, 2008[33]; Englund et al., 2008[34]). For instance, early onset of drinking and early onset of excessive drinking were related to hazardous drinking in young adulthood in Norway and Australia (Enstad et al., 2019[35]). Using longitudinal data from the United States (Harris and Udry, 2015[36]), OECD analysis shows that drinking in childhood (between ages 15 and 18) is predictive of future drinking, even after adjusting for family income and minority status. Men who drank weekly when aged 15 to 18 were 56% more likely to drink weekly when aged 21 to 25 than men who rarely drank during childhood (Figure 2.13). Even monthly drinking during childhood increased the risk of weekly drinking six years later by 49% in men. For women, the effect was even larger, as women who drank weekly when aged 15 to 18 were more than twice as likely to drink weekly when aged 21 to 25, compared to women who rarely drank during childhood.

These effects were still observed 13 years later in both sexes, at ages 28 to 31. Monthly and weekly drinking at age 15 to 18 increased the likelihood of weekly drinking at age 28 to 31 by 55% to 68%.

Patterns of drinking across different social groups are not straightforward. This section looks at the relationship between alcohol consumption and social factors such as income and educational attainment, and the gender effect on this relationship. There are other dimensions of social inequalities in drinking that are overlooked here, such as differences in drinking related to ethnicity, minority or migrant status, and differences in drinking during pregnancy related to social conditions.

In many countries, there is a clear relationship between income and the likelihood of drinking alcohol at least weekly. On average in OECD countries, both men and women in higher income groups are more likely to drink weekly (Annex Figure 2.A.3). In some countries, including Belgium, Canada, Finland, Luxembourg and the United Kingdom, the gradient is steep. However, other countries see a U- or J-shaped curve, for one or both sexes, according to which individuals in the highest and lowest income categories are more likely to be weekly drinkers, compared to individuals in the middle-income categories. For example, men in Estonia, Greece, Latvia and Lithuania are less likely to be weekly drinkers if they are part of the middle socio-economic groups, with peaks in drinking at both the high and low ends of the income distribution. The same effect can be observed for women in Ireland, Lithuania and the Slovak Republic.

When looking at binge drinking, this U- or J-shaped curve is even more common (Figure 2.14). Many countries see the lowest rates of monthly binge drinking in the middle socio-economic classes. On average in OECD countries, women and men are more likely to binge drink monthly if they are in the lowest or two highest income groups. Exceptions are Belgium, Canada and Slovenia, where a positive relationship between income and binge drinking is observed. France, Greece and the United States see a negative relationship, where people on a lower income are more likely to binge drink monthly.

The U-shaped curve in binge drinking prevalence may be partly driven by other drinking patterns. In particular, evidence from two different studies suggests that the specific act of binge drinking increases with income, while some people in the lowest income groups exceed binge drinking limits owing to their generally heavy drinking (Cerdá, Johnson-Lawrence and Galea, 2011[37]; Lewer et al., 2016[38]). In addition, these findings should be interpreted in the light of the fact that data are based on self-reported alcohol consumption from national surveys. Self-reported alcohol consumption is known to be considerably underestimated, especially among heavy drinkers (Boniface, Kneale and Shelton, 2014[16]). Further, different population groups may underestimate their consumption to various degrees, creating misestimations in the size of social inequalities (Devaux and Sassi, 2016[39]).

In almost all countries, people with higher educational attainment (i.e. those who have completed tertiary or university education) are more likely to be weekly drinkers (Annex Figure 2.A.4). This effect is considerably stronger in women, who are up to three times more likely to drink weekly if they have completed tertiary education in Latvia. On average across 25 OECD countries, women with higher educational attainment are 60% more likely to drink alcohol weekly (30% of women with higher education drink weekly versus 19% of women without higher education). For men, this effect is only 24% (49% versus 40%). Moreover, in the Slovak Republic, Lithuania, Mexico and Romania, men with a lower education are more likely to drink weekly. Previous studies have also found that people with a higher education are more likely to be current drinkers, with a greater effect in women than in men for most countries (French et al., 2014[40]; Grittner et al., 2013[41]).

Binge drinking presents a more varied inequalities picture than weekly drinking. On average across 26 OECD countries, women with higher educational attainment are 13% more likely to engage in monthly binge drinking (14% of women with higher education binge drink monthly versus 12% of women without higher education) (Figure 2.15). However, for men a considerable number of countries show an inverse relationship – where people with lower educational attainment are more likely to binge drink monthly. As noted above, these findings should be interpreted in the light of the fact that self-reports on alcohol use may vary across different population groups, creating misestimations in the size of social inequalities. Grittner et al. (2013[41]) also found mixed results on the relationship between education and risky single-occasion drinking (RSOD), with a significant relationship between lower education and RSOD among men, but no significant relationship between education and RSOD among women. However, they did find a significant association between higher education and RSOD for women in lower-income countries.

Alcohol affordability plays a key role in determining the level of consumption and is influenced by three key factors: income, the price of alcohol (which is affected by the rate of taxation) and the price of other goods (Elder et al., 2010[42]; Rabinovich et al., 2009[43]).

This section analyses trends in alcohol affordability in the off-premise market (e.g. supermarkets) across several European countries as well as Australia, Canada and the United States for 2000-18.3 The analysis takes into account both the relative price of alcohol and real income (see Annex Box 2.A.1 for further methodological details).

Figure 2.16 shows the change in alcohol affordability between 2000 and 2018, with figures above 100 indicating an increase in affordability relative to the year 2000, and vice versa.4 Across the 28 OECD countries analysed, alcohol affordability increased by nearly 50% over 2000-18. This means that in 2018, purchasing the same quantity of alcohol was, on average, 50% cheaper than in 2000, once changes in real income and the relative price of alcohol are taken into account.

It is important to reiterate that these findings represent the off-premise sector only, given previous research indicates affordability in the off-premise market has grown at a faster rate than in the on-premise market (Public Health England, 2016[44]; Rabinovich et al., 2009[43]).

Between 2000 and 2018, alcohol became more affordable in the majority of countries, particularly among those located in Eastern Europe. Only three countries – Iceland, Greece and Italy – experienced a decline in affordability: specifically by 33%, 30% and 4%, respectively. These results are not surprising, given that they were all severely affected by the global financial crisis. As an example, in the aftermath of the global financial crisis Greece saw the relative price of alcohol increase, while real incomes dropped markedly from 2009 onwards.

Figure 2.17 shows alcohol affordability in two countries experiencing significantly different trends: the Slovak Republic and Greece.

Trends in alcohol affordability were also assessed post-global financial crisis, given that trends in affordability between 2000 and 2018 were largely driven by marked falls in real income. Between 2013 and 2018, the number of countries that experienced a fall in alcohol affordability increased from three (Italy, Greece and Iceland) to five (Greece, Norway, Sweden, Belgium and Estonia) (Annex Figure 2.A.6).

Alcohol affordability trends were also examined for young people: those aged between 16 and 24 (Figure 2.18). There was greater variation in alcohol affordability trends for young people, with approximately one-third of all countries experiencing a decline in alcohol affordability between 2013 and 2018. Countries where alcohol affordability declined for all ages between 2013-18 experienced the same trend for young people (Belgium, Estonia, Greece, Norway and Sweden). In Austria, Germany, France and Finland, however, alcohol affordability fell for young people only.

Among OECD countries, the largest disparity in alcohol affordability trends between the total population and young people occurred in Norway, the Slovak Republic, Germany and Belgium (Annex Figure 2.A.7). Both Norway and Belgium experienced declines in affordability for young people and all ages, while in Germany affordability fell for young people only. Conversely, the Slovak Republic saw affordability increase in both groups. Given the same data for alcohol prices were used across age groups, these results reflect differences in real income.

Figure 2.19 outlines the “driving force” behind trends in alcohol affordability between 2013 and 2018 for all people.5 That is, whether the change in real income was greater than the change in the relative price of alcohol, or vice versa. Results from the analysis show that the growth in real income was the main driver of affordability, with the exceptions of Belgium, Estonia, Greece, Sweden and the United Kingdom. For example, in Belgium, real income rose by 5%, which was lower than the 9% increase in the relative price of alcohol, causing alcohol affordability to decline.

Of the eight countries that saw a decline in the relative price of alcohol between 2013 and 2018, seven do not adjust their alcohol excise tax rate for inflation (e.g. United Kingdom, Ireland and Norway) (see Figure 6.4 in Chapter 6). Conversely, countries that do adjust for inflation – i.e. Australia, Belgium, Canada, France, Italy and Spain – experienced either no change or an increase in the relative price of alcohol.

Alcohol consumption is a risk factor for numerous diseases, and can cause harm to others. People in OECD countries drink on average 10 litres of pure alcohol per year per person – this is equivalent to two bottles of wine, or nearly 4 litres of beer, per week. Men consume more than women. On average across OECD countries, 14% of total alcohol consumed is through unrecorded channels, such as illicit alcohol production and trade. During the last decade, per capita alcohol consumption in OECD countries remained largely stable, with few countries experiencing significant shifts in consumption.

But beyond average trends, the analyses presented in this chapter identified a number of risky drinking behaviours such as binge drinking, heavy drinking, alcohol dependence and early onset of drinking in childhood. As discussed in Chapter 4, these drinking behaviours have significant implications for the burden of disease, the health costs and the wider economy.

Analyses in this chapter also showed that alcohol use evolves over the life course. Inequalities exist, since some population groups are more at risk for alcohol consumption, including teenagers, women with higher education and people in both the lowest and highest income groups. Over the past two decades, while real income has increased, relative alcohol prices have remained stable, making alcohol more affordable. Understanding individual patterns and the drivers of drinking is crucial for designing better policies to tackle harmful alcohol use, as discussed in Chapter 6 and Chapter 7.

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Various data sources were used in Chapter 2 to analyse the levels and trends in alcohol consumption. Both international data collection, and international and national health surveys were employed. International surveys and data collection are generally harmonised to allow comparison across countries and over time. National survey data provide the opportunity to make an assessment of a situation in a country. Annex Table 2.A.1 provides information on data sources, including country, survey name, survey years, data providers and a link to the survey where more information (survey sampling method, response rates and representativeness of the general population) can be sought.

## Notes

← 1. Spirits include all distilled beverages.

← 2. Individual-level data for HBSC 2017-18 were not available at the time of writing, and the analysis could not include the latest year.

← 3. An analysis of alcohol affordability, specifically for beer, in Latin America was undertaken by Paraje & Pincheira (2018[56]). Results from the study align with findings in this chapter, with the affordability of beer rising in most of the countries examined. For example, in Colombia, beer affordability rose by an average annual rate of 1.4% between 2009 and 2016.

← 4. The alcohol affordability index is a relative measure; for example, alcohol affordability values in Figure 2.16 represent relative change since 2000. The results do not reflect absolute affordability or differences in affordability across countries. Lastly, the results represent changes in affordability in the off-premise market only. Further information on the limitations of the alcohol affordability index measure can be found in (Rabinovich et al., 2009[43]).

← 5. Between 2000 and 2018, the relative price of alcohol rose in 11 out of 31 countries (i.e. in 20 countries, including Finland, Latvia and Ireland, the relative price of alcohol fell). Over the same period, real income rose in 28 of the 31 countries. In all but two countries (the United Kingdom and Italy), the change in real income drove the change in alcohol affordability.