The harmful use of alcohol is responsible for about 3.3 million deaths worldwide, each year.¹1. World Health Organization. Global status report on alcohol and health. Geneva: World Health Organization; 2014. Time comparisons of estimates of the global burden of diseases attributed to different risk factors suggest that deaths and years lost (Disability-Adjusted Life Years - DALYs) due to alcohol use have increased in recent decades at global level. These changes led to an increase in the alcohol position in the ranking of the leading causes of death and disability in the world, moving from the eighth place in 1990 to fifth in 2010. The data available in many countries suggest that the harmful use of alcohol is the leading risk factor for death and disability of individuals between 15 and 49 years old.²2. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec;380(9859):2224-60.

It is important to mention that the severity of the consequences of alcohol depends on the consumption frequency and amount.³3. Norström T, Ramstedt M. Mortality and population drinking: a review of the literature. Drug Alcohol Review. 2005 Nov;24(6):537-47. A pattern of risk consumption that has aroused international interest and only recently began to be investigated in Brazil is the so-called binge drinking (BD),⁴4. Wechsler H, Nelson TF. Binge drinking and the American college student: what's five drinks? Psychol Addict Behav. 2001 Dec;15(4):287-91. or 'episodic heavy drinking'.⁵5. Kuntsche E, Rehm J, Gmel G. Characteristics of heavy episodic drinkers in Europe. Soc Sci Med. 2004 Sep;59(5):113-27. This pattern is usually characterized by the intake of at least four doses of alcohol in one occasion for women and five doses for men, leading to an ethanol concentration in the blood of 0.08% or higher.⁶6. U. S. Department of Health and Human Services. National Institute Alcohol Abuse Alcoholism. NIAAA Council approves definition of binge drinking. NIAAA Newsletter. 2004;3:3. However, BD definition is controversial, permeated by conceptualizing conflicts influenced by the culture and pharmacokinetic aspects of alcohol.⁷7. Courtney KE, Polich J. Binge drinking in young adults: data, definitions, and determinants. Psychol Bull. 2009 Jan;135(1):142-56.^,88. Lange JE, Voas RB. Defining binge drinking quantities through resulting blood alcohol concentrations. Psychol Addict Behav. 2001 Dec;15(4):310-6.

Episodes of acute alcohol abuse not only affect general mortality, but also contribute to health problems, especially from accidents⁹9. Zhao G, Wu C, Houston RJ, Creager W. The effects of binge drinking and socio-economic status on sober driving behavior. Traffic Inj Prev. 2010 Aug;11(4):342-52. and aggressions,¹⁰10. Brewer RD, Swahn MH. Binge drinking and violence. JAMA. 2005 Aug;294(5):616-8. putting the intoxicated individual and the community at risk. Among the general population, BD is associated with higher occurrences of sexual abuse, suicide attempts, unprotected sex, unwanted pregnancy, acute myocardial infarction, alcohol overdose, falls, gastritis and pancreatitis.¹¹11. Naimi TS, Brewer RD, Mokdad A, Denny C, Serdula MK, et al. Binge drinking among US adults. JAMA. 2003 Jan;289(1):70-5.

However this issue is still little studied in the Brazilian population,¹²12. Silveira CM, Silveira CC, Silva JG, Silveira LM, Andrade AG, Andrade LHSG. Epidemiologia do beber pesado e beber pesado episódico no Brasil: uma revisão sistemática da literatura. Rev Psiquiatr Clin. 2008;35 supl 1:31-8. despite its relevance for Public Health. The first national survey on patterns of alcohol intake in Brazil, conducted in 2005-2006, identified a prevalence of BD in the year that preceded the study of 28% in adults, 40% in the age groups from 18 to 24 years,¹³13. Laranjeira R, Pinsky I, Sanches M, Zaleski M, Caetano R. Padrão de uso de álcool em brasileiros adultos. Rev Bras Psiquiatr. 2010 set;32(3):231-41. and 53% among male adolescents.¹⁴14. Pinsky I, Sanches M, Zaleski M, Laranjeira R, Caetano R. Patterns of alcohol use among brazilian adolescents. Rev Bras Psiquiatr. 2010 Sep;32(3):242-49. A study conducted in 2010 with high school students from 27 municipalities in the country revealed a 32%prevalence of BD practice that year, which was higher among richer adolescents and in the North and Northeast regions.¹⁵15. Sanchez ZM, Locatelli DP, Noto AR, Martins SS. Binge drinking among Brazilian students: a gradient of association with socioeconomic status in five geo-economic regions. Drug Alcohol Depend. 2013 Jan;127(1-3):87-93.

Although alcohol is a legal drug, its sale and supply for persons under 18 years old is prohibited by law in Brazil (Federal Law No. 13,106, dated March 17, 2015).¹⁶16. Brasil. Lei nº 13.106, de 17 de março de 2015. Altera a Lei nº 8.069, de 13 de julho de 1990 - Estatuto da Criança e do Adolescente, para tornar crime vender, fornecer, servir, ministrar ou entregar bebida alcoólica a criança ou adolescente; e revoga o inciso I do art. 63 do Decreto-Lei nº 3.688, de 3 de outubro de 1941 - Lei das Contravenções Penais. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2015 mar 18;Seção 1:1. This prohibition did not extinguish the practice, nor the consumption of alcohol among adolescents; however, there are evidences that the improvement of laws have contributed to the reduction of alcohol consumption among Brazilian adolescents from the late 1980.¹⁷17. Sanchez ZM, Prado MCO, Sanudo A, Carlini EA, Nappo AS, Martins SS. Trends in alcohol and tobacco use among Brazilian students: 1989 to 2010. Rev Saude Publica. 2015;49:70.

Bars and nightclubs are the main places for BD practice by the general population¹⁸18. Presidência da República. Gabinete de Segurança Institucional. Secretaria Nacional Antidrogas. I Levantamento Nacional sobre os padrões de consumo de álcool na população brasileira. Brasília: Secretaria Nacional Antidrogas; 2007. and students.¹⁹19. Sanchez ZM, Martins SS, Opaleye ES, Moura YG, Locatelli DP, Noto AR. Social factors associated to binge drinking: a cross-sectional survey among Brazilian students in private high schools. BMC Public Health. 2011 Mar;11:201. Worldwide, these establishments are known as places of intense consumption of alcohol, and other drugs.²⁰20. Calafat A, Blay NT, Hughes K, Bellis M, Juan M, Duch M, Kokkevi A. Nightlife young risk behaviours in Mediterranean versus other European cities: are stereotypes true? Eur J Public Health. 2011 Jun;21(3):311-5. However, little attention has been given to these environments as risky places and of extreme exposure to BD practice and other associated behaviors.

Binge drinking is also the most prevalent risk behavior in São Paulo-SP nightclubs. A study conducted in 2013,²¹21. Sanchez ZM, Ribeiro KJ, Wagner GA. Binge drinking associations with patrons' risk behaviors and alcohol effects after leaving a nightclub: sex differences in the "balada com ciência" portal survey study in Brazil. PLoS One. 2015 Aug;10(8):e0133646. among young people from that city in different nightclubs, showed that about 30% of the interviewed individuals left those establishments with alcohol dosage in the blood equivalent to BD practice. This practice increased by 9 times for men and 5 times for women the chance of suffering blackouts, or not knowing what had happened to them after leaving the nightclub, when compared to "clubbers" who had drunk but had not practiced BD. The same study showed that the ‘open bar’ nightclubs favored BD practice in both sexes. The fact that the establishments that adopt open bar system to charge a fixed amount (usually low) and allow people to drink unlimited amounts, all night long, makes its visitors feel compelled to drink as much as they can, to justify ther expenses.²²22. Carlini C, Andreoni S, Martins SS, Benjamin M, Sanudo A, Sanchez ZM. Environmental characteristics associated with alcohol intoxication among patrons in Brazilian nightclubs. Drug Alcohol Rev. 2014 Jul;33(4):358-66.

The strategy of bars’ and clubs’ managers and owners is to focus on stimulating excessive alcohol consumption in order to attract more customers, whom, in most cases, end up choosing the establishment where they will spend the night, according the best deals for alcohol.²³23. Carlini CMA. Fatores ambientais associados ao uso de álcool e outras drogas, violência e sexo inseguro nas baladas de São Paulo [tese]. São Paulo: Universidade Federal de São Paulo, Escola Paulista de Medicina; 2016. Here are some examples of this appeal: alcohol sales such as open bar, minimal consumption (fixed-price, paid on the entrance of the club, which can be converted into alcoholic drinks; in case this value is not consumed, it is not returned to the customer), special offers as 'pay 1 and take 2' and combos - combined sale - of distillates (usually vodka) and energetic drinks, where the purchase of the products mix ends up being financially advantageous, compared to sales of individual products. It is worth mentioning that charging minimal consumption, although being a widespread practice in nightclubs, is prohibited by the Costumer’s Defense Code (Law No. 8,078 dated September 11, 1990),²⁴24. Brasil. Lei nº 8.078 de 11 de setembro de 1990. Dispõe sobre a proteção do consumidor e dá outras providências. Diário Oficial da República Federativa do Brasil, Brasília (DF), 1990 set 12;Seção 1:1. characterized as an abusive sale practice, because the customer pays the minimum amount charged even if they do not consume the equivalent amount in beverages; i.e., they pay for something that they will not receive. In this sense, monitoring is essential so the law can be complied. The combined sale of distillates and energetic drinks is another example of abuse, and must be strictly suppressed. Besides, energetic drinks mask the depressant effects of alcoholic beverages and increase the appetite for alcohol, stimulating much larger intake of doses than tolerated by the organism. The combined consumption has been identified as a predictor of BD practice.²⁵25. Marczinski CA, Fillmore MT, Stamates AL, Maloney SF. Desire to drink alcohol is enhanced with high caffeine energy drink mixers. Alcohol Clin Exp Res. 2016 Sep;40(9):1982-90.

The open bar is the form of alcoholic beverage sales more associated with intense alcohol consumption in the country²²22. Carlini C, Andreoni S, Martins SS, Benjamin M, Sanudo A, Sanchez ZM. Environmental characteristics associated with alcohol intoxication among patrons in Brazilian nightclubs. Drug Alcohol Rev. 2014 Jul;33(4):358-66. and abroad.²⁶26. Thombs DL, O’Mara R, Dodd VJ, Hou W, Merves ML, Weiler RM, et al. A field study of bar-sponsored drink specials and their association with patrons intoxication. J Stud Alcohol Drugs. 2009 Mar;70(2):206-14. In Brazil, the sale of alcoholic drinks in open bar is allowed and widespread. In the past, a bill aiming to ban it (Bill No. 3,414/2008) was presented, but it has been filed. It is essential that the society discusses the suitability of this type of fun, responsible for many alcoholic intoxication, coma cases - maximum degree of consciousness alteration caused by excessive the consumption - and even death.

International studies show that excessive intake of alcoholic beverages in nightclubs and bars is associated with more episodes of physical aggression,²⁷27. Blay N, Calafat A, Juan M, Becoña E, Mantecón A, Ros M, et al. Violence in nightlife environments and its relationship with the consumption of alcohol and drugs among young Spaniards. Psicothema. 2010 Aug;22(3):396-402. sexual risky behavior,²⁸28. Bellis MA, Hughes K, Calafat A, Juan M, Ramón A, Rodriguez JA, et al. Sexual uses of alcohol and drugs and the associated health risks: a cross sectional study of young people in nine European cities. BMC Public Health. 2008 May;8:155. sexual violence,²⁹29. Kelley-Baker T, Mumford EA, Vishnuvajjala R, Voas RB, Romano E, Johnson M. A night in Tijuana: female victimization in a high-risk environment. J Alcohol Drug Educ. 2008;52(3):46-71. traffic accidents³⁰30. Livingston M, Chikritzhs T, Room R. Changing the density of alcohol outlets to reduce alcohol-related problems. Drug Alcohol Rev. 2007 Sep;26(5):557-66. and violence on the streets, not to mention the various instances of violence within night leisure facilities, affecting the youngsters and the community.³¹31. Hughes K, Anderson Z, Morleo M, Bellis MA. Alcohol, nightlife and violence: the relative contributions of drinking before and during nights out to negative health and criminal justice outcomes. Addiction. 2008 Jan;103(1):60-5.^-3232. Downing J, Hughes K, Bellis MA, Calafat A, Juan M, Blay N. Factors associated with risky sexual behaviour: a comparison of British, Spanish and German holidaymakers to the Balearics. Eur J Public Health. 2011;21(3):275-81.

The violence in these establishments is seen as a complex relation between personal characteristics of the goers, patterns of alcohol and other drugs intake, environmental factors, behavior of employees and type of place,³³33. Graham K, West P, Wells S. Evaluating theories of alcohol-related aggression using observations of young adults in bars. Addiction. 2000 Jun;95(6):847-63. and can only be effectively reduced with the implementation of measures aimed at reducing the amount of alcohol doses taken.³⁴34. Hughes K, Furness L, Jones L, Bellis MA. Reducing harm in drinking environments: evidence and practice in Europe. Liverpool: Centre for Public Health; 2010. A study conducted in 2007, in night recreational settings in Spain, found that 45% of its visitors had gotten drunk more than 2 times in the previous month, and 23% of them had been involved in fights in the previous year, inside those establishments.²⁷27. Blay N, Calafat A, Juan M, Becoña E, Mantecón A, Ros M, et al. Violence in nightlife environments and its relationship with the consumption of alcohol and drugs among young Spaniards. Psicothema. 2010 Aug;22(3):396-402.

Based on this evidence, an immediate intervention is necessary for a reduction on individual and social damage from BD practice. We know that the best way to prevent the harm associated with alcohol abuse in a community is the implementation of public policies in different dimensions, and taxation on alcohol sales and sales control have demonstrated greater success, according to international studies of severe restriction policies on alcohol advertising.³⁵35. Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: no ordinary commodity. 2nd ed. Oxford: Oxford University Press; 2010. For individuals who go to bars and clubs, policies as laws that prohibit the sale of alcohol to people who are already drunk would be important from the point of view of immediate individual and collective protection.³⁶36. Scherer M, Fell JC, Thomas S, Voas RB. Effects of dram shop, responsible beverage service training, and state alcohol control laws on underage drinking driver fatal crash ratios. Traffic Inj Prev. 2015;16(Suppl 2):S59-65. In many countries, one of the most effective legislations to prevent the damage caused by alcohol intoxication is controlling the density of licensed sites for the alcoholic beverages sales, imposing a limit on the number of outlets selling alcohol in each administrative region of the city.³⁷37. Connor JL, Kypri K, Bell ML, Cousins K. Alcohol outlet density, levels of drinking and alcohol-related harm in New Zealand: a national study. J Epidemiol Community Health. 2011 Oct;65(10):841-6. In Brazil, a first step to be taken would be to establish the need for differentiated licenses to establishments for selling alcohol. The control in the concession of licenses as well as increased taxation on alcohol must be monitored properly, in order not to encourage illegal sales by street sellers who usually assemble in front of bars and clubs offering drinks of dubious origin with really low prices. The license control for sale is, therefore, the previous step to all other known effective public policies aimed at reducing harm associated with alcohol abuse.

The necessary changes are not easy to achieve and may not have sufficient social support, as they confront the culture of extreme drinking, which widespread in the country. Therefore, the success of measures to regulate trade of alcohol firstly depends on the choice of evidence-based policies, in addition to a broad public and political support so the implementation of a preventive law of alcohol abuse can succeed in Brazil.

Publication Dates