The precariousness of the work environment is a social determinant of health; research shows that being employed in an unstable manner in early adulthood is associated with an increased risk of mental health problems and higher alcohol consumption (1).

The rise of non-standard forms of work has blurred the boundaries between being employed and unemployed. Jobs without formal contracts tend to be less secure and often come with fewer benefits compared to more traditional forms of employment, such as permanent labor contracts, commonly known in Brazil as CLT (Consolidação das Leis do Trabalho, or Consolidation of Labor Laws). Disadvantages may include lack of contractual security (e.g., temporary employment), low wages, economic difficulties, limited social protection, and reduced workplace rights.

The "emerging adulthood" phase is a particular stage of life that describes the transition from youth to the workforce, which can be considered a challenging and delicate period (2). Young adults, aged between 15 and 29, entering the job market after completing their studies face particular vulnerability due to a lack of professional experience, job opportunities, and social protection in cases of unemployment. Additionally, there is evidence that difficulty in establishing oneself in the job market can result in long-term negative health effects (3).

A Swedish study aimed to analyze whether freelance (self-employed) or informal contract work during early adulthood is related to an increased risk of developing alcohol-related health problems in the long term, such as alcohol-related liver disease, alcohol use disorder, and intoxication. To conduct this analysis, data from national registers in Sweden were used, tracking a large population of young adults over 28 years. The results of this study suggest that being employed as a freelancer or in informal work during "emerging adulthood" is associated with an increased risk of alcohol-related morbidity later in life, especially among young men, but also among young women (4). The reasons for this increased risk may be related to using alcohol as a coping strategy for stress, and this habit may persist when these individuals transition to more stable jobs with greater benefits.

It is important to highlight that in a context where flexible employment forms are becoming increasingly common, understanding the implications of employment type on the health of young people is crucial. Evidence suggests that, in addition to economic effects, this form of work may have significant consequences for mental and physical health. Therefore, it is essential that public policies and interventions are directed not only towards improving working conditions but also towards providing adequate support to these young individuals, preventing future alcohol-related health issues.

References:

1. Benach J, Vives A, Amable M, et al. Precarious employment: understanding an emerging social determinant of health. Annu Rev Public Health 2014;35:229–53. 
2. Thern E, Matilla-Santander N, Hernando-Rodriguez JC, et al. Precarious employment in early adulthood and later mental health problems: a register-linked cohort study. J Epidemiol Community Health 2023;77:755–61.
3. Gray BJ, Grey C, Hookway A, et al. Differences in the impact of precarious employment on health across population subgroups: a scoping review. Perspect Public Health  2021;141:37–49.
4. Thern, E., Elling, D. L., Badarin, K., Hernando Rodríguez, J. C., & Bodin, T. (2024). Precarious employment in young adulthood and later alcohol-related morbidity: a register-based cohort study. Occupational and environmental medicine, 81(4), 201–208.

Alcohol Consumption and Colorectal Cancer: Evidence and Prevention

Colorectal cancer (CRC) ranks as the third most common type of cancer and is the second leading cause of cancer deaths globally. A sedentary lifestyle, obesity, metabolic syndrome, and alcohol consumption can be factors that increase the risk of early-onset CRC (1).

 Alcohol consumption, even in small amounts, has been linked to an increased risk of colorectal cancer (CRC). The relationship between alcohol intake and CRC risk depends on the dose consumed. The risk of CRC is particularly evident in cases of heavy alcohol consumption, although evidence regarding the risk associated with light to moderate consumption is varied (2).

 Several mechanisms link alcohol consumption to the development of cancers in general, with genotoxicity being one of the most scientifically understood factors. In this process, acetaldehyde, a byproduct of alcohol metabolism, causes DNA damage, such as breaks and alterations in its structure. These changes can result in errors during DNA replication, leading to mutations. Over time, the accumulation of these mutations may culminate in the development of cancer (3).

 In addition to alcohol consumption itself, other alcohol-related factors may influence the risk of colorectal cancer (CRC). A family history of the disease is one such factor, with the risk of CRC being significantly higher in individuals with a family history of cancer (4). Gender also appears to have an impact, with men tending to have a higher risk of developing alcohol-associated CRC compared to women. Body mass index (BMI) and body weight may also interact with alcohol, increasing the risk of CRC, especially in obese individuals (5). Although smoking is an established risk factor for CRC, there is no conclusive evidence that it modifies the alcohol-induced CRC risk (6).

 In light of the evidence, it is crucial to raise awareness about the risks of alcohol consumption in relation to colorectal cancer. Although various factors can influence this risk, alcohol consumption alone is a significant modifiable risk factor. Prevention strategies, including moderating alcohol consumption and adopting healthy lifestyle habits, are essential to reduce the incidence of CRC. Continued research is also necessary to better understand the mechanisms by which alcohol contributes to the development of CRC.

References:

1. Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: a cancer journal for clinicians, 71(3), 209–249. https://doi.org/10.3322/caac.21660
2. Cai, S., Li, Y., Ding, Y., Chen, K., & Jin, M. (2014). Alcohol drinking and the risk of colorectal cancer death: a meta-analysis. European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation (ECP), 23(6), 532–539. https://doi.org/10.1097/CEJ.0000000000000076
3.  International Agency For Research On Cancer. IARC Handbooks of Cancer Prevention: volume 20A - Reduction or cessation of alcoholic beverage consumption. Lyon: IARC, 2024
4. Cho, E., Lee, J. E., Rimm, E. B., Fuchs, C. S., & Giovannucci, E. L. (2012). Alcohol consumption and the risk of colon cancer by family history of colorectal cancer. The American journal of clinical nutrition, 95(2), 413–419. https://doi.org/10.3945/ajcn.111.022145
5. Fedirko, V., Tramacere, I., Bagnardi, V., Rota, M., Scotti, L., Islami, F., Negri, E., Straif, K., Romieu, I., La Vecchia, C., Boffetta, P., & Jenab, M. (2011). Alcohol drinking and colorectal cancer risk: an overall and dose-response meta-analysis of published studies. Annals of oncology : official journal of the European Society for Medical Oncology, 22(9), 1958–1972. https://doi.org/10.1093/annonc/mdq653
6. Fagunwa, I. O., Loughrey, M. B., & Coleman, H. G. (2017). Alcohol, smoking and the risk of premalignant and malignant colorectal neoplasms. Best practice & research. Clinical gastroenterology, 31(5), 561–568. https://doi.org/10.1016/j.bpg.2017.09.012

New Fiocruz Study Analyzes the Cost of Alcohol Consumption in Brazil 

A new study reveals that alcohol consumption in Brazil generates up to R$18.8 billion in annual costs, highlighting the urgency for preventive policies.

The study (1), conducted by the Oswaldo Cruz Foundation (Fiocruz), aimed to estimate the economic costs of alcohol consumption in Brazil, addressing both direct and indirect costs to society. Using public health data and scientific literature, the research estimated the financial impacts of alcohol consumption in the country in 2019.

The key findings indicated that the total costs attributable to alcohol consumption ranged from R$10.1 billion to R$18.8 billion. These costs were divided into direct costs, such as hospitalizations and outpatient procedures, which ranged from R$483 million to R$1.1 billion, and indirect costs, estimated between R$9.7 billion and R$17.7 billion, which include lost productivity due to absenteeism, premature deaths, and social security expenditures. Additionally, alcohol-attributable deaths were estimated to range from 47,900 to 104,800 in the year.

Another key point in the analysis is the increasing prevalence of alcohol consumption among Brazilians, with a sharp rise among women and an early onset during adolescence, leading to a significant burden of disease and death. Cardiovascular diseases, cancers, and alcohol-related accidents are some of the leading causes of hospitalizations and alcohol-attributable deaths. To support these points, the study uses data from the 2019 PNS (National Health Survey), Vigitel, Datasus, and the World Health Organization (WHO). It is important to highlight that these data on the increasing alcohol consumption over the years are significant, even though this study focused only on 2019. Thus, the cost analysis is framed under the perspective that such expenditures are likely to continue to rise.

The study presents several limitations related to the statistical model used, but these limitations, given the available data, incorporate the best evidence and approximations to adjust the analysis to the Brazilian population. Another point is that the morbidity and mortality data were obtained from Datasus, the Ministry of Health database, which may underestimate the actual scale of alcohol-related problems, especially in cases where alcohol may not be recorded as the direct cause of hospitalization. In terms of costs, the direct cost of primary health care and family expenses could not be estimated, and the indirect cost of variables such as "presenteeism" was also not included. Despite these limitations, it should be emphasized that the analysis is robust and supported by scientific literature.

In summary, the findings highlight a significant economic and social burden from alcohol consumption in Brazil, suggesting the need for public policies to control harmful use, such as those presented by the WHO in 2018 through the SAFER initiative.

References:

1. Nilson, E. Estimação dos custos diretos e indiretos atribuíveis ao consumo de álcool no Brasil. Fiocruz, 2024.

Brief Intervention to Reduce Risky Alcohol Consumption Has Proven Effective in the Elderly

A study conducted by researchers from the University of São Paulo (USP) in Ribeirão Preto observed a reduction in risky alcohol consumption among the elderly through a brief intervention protocol.

Harmful alcohol use among the elderly population leads to serious health complications and can even result in death. It is known that alcohol is the 7th largest risk factor for the total disease burden among individuals aged 50 to 69 years and the 10th for those over 70 years old (1). 

According to the WHO (World Health Organization), brief intervention (BI) is one of the most cost-effective measures for treating harmful alcohol use (2). This therapeutic approach, widely used in the treatment of alcoholism, can also be applied to other mental health disorders. It consists of a set of practices aimed at identifying a real or potential problem related to alcohol use and motivating the person to take action about it.

Recently, researchers from the University of São Paulo (USP) in Ribeirão Preto assessed the effectiveness of brief intervention in reducing risky alcohol consumption among elderly individuals attended to in Primary Health Care (3). The study, conducted in the city of Ribeirão Preto, in Brazil, involved individuals aged 60 or older who reported alcohol use and scored between ≥ 5 and ≤ 19 on the AUDIT (Alcohol Use Disorders Identification Test) scale. Most participants were male, married, with a family income between 1 and 3 minimum wages, and some were retired, with 1 to 4 years of schooling. 

According to the author of the research, the characteristics of BI for the elderly may include providing information about health behaviors and the risks associated with their level of consumption; interpreting screening results and discussing reasons for drinking and its potential consequences; understanding their support networks; and negotiating a plan for reducing alcohol consumption.

Sociodemographic results of the research showed that 46.5% (n=234) of participants had low-risk alcohol consumption; 44.5% (n=224) had risky drinking patterns, and 9.1% (n=46) were potential dependents. For individuals who displayed risky drinking patterns, the study evaluated the brief intervention protocol, analyzing alcohol consumption patterns, the amount of drinks, frequency, and binge drinking behavior in these individuals before and after they were subjected to the intervention or the delivery of informational pamphlets (control group).

As the main outcome, the study showed a significant reduction in alcohol consumption patterns in the group that underwent the brief intervention over time (between 3 to 6 months). Additionally, a decrease in habitual consumption and binge drinking behavior was observed. Therefore, the study concludes with the recommendation of the brief intervention protocol for elderly individuals with risky alcohol consumption who are assisted by Primary Health Care.

Alcohol is one of the leading risk factors for the global disease burden in people aged 50 and older, and the consequences of harmful alcohol use during this stage include cognitive and intellectual functioning deficits, as well as the recurrence of other age-related health issues. For this reason, care by healthcare professionals tailored to this population is essential to understand this behavior and its consequences, so that proper guidance and treatment can be developed for the best care of the elderly's health.

To discuss more about this research and the impact of the brief intervention protocol for elderly individuals with risky alcohol consumption, CISA spoke with Deivson Wendell da Costa Lima, the principal investigator of the study. Here’s what he had to say:

1. What are the main advantages of brief intervention (BI) for elderly individuals with risky alcohol consumption? Was any specificity identified both regarding the risky use and the application of the protocol for this age group?

The implementation of BI for the elderly was strategic within the context of Primary Health Care (PHC) as it emphasized a preventive action in the community, addressed different health problems and interactions with medications that could be related to alcohol use, evaluated the elderly’s motivation to change their alcohol consumption, and helped understand the need to reduce consumption from risky levels to low risk or no consumption. It also involved working with Community Health Agents (ACS), who contributed to the development of the protocol.

The brief intervention took place through a scheduled home visit by a single researcher with a nursing background, conducted individually, face-to-face, in a location chosen by the elderly person within their home.

The home visit proved to be an appropriate tool for addressing alcohol consumption and preventing alcohol-related risks in the elderly’s home environment, as it made early intervention easier and provided insight into their health conditions and family and social dynamics.

Our brief intervention was carried out by a researcher with a nursing degree, specialized in mental health, and trained in alcohol and drug research. This researcher was the sole person who led the brief intervention protocol, following the guidelines for each phase. Studies show that elderly individuals assisted by nurses in PHC settings, who receive brief interventions, are less likely to engage in risky drinking than those who do not receive this approach.

Shorter questions regarding health conditions and then about alcohol consumption were part of the initial interview approach and served as an alternative for the elderly to feel more comfortable discussing their relationship with alcohol consumption.

The session lasted an average of 30 minutes, which seems to be more acceptable for the target population. Researchers have shown that shorter counseling sessions tend to have a greater additional effect on brief interventions for reducing alcohol consumption.

Our brief intervention protocol involved motivational interviewing techniques based on Cognitive Behavioral Theory, which facilitated discussions about risky drinking. Researchers agree that this engagement can help reduce complications arising from alcohol’s interaction with medications, mitigate health problems exacerbated by alcohol consumption, and improve quality of life.

The mere fact that the elderly person agreed to participate in the brief intervention may have been the start of a positive behavior change process regarding alcohol consumption. Elderly individuals seem more willing to engage in research than the general population and are more likely to participate in follow-up protocols compared to younger populations.

Each phase of our brief intervention protocol provided age-appropriate care with specific guidance, questions, and complexities unique to people aged 60 and older. It’s worth noting that there was not just one key element of the protocol, but several interconnected factors. More research is needed to understand the most effective components of brief alcohol interventions for the elderly.

2. What were the main challenges encountered in applying the screening protocol and BI in the units studied?

Alcohol consumption is often a behavior that health professionals rarely question, and as a result, drinking patterns are not assessed. The risks associated with alcohol consumption are often discovered only when elderly individuals seek consultations for other health issues.

Elderly individuals are less likely to access or seek help, either from PHC or specialized care, for alcohol-related problems. They often have difficulty recognizing the health risks of alcohol consumption, and may attribute symptoms related to this psychoactive substance to other comorbidities or aging-related complaints, rather than to alcohol itself.

Healthcare professionals lack training in screening tools and in strategies for appropriate interventions for elderly individuals, whether in-person or online. They also need more time to address the alcohol-related needs of the elderly.

Other challenges in this study include an emphasis on self-reported data regarding alcohol consumption history. There is a likelihood of underreporting when elderly individuals are asked to recall their drinking habits. Responses may only reflect socially acceptable behaviors, without revealing the full extent of their issues. In general, emotional state and memory problems can also impact elderly individuals' ability to provide accurate reports.

3. In your opinion, would it be important to expand this screening protocol and brief intervention to other locations and age groups? What challenges would need to be overcome for this to advance in our country?

The steps prior to the brief intervention—pre-screening and screening—were necessary to raise awareness among ACS workers and nurses about participating in our research. The pre-screening was done using a single question about alcohol consumption, already included in the elderly person’s individual record used by ACS workers in Family Health Units. This screening was brief and easy to administer. The responses from the elderly contributed to updating their records and identifying those classified as having risky drinking patterns.

The pre-screening strategy allowed data collection from the entire eligible population. A positive aspect of this strategy was that it avoided sample selection bias, such as only recruiting elderly individuals who consumed large quantities of alcohol more frequently.

Another option for the pre-screening process could be the use of the AUDIT-C in future research and clinical practice. In the context of Primary Health Care, the initial alcohol consumption assessment through AUDIT-C could be incorporated into the individual registration forms used by ACS workers, as well as during routine consultations with nurses and other health professionals. After evaluating the responses, elderly individuals who score ≥ 4 on the AUDIT-C could then receive the full AUDIT to determine their level of risk and any signs of possible dependence.

References:

1. Murray CJL, Aravkin AY, Zheng P, Abbafati C, Abbas KM, Abbasi-Kangevari M, et al. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020 Oct;396(10258):1223–49.
2. WHO. SAFER - Brief interventions and treatment [Internet]. www.who.int. Available from: https://www.who.int/initiatives/SAFER/brief-interventions-and-treatment
3. Lima DW da C. Efetividade da intervenção breve para redução do consumo de risco de álcool em idosos na atenção primária à saúde [Internet]. www.teses.usp.br. 2023 [cited 2023 Nov 23]. Available from: https://www.teses.usp.br/teses/disponiveis/22/22131/tde-09082023-164723/en.php