Unrecorded Review DAR .pdf

R E V I E W

Drug and Alcohol Review (July 2010), 29, 426–436
DOI: 10.1111/j.1465-3362.2009.00140.x

REVIEW

Unrecorded consumption, quality of alcohol and
health consequences
dar_140

426..436

JÜRGEN REHM1,2,3*, FOTIS KANTERES1 & DIRK W. LACHENMEIER4*
1

CAMH—Centre for Addiction and Mental Health,Toronto, Canada, 2Dalla Lana School of Public Health, Faculty of
Medicine, University of Toronto,Toronto, Canada, 3Technische Universität Dresden, Klinische Psychologie and Psychotherapie,
Dresden, German, and 4Chemisches undVeterinäruntersuchungsamt (CVUA) Karlsruhe, Karlsruhe, Germany

Abstract
Issues. This contribution aims to examine systematically the evidence on the impact of the quality of unrecorded alcohol
products on health consequences. Approach. Systematic computer assisted review of the literature. Key Findings.There are
a number of pathways related to alcohol quality that may lead to acute or chronic health problems.The following constituents
and contaminants of alcoholic beverages were identified as likely contributors to these problems: (i) toxic metals (e.g. lead) from
contaminated water sources or unsuitable distillation equipment; (ii) volatile constituents, such as acetaldehyde or higher
alcohols, which may be produced in significant amounts due to faults in production technology or microbiological spoilage; (iii)
ethyl carbamate (urethane), a carcinogenic contaminant with major occurrence in certain fruit and sugarcane spirits; (iv)
biologically active flavour compounds (e.g. coumarin in cosmetics used as non-beverage alcohol); (v) toxic compounds used to
denature alcohol (e.g. methanol or diethyl phthalate). In addition, the often higher ethanol content may have detrimental health
effects. These pathways should not be assumed as present for all subcategories of unrecorded alcohol, but are more relevant to
certain types and geographic regions. Implications.A health impact of unrecorded alcohol over and above the effect of ethanol
cannot be excluded. More research is urgently needed, especially with respect to liver disease and alcohol poisoning as endpoints.
Conclusion.A feasible approach for new research on the effects of unrecorded alcohol could be based on a representative sample
from low socioeconomic regions with high prevalence of unrecorded consumption. [Rehm J, Kanteres F, Lachenmeier DW.
Unrecorded consumption, quality of alcohol and health consequences. Drug Alcohol Rev 2010;29;426–436]
Key words: alcohol, unrecorded alcohol, quality of alcoholic beverages, alcohol poisoning, liver disease.
Issues
Alcohol has been identified as a major risk factor for the
global burden of disease [1]. According to the International Classification of Disease, it has a detrimental
impact on more than 50 different major disease and
injury categories [2,3]. Alcohol-attributable health
burden is particularly high in Central and Eastern
Europe, Central and South America, and countries of
the former Soviet Union [4]. In the year 2000, 30% of
global alcohol consumption was estimated to be unrecorded [5,6]; a high proportion of this was found to

come from both countries of lower to middle income
and the former Soviet Union. ‘Unrecorded’ is an overview category for any kind of alcohol that is not taxed as
beverage alcohol or registered in the jurisdiction where
it is consumed [7]. Due to the relatively limited information and difficulties in measuring this category, its
public health consequences are not clear.
Currently the main determinants of alcohol-related
public health consequences considered by agencies,
such as the World Health Organization (WHO), are
volume and patterns of consumption, particularly
heavy drinking occasions [8]; these two dimensions are

*Both authors contributed equally to this work and share the responsibility as principal author.
Jürgen Rehm PhD, Professor (CAMH—Centre for Addiction and Mental Health), Fotis Kanteres BSc (Hons), Research Analyst (CAMH—
Centre for Addiction and Mental Health), Dirk W. Lachenmeier PhD, Food Chemist and Toxicologist [Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe].
Correspondence to Prof Dr Jürgen Rehm, CAMH—Centre for Addiction and Mental Health, 33 Russell Street, room 2035B, Toronto, ON,
Canada, M5S 2S1. Tel: +1 416 535 8501 ext 6907; Fax: +1 416 260 4156; E-mail: jtrehm@aol.com
Received 11 October 2009; accepted for publication 9 August 2009.
© 2010 Australasian Professional Society on Alcohol and other Drugs

Unrecorded alcohol and health

the only ones included in the alcohol portion of the
Comparative Risk Assessment for the Global Burden of
Disease Study [1,4]. In the estimation and monitoring
of consequences and risk factors of alcohol, unrecorded
and recorded consumption are treated equivalently.
However, product quality, especially for, but not
restricted to, certain categories of unrecorded alcohol,
may have an important additional impact on health.
This article systematically reviews the literature on the
different categories of unrecorded alcohol and health
outcomes, in order to determine whether this kind of
alcohol carries a health risk over and above that associated with ethanol.
Approach

427

selected articles.This was accompanied by a hand search
of the reference lists of all selected articles for any
relevant studies not included in the databases, which
resulted in 91 selected articles and five books. In total, we
retained 140 articles and five books for the current
evaluation of the health impact of unrecorded alcohol.
English was the main language of the electronic databases; however, there were no language restrictions and
authors were able to review articles in English, French,
Spanish, Portuguese, German, Russian, Polish and
Chinese. The references, including abstracts, were
imported into Reference Manager V.12 (Thomson
Reuters, Carlsbad, CA, USA) and the relevant articles
were manually identified and obtained in full text.
Key findings

A computer-assisted literature search was conducted
using a combination of the key words: alcohol, unrecorded, homemade, illegal, illicit, clandestine and surrogate. The criteria for inclusion/exclusion were that the
literature contain information on morbidity or mortality
related to unrecorded consumption (as defined in [7];
see below), including animal studies testing the effects of
components of unrecorded alcohol products (e.g. acetaldehyde). Literature that focused solely on consumption
or drinking patterns and not on health effects, while used
to aid the search on the whole, was not included in the
final evaluation. The search resulted in 234 abstracts in
OVID (MEDLINE) of which 19 articles were selected,
317 references in Pubmed of which three additional
articles were selected (16 overlapped), and 221 in
ETOH (database of the National Institute for Alcohol
Abuse and Alcoholism) of which additional 27 were
selected (five overlapped); resulting in a total of 49

The classification and global presence of unrecorded
alcohol products
The last systematic attempt to assess the amount of
unrecorded consumption was for the year 2002 [9],
based on information systematically collected by the
Global Information System on Alcohol And Health
(GISAH) of the WHO [10]. Information about unrecorded consumption was obtained from key informants
via a questionnaire distributed to all governments by
the WHO; in addition, specific surveys and other systematic empirical studies on unrecorded consumption
were included [11]. The results are summarised in
Table 1. As can be seen, the prevalence for unrecorded
consumption is generally proportional to a country’s
level of income, with lower-income countries having a
higher percentage of consumption that is unrecorded.
Overall, there is a high potential measurement bias in

Table 1. Estimates of recorded and unrecorded per capita adult (15+) alcohol consumption 2002 ([9], based on GISAH)

WHO regions
Africa
America A: Canada and United States
Central and South America
Eastern Mediterranean
Western Europe (Europe A)
European B: Central and Eastern Europe
European C: Russia and surrounding countries
South East Asia (including India)
Western Pacific A: Australia, Japan, and New Zealand
Western Pacific B: China and Pacific
World

Adult per capita
recordeda + unrecorded
alcohol consumption (in
litres of pure alcohol)

Adult per capita
unrecorded alcohol
consumption (in litres
of pure alcohol)

Percentage of
unrecorded
consumption to
total consumption

7.0
9.4
8.0
0.7
12.2
7.5
14.9
2.0
9.4
6.0
6.2

2.5
1.1
2.5
0.5
1.3
2.8
6.1
1.5
1.7
1.1
1.7

35
12
32
74
11
38
41
74
18
19
28

a

Recorded consumption for 2002 was calculated as an average of recorded per capita alcohol consumption 2001–2003.
GISAH, Global Information System on Alcohol And Health [10]; WHO, World Health Organization.
© 2010 Australasian Professional Society on Alcohol and other Drugs

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J. Rehm et al.

estimating unrecorded consumption, including the possibility of double counting between countries (e.g.
unrecorded alcohol produced in country x and
smuggled to y may be counted in both countries).
Within the overview category of unrecorded alcohol
products four main categories can be distinguished [7]:

• Unrecorded legal alcohol products (e.g. home•
•
•

made alcohol in jurisdictions where home production is legal);
Unrecorded illegal alcohol products (e.g. either
from illegal production or from smuggling);
Surrogate alcohol not officially made for human
consumption, but in many instances produced and
distributed with clear intent for this exact purpose
(e.g. cosmetics, medicinal alcohol);
Recorded alcohol from different jurisdiction (e.g.
cross-border shopping).

While there is no adequate global data on the distribution of unrecorded consumption across these categories, there are good indications that it varies across
regions [12]. Significant proportions of ‘traditional’
homebrew have been found in Sub Sahara Africa
[13–23] and Latin America [24–29]. It should be noted
that legality can vary in terms of local legislature [30],
thus similar alcohol products may fall on different sides
of the legal divide. As such, alcohol may be produced
and distributed in a purported ‘traditional’ manner, yet
be classified as illegal by authorities [31].
McKee et al. found surrogate alcohol in Russia to
include medicinal compounds (e.g. tinctures) and
‘other’ spirits (mainly sold as aftershaves) [32]. This
form of alcohol product and its consumption have been
most notably reported in Russia [32–38] and countries
of Central and Eastern Europe [7,38–41]. However,
the Nordic countries of Europe have also historically
reported impact of surrogate alcohol [42]. Limited use
of surrogate alcohol, especially by people with alcohol
use disorders, is suspected in many countries.
In India, a recent article estimated 2/3 of the alcohol
consumed in the country as unrecorded [43]. Most of
the illicit consumption is so-called ‘country liquor’,
spirit made from locally available cheap raw material,
such as sugarcane, rice, palm, coconut and cheap
grains, with an alcohol content between 25% and 45%,
which appears in both recorded and unrecorded forms
[12]. Illegal country liquor is mostly produced clandestinely in small production units, and with no legal
quality control checks, alcohol concentration of this
liquor varies greatly (up to 56%). Adulteration is quite
frequent, with industrial methylated spirit previously
identified as a common adulterant, and as having
caused incidents, such as mass poisonings with consumers losing lives and suffering irreversible damage to
© 2010 Australasian Professional Society on Alcohol and other Drugs

their eyes (see below). Cheaper than licensed country
liquor, illicit liquor is popular among the poorer sections of the population ([12]; for an ethnographic
report [44]). While India has high rates of abstinence
[43], those who drink often have a pattern of heavy
drinking occasions, and this patterns also holds for
country liquor consumption (e.g [45]).
Higher income regions (North America, Western
Europe) have relatively high alcohol consumption, and
have generally provided the most overall information
and scientific literature on the topic. While data on
unrecorded alcohol are sparse, there have been some
significant studies in the Nordic countries (Norway,
Sweden, Finland) [42,46–50] and the Netherlands
[51]. The main area of concern in these works is home
production, smuggling and untaxed trade/traveller’s
items, and not health issues specifically related to unrecorded alcohol. In North America, literature has also
been limited, mainly focused on production and consumption [52–55].
Globally, cross-border shopping is of minimal relevance: this can be easily illustrated when one compares
the volume and sources of unrecorded alcohol in different parts of the world.The overwhelming majority of
unrecorded consumption stems from India, Africa,
South America and the countries of the former Soviet
Union, where cross-border shopping plays only a
minimal role (see above for overviews on the respective
sources). While cross-border shopping may be important in some parts of Europe (e.g. Nordic countries
[42,49–51,56]). In terms of quality and potential health
consequences over and above those of recorded
alcohol: this form of alcohol is recorded and quality
controlled in the jurisdiction it originates and thus
should not have any additional health consequences. As
such, the following paragraphs will only be relevant for
other forms of unrecorded consumption.
Chemical composition of unrecorded alcohol
Table 2 gives an overview of the main potential components in unrecorded alcohol. This is only a selection,
as alcohol may contain more than 1000 different components [113]; most of the components listed may also
appear in recorded alcohol.
From all compounds that are potentially present in
unrecorded alcohol, methanol appears to have the
highest potency for acute toxic effects. The problems
associated with methanol intoxication were previously
discussed in detail [65]. We found that the incidence of
methanol poisoning was relatively infrequent, yet as
the consequences of such instances were often severe,
the few outbreaks received high media exposure. The
problem appears to be on the decline of late, as most
jurisdictions have abolished the practice of using

Contamination of water source.

Residues on or contamination of
raw materials (e.g. grain) for
alcohol production.

Nitrate, water
quality

Pesticides/
mycotoxins

WHO, World Health Organization.

Natural occurrence due to certain
ingredients (herbs), addition for
flavouring, ingredient in cosmetic
alcohol.

Contaminant due to food-contact
materials.

Lead

Biologically
active flavourings

Process-derived contaminant may
be formed from hydrocyanic acid
or other precursors.

Ethyl carbamate

Denaturing agent in certain
jurisdictions. May also occur as
ingredient in cosmetic alcohol.

Natural by-product of alcohol
fermentation, higher
concentrations due to
microbiological spoilage, enriched
in the first fractions of distillation.

Acetaldehyde

Diethyl
phthalate

Natural by-product of alcohol
fermentation, in pure form as
‘surrogate alcohol’ (e.g. windshield
washer).

Higher alcohols
(e.g. propanol,
butanol, etc.)

Contaminants due to food-contact
materials.

Natural by-product of alcohol
production in low concentrations,
in criminal cases addition of spirits
denatured with methanol or even
addition of pure methanol.

Methanol

Metals

Natural fermentation and/or
addition of neutral or denatured
alcohol.

Sources

Ethanol

Compound

Different effects including
carcinogenicity [91].

No guidelines for alcohol, limits for raw
materials in certain jurisdictions

No international maximum levels for
alcohol. EU or WHO drinking water levels
can be used as guideline [106,107].

International limits available (e.g. from
Codex Alimentarius or EU) [110,111].

Different effects (e.g.,
hepatotoxicity of coumarin [109]).

Nitrate, ingested under conditions
that result in endogenous
nitrosation, is an IARC group 2A
carcinogen [91].

Tolerable daily intake of 5 mg/kg body
weight [108].

No systematic data available. However, highly unlikely to occur in
any alcohol due to degradation during fermentation as well as
separation during distillation.

No systematic data available.

Single cases, for example, coumarin in surrogate alcohol from
Lithuania [7]. Anecdotal evidence on nitro musk compounds in some
eau-de-colognes in Russia [112].

No systematic data available. Detected in some unrecorded samples
from Russia [62].

Metals (e.g. lead, arsenic, antimony, cadmium, copper, zinc) may be
found in unrecorded alcohol due to deficiencies in production
technology No systematic current data available. Metal
contaminations were especially described in moonshine from the
USA [65]. (see lead above)

Lead intoxications were commonly described in consumers of
American moonshine. Moonshine is typically produced in ground
stills using barrels, automobile radiators, and multiple copper tube
units sealed with solder as condensers. During the production of
moonshine, the leaching of lead from solder or other lead-containing
materials in the radiators can result in lead contamination
[52,98–105].

Lead Maximum Level in Wine: 200 mg L-1
[97].

No international maximum levels for
alcohol (besides for lead). EU or WHO
drinking water levels can be used as
guideline [106,107].

No systematic studies available. Found in some unrecorded alcohols
from Hungary [7], Poland [41], and Brazil [95]. Relatively low or
undetectable concentrations in Guatemala and Mexico [96].

No systematic studies available. Found in some unrecorded alcohols
from Guatemala [31]. Limited evidence points to public health risk
[90]. Russian samogons may contain higher levels of acetaldehyde
than recorded beverages (vodka) [60].

Limited and contradictory evidence [32,39,60–63,87,88] Own
research shows that the content of higher alcohols in unrecorded
alcohol is very similar to recorded distilled beverages (e.g. fruit
spirits, rum) [7,86]. The preliminary maximum level is seldom
exceeded.

Several methanol poisoning outbreaks associated with unrecorded
alcohol [68–85].

Unrecorded alcohol often contains higher ethanol concentrations.
This was consistently shown in a number of countries
[7,32,36,60–63].

Incidence in unrecorded alcohol

No harmonised international limits.
Canadian upper limit for distilled spirits:
0.15 mg L-1 [94].

Limited epidemiological evidence [92,93].
Margin of Exposure in Health Relevant
Ranges [90].

Higher alcohols have been speculated as
cause for unrecorded alcohol toxicity in
Eastern Europe. However, no
epidemiological evidence. Limited evidence
from animal experiments. Preliminary
maximum level 1000 g hl-1 of pure alcohol
for the sum of all higher alcohols [86].

Methanol has been described to be the
most common cause for surrogate alcohol
toxicity [65,66]. Maximum tolerable
concentration: 2%/vol [66]. EU provides
limits for certain spirits [67].

No safe level. Drinking guidelines for
‘low-risk’ drinking [58,59].

Toxicological Evaluation

Hepatic effects and reproductive
toxicity in animal experiments
[108].

Toxic and/or carcinogenic effects.

Poisoning as well as chronic toxic
effects (IARC group 2B [91]).

Typical carcinogenic contaminant
of alcoholic beverages (IARC
group 2A [91]).

Acetaldehyde may contribute to
the carcinogenicity of alcoholic
beverages [89,90] (IARC group
2B [91]).

Similar to effects of ethanol.
Potency may increase with chain
length [86].

Fatal poisoning, blindness [64].

Acute intoxication and poisoning,
as well as over 50 different major
disease conditions including some
cancer types such as oesophageal
cancer [4,57].

Major toxic effects

Table 2. Chemical composition of unrecorded alcohol

Unrecorded alcohol and health
429

© 2010 Australasian Professional Society on Alcohol and other Drugs

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J. Rehm et al.

methanol to denature alcohol (which therefore cannot
lead to problems if ingested as surrogate alcohol).
However, there are still spectacular outbreaks, such as
the recent ‘toxic alcohol episode’ in Gujarat, a dry
Indian state, in which over 100 people were killed and
hundreds hospitalised [114].
Thus far, the largest study on the chemical composition of unrecorded alcohol was conducted by Nuzhnyi
[60], which predominantly consisted of samples from
Russia (n = 81), as well as different African countries,
India and Mexico (n < 10 for each country). The
general conclusion was that the samples of unrecorded
alcohol did not pose a toxic hazard, and were even
considered to be of high quality in terms of taste.
In our own research we have studied the general
composition of unrecorded alcohol from Nigeria [19],
Lithuania and Hungary [7], Poland [41], Guatemala
[31] and Vietnam [115]. More specific studies on ethyl
carbamate contamination were conducted in Guatemala and Mexico [96], and Brazil [95].
In general, we are in agreement with Nuzhnyi [60], as
the alcohols we studied were in most cases, of a relatively high quality and regarded to be safe according to
international food standards (see rationale for toxicological evaluation in Table 2). Only single samples were
suspicious, for example, surrogate alcohols from
Lithuania with coumarin contents [7], or artisanally
produced samples from Guatemala with very high
acetaldehyde contamination [31]. Ethyl carbamate contamination was detected in samples from Hungary,
Poland and Brazil [7,41,95].
For all other compounds (e.g. metals, diethyl phthalate, flavourings, etc.), we have only very old and apparently outdated information (e.g. regarding lead in
American moonshine), or literature that lacks systematic data.
In sum, while there have been a number of recent
small scale studies undertaken in different parts of the
world, the exact chemical composition of unrecorded
alcohol is generally unknown. Due to its nature, there is
no labelling of content as well as no systematic controls
by authorities for major parts of unrecorded consumption, such as homemade, illegal and surrogate alcohol.
The category of surrogate alcohol may be quality controlled, but only with the original use in mind (e.g.
cosmetic use, etc.) and not for human consumption.
The available knowledge from small scale studies points
to relatively little contamination, but more systematic
and larger studies are needed before we can draw better
conclusions.
Health consequences of low-quality alcohol
Listed in Table 2 is a selection of the most relevant
components and contaminants of low-quality alcohol
© 2010 Australasian Professional Society on Alcohol and other Drugs

and their hypothesised health impacts. If we look at the
potential of chronic toxic effects that are anecdotally
associated with unrecorded consumption (e.g. liver cirrhosis), there is only one consistent finding: unrecorded
alcohols often contain higher ethanol concentrations
than recorded alcohols [7,32,36,60–63].
In addition to ethanol, over 1000 different components, usually at trace levels, may occur in alcoholic
beverages [113]. Although the health effects of these
constituents have been demonstrated in animals as well
as at the human level, many countries generally lack
data regarding their presence in alcoholic beverages and
public health consequences over time. As mentioned,
while relatively uncommon and certainly not comparable with the overall health impact of alcohol [3,5],
instances of methanol-attributable deaths or blindness
receive a disproportionate amount of exposure in the
press and scientific literature [65]. Conversely, there are
almost no data on more long-term consequences, such
as chronic diseases, which may stem specifically from
unrecorded consumption. This is partially due to the
fact that few people consume only unrecorded alcohol
over time. Consider the example of a person who died
of alcoholic liver cirrhosis in Russia, and had been
mainly consuming unrecorded alcohol products in his
final years. Typically they would have been drinking
only recorded alcohol for some time, and when drinking more and more heavily, switched to surrogate
alcohol for economic reasons [36].With this switch and
subsequent exposure to ‘other’ alcohol, there are three
possible impacts:

• The
•
•

alcoholic liver cirrhosis would have taken
exactly the same course, if, ceteris paribus, this
person had consumed recorded alcohol only.
The alcoholic liver cirrhosis would have taken a
different course, for example, later onset, longer
duration, or no fatal outcome, if, ceteris paribus,
this person had consumed recorded alcohol only.
The alcoholic liver cirrhosis would not have
occurred with recorded consumption.

It is extremely difficult to show that unrecorded consumption or mainly unrecorded consumption is causal
in the onset of a chronic disease, that is, that the components which differ between recorded and unrecorded
alcohol consumption cause certain health consequences [116]. As a result, there are not many studies
investigating whether unrecorded consumption causes
health consequences over and above those of recorded.
Notably, such a study was conducted in India [117],
wherein the authors concluded that unrecorded consumption (country liquor) was associated with a
general risk of alcoholic liver disease, particularly alcoholic liver cirrhosis, despite having relatively lower

Unrecorded alcohol and health

alcohol concentrations than the local recorded type.
However, this study was not well controlled, and confounding by social status and other factors can thus not
be excluded.
For the most part, evidence on the health impact of
unrecorded alcohol is indirect, leaving alternative explanations for the significant, proportionally high levels of
disease. For instance, data on the rates (levels and
trends) of liver cirrhosis morbidity and mortality differ
dramatically between European countries, including
instances of a difference of more than a factor of 10
between countries with similar levels of drinking [118].
On a wider regional basis, the South Eastern European
countries and countries of the former Soviet Union had
at least threefold liver cirrhosis mortality rates compared
with Mediterranean and other EU countries, for both
men and women, even though their overall volume of
drinking did not differ [119]. Therefore, while the
volume of alcohol consumption has been shown to be
strongly related to liver cirrhosis rates, neither this sole
variable nor its association with hepatitis C virus rates
are capable of explaining these differences. As hypothesised by Szücs and colleagues [39], product quality may
be an important contributing cause. These authors
found significantly higher concentrations of methanol,
isobutanol, 1-propanol and isoamyl alcohol in illicitly
distilled spirits in Hungary, and argued that this may
cause hepatic damage in various ways, subsequently
contributing to the high level of alcohol-induced liver
cirrhosis in the country. However, current toxicological
evaluations [86] cast doubt on this hypothesis. This is
compounded by the fact that many recorded alcohol
products contain the same levels of higher alcohols as
unrecorded alcohols [7,86]. More recently, Solodun and
colleagues presented evidence that unrecorded alcohol
was specifically hepatotoxic and, among other components, identified polyhexamethylenguanidine hydrochloride, which is part of medicinal alcohol, as a
potential cause [116]. These findings still have to be
corroborated by other researchers.
In Central Mexico, another region with extremely
high liver cirrhosis rates [12], pulque mixed with contaminated water at the retail levels has been speculated
to be the cause [120]. In Africa, iron overload from the
consumption of large volumes of traditional beer that is
home-brewed in iron pots or drums has been associated
with liver fibrosis, cirrhosis and hepatocellular carcinoma [121]. Overall, these observations have led to the
hypothesis that unrecorded consumption has an effect
on liver disease over and above that of ethanol, but the
evidence is not conclusive.
Another aspect of this health concern is that poisoning, and alcohol poisoning in particular, are especially
prevalent in countries with significant unrecorded consumption, namely surrogate alcohol consumption. In

431

2002, the rate of poisoning of men in countries of the
Former Soviet Union (Russia, Belarus, and Ukraine)
and Baltic countries was almost 17-fold and eightfold
higher, respectively, when compared with the other EU
countries (own calculations based on WHO mortality
data; see also [119]). We hypothesise that high ethanol
concentrations and product quality may play an important role. As mentioned above, unrecorded products are
generally higher in alcohol concentration, but especially
for countries of the former Soviet Union (see Table 2).
For other aspects of product quality, Solodun et al.
provide some hypotheses, which mainly rely on acute
liver toxicity related to several chemicals found in
typical products [116]. Nevertheless, coding practices
and drinking patterns cannot be ruled out as alternative
explanations. However, recent research has shown that
there is very substantial under-reporting of alcohol poisoning deaths in Russia, suggesting that the above differences may be even greater [122,123].
Recently, Leon and colleagues [34] presented data
suggesting that the ceteris paribus consumption of nonbeverage alcohol accounted for more than 30% of mortality among men between the ages of 25 and 54 in the
Russian town of Izhevsk (proportion calculated by
Lachenmeier et al. [65]). Notably, the mortality impact
went beyond poisoning and liver disease, and included
problems, such as cardiovascular disease. However, the
cause of these high levels was not clear, and could have
simply been the result of the ethanol per se, a component in addition to alcohol, or of the interaction of
ethanol with lower socioeconomic status [124].
Given the lack of evidence for unrecorded alcohol
containing substantially toxic components over and
above recorded alcohol, other variables may be considered for an alternative explanation for the apparent
ecological differences in rates of liver cirrhosis and
other health outcomes between countries. For instance,
higher alcohol content, problematic drinking patterns,
lower socioeconomic status and poor health status may
all play a role, including in combination, and the interaction effect of these factors may well be even greater
than the sum of its parts. This phenomenon is exemplified for several cancers where drinking and smoking
occur together [125].
In summation, there are health phenomena, especially in regards to high rates of liver, and alcohol poisoning and mortality, where the quality of alcohol
products cannot be ruled out as having an effect over
and above that of ethanol. However, the evidence is far
from conclusive.
Implications
Our review has revealed that unrecorded consumption
is widespread and we cannot exclude that it may have
© 2010 Australasian Professional Society on Alcohol and other Drugs

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J. Rehm et al.

detrimental health consequences over and above the
impact of ethanol alone.

• First, we do not have sufficient information on the

•

•
•

extent of unrecorded consumption. Many of the
current estimates of unrecorded alcohol are based
on expert judgments, including government estimates. We need to develop more standardised
methods to quantify the extent of unrecorded consumption empirically, including the quantification
of different subcategories, as they may be relevant
for public health.
Second, there has been no systematic controlled
research on comparing health consequences for
recorded versus unrecorded consumption. While
such research is methodologically challenging, it
has to be established to increase our understanding of the consequences of unrecorded consumption. Given the current knowledge and
consumption data, unrecorded consumption is
public health relevant even if it has little or no
health effects over and above those of ethanol. If
such effects exist, their systematic examination
would be even more pertinent. Below we propose
a first strategy to screen for potentially health relevant compounds of recorded and unrecorded
alcohol. This step has to be complemented by
carefully controlled epidemiological studies, which
compare the effects of recorded versus unrecorded
consumption on health outcomes mentioned
above.
Third, even while developing better methods, the
level of unrecorded consumption should be monitored with current methodology.
Fourth, where potential problems with the quality
of alcohol have been identified (e.g. high acetaldehyde concentrations in Cuxa in Guatemala [31]),
measures should be taken. A number of different
measures are possible. These range from trying to
legalise unrecorded consumption with subsequent
quality control to teaching the producers of unrecorded products how to avoid the quality problems detected. In the example of high
acetaldehyde concentrations, one way would be to
instruct the producers to discard the first
acetaldehyde-rich fractions during distillation.

Conclusion
Given the high level of alcohol-attributable burden of
disease, a recent expert committee to the WHO on
problems related to alcohol consumption [126] recommended the establishment of a monitoring system for
alcohol consumption and alcohol-related harm indicators, which could aid in advancing the current WHO
© 2010 Australasian Professional Society on Alcohol and other Drugs

GISAH [10]. Currently, none of the indicators in the
GISAH, which are used for regular global status
reports, are designed to measure the product quality of
alcohol beverages and other consumed alcohol products, such as composition, including the concentrations
of different compounds. Quality has the potential to
impact health and it may thus account for a significant
part of the high level of alcohol-attributable burden of
disease in low- and middle-income countries in Central
and Eastern Europe, as well as the Americas. Considering the potential public health importance, the
quality of alcohol should be analysed more systematically. This should include, but not be limited to, unrecorded alcohol products. The reasoning for this can be
seen in the relatively high proportion of recorded
alcohol samples with problems. For example, in the
German Federal State Baden-Württemberg in 2007,
dependent on spirit type, up to 28% of commercial
samples analysed had problems with alcohol quality
[127].
Low product quality of alcoholic beverages, as
defined above, may impact health and account for a
sizable proportion of alcohol-attributable disease
burden in low- to middle-income countries, over and
above the volume of alcohol consumption and patterns
of drinking. Research on alcohol quality can and should
be undertaken to investigate potential health impact
and contribute to health policy interventions [128].
Alcohol quality can be primarily tested by the chemical
analysis of representative samples of regularly consumed alcohol in areas with high liver cirrhosis rates
and alcohol poisoning, with methods routinely available
in every alcohol test laboratory (e.g. see the European
Union’s reference methods [129]). The major challenge, however, is the procurement of samples in a
quantity sufficient enough to enable researchers to
draw conclusions about the public health impact of
alcohol quality.
We suggest the following sampling strategy. Because
unrecorded consumption, liver cirrhosis and alcohol
poisoning disproportionately affect people of lower
socioeconomic status (SES) [65], representative
samples should be drawn from lower SES areas (e.g.
random walk samples). Next, participants should be
asked about their alcohol consumption, including how
they purchase and get access to alcohol. A random
subset of these participants should be asked to provide
samples for chemical analysis or to identify their suppliers for sampling. We are well aware of the potential
problems of such a strategy. People may fear identifying
illegal material and activities. However, field experiences in Guatemala [31] and the recent WHO study on
unrecorded consumption in Brazil, China, India and
Russia (unpublished; see [130] for Indian results)
provide relatively optimistic predictions: people are

Unrecorded alcohol and health

willing to identify unrecorded products, especially in
countries or regions, where unrecorded alcohol is
highly prevalent. In addition, or alternatively, alcohol
outlets that sell unrecorded alcohol products may also
be included for sampling in the study area [31]. In any
case, we need good regional feasibility studies before
we can conduct such full scale studies in different
countries.
Depending on the area, the alcohol consumed may or
may not primarily concern unrecorded alcohol. As
there may also be problems with recorded consumption, all sources should be subjected to chemical analysis. Regarding postulated outcomes, case–control (with
respect to liver cirrhosis and alcohol poisoning) and
additional case-crossover studies in emergency rooms
(with respect to alcohol poisoning) could be conducted,
with chemical analyses integrated into both designs.
This would allow for a more direct way to test the
hypothesis that certain compounds are causally relevant
for the above outcomes.
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