Tuesday, October 11, 2011 Sessions moderated by Marcin Wojnar, MD, PhD

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1 Alcohol Policy in Poland and around Europe: Medical and Economic Disadvantages of Using Alcohol (MEDUSA)

2 Tuesday, October 11, 2011 Sessions moderated by Marcin Wojnar, MD, PhD Marcin Wojnar, MD, PhD is a Professor of Psychiatry at the Medical University of Warsaw and the Chair of Department of Psychiatry. He graduated from the same university in His main research interests include addictions, depression and psychiatric genetics. Both his doctoral dissertation and habilitation research were based on a complex longitudinal study of treatment outcomes in alcohol dependence. He authored and coauthored more than 100 publications and about 140 conference papers. Since 2003 he is the head of the psychiatric ward at the Nowowiejski Psychiatric Hospital in Warsaw where he initiated a treatment program for patients with complicated alcohol withdrawal. He is a research advisor at the State Agency for Prevention of Alcohol Related Problems. In 2007 he initiated and was a founding member of the Polish Society for Research on Addictions, in which he serves as a president since then. He is also a member of the Polish Psychiatric Association, the European Society for Biomedical Research on Alcoholism, the Research Society for Alcoholism, the International Society of Addiction Medicine and the European Society on Treatment of Alcohol Dependence.

3 Witold Zatoński, M.D., Ph.D. Witold Zatoński M.D., Ph.D. is a Director and Professor in the Division of Cancer Epidemiology & Prevention at Cancer Center & Institute of Oncology in Warsaw, Poland. As founder and President of the Health Promotion Foundation, Professor Zatoński has been instrumental in launching numerous health campaigns implemented in Poland and other areas of Eastern Europe. Professor Zatoński has recently completed work on the HEM Closing the Gap project, a complex study examining health inequalities between eastern and western parts of the European Union. The final project report has been recently published and it is available at the project website ( The HEM project is currently in the dissemination phase. Currently Professor Zatoński implements project PONS, aiming at establishing infrastructure for prospective cohort study of population health in Poland ( Professor Zatoński has been at the forefront of public health and tobacco control in Poland, Eastern Europe, and internationally for over 35 years. A passionate activist and researcher, and he has helped promote policy development through research and dissemination of research evidence and best practice. In 2006 he was awarded the Luther L. Terry award for Distinguished Career by the American Cancer Society. Health inequality between European Union countries. The case of alcohol Inequalities in access to health between member states constitute one of the biggest challenges faced by the European Union. Premature mortality (before the age of 65) divides significantly the western (EU15) and eastern (EU10) parts of the EU. One of the main causes for high premature mortality, especially among men, in the EU10 countries are the health damages attributable to alcohol. It is estimated that among men alcohol-attributable risk accounts for 25% of the difference in life expectancy between EU15 and EU10 countries; this proportion is highest in the Baltic States (48%). Volume of alcohol consumption and the low quality of the product seem to be the causes for the highest ever risk of liver cirrhosis in Europe recorded in Hungary and Romania. Generally, EU10 countries, and especially the Baltic States, where binge drinking is dominating, can be characterized by extremely high levels of sudden deaths from injuries. Additionally, in contrast to western Europe, there is more and more evidence indicating that alcohol is the direct cause of a high proportion of sudden non-ischemic cardiac deaths. ( In the EU10 countries there is an urgent need for establishing a comprehensive intervention program aiming at diminishing health damages attributed to alcohol.

4 Zbigniew Gaciong Professor of Medicine Department of Internal Medicine, Hypertension and Vascular Diseases The Medical University of Warsaw Zbigniew Gaciong M.D. Ph.D. graduated from Warsaw Medical School where he performed his residency in internal medicine and also was a fellow of American Heart Association in University of Southern California. Since 1998 he is a chairman of the Department of Internal Medicine, Hypertension and Vascular Diseases (Medical University of Warsaw) - the biggest reference center in the country. His research interest includes primary cardiovscular prevention, pathogenesis of hypertension and mechanisms of vascular remodelling and the results were published in leading international journals (New England Journal of Medicine, Lancet, PNAS, Cancer Cell, PloS Medicine, American Journal of Hypertension, Cardiovascular Research). Prof Gaciong also serves as Dean for Postgraduate Education and he developed and introduced into curriculum courses on the methodology of clinical trials. He also served as a member of International Advisory Board in JAMA and Union of European Medical Specialists. Is drinking good for your heart? There is a common belief that small amount of alcohol glass of red wine in particular, taken regularly prevents cardiovascular diseases. Regular moderate alcohol consumption has been associated with a decreased incidence of coronary heart disease and mortality benefits were observed in those with no cardiac risk factors, as well as in those with risk factors including hypertension or diabetes mellitus, or established coronary heart disease. A J-shaped curve describes this relationship, with increased mortality found in those with alcohol intake that exceeds moderate limits and in binge drinkers. Heavy alcohol drinking can induce cardiomyopathy and increases the risk for all types of stroke. Actually, the evidence that relates alcohol consumption to cardiovascular risks and benefits is based on data from observational studies which may be biased by uncorrected confounding issues. Also, there is a wide range of effective doses reported in different studies and the protective dose for women is significantly lower as compared to males. Evidence from randomized trials, comparing long-term effects of alcohol in participants assigned to alcohol abstinence or moderate intake, is not currently available. Moderate alcohol consumption is associated with changes in HDL cholesterol, insulin sensitivity, thrombotic activity, and inflammation, yet there is not enough data to accept causal relationship between alcohol consumption and cardiovascular risk. For example, red wine is considered cardioprotective due to high content of anti-oxidants but no randomized clinical trial showed any benefit from administration of anti-oxidant vitamins. It is likely that amount of alcohol consumed and the pattern of intake may present a marker of healthy behavior. The presumed cardiovascular benefit of moderate alcohol intake must be balanced against the multiple deleterious effects of alcohol on conditions such as liver disease, cancer, depression and accidental deaths. The American Heart Association recommends against advising people who don't currently drink to initiate light alcohol use and theories on beneficial effects of drinking should not be popularized in the society.

5 Dr Nick Sheron MD, FRCP Dr Sheron is Head of Clinical Hepatology at the University of Southampton; he has around 60 academic publications on liver damage and other aspects of alcohol related harm. He is a member of the Royal College of Physicians Alcohol Committee, the EU Alcohol Forum, BSG Public Affairs Committee, Honorary Secretary of the Alcohol Health Alliance UK, trustee of the Drinkaware Trust and runs the drinksafely.info website. Alcohol related liver disease Alcohol related liver disease Alcohol related liver disease accounts for a large proportion of the directly attributable alcohol liver mortality and morbidity in the EU. Death rates in some EU countries have fallen markedly as alcohol consumption has declined, but in other countries have increased substantially. For example in the UK liver deaths have increased five fold as deaths from practically all other diseases have fallen. Liver disease presents late with often-fatal disease, and patients exhibit the full spectrum of alcohol dependency. The main opportunity to reduce deaths will result from the implementation of evidence based policies to reduce overall alcohol consumption at a population level. As with tobacco political change will occur only if determined advocacy from the health community is able to successfully counter the fierce and highly effective lobbying power of the drinks and retail industries. In addition the hepatology community must move the focus from patients with end stage disease in hospitals. New technologies for the detection of liver disease mean that liver diagnosis and management can move out of secondary care and into the community. In the future the behavioural risk factors of obesity together with the consequences of intravenous drug use and social inequality are likely to contribute even more to liver death rates. The challenge of unhealthy behaviours, the important preservation of individual freedoms and the vested interests of various global industries are the backdrop against which the challenges for liver health in the 21st century will be played out. Alkoholowe uszkodzenie wątroby Alkoholowe uszkodzenie wątroby jest odpowiedzialne za znaczny odsetek bezpośrednio wywołanych spożywaniem alkoholu zachorowań na wątrobę i zgonów z tego powodu w UE. Śmiertelność w niektórych krajach UE zmniejszyła się wyraźnie, gdy spadła konsumpcja alkoholu, ale w innych znacznie wzrosła. Na przykład w Zjednoczonym Królestwie śmiertelność z powodu chorób wątroby wzrosła pięciokrotnie, podczas gdy śmiertelność spowodowana niemal wszystkimi innymi chorobami spadła. Alkoholowe uszkodzenie wątroby ujawnia się późno i często na etapie, gdy jest już nieuleczalne, a pacjenci znajdują się w ostatniej fazie uzależnienia. Główną szansą na ograniczenie śmiertelności jest wprowadzenie rozwiązań opartych na dowodach naukowych, które mają na celu zmniejszenie całkowitej konsumpcji alkoholu na poziomie populacji. Podobnie jak w przypadku tytoniu, zmiany polityczne nastąpią jedynie wtedy, gdy środowiska promujące zdrowie swoim zdeterminowanym poparciem będą w stanie z sukcesem przeciwstawić się nieustannemu i bardzo skutecznemu lobbingowi producentów alkoholu i sprzedawców detalicznych.

6 Ponadto, środowisko hepatologów powinno przestać skupiać uwagę jedynie na pacjentach szpitali znajdujących się w końcowej fazie choroby. Dzięki istnieniu nowych technologii służących do wykrywania chorób wątroby, diagnozowanie i leczenie chorób wątroby może zostać przeniesione z placówek opieki specjalistycznej do placówek środowiskowych. W przyszłości behawioralne czynniki ryzyka otyłości wraz z konsekwencjami stosowania leków dożylnych oraz nierówności społeczne będą prawdopodobnie w większym stopniu przyczyniały się do śmiertelności spowodowanej chorobami wątroby. Wyzwanie, jakie stanowią zachowania szkodliwe dla zdrowia, znaczenie ochrony indywidualnej wolności oraz rozległe interesy globalnego przemysłu tworzą tło, na którym rozpatrywane będą w 21 wieku problemy dotyczące chorób wątroby.

7 Przemysław Bieńkowski Institute of Psychiatry and Neurology, Warsaw, Poland Przemyslaw Bienkowski, MD, PhD is a Professor in the Department of Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland. His scientific interests focus on neural mechanisms of psychiatric disorders and drug addiction. He is involved in searching for new drugs for schizophrenia, depression, and alcohol addiction as well as in identifying biomarkers of neuropsychiatric disorders. Alcohol-induced brain disorders: etiopathology and treatment Ethanol (alcohol) can damage the human brain. However, any central effect of alcohol largely depends on drinking pattern, daily dose, somatic and psychiatric comorbidities and, last but not least, on other drug habits. A large body of evidence suggests that alcohol withdrawal can also be dangerous for brain cells. It remains an open question whether alcohol or alcohol withdrawal is more devastating for the brain of alcohol addict. Effects of alcohol on the brain are both different and similar to those exerted by other drugs of abuse. Some alcohol-induced brain disorders result from direct toxic effects of alcohol on brain cells. Some disorders are not linked to any obvious alterations in brain structure. One may assume that the impressive progress in neuroimaging will allow identification of more subtle alcohol-induced abnormalities in brain function and structure. Indirect effects of alcohol on brain structure and function (e.g. secondary to alcohol-induced somatic problems) are less frequently studied. Alcohol alters homeostasis of the various body organs and systems. It is widely accepted that alcohol-induced vitamin deficiencies result in brain damage. In contrast, relatively little is known about links between alcohol-induced immunological or hormonal disturbances and brain disorders. Future preclinical and clinical studies should concentrate on biomarkers of early brain dysfunction and damage induced by alcohol consumption. One may also wish to consider alcohol-induced brain damage detected by neuroimaging as primary end-point in studies on novel anti-alcohol drugs or psychotherapeutic interventions.

8 Dirk Lachenmeier CVUA Karlsruhe Dr. Dirk Lachenmeier, State Certified Food Chemist and Toxicologist, is head of the alcohol laboratory at the Chemical and Veterinary Investigation Laboratory (CVUA) of Karlsruhe, which is a governmental food and alcohol control authority in Germany. Multifacetted interdisciplinary research interests span from food science and toxicology to epidemiology and cancer risk assessment. Authored more than 150 peer reviewed publications and participated in WHO IARC working group Vol. 96 on alcoholic beverage consumption, acetaldehyde and ethyl carbamate. Major work in alcohol field on quality control and quantitative risk assessment of alcoholic beverages regarding carcinogenic contaminants (including acetaldehyde, ethyl carbamate). Participation in EU FP7 AMPHORA project on public health assessment of unrecorded alcohol. Alcohol, acetaldehyde and cancer - an infamous alliance According to epidemiological findings, the consumption of alcoholic beverages is causally related to the occurrence of malignant tumours of the oral cavity, pharynx, larynx, oesophagus, liver, colorectum, and female breast; this includes a classification as carcinogenic to humans (group 1) by the WHO International Agency for Research on Cancer (IARC). Because the carcinogenicity was generally noted with different types of alcoholic beverage, and in view of the carcinogenicity of ethanol in animals, the IARC also classified ethanol in alcoholic beverages as carcinogenic to humans (group 1). A major mechanism appears to be the oxidation of ethanol to acetaldehyde. The association between alcohol, acetaldehyde and cancer was proven by genetic-epidemiological evidence, which showed that humans deficient in aldehyde dehydrogenase (ALDH) are at increased risk for oesophageal cancer, as they have higher levels of acetaldehyde in their blood but especially in their saliva after drinking alcohol, and higher levels of acetaldehyde-related DNA adducts have been measured in their lymphocytes. Acetaldehyde associated with alcohol consumption was recently upgraded to group 1 by the IARC. During alcohol consumption, the human exposure to acetaldehyde is threefold: (1) metabolic formation in the epithelia mediated by alcohol dehydrogenase (ADH) and other enzymes (2) microbial oxidation of ethanol by the oral microflora, and (3) acetaldehyde directly contained in the beverages. In vivo research has shown that even moderate consumption of alcoholic beverages may elevate acetaldehyde levels above the threshold of concern. The acetaldehyde-mediated mechanism plausibly explains the epidemiological findings of increased oral cancer risks related to alcohol consumption. Alkohol i aldehyd octowy a nowotwory niechwalebny związek Zgodnie z wynikami badań epidemiologicznych, spożycie napojów alkoholowych jest powiązane przyczynowo z występowaniem nowotworów złośliwych jamy ustnej, gardła, krtani, przełyku, wątroby, jelita grubego i piersi oraz zaklasyfikowane jako rakotwórcze dla ludzi (grupa 1) przez Międzynarodową Agencję Badania Raka WHO (WHO International Agency for Research on Cancer - IARC). Ponieważ działanie rakotwórcze zostało zaobserwowane dla różnych rodzajów napojów alkoholowych, a także mając na względzie rakotwórcze działanie etanolu na zwierzęta, IARC zaklasyfikowała również etanol w napojach alkoholowych jako rakotwórczy dla ludzi (grupa 1). Głównym mechanizmem wydaje się być utlenianie etanolu do aldehydu octowego. Związek pomiędzy alkoholem, aldehydem octowym i rakiem został udowodniony za pomocą dowodów genetycznoepidemiologicznych, które wykazały, że osoby z deficytem dehydrogenazy aldehydowa (ALDH) są narażone na

9 większe ryzyko raka przełyku, ponieważ mają wyższy poziom aldehydu octowego we krwi i zwłaszcza w ślinie po wypiciu alkoholu. Jednocześnie w ich limfocytach wykazano wyższy poziom adduktów aldehydu octowego z DNA. Aldehyd octowy związany ze spożywaniem alkoholu został ostatnio przeniesiony przez IARC do grupy 1. Podczas konsumpcji alkoholu oddziaływanie aldehydu octowego na człowieka jest trojakie: (1) poprzez powstawanie aldehydu octowego w nabłonku wskutek działania dehydrogenazy alkoholowej (ADH) i innych enzymów (2) poprzez mikrobowe utlenianie etanolu przez mikroflorę jamy ustnej oraz (3) poprzez aldehyd octowy obecny w napojach. Badania in vivo pokazały, że nawet umiarkowana konsumpcja napojów alkoholowych może podnieść poziom aldehydu octowego powyżej progu, którego przekroczenie budzi niepokój. Mechanizm zmian, w których pośredniczy aldehyd octowy wiarygodnie wyjaśnia wyniki badań epidemiologicznych dotyczące związku konsumpcji alkoholu z podwyższonym ryzykiem raka jamy ustnej.

10 Prof. Emanuele Scafato Istituto Superiore di Sanità. Rome. Italy Prof. Emanuele Scafato, MD, is a senior researcher, epidemiologist and gastroenterologist, director of Population s Health and Health Determinants Unit, of the WHO CC for Research and Health Promotion on Alcohol, and of the National Observatory on Alcohol (NOA) at the CNESPS-ISS (The WHO CC Research and Health Promotion on Alcohol and the NOA are formally charged at ISS by the Ministry of Health for the realization and implementation of the National Alcohol Prevention Day and of the national campaigns and communication strategy on alcohol according to the law 125/2001). Prof. Scafato research group provides the formal epidemiological report on alcohol that the Minister of Health submits yearly to the Italian Parliament. The professional experience of Prof Scafato in the field is the results of more than 20 years of activity always performed into multi-disciplinary and international approach and environment with tight invovement and connection with World Organization and European Commission fromal activity in the quality of former National Counterpart for the implementation of alcohol policies as well as as governmental representative in the DG SANCO Committe on National Alcohol Policies and Actions - CNAPA.. Prof. Scafato is appointed by Italian government, as expert of several High Level Panel, Committees, Commissions, Working groups on topic issues: alcohol, ageing, cognitive impairment, health monitoring and diseases impact assessment on health and health system. He is/has been partner of almost all the past and current EU Projects on alcohol and health monitoring such as PHEPA, PHEPA2, AMPHORA, ECAT, Building Capacity, ELSA, Alcohol Policy Network BtG, MEGAPOLE, ECHI, ECHI2, ECHIM and coordinator of VINTAGE. Particularly, Prof. Scafato is implementing the training programme on early identification and brief intervention at national level opened to GPs and to physicians involved in the PHC provided by the European Project PHEPA - Primary Health care European Project on Alcohol. Moreover, as regards addictions, he is appointed by the Prime Minister as Member of the National Committee on drug-dependencies and by the MoH as Member of the National Committee on Alcohol. Dr Scafato is the scientific coordinator and the Research manager of more than 20 projects funded by the Ministry of Health, the Prime Minister Office and of the Ministry of Social Affairs (budget managed during the last 5 years: 7 millions of euros). He is co-author of more than 250 scientific publications. He his the President of the Italian Society of Alcohology, the key scientific society on alcohol since 1976 and Vice-President of EUFAS, European Federation of Addiction Societies. He is also board member of ESOCAP, the European Society of Cardiovascular Prevention. Alcohol use and healthy aging: the need for monitoring and prevention to add life to years. The ageing of the population is one of the current priorities for public health prevention in Europe. Healthy ageing is a challenge that EU is dealing with through a series of initiatives and actions that aimed at adding life to years and not only an increased life expectancy; disease free life expectancy is a much more adequate target to improve the health status of the population. Alcohol is in Europe the second out of the 10 leading risk factors in terms of premature death, disability and chronic diseases and alcohol consumption by the elderly has been identified as a neglected target for health policy in the EU. The lack of comprehensive and harmonized data for individuals aged 65 years prevents an evaluation of the real impact of drinking on the elderly. Nonetheless, the existing evidences solicit the need to develop specific strategies targeting the early identification of harmful alcohol use and brief intervention for the elderly. The most recent reports on alcohol and the elderly indicate that alcohol problems among 65+ individuals adults are

11 frequently undetected or misdiagnosed, whit an increased probability of exacerbation of negative health effects associated with harmful consumption. Furthermore, the presentation of elderly people with alcohol use problems may be atypical (such as falls, confusion, depression, road accidents) or masked by co-morbid physical or psychiatric illnesses, which makes detection difficult and, on the other hand, increase the already higher vulnerability of aged men and women magnify existing health risks connected with the negative physical and cognitive effects of alcohol. Evidence suggests that the epidemiological and the demographic transition combined with a lower welfare state will affect significantly the elderly people in the near future. There is considerable debate regarding the reported health benefits of moderate alcohol consumption by the elderly; however, if a benefit does exist, those most likely to experience a positive effect should also share at the same time the increased risk for 60 diseases and a relevant number of cancers related with the same amount of alcohol drunk. Even if the net impact of alcohol on the health of elderly Europeans has not been reported, probably alcohol produces more harms than benefits and, focusing on VINTAGE project experience and results, it looks relevant the need for forthcoming EU targeted nutritional guidelines, the implementation of good practices related with the increased availability of actions aimed at decreasing alcohol-related burden of disease, tackling unhealthy models of consumption, integrating interventions aimed at early detection of alcohol use disorders or harmful use as a key step in increasing awareness and the level of protection in this sensible target of population. Picie alkoholu a zdrowe starzenie się: potrzeba monitoringu i działań profilaktycznych celem wydłużenia życia i zdrowia Starzenie się populacji to obecnie jeden z priorytetów profilaktyki zdrowia publicznego w Europie. Zdrowe starzenie się to wyzwanie, z którym UE zmaga się za pomocą serii inicjatyw i działań mających na celu wydłużenie życia. Nie tylko zwiększanie oczekiwanej długości życia, ale zwiększanie oczekiwanej długości życia wolnego od chorób, jest bardziej adekwatnym celem poprawy stanu zdrowia populacji. Alkohol jest w Europie drugim z 10 wiodących czynników ryzyka dla przedwczesnej śmierci, niepełnosprawności i chorób chroniczny, a konsumpcja alkoholu przez osoby starsze została rozpoznana jako jeden z zaniedbywanych celów polityki zdrowotnej UE. Brak wszechstronnych i spójnych danych dla osób w wieku 65 lat uniemożliwia ocenę rzeczywistego wpływu picia na osoby starsze. Niemniej jednak, istniejące dowody wzmacniają potrzebę stworzenia specyficznych strategii wczesnych interwencji w przypadku szkodliwego picia alkoholu oraz krótkich interwencji adresowanych do osób starszych. Najnowsze raporty dotyczące alkoholu i osób starszych wskazują, że problemy alkoholowe w grupie wiekowej 65+ często nie są wykrywane lub są błędnie diagnozowane przy jednoczesnym podwyższonym ryzyku nasilenia się negatywnych skutków zdrowotnych związanych ze spożywaniem alkoholu w sposób szkodliwy. Co więcej, problemy związane ze spożywaniem alkoholu mogą się w przypadku osób starszych objawiać w nietypowy sposób (np. upadki, dezorientacja, depresja, wypadki drogowe) lub być zamaskowane przez współwystępujące choroby fizyczne lub psychiczne, które utrudniają ich wykrycie i z drugiej strony podnoszą już zwiększoną podatność starszych kobiet i mężczyzn na doznawanie szkód, zwiększając istniejące ryzyko dla zdrowia związane z negatywnymi fizycznymi i poznawczymi skutkami spożywania alkoholu. Dowody sugerują, że zmiany epidemiologiczne i demograficzne połączone ze zmniejszoną opieką państwa będą w znacznym stopniu oddziaływały na osoby starsze w bliskiej przyszłości. Toczy się godna uwagi debata dotycząca rzekomych korzyści zdrowotnych wynikających z umiarkowanego pica alkoholu przez osoby starsze, jednakże, jeśli takie korzyści naprawdę istnieją, osoby, w przypadku których prawdopodobieństwo pojawienia się pozytywnych skutków jest największe, są jednocześnie narażone na podwyższone ryzyko wystąpienia 60 chorób i wielu różnych odmiana raka, które wiąże się z tą samą ilością wypijanego alkoholu. Nawet jeśli wypadkowy wpływ alkoholu na

12 zdrowie osób starszych nie został określony, prawdopodobnie alkohol przynosi więcej szkód niż korzyści. Gdy odniesiemy się do doświadczeń związanych z projektem VINTAGE i jego wyników, bardzo potrzebne wydają się być następujące działania: ukazanie się w najbliższym czasie wytycznych dotyczących odżywania się przeznaczonych dla krajów UE, wprowadzenie dobrych praktyk związanych ze zwiększoną dostępnością działań skierowanych na zmniejszenie szkód zdrowotnych związanych z alkoholem, rozwiązanie problemu szkodliwych dla zdrowia sposobów konsumpcji alkoholu, zintegrowanie interwencji mających na celu wczesne wykrywanie zaburzeń związanych ze spożywaniem lub szkodliwym spożywaniem alkoholu jako kluczowy krok w podnoszeniu świadomości istnienia ww. problemów wśród osób starszych oraz poziomu ochrony tej wrażliwej grupy wiekowej w populacji.

13 Jerzy Mellibruda, M.D., Ph.D. Jerzy Mellibruda is a Professor of Psychology at the Warsaw School of Social Psychology, certified psychotherapist and supervisor of psychotherapy. His main are of professional activity include individual and group psychotherapy, training and supervision of psychotherapists, psychologists, physicians, nurses and social workers, clinical research on traumatic experiences in family and their health consequences, prevention of alcohol problems and family violence counteraction. He is a temporary advisor and expert at the European Office of the World Health Organization. Since 1989 he has been Director of the Institute of Health Psychology, since 2000 Head of the Department of Psychology of Addictions, Violence and Crisis at the Warsaw School of Social Psychology and Director of Professional School of Psychotherapy. In the past he served as plenipotentiary of Minister of Health for prevention of alcohol problems and as the Director of the State Agency for Prevention of Alcohol Problems. HEALTH, PERSONAL AND FAMILY PROBLEMS CREATED BY ALCOHOL-RELATED VIOLENT BEHAVIOR 1. Alcohol policy is often too narrowly focused on direct and biological influence of drinking on organizm and on counteraction of easy alcohol availability. Term Alcohol policy commonly suggesting limitation of availability of alcohol as a basic priority of public action related to alcohol problems and also recommend concentration of research and depth analysis influence of alcohol on biological side of human functioning. Problems related with family harm caused by alcohol related destructive behaviors are treated as a second-rated. For a long time I observe a alarming assymetry in this scope of alcohol policy in Europe Region. 2. There are millions of people living in alcohol disturbed familie across Poland and Europe. Family members of abusing alcohol persons experience psychological i biological harm. They live under acute traumatic and chronic stress, which cause dangerous somatic and emotional deseases. Traumas. destruction of family bonds and loss of basic personal safety make a negative influences on subsequent years of their life. 3. We should not expect that attainable outomes in reduction of alcohol consumption bring meanigful change for better for these people. Extending and changing of priorities of curent strategy of public action w European Region seems to be urgently neded. Reduction of availability and consumption of alcohol, counteraction of drink driving, early intervention and treatment of alcoholics are set of important but insufficient goals. We dont notice a big achievements in previous strategy and a lot of money designed for it is wasted. We dont observe also meaningful changes in difficult i crisis situation of children and adults who are caused by alcohol related violent behavior. Reduction of consumption of alcohol should not be a main goal of action directed on reduction of alcohol problems. 4. Member States adopted the European Charter on Alcohol in 1995 at the WHO European Conference on Health, Society and Alcohol in Paris. The Charter encouraged the development of comprehensive national policies adapted to the differing socio-cultural, legal and economic environments of each state. According to the Charter, this should be done by implementing five ethical principles and goals promoting and protecting the health and well-being of people: 5. Four of these principles refer to harm caused by violent alcohol behavior not to drinking itself. We should to think why we neglecting tasks which are formated by these principles. Current policy recommendations in Europe are in majority out of these challenges. We should develop and make wide available diverse kind of actions which will serve of children and adult who suffer harm in order of overcome of adverse effect of alcohol upset family life. We know a lot what should be done we should do it with support and money from the state and from local communities. A change of priorities in alcohol policy is needed.

14 Professor Colin Drummond Professor of Addiction Psychiatry National Addiction Centre, Institute of Psychiatry, King s College London Colin Drummond, MBChB, MD, FRCPsych, Professor of Addiction Psychiatry and Consultant Psychiatrist at the National Addiction Centre, Institute of Psychiatry, Kings College London and South London and Maudsley NHS Foundation Trust. Before that he was Professor and Head of the academic Section of Addictive Behaviour at St George s, University of London where he worked from 1993 to Previously he was Lecturer and later Senior Lecturer in Addiction Behaviour at the Medical Research Council Addiction Research Unit at the Institute of Psychiatry from 1987 to His doctorate was on the subject of alcohol and public health. He is principal investigator on several research grants from the Department of Health, the Medical Research Council and the European Commission, including the DH funded national alcohol needs assessment project and a national research programme on alcohol screening and brief intervention, also funded by DH. Member of the editorial boards of Addiction and British Journal of Psychiatry. Published papers and books on a wide range of topics including epidemiology, clinical trials, drug and alcohol policy and theories of craving. He has provided advice to government on alcohol and drug misuse strategy. He is a member of the Faculty of Addictions of the Royal College of Psychiatrists and served as the Academic Secretary. He has recently completed 7 years as director of the Specialist Clinical Addiction Network based at the National Treatment Agency. He is a member of the WHO Expert Committee on Drug Dependence and Alcohol Problems, and Chair of the NICE guideline development group on management of alcohol dependence and NICE topic expert group on alcohol treatment quality standards. Alcohol problems in health settings Alcohol is a toxic and dependence producing substance which can affect almost every organ in the body and is implicated in over 60 different diseases. The global disease burden from alcohol is considerable and alcohol is the third leading cause of disability in Europe. Recent evidence suggests that the potential health benefits of alcohol are outweighed by its adverse effects such that there is no universally safe level of alcohol consumption. Much of this burden of disease falls on health services with considerable health care costs. This paper will examine the prevalence and burden of alcohol on health services and review the evidence for the effectiveness of screening and brief intervention in health settings. This will include presentation of results from a recently completed UK trial of brief intervention in primary health care and emergency departments: the SIPS programme. The main conclusion is that cost effective strategies to reduce the health burden of alcohol have been identified by research and should be implemented. Problemy związane z piciem alkoholu w placówkach opieki zdrowotnej Alkohol to substancja toksyczna i uzależniająca, która oddziałuje na niemal każdy organ ciała i jest powiązana z ponad 60 różnymi chorobami. Globalne obciążenie chorobami wynikającymi ze spożywania alkoholu jest znaczne, a alkohol stanowi trzecią wiodącą przyczynę niepełnosprawności w Europie. Najnowsze badania sugerują, że nad potencjalnymi korzyściami zdrowotnymi wynikającymi z picia alkoholu przeważają skutki negatywne, a co za tym idzie, nie ma uniwersalnego, bezpiecznego poziomu spożywania alkoholu. Znaczna część tego obciążenia chorobami przypada na służbę zdrowia, generując pokaźne koszty dla opieki zdrowotnej. Celem tej pracy jest zbadanie rozpowszechnienia obciążenia służby zdrowia chorobami związanymi z alkoholem oraz przegląd dowodów skuteczności badań przesiewowych i krótkich interwencji w służbie zdrowia. Będzie ona obejmowała również prezentację wyników niedawno zakończonego badania, polegającego na testowym przeprowadzaniu krótkiej interwencji w placówkach podstawowej opieki zdrowotnej oraz na oddziałach ratunkowych w Zjednoczonym Królestwie (program SIPS). Główny wniosek jest taki, że w badaniu wyróżniono efektywne pod względem kosztów strategie ograniczania obciążenia chorobami związanymi z alkoholem, które powinny być wdrożone.

15 Kenneth R. Warren, PhD Acting Director, National institute on Alcohol Abuse and Alcoholism U.S. National Institutes of Health Kenneth R. Warren, Ph.D., a nationally-recognized expert on alcohol and pregnancy, and a long-time senior administrator at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) became Acting Director of NIAAA on November 1, Dr. Warren was named as the NIAAA Deputy Director in February He joined NIAAA in 1976 as a staff member of the then Division of Research. He later became chief of the Biomedical Research Branch, and then deputy director of the Division of Extramural Research. From 1984 to 2005 he directed the Office of Scientific Affairs, whose responsibilities included peer review, grants management, committee management, scientific communications, and activities of the NIAAA National Advisory Council and Extramural Advisory Board. From 2002 to 2007, Dr. Warren served as Associate Director for Basic Research, and over the past year he has also served as acting director of the institute s Office of Science Policy and Communications. A graduate of the City College of New York, Dr. Warren earned his doctorate degree in Biochemistry from Michigan State University in He subsequently undertook postdoctoral positions at the University of California, Los Angeles and at University of Michigan Mental Health Research Institute before joining the Federal government in a research position at the Walter Reed Army Institute of Research in Dr. Warren has maintained an active interest in all areas of alcohol and health and in past years often served as the editor of the triennial Reports to Congress on Alcohol and Health. He has been particularly active in research on the effects of alcohol use during pregnancy, including fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders (FASD). Dr. Warren initiated NIAAA s research program on FAS over 30 years ago. He currently chairs the government-wide Interagency Coordinating Committee on FAS. Dr. Warren has received numerous honors, including a superior service award from the Public Health Service in 1982 for his work in development of the first Surgeon General s Advisory on FAS. In 1994, Dr. Warren received the Seixas Award from the Research Society on Alcoholism (RSA). In 2002, he received the Henry Rosett Award from the Fetal Alcohol Syndrome Study Group of RSA. In 2007, the National Organization on Fetal Alcohol Syndrome (NOFAS) honored Dr. Warren by placing his name into their Tom and Linda Daschle FASD Hall of Fame, followed by the receipt of the NOFAS Excellence Award in Fetal Alcohol Spectrum Disorders: Etiology, Epidemiology, and Advances in Diagnosis Fetal Alcohol Syndrome (FAS) is one of the most serious consequences of heavy drinking during pregnancy. The umbrella term Fetal Alcohol Spectrum Disorders (FASD) is used to characterize the full range of prenatal alcohol damage varying from mild to severe and encompassing a broad array of physical defects and cognitive, behavioral, and emotional deficits. Historically, unhealthy alcohol use has been associated with a host of medical, mental health, and social problems, but the recognition of alcohol use in pregnancy as a specific cause of birth defects was not recognized until relatively recently. Clinician researchers in both France (Lemoine) and the United States (Smith and Jones) coincidently described FAS in the scientific literature, and it necessary for collaborative efforts among European and U.S. investigators, clinicians, and advocates (as well as those from other countries) to flourish in order to develop a full understanding of FASD and the most effective strategies for its prevention and treatment. This overview of the consequences of alcohol exposure on the developing fetus will focus on the following objectives:

16 Factors that delayed the recognition of alcohol teratogenesis until the late 20 th century The defining features of FAS and FASD and diagnostic criteria Prevalence of FAS in countries where it has been measured An update of on-going research in the following areas: 1. Improved case recognition; 2. Prevention of at-risk pregnancy drinking; 3. Amelioration of the deficits in FASD Spektrum zaburzeń związanych z prenatalną ekspozycją na alkohol (FASD): etiologia, epidemiologia i postępy w diagnostyce Alkoholowy Zespół Płodowy (Fetal Alcohol Syndrome FAS) to jedna z najpoważniejszych konsekwencji intensywnego picia alkoholu przez kobietę podczas ciąży. Zbiorcze określenie Poalkoholowe Spektrum Zaburzeń Rozwojowych (Fetal Alcohol Spectrum Disorders - FASD) jest używane do opisu całego spektrum prenatalnych szkód spowodowanych alkoholem, od umiarkowanych aż po bardzo dotkliwe, i obejmuje szeroki zakres defektów fizycznych, poznawczych i behawioralnych oraz deficytów emocjonalnych. Przez długi czas spożywanie alkoholu w sposób szkodliwy dla zdrowia było kojarzone z wieloma problemami medycznymi, zdrowia psychicznego i społecznymi, ale dopiero stosunkowo niedawno rozpoznano spożywanie alkoholu podczas ciąży jako specyficzną przyczynę wad wrodzonych płodu. Badacze kliniczni we Francji (Lemoine) i Stanach Zjednoczonych (Smith i Jones) jednocześnie opisali FAS w literaturze naukowej. Wspólne wysiłki badaczy, klinicystów i innych osób udzielających poparcia tej sprawie z Francji, Stanów Zjednoczonych oraz innych krajów są niezbędne do rozwoju owocnej współpracy, służącej pełnemu zrozumieniu FASD i stworzeniu najbardziej skutecznych strategii zapobiegania i leczenia FASD. Ten przegląd konsekwencji oddziaływania alkoholu na rozwijający się płód będzie skupiony wokół następujących zagadnień: Czynniki, które opóźniały rozpoznanie teratogenezy spowodowanej alkoholem aż do końca XX wieku Cech definiujące FAS i FASD oraz kryteria diagnostyczne dla nich Rozpowszechnienie FAS w krajach, w których był on mierzony Aktualizacja przeglądu prowadzonych badań z następujących dziedzin: 1. Ulepszone rozpoznawanie przypadku; 2. Profilaktyka ryzykownego picia alkoholu podczas ciąży; 3. Naprawa deficytów wynikających z FASD

17 Dr. Miguel Del Campo Casanelles Unidad de Genética. Hospital Vall d Hebron, Barcelona Profesor asociado. Unitat de Genètica/ Departament de Ciències Experimentals i de la Salut Universitat Pompeu Fabra Miguel del Campo Casanelles is a Medical Doctor graduated at the Universidad Complutense de Madrid in He received PhD at the Universidad Autónoma de Madrid in He completed residency in pediatrics (M.I.R. Hospital Universitario La Paz, ), received board certification in Clinical Genetics (1999) after a 3-year Fellowship in Human Genetics at the University of California in San Diego (UCSD, ). He developed a research program in Telegenetics at the University Pompeu Fabra in Spain. Currently he is an Associate Professor at the University Pompeu Fabra in Barcelona and Clinical Senior Consultant in Medical Genetics at Hospital Vall d Hebron. In he coordinated Orphanet Spain funded by the European Commission and is currently Director of its Scientific Committee. A subject of his dissertation was to study of correlation among physical features and cognitive impairment in FAS, and has later been part of a collaborative international project on FAS funded by NIH-NIAAA. Dr del Campo is currently coordinator of the Masters in Genetic counseling at UPF. Besides FAS, his main areas of research have been limb defects and HOX signalling pathways, Williams Syndrome, Autism, prenatal diagnosis through array CGH and other malformation and intellectual disability syndromes. PHYSICAL PHENOTYPE IN FAS. SPECIFICITY AND CORRELATION WITH COGNITIVE IMPAIRMENT Objective: To determine whether there are associations and correlations between the presence and severity of the physical features characteristic of FAS and the degree of cognitive impairment. This could result in a potential use of the physical phenotype as markers for prediction of IQ. Methodology: Design: This is a retropective study ascertaining 61 patients with high prenatal alcohol exposure that have consulted a reference clinic for FAS during the years Setting: The study was performed at the Dysmorphology Unit and the California Teratogen Information Service of the University of California in San Diego and the Department of Psychology, San Diego State University. Patients: Sixty one patients were included in this study, all having had prenatal alcohol exposure (PEA) greater than 5 drinks per week, as well as complete physical dysmorphology exams and neuropsychological evaluations. Interventions: Standardized physical dysmorphology examination and neuropsychological testing including ageappropriate Weschler scales IQ testing. Outcome measures: Outcome measures included FSIQ and its verbal (VIQ) and performance (PIQ) components. Statistical methods included calculation of the mean and standard deviation for each variable representing the physical features of FAS. For qualitative variables, IQs were compared using, Kruskall-Wallis or Mann-Whitney U test. For quantitative variables correlation studies with IQ were performed using Pearson correlation coefficient. Multivariate analysis included multiple linear regression studies and regression tree models. Sensitivity and specificity were calculated for each variable to determine its impact on prediction of IQ. Results: Variables that showed statistically significant associations with lower IQ were: ptosis, smooth philtrum and linear upper lip, abnormal hand creases and the hockey stick crease. Variables that showed statistically significant correlations with IQ variation were: height, head circumference, upper lip and philtrum smoothness scores, as well

18 as the number of these physical diagnostic criteria. Multiple linear regression analysis identified head circumference and the hockey stick crease as the variables with significant multivariate correlation with IQ variation. Regression trees allowed stratification of the variables as potential predictors of cognitive outcome. A predictive score for the physical examination was proposed. Conclusions: The presence and severity of the physical features of FAS in patients with PEA is associated with the severity of the cognitive deficit in a retrospectively assessed population with high alcohol exposure. Microcephaly and the hockey stick crease can be considered higher impact markers of a lower IQ; postnatal growth retardation, abnormal palmar creases, and smooth philtrum and vermillion boarder of the upper lip can be considered lower impact markers of cognitive impairment. The remaining findings of the physical exam, some of which are important FAS diagnostic criteria, are not significant markers of cognitive outcome. A score for FAS is proposed according to this study that could be used to predict outcome in children with PEA and physical features characteristic of FAS. Several other studies conducted within the frame of the International consortium for FASD (NIAAA-NIH), in Finland, Russia, South Africa, support the correlation among the physical features and the severity of the cognitive impairment A review of these studies will be performed and speculation on wheather the physical exam in newborns and infants can predict cognitive outcome will be made. Counseling of the families regarding prognosis and the need for early intervention and theapies can benefit from the conclusions of a precise physical exam. Fenotyp fizyczny w alkoholowym zespole płodowym. Specyficzność oraz korelacja z upośledzieniem czynności poznawczych. Cel: Stwierdzić, czy istnieją powiązania i korelacje pomiędzy występowaniem i zaawansowaniem cech fizycznych charakterystycznych dla FAS a stopniem upośledzenia czynności poznawczych. Mogłoby to prowadzić do potencjalnego użycia fenotypu fizycznego jako markera przewidywalności IQ. Metodologia: Projekt badawczy: Jest to badanie retrospektywne obejmujace 61 pacjentów z bardzo dużą prenatalną ekspozycją na alkohol, którzy w latach poddawali się konsultacjom w klinikach zajmujących się FAS. Lokalizacja: To badanie zostało przeprowadzone na Oddziale Dysmorfologii oraz w California Teratogen Information Service na Uniwarsytecie Kalifornijskim w San Diego oraz na Wydziale Psychologii Uniwersytetu Stanowego San Diego. Pacjenci: badniem objęto 61 pacjentów; wszyscy byli poddawani prenatalnej ekspozycji na alkohol (PEA) większej niż 5 drinków na tydzień, a także całościowym badniom dysmorfologii fizycznej oraz ocenom neuropsychologicznym. Zastosowane badania: Standaryzowane badania dysmorfologii fizycznej oraz testy neuropsychologiczne, włączając w to testy IQ za pomocą dopasowanych do wieku pacjenta skal Wechslera. Pomiar wyników: Wyniki były mierzone za pomocą FSIQ oraz komponentów tej skali dotyczących zdolności werbalnych (VIQ) i wydajności (PIQ). Metody statystyczne obejmowały liczenie średniej i odchylania standardowego dla każdej zmiennej reprezentującej cechy fizyczne FAS. W przypadku zmiennych jakościowych,

19 poziomy IQ zostały porównane przy użyciu testu Krusskalla-Wallisa oraz testu U Manna-Whitney a. W przypadku zmiennych ilościowych zbadano korelacje z IQ za pomocą współczynnika korelacji Pearsona. Analiza wielowymiarowa objęła wielokrotną analizę regresji liniowej oraz modele drzew regresji. Obliczono czułość i swoistość każdej zmiannej, aby określić ich wpływ na przewidywanie IQ. Wyniki: Zmienne, które okazały się być statystycznie istotnie powiązane z niższym IQ to: opadanie powiek, wygładzona rynienka podnosowa, cienka górna warga, abnormalne fałdy na skórze dłoni oraz fałda kija hokejowego ( the hockey stick crease). Zmienne, które okazały się być statystycznie istotnie powiązane z odchyleniami IQ to: wzrost, obwód głowy, oceny dla górnej wargi i ryniennki podnosowej, podobnie jak znczna liczba fizycznych kryteriów diagnostycznych. Wielokrotna analiza regresji liniowej zidentyfikowała obwód głowy oraz fałdę kija hokejowego jako zmienne z istotnymi korelacjami wielokrotnymi z IQ. Drzewa regresji umożliwiły stratyfikację zmiennych jako potencjalnych predyktorów wyników poznawczych. Zaproponowano przewidywany wynik dla badań fizycznych. Wnioski: Występowanie i zaawansowanie cech fizycznych charakterystycznych dla FAS u pacjentów z PEA jest powiązane ze stopniem zaawansowania upośledzenia czynności poznawczych w populacji badaniej retrospektywnie, która doświadczyła znacznej ekspozycji na alkohol. Małogłowie oraz fałda kija hokejowego mogą być uznane za markery niższego IQ o większym oddziaływaniu; zapóźnienia we wzroscie po urodzeniu, abnormalne fałdy na skórze dłoni, wygładzona rynienka podnosowa oraz cienka górna warga mogą być uznane za markery ujpośledzenia funkcji poznawczych o mniejszym oddziaływaniu. Pozostałe wnioski z badań fizycznych, a z pośród nich niektóre stanowiły ważne kryteria diagnostycze FAS, nie są istotnymi markerami wyników dotyczących zdolności poznawczych. Wyniki dla FAS zaproponowane w oparciu o to badanie mogą być wykorzystwane do przewidywania wyników dzieci z PEA oraz cech fizycznych charakterystycznych dla FAS. Kilka innych badań przeprowadzonych w ramach międzynarodowego konsorcjum FAS the International consortium for FASD (NIAAA- NIH) w Finlandii, Rosji, Afryce Południowej, potwierdza korelacje pomiędzy cechami fizycznymi a zaawansowaniem upośledzenia funkcji poznawczych. Zaprezentowany będzie przegląd tych badań wraz z rozważaniami, czy badania fizyczne noworodków i niemowląt mogą służyć do przewidywania wyników umiejętności poznawczych. Doradztwo rodzinne dotyczące prognozy i potrzeby wczesnej interwencji i terapii może skorzystać z wyników z dokładnego badania fizycznego.

20 Andrzej Urbanik, MD, PhD ANDRZEJ URBANIK, MD, PhD is a Professor of radiology at the Jagiellonian University in Cracow, Poland. Currently he has a position of Chair of Department Radiology at the Jagiellonian University and Department of Diagnostic Imaging, University Hospital of Cracow. He is vice President of the Polish Medical Society of Radiology, regional consultant of radiology and Editorial Board Member of several journals: Polish Journal of Radiology, Medical Review, The Neuroradiology Journal. He is and author of 238 publications in Polish and international journals, his 629 presentations (abstracts published) were presented at Polish and international congresses, He received 22 honors or awards (9 international). EFFECT OF ETHYL ALCOHOL ON THE CENTRAL NERVOUS SYSTEM DETERMINED WITH THE HMRS TECHNIQUE The purpose of the research was to assess the effect of ethyl alcohol on the central nervous system with the HMRS technique. The research, performed with the MRI 1.5T system (GEMS), covered 14 healthy male volunteers aged 22 to 55 (the average age 34.8), occasionally consuming alcohol. The experiment consisted of four sessions in different time intervals. The volunteers were examined before the first meal of the day in the first session prior to drinking alcohol. In the following sessions the volunteers were examined after drinking alcohol in separate time periods: half an hour later, after 1 hour and 2 hours. All the volunteers drank 150 ml of vodka (40 %). The readings (Single Voxel Spectroscopy) were taken in four selected brain locations. SAGE (GEMS) firmware was used for processing spectroscope data. In all the examined volunteers a 1.2 ppm peak was found in all the assigned locations when compared with the initial spectra from the first session prior to drinking alcohol. Moreover, distinct increase of: Lip/Cr (up to 53%), Lac/Cr (up to 76%) and decrease in GABA/Cr (up to 23%), Glx/Cr (up to 14%) were found. CNS IMAGE OF CHILDREN EXPOSED TO ALCOHOL DURING THE PRENATAL LIFE This presentation shows results of the research over (concerning) Central Nervous System of 120 children (group A) exposed to alcohol while in a fetus period of life. As part of the same research another group of 30 children (group B) was examined, whose mothers did not drink alcohol while being pregnant and during lactation. Each child was examined (MRI 1,5 T system) using following imagining techniques : MRI size of the sagittal corpus callosum section was analyzed as well as its shape DWI the diffusion of CNS in 6 chosen localizations was examined HMRS performed in SVS technique in six chosen localizations voxels were localized. Statistically significant decrease of the section area as well as change of a shape (thinning) of the corpus callosum in the group A has been affirmed in relation to the group B. The research also confirmed statistically significant increase of diffusion in group A in relation to group B. In case of HMRS significant changes in concentration of NAA, Cho and ml were revealed.