Drug and Alcohol Review (November 2006), 25, 489 – 502

Global use of alcohol, drugs and tobacco

PETER ANDERSON

Consultant in Public Health, Copenhagen, Denmark

Abstract
Humans have always used drugs, probably as part of their evolutionary and nutritional heritage. However, this previous
biological adaptation is unlikely to be so in the modern world, in which 2 billion adults (48% of the adult population) are
current users of alcohol, 1.1 billion adults (29% of the adult population) are current smokers of cigarettes and 185 million adults
(4.5% of the adult population) are current users of illicit drugs. The use of drugs is determined largely by market forces, with
increases in affordability and availability increasing use. People with socio-economic deprivation, however measured, are at
increased risk of harmful drug use, as are those with a disadvantaged family environment, and those who live in a community
with higher levels of substance use. Substance use is on the increase in low-income countries which, in the coming decades, will
bear a disproportionate burden of substance-related disability and premature death. [Anderson P. Global use of alcohol,
drugs and tobacco. Drug Alcohol Rev 2006;25:489 – 502]

Key words: alcohol, drug, substance use, tobacco.

was actively cultivated [16]. Already by the beginning of

Introduction
Drug use as part of the human diet has a long
history, following biological exposure to low level of
alcohol through eating fruit [1] and as a potential
source of micronutrients and neurotransmitter-related
chemicals [2].
Betel nut, the fourth most used drug in the world
after nicotine, ethanol and caffeine [3], was being
chewed approximately 13 000 years ago in Timor
[4,5] and 10 700 years ago in Thailand [6,7]. At the
time of European contact, indigenous people were
exploiting the native plant pituri for its nicotine
content in western Queensland, and nicotiana in
central Australia [8,9]. Tobacco species were spread
throughout most of the Americas by the time of
conquest, being one of the oldest of the ‘New World’
cultivated substances [10]. Similarly, the use of khat
in Ethiopia and north-east Africa was already an old
practice before the arrival of colonists [11]. Coca was
being domesticated in the western Andes by 7000
years ago [12], and archaeological artefacts date the
use of coca in Ecuador to at least 5000 years
ago [13].
Early societies produced alcohol from a variety of
different substances that were locally available [14],
including grain, honey [15] and the grapevine, which
the second century BC, wine played an important
economic role in the Italian home market and it
became a valuable trade commodity and a major source
of wealth [17], spreading throughout Europe following
the Roman conquests. Wine was brought to England
by the Romans, but when they left subsequent invaders,
the Angles, Saxons, Jutes and Vikings, favoured ale and
cider and the wine trade diminished. In countries such
as England and Germany, wine remained the drink of
the aristocracy and the wealthy classes while most
people drank ale, mead or whatever was cheapest and
most easily produced [18]. Economic factors under-
pinned the ‘gin epidemic’ in 18th-century England,
when consumption rose from 2.5 million litres in 1700
to over 25 million in 1735 [19]. The rise followed
government action to help farmers find a market for
excess grain and to destroy the trade in smuggled
French brandy.
This paper, largely using data derived from the
World Health Organisation’s Global Burden of Disease
study, describes the current use of alcohol, illicit drugs
and tobacco throughout the world, considers the
impact of poverty and market forces on the harmful
use of substances, describes some of the risk and
protective factors and discusses some of the likely
future trends in substance use.

Peter Anderson MD, PhD, Consultant in Public Health, Strandvejen 97 1tv, 2900 Hellerup, Denmark. Correspondence to Peter Anderson.
E-mail: pdanderson@compuserve.com
Received 30 June 2006; accepted for publication 31 August 2006.

ISSN 0959-5236 print/ISSN 1465-3362 online/06/060489–14 ª Australasian Professional Society on Alcohol and Other Drugs
DOI: 10.1080/09595230600944446
490 Peter Anderson

The use of alcohol, drugs and tobacco

Alcohol
World-wide, one half of the total adult population
(2billion people) uses alcohol [20]. The proportion of
users varies across countries from 18% to 90% of adult
males, and from 1% to 81% of adult females. Per capita
consumption varies widely across the world (Fig. 1).
The epidemiological sub-regions used in the global
burden of disease studies referred to in this paper are
summarised in Appendix 1.
The use of alcohol is distributed unevenly throughout
the population [21]; most of the alcohol in a society is
drunk by a relatively small minority of drinkers. In the
Netherlands in the mid-1980s, the top one-tenth of
drinkers consumed more than one-third of the total
alcohol, and the top 30% of the drinkers accounted
for up to three-quarters of all consumption [22]. In
China, it has been estimated that the top 12.5% of
the drinkers consume 60% of the total amount of
alcohol [23].
World-wide, it is estimated that there are 76.4 million
people with alcohol use disorders, 63.7 million men
and 12.7 million women [20]. Table 1 shows the dis-
tribution of ‘high-risk drinking’ (defined as more than
40 g alcohol per day for men and more than 20 g a day
for women) by age and by World Bank region. The table
excludes the Middle East and North Africa because
prevalence rates of high-risk drinking are con-
siderably lower than 1%. ‘High-risk drinking’ is, in
general, more prevalent among men than among
women [24].

Illicit drugs
World-wide, 185 million adults are estimated to have
used illicit drugs in 2002 [25,26]; 146.2 million
adults (3.7% of the population) used cannabis in
2002, 29.6 million used amphetamines, 13.3 million
used cocaine and 8.3 million used ecstasy. An
estimated 15.3 million, or 0.4% of the world
population aged 15 – 64 years, used illicit opioids;
more than half used heroin and the remainder used
opium or diverted pharmaceutical opioids. Cannabis
is used across all countries of the world. Opiate use is Figure 1. Population weighted means of the recorded adult per
concentrated in Asia and Europe and cocaine use is capita consumption in the WHO Regions 1961 – 99. SEARO
(South-East Asia); WPRO (Western Pacific); EURO (European);
concentrated in the Americas and to a lesser extent
AMRO (Eastern Mediterranean); AMRO (Americas) AFRO
Europe. (Africa). Source: Rehm et al., 2004 [24].
Illicit opioids continue to be the major illicit drug
problem in most regions of the world in terms of impact
Tobacco
on public health and public order [25]. It is estimated
that there are 15.2 million injecting drug users globally, It is estimated that 1.1 billion adults (29% of the
10.3 million in low-income countries [27]. It is population aged 15 years and over) smoke cigarettes or
estimated that there are 15.3 million people world- bidis (a hand-rolled cigarette common to South East
wide with drug use disorders, 11.7 million men and 3.6 Asia and India) daily [29,30] (Table 2). Smoking
million women [28]. prevalence is highest in Europe and Central Asia, where
 Global use of alcohol, drugs and tobacco 491

Table 1. Distribution of high risk drinking (more than 40 g alcohol per day for men and more than 20 g a day for women) by World Bank
region, year 2000 (% of the population)

Age group (years)

World Bank Region Gender 15 – 29 30 – 44 45 – 59 60 – 69 70 –

Europe and Central Asia Male 20.8 18.7 21.4 15.2 8.1
Female 11.2 10.4 11.5 7.9 5.7
Latin America and the Caribbean Male 9.7 11.1 10.6 7.9 3.4
Female 6.8 7.5 6.5 5.8 3.1
Sub-Saharan Africa Male 10.4 14.3 12.9 11.3 8.4
Female 3.1 4.7 5.1 3.2 2.2
East Asia and the Pacific Male 6.2 7.5 7.1 6.5 5.0
Female 0.3 0.2 0.1 0.1 0.0
South Asia Male 0.8 2.5 0.3 0.1 0.0
Female 1.2 0.4 0.4 0.0 0.0
High-income countries Male 18.0 17.9 16.2 10.9 7.6
Female 10.9 8.7 9.8 6.8 5.4

Source: Rehm et al. [133].

Table 2. Estimated smoking prevalence (by gender) and number of smokers, 15 years of age and older, 2000

Smoking prevalence (%) Total smokers

World Bank region Males Females Overall Millions Percentage of all smokers

East Asia and the Pacific 63 5 34 429 38

Europe and Central Asia 56 17 35 122 11
Latin America and the Caribbean 40 24 32 98 9
Middle East and North Africa 36 5 21 37 3
South Asia 32 6 20 178 15
Sub-Saharan Africa 29 8 18 56 6
Low- and middle-income economies 49 8 29 920 82
High-income economies 37 21 29 202 18

Source: Jha et al. [134].

35% of all adults are smokers. Low-income and
middle-income countries, whose populations account
for four-fifths of the global adult population, account
for 82% of the world’s smokers [31]. On average, the
world’s smokers consume 14 cigarettes (or bidis) each
per day. Daily consumption per smoker is highest in
high-income countries, where both males and females
smoke on average 20 cigarettes a day and lowest in
Latin America [30].
Globally, the prevalence of daily smoking is higher
for men (47%) than for women (11%) and highest for
people aged 30 – 49 years (36 – 37%) [30]. Males in
low-income countries have a higher prevalence of daily
smoking (49%) than do males in high-income countries
(38%), while the reverse is true for females (9% in low-
income countries and 21% in high income countries).
Most smokers start smoking before the age of 25 years,
often in childhood or adolescence.
While overall smoking prevalence continues to
increase in many low- and middle-income countries,
many high-income countries have witnessed
decreases, most clearly in men. A study in 36 mostly
high-income countries, from early 1980 to the mid-
1990s, suggested that the decrease in smoking
prevalence observed among men was caused by the
higher prevalence in younger age groups of those
who have never smoked. Among women, there was
little overall change in smoking prevalence because
the increasing prevalence of smokers in younger
cohorts counterbalanced increasing cessation in
older age groups [32].
Market forces and substance use
Two of the main determinants of substance use are
affordability and availability.
492 Peter Anderson

result of reduced initiation of tobacco use, increased

Affordability
cessation and reductions in the consumption of tobacco
Affordability relates to both income and price. Table 3 products by continuing users. Price is particularly
summarises the prevalence of alcohol and tobacco use effective in reducing tobacco use among youth and
by poverty for selected regions of the world, by three young adults, for whom demand is estimated to be up
daily income categories (5US$1/day, US$1 – 2/day and to three times more sensitive to price [34].
4US$2/day). People with higher incomes are more Increases in the price of alcohol reduce both the use
likely to use alcohol than people with low incomes, and consumption of alcohol products. A 10% increase
whereas income level has little relation to tobacco use. in price can reduce the long-term consumption of
In two sub-regions—AFR-E (South Africa data only) alcohol by about 7% in high income countries and,
and AMR-B (Panama only)—poor people had appro- although there are very limited data, by about 10%
ximately half the prevalence of alcohol use of non- in low income countries [35]. Young drinkers and
poor people. In AFR-E (South Africa data only) and frequent and heavy drinkers are more sensitive to price
AMR-D (Ecuador data only) there was a suggestion of than older drinkers or infrequent or light drinkers (see
lower prevalence of tobacco use among the poorest, Chaloupka, this issue).
and in EMR-B (Pakistan only) the converse. Economic modelling from black markets in other
The price of tobacco affects the prevalence and con- commodities (tea, coffee and tobacco) suggests that
sumption of tobacco products [33]. A price rise of 10% rendering a substance illegal results in substantial
will reduce cigarette smoking in high-income countries increases in its price [36]. Silverman & Spruill [37]
by up to 5% and in low-income and middle-income obtained indirect evidence that demand for heroin
countries by up to 8% [33]. The reductions are the shows little elasticity (a term to measure how much use
changes when price changes) in the long term, but
significant elasticity in the short term. On the other
Table 3. The prevalence of alcohol and tobacco use by poverty for hand, Van Ours [38] estimated for pre-World War II
selected WHO regions opium production that a 10% increase in price would
result in a 7% decrease in consumption in the short
Prevalence Prevalence term and a 10% decrease in the long term. Grapendall
(%) of (%) of
Sub-region Income level alcohol use tobacco use [39] concluded on the basis of interview data that
demand for heroin is price-elastic because heroin users
AFR-D 5US$ 1/day 35.5 16.5 report adjusting their consumption levels to their daily
US$ 1 – 2/day 38.3 13.7 income rather than vice versa. Saffer & Chaloupka [40]
4US$ 2/day 45.5 14.7 and Caulkins [41] both estimate relatively high
AFR-E 5US$ 1/day 28.9 19.2 elasticities for both cocaine and heroin in the United
US$ 1 – 2/day 38.7 22.4 States. More recently Grossman, Chaloupka & Brown
4US$ 2/day 60.6 26.5 [42] have obtained similar results for cocaine. A
AMR-B 5US$ 1/day 35.7 31.2 reduction in supply of heroin in Australia during
US$ 1 – 2/day 51.6 34.8 December 2000 increased the price of heroin by
4US$ 2/day 75.0 29.5
112%, which led to a reduction in heroin overdoses
AMR-D 5US$ 1/day 54.8 19.2
of 53%. There was some evidence of substitution with
US$ 1 – 2/day 60.2 23.6
4US$ 2/day 65.9 31.9 an increase in cocaine use [43].
EMR-D 5US$ 1/day – 29.2
US$ 1 – 2/day – 24.8 Availability
4US$ 2/day 17.6
EUR-B 5US$ 1/day 51.3 31.1 A natural experiment that occurred nearly 100 years
US$ 1 – 2/day 47.6 28.6 ago illustrates the relationship between the availability
4US$ 2/day 64.9 36.7 of alcohol and alcohol consumption and the harm
EUR-C 5US$ 1/day 67.9 37.1 caused by alcohol. Prompted by the shortage of food
US$ 1 – 2/day 73.2 35.4 supply during the First World War (but also motivated
4US$ 2/day 89.1 34.4
by state revenues and temperance concerns [44]), the
WPR-B 5US$ 1/day 51.4 36.0
Danish government imposed a number of alcohol
US$ 1 – 2/day 54.5 34.3
4US$ 2/day 62.0 34.6 restrictions and tax increases in 1917 and 1918. The
Total (of the 5US$ 1/day 44.2 28.7 result was that spirits prices multiplied, and that per
sub-regions US$ 1 – 2/day 52.7 30.6 capita consumption dropped sharply from about 10
in the table) 4US$ 2/day 67.6 31.9 litres in 1916 to a little more than 2 litres in 1918.
In subsequent years, consumption grew somewhat but
Source: Blakely et al. [135]. remained on a low level, 3 – 4 litres, until after the Second

World War. As can be seen in Fig. 2, the drop in alcohol
consumption in 1917 and 1918 was accompanied by a
marked decline in all of the harm indicators [45].
Similar relationships happened in Paris during both
World Wars, when extreme shortages of alcohol were
followed by dramatic declines in cirrhosis mortality
[46]. More recently, the anti-alcohol campaign pursued
by Gorbachev from 1985 – 88 was followed by a
dramatic decrease in death rates, followed by an even
steeper increase in death rates as alcohol consumption
increased in the early 1990s following socio-economic
transition [47].
A second natural experiment is the impact of trade
liberalisation on cigarette consumption. Cigarette ex-
ports, which had been relatively stable between 1975 and
1985, began rising at an increasing rate in the mid-1980s,
accelerating since the Global Agreement on Tariffs and
Trade (GATT) (1994), with global cigarette exports
rising by 42% between 1993 and 1996. At the same time,
global cigarette consumption increased by 5% [48].
Between 1986 and 1990, US bilateral trade agreements
forced Japan, Taiwan, South Korea and Thailand to
open up their closed markets to American cigarette
exports [48,49]. It has been estimated that per capita
cigarette consumption was 10% higher on average by
1991 in the four countries than it would have been in
the absence of the bilateral agreements [49] due to
both market expansion [50] and increased cigarette
advertising [51,52]. An analysis of the impact of trade
Figure 2. Per capita alcohol consumption and indicators of alcohol-related harm in Denmark 1911 – 24. Index, 1916 ¼ 100. Source:
(Thorsen [45]).
Global use of alcohol, drugs and tobacco 493
liberalisation on tobacco consumption in 42 countries
between 1970 and 1995, found that trade liberalisation
had a large and significant impact on smoking in low-
income countries, and a smaller, but still important effect
on smoking in middle-income countries, while having no
effect on higher income countries [53].
A third natural experiment follows reductions in
heroin supply to Australia and Canada in the early
2000s from the assumed major source, Myanmar, the
effects of which were mediated by steep increases in the
price of heroin [54 – 56]. After the reduction in heroin
supply, fatal and non-fatal heroin overdoses decreased
by between 40% and 85% in Australia and 35% in
Canada. Despite some evidence of increased cocaine,
methamphetamine and benzodiazepine use and reports
of increases in harms related to their use, there were no
increases recorded in the number of either non-fatal
overdoses or deaths related to these drugs. There was a
sustained decline in injecting drug use as indicated by a
substantial drop in the number of needles and syringes
distributed.
Substance use and socio-economic
disadvantage
Alcohol
Whereas people who are in lower-income groups are
less likely to use alcohol than people in higher-income
494 Peter Anderson
groups, a different picture emerges among alcohol
users, where people in lower socio-economic groups
tend to have a more hazardous and harmful pattern of
use than people in higher socio-economic groups. This
relationship has been observed in China [57], Brazil
[58,59], Ethiopia [60] and Nigeria [61], as well as in
high-income countries, such as France, Italy, Spain and
Switzerland [62], the United Kingdom [63] and the
United States [64, 65].
In England, for men aged 25 – 69 years, those in the
lowest socio-economic status (SES) category (un-
skilled labour) had a 15-fold higher risk of alcohol-
related mortality than professionals in the highest
SES category [66]. In Sweden, up to 30% of the
differential mortality for middle-aged men by socio-
economic group is explained by alcohol consumption
[67]. A review by the International Agency for
Research on Cancer (IARC) noted a probable role
of alcohol in inequalities found for certain cancers in
France and Italy, and were also suggestive of a
possible role in Denmark, Switzerland and the United
Kingdom, but not in Finland or Sweden [68].
Similarly, alcohol has been found to be responsible
for a proportion of the inequalities found for
hypertension Colhoun et al. [69]. The INTERSALT
study, involving 52 centres in 18 high-income and
12 low-income countries, found that adjusting for
alcohol (along with body mass index, smoking and
sodium and potassium excretion) halved the associa-
tion between low SES and higher blood pressure
in men so that it was no longer statistically signifi-
cant [70].
Illicit drugs
Urban poverty is associated with increased illicit drug
use in cities in India [71], Nepal [72] and Brazil
[73 – 75]. Similar findings have been found in the
United States [76 – 78]. In New Zealand [79 – 81] and
Australia [82] illicit drugs use is higher among
indigenous peoples.
Tobacco
Smoking rates are higher among Chinese men and
women with lower educational achievement in both
urban [83,84] and rural areas [85]. Similar findings are
found in India [86 – 89], Pakistan [90], Bangladesh
[91], Brazil [59], Nigeria [92] and Tonga [93].
In most high-income countries, the prevalence
of cigarette smoking is higher in lower socio-
economic groups [94]. Similarly, the INTERSALT
study involving 52 centres in 18 high-income and
12 low-income countries [95] found that smoking
prevalence was related to low educational attain-
ment [70].
Risk and protective factors for substance use
There are a number of factors that place individuals,
and in particular young people, at increased risk of
substance use, dependence and the social and health
consequences [96]. Risk factors act in a cumulative way
over time. Some are present from the early years, others
emerge in adolescence.
Earlier and problematic drug use during adolescence
is more likely among young people who are raised in
circumstances of extreme economic deprivation
[97,98], in a sole parent household [99] and/or where
parents or other family members use drugs [100]. An
easy temperament in early childhood is protective, both
helping the child to adjust in positive ways and reducing
the influence of risk factors [101].
Parents continue to be an important influence
throughout the primary school years but other factors,
including relationships with teachers, adjustment to
school and experiences with peers, play an increasing
role. Early school failure is a risk factor for later alcohol
problems [102]. Children with behaviour problems
through primary school are at risk of later drug use
problems, with conduct disorder possibly more im-
portant than attention deficit and hyperactivity disorder
(ADHD) [97]. Aggression is a risk factor for later drug
use [101], but the role of childhood depression is
unclear. Children who are socially and emotionally
competent are more resilient in the face of risk factors
and, therefore, less likely to engage in alcohol and illicit
drug use [103].
Two aspects of the family environment are associated
with increased rates of both licit and illicit drug use in
young people in high-income countries. The first is
exposure to a disadvantaged home environment, with
parental conflict and poor discipline and supervision;
the second is exposure to parents’ and siblings’ use of
alcohol and other drugs [102]. In high-income coun-
tries, children who perform poorly in school because of
impulsive or problem behaviour and those who are
early users of alcohol and other drugs are most likely to
use illicit opioids [104]. Affiliation with drug-using
peers is a risk factor for drug use that operates
independently of individual and family risk factors
[102,105].
In the teenage years, young people become increas-
ingly independent of the family, making choices about
their own identity including their attitudes and beha-
viours about substance use. Relationships with parents,
other adults and the peer group all influence the risk of
substance use [96]. At the same time, the attitudes,
behaviours and relationships developed at earlier stages
of childhood continue to be influential.
Factors that help to protect adolescents against
harmful substance use include attachment to the family
[100], parental harmony [106] and parents who

monitor and supervise their children and have good
skills in communication and negotiation [107]. Young
people are at increased risk where there is parent –
adolescent conflict [108], favourable parental attitudes
to substance use [97], parental substance use problems
[100] and parental approval of substance (e.g. alcohol)
use in childhood or early adolescence [100].
Substance use problems are more likely in young
people who do not complete high school and this is
influenced by earlier childhood development, includ-
ing school adjustment and behaviour problems [109].
Academic achievement and feelings toward school are
also relevant to illicit drug use [109]. Adolescents are
more likely to use substances if they associate with
other young people who are using them [110].
Delinquency in adolescence is also a risk factor
[101], but the influence of adolescent anxiety and
depression is unclear [96]. Other risk factors at this
age include sensation-seeking and an adventurous
personality [102] and favourable attitudes to substance
use [110].
The use of substances escalates after the age of about
18 years and often peaks in early adulthood. Substance
use in these years is strongly influenced by behaviours
developed during the adolescent years, but other
influential factors include relationships with peers and
spouse, and patterns of behaviour in social, educational
and employment settings [96]. Effective regulation of
alcohol in the community [111] and marriage are both
protective [112]. Unemployment in early adulthood is
associated with harmful alcohol use but this may be
because both are outcomes of earlier risk factors [113].
There is strong co-morbidity between adult mental
health problems and harmful drug use.
Adolescent health and social problems tend to cluster
[102,114]. Thus a young tobacco user is more likely to
be a heavy drinker, use cannabis, engage in risky sexual
activity, have higher antisocial behaviour and, if female,
experience symptoms of depression. Similarly, different
social settings (e.g. schools, local neighbourhoods) vary
markedly in the rates and range of problems experi-
enced. This clustering reflects the clustering of social
and individual risk and protective factors. An adoles-
cent’s positive connection or attachment to family,
school and community protect against a range of risk
behaviours as well as promoting positive educational
and social outcomes. Many adolescent health problems
share important risk factors. Academic failure and
school dropout are associated with antisocial behaviour,
higher rates of substance use, tobacco use and emo-
tional problems; factors such as poor family attachment
and family conflict are linked to a broad range of
adolescent health problems.
Finally, there are marked temporal and develop-
mental sequences concerning the ages of first use and
the order of onset of use of substances [96]. It is
Global use of alcohol, drugs and tobacco 495
apparent that early use of tobacco and alcohol is
predictive of later problems with tobacco dependence,
alcohol and illicit drugs. It is also clear from long-
itudinal research that use of alcohol and tobacco at an
early age predicts progression to heavier drug use, even
after adjusting for the influence of a range of known
developmental risk factors [115]. The mechanisms by
which legal drugs serve as ‘gateways’ in some sense for
illegal drugs are not clear. Adolescent use of cannabis
significantly increases the risk of later use of other illicit
drugs [116] but, none the less, only a small proportion
of cannabis users progress to use other illicit drugs
[101].
Hippocrates, writing 2500 years ago, advised anyone
coming to a new city to enquire whether it was likely
to be a healthy or unhealthy place to live, depending
on its geography, and the behaviour of its inhabitants
‘whether they are fond of excessive drinking’ [117].
He continued ‘as a general rule, the constitutions and
the habits of a people follow the nature of the land
where they live’. The impact of the area and popu-
lation in which people live is demonstrated clearly by
studies of large-scale migrations from one culture to
another in which, for example, an increase in risk
factors and coronary heart disease is observed when
individuals migrate from a low- to a high-risk culture
and assume the lifestyle of the new culture [118]. In
other words, and this applies to many risk factors and
conditions [119], including suicide [120], the beha-
viour and health of individuals are profoundly
influenced by a society’s collective characteristics and
social norms.
Thus, it is not surprising that the risk of harmful
substance use is heightened in a community where
there are higher levels (perceived and/or actual) of
substance use [102], community disadvantage and
disorganisation [121], ready availability of substances
[102] and positive media portrayals of substance use
[122]. There is a linear relationship between cannabis
use among the general population and cannabis use
among 15 – 16-year-olds [123], and a linear relation-
ship between the overall per capita alcohol consump-
tion and the proportion of heavy drinkers in a
population [124].
Trends in substance use
Alcohol
Based on recent trends in alcohol consumption (see
Fig. 1), it is reasonable to assume that in most countries
of the world, alcohol consumption over the next 10 – 20
years is likely to remain reasonably stable. The
exception to this is for the countries of the South-East
Asian Region, and the low- to middle-income countries
of the Western Pacific Region (WPR-B) (constituting
496 Peter Anderson

nearly half of the world’s population), where consump- consumers will increase by 2.1% over those of the
tion is likely to increase. It has been predicted that year 2000 for SEAR-B and WPR-B, and by 0.7% for
the proportion of hazardous and harmful alcohol SEAR-D [24].

Figure 3. Stages of the topic epidemic for men and women. (1, early; 2, rising; 3, peak or maturity; 4, declining; and 5, late). Source: Ezzati
& Lopez (2004) [136].
 Global use of alcohol, drugs and tobacco 497

deaths have fallen sharply, often after various drug sub-

Drugs
There are a number of indications that rates of illicit drug
use and illicit drug-related harm have risen in the past
decade. High-income countries with reasonable mortality
data have shown steady increases in drug-related deaths,
especially drug overdose deaths [125 – 127], and in the
estimated number of dependent opioid users [125,
128]. Illicit drug use has also been reported in an
increasing number of countries where it was previously
rare, such as in eastern Europe, the former Soviet
Union, Asia and Africa [123,129,130]. Despite indica-
tions that drug-related harm is increasing, it is difficult
to predict future patterns of illicit drug use and drug-
related harm as there is a lack of good time – series data.
And, although the general trend has been for drug-
related deaths to increase during the 1990s, there have
also been a number of countries in which drug-related
stitution policy initiatives have been introduced [131].
The scale of illicit drug production and the choice of
drugs for illicit manufacture also change [123]. At a
minimum it has been suggested that global drug-related
harm will remain at about the current level, with
declines in drug-related deaths in high-income coun-
tries (resulting from expanded opioid substitution
treatment) being offset by increases in drug-related
deaths in low income countries [28]. A more likely
option is a continuing increase in drug use and drug-
related harm throughout the world, with the brunt of
the increase occurring in low-income countries.
Tobacco
The tobacco epidemic can be described in five stages
(1, early; 2, rising; 3, peak or maturity; 4, declining; and

Table 4. Status of the tobacco epidemic in 2000 among males and females

Epidemic stage Country

Males
0.5 – 1 NA
1.5 – 2 AFR-D – all except Algeria, Mauritius, Seychelles; AFR-E – all except South Africa; EMR-B – Iran (Islamic
Republic of); EMR-D – Afghanistan, Djibouti, Somalia, Sudan; EUR-B – Azerbaijan, Tajikistan,
Turkmenistan, Uzbekistan
2.5 – 3 AFR-D – Algeria, Mauritius, Seychelles; AFR-E – South Africa; AMR-A – Cuba; AMR-B – all except
Argentina, Brazil, Chile; AMR-D – all; EMR-B – all except Iran (Islamic Republic of); EMR-D – Egypt,
Iraq, Morocco, Pakistan, Yemen; EUR-A – Croatia, Czech Republic, Greece, Portugal, Slovenia;
EUR-B – all except Azerbaijan, Tajikistan, Turkmenistan, Uzbekistan; EUR-C – all; SEAR-B – all; SEAR-
D – all; WPR-A – Brunei Darussalam, Japan; WPR-B – all
3.5 – 4 AMR-B – Argentina, Brazil, Chile; EUR-A – Andorra, Austria, Denmark, France, Germany, Ireland, Israel,
Italy, Luxembourg, Malta, Monaco, San Marino, Spain, Switzerland
4.5 – 5 AMR-A – Canada, USA; EUR-A – Belgium, Finland, Iceland, Netherlands, Norway, Sweden, United
Kingdom; WPR-A – Australia, New Zealand, Singapore
Females
0.5 – 1 AFR-D – all except Seychelles; AFR-E – all except South Africa; AMR-B – Antigua and Barbuda, Bahamas,
Barbados, Belize, Dominica, Grenada, Guyana, Paraguay, Saint Kitts and Nevis, Saint Lucia, Saint
Vincent and Grenadines, Suriname; EMR-B – all except Cyprus, Jordan, Lebanon, Syrian Arab Republic;
EMR-D – all except Morocco; Albania, Azerbaijan, Tajikistan, Turkmenistan, Uzbekistan; SEAR-B –
Indonesia, Sri Lanka; SEAR-D – all except Myanmar, Nepal; WPR-A – Singapore; WPR-B – Cambodia,
China, Malaysia, Mongolia, Republic of Korea, Viet Nam
1.5 – 2 AFR-D – Seychelles; AFR-E – South Africa; AMR-B – Colombia, Costa Rica, Dominican Republic,
El Salvador, Honduras, Jamaica, Mexico, Panama, Trinidad and Tobago, Uruguay, Venezuela; AMR-D –
all; EMR-B – Cyprus, Jordan, Lebanon, Syrian Arab Republic; Morocco; EUR-A – Croatia, Czech
Republic, Greece, Israel, Malta, Portugal, San Marina, Slovenia; EUR-B – all except Albania, Azerbaijan,
Tajikistan, Turkmenistan, Uzbekistan; EUR-C – all; SEAR-B – Thailand; SEAR-D – Myanmar, Nepal;
WPR-A – Brunei Darussalam, Japan; WPR-B – Cook Islands, Fiji, Kiribati, Lao People’s Democratic
Republic, Marshall Islands, Micronesia (Federated States of), Nauru, Niue, Palau, Philippines, Samoa,
Solomon Islands, Tonga, Tuvalu, Vanuatu
2.5 – 3 AMR-A – Cuba; AMR-B – Argentina, Brazil, Chile; EUR-A – Andorra, Austria, Denmark, Finland, France,
Germany, Ireland, Italy, Luxembourg, Monaco, Spain, Switzerland; WPR-B – Papua New Guinea
3.5 – 4 AMR-A – Canada, USA; EUR-A – Belgium, Iceland, Netherlands, Norway, United Kingdom; WPR-A –
Australia, New Zealand
4.5 – 5 EUR-A – Sweden

Source: Ezzati & Lopez [136].

498 Peter Anderson
5, late, Fig. 3), and it seems clear that all countries
progress through these stages.
When classified by their country stage, it is the low-
income countries that are in the early stages of the
tobacco epidemic (3 or earlier) with all of them facing
huge increases in the consequences of tobacco use over
the coming decades, Table 4.
Conclusions
Two billion adults drink alcohol, 1.1 billion smoke
cigarettes and less than 0.2 billion use illicit drugs, with
substance use likely to increase over the coming
decades. With economic development, alcohol use is
likely to increase in low- and middle-income countries.
Such countries are also likely to see an increase in the
use of illicit substances, and many of them are still in
the early stages of the tobacco epidemic. Thus,
substance use disorders are increasingly going to be
disorders of low-income countries. Already, alcohol
and tobacco are the first and third most important risk
factors for ill-health and premature death in low
mortality, low income countries, and 11th and ninth
in high-mortality, low-income countries [132]. This
will be compounded by the observation that in all
countries hazardous and harmful substance use is
concentrated in socio-economic disadvantaged groups.
To some extent, what will determine the extent of
global substance use and substance use disorders over
the next decades is what happens in south east Asia and
the Western Pacific; these are areas of the world with
nearly half the world’s population, and are areas of the
world in which the prevalence of alcohol and illicit drug
use are increasing and which are still to face the full
brunt of the tobacco epidemic.
The prevalence of illicit drug use is less than one-
tenth that of alcohol use and less than one-fifth that of
tobacco use, suggesting that the UN Conventions on
illicit drugs are, despite an increasing use of such drugs,
having an impact. The extent to which the World
Health Organisation’s Framework convention on to-
bacco control will reduce tobacco use and whether or
not a similar convention is appropriate for alcohol
control remain to be seen.
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Appendix 1. The 14 GBD epidemiological sub-regions

WHO Mortality
region stratum1 Countries

AFR D Algeria, Angola, Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Comoros, Equatorial
Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Madagascar, Mali,
Mauritania, Mauritius, Niger, Nigeria, Sao Tome and Principe, Senegal, Seychelles, Sierra
Leone, Togo
E Botswana, Burundi, Central African Republic, Congo, Côte d’Ivoire, Democratic Republic of
the Congo, Eritrea, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda,
South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia, Zimbabwe
AMR A Canada, Cuba, United States of America
B Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Brazil, Chile, Colombia, Costa
Rica, Dominica, Dominican Republic, El Salvador, Grenada, Guyana, Honduras, Jamaica,
Mexico, Panama, Paraguay, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the
Grenadines, Suriname, Trinidad and Tobago, Uruguay, Venezuela
D Bolivia, Ecuador, Guatemala, Haiti, Nicaragua, Peru
EMR B Bahrain, Cyprus, Iran (Islamic Republic of), Jordan, Kuwait, Lebanon, Libyan Arab
Jamahiriya, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Tunisia, United Arab
Emirates
D Afghanistan, Djibouti, Egypt, Iraq, Morocco, Pakistan, Somalia, Sudan, Yemen
EUR A Andorra, Austria, Belgium, Croatia, Czech Republic, Denmark, Finland, France, Germany,
Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, Netherlands, Norway,
Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland, United Kingdom
B Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Georgia, Kyrgyzstan,
Poland, Romania, Serbia and Montenegro, Slovakia, Tajikistan, The former Yugoslav
Republic of Macedonia, Turkey, Turkmenistan, Uzbekistan
C Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, Republic of Moldova, Russian
Federation, Ukraine
SEAR B Indonesia, Sri Lanka, Thailand
D Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Maldives, Myanmar,
Nepal
WPR A Australia, Brunei Darussalam, Japan, New Zealand, Singapore
B Cambodia, China, Cook Islands, Fiji, Kiribati, Lao People’s Democratic Republic, Malaysia,
Marshall Islands, Micronesia (Federated States of), Mongolia, Nauru, Niue, Palau, Papua
New Guinea, Philippines, Republic of Korea, Samoa, Solomon Islands, Tonga, Tuvalu,
Vanuatu, Viet Nam
1
A: very low child mortality and very low adult mortality; B: low child mortality and low adult mortality; C: low child
mortality and high adult mortality; D: high child mortality and high adult mortality; E: high child mortality and very
high adult mortality. High-mortality developing subregions: AFR-D, AFR-E, AMR-D, EMR-D and SEAR-D. Low-
mortality developing subregions: AMR-B, EMR-B, SEAR-B, WPR-B. Developed subregions: AMR-A, EUR-A,
EUR-B, EUR-C and WPR-A. Source: Ezzati et al. [137].