Report on the Panel “Alcohol Consumption in Iran”

The panel of the Scientific-Specialized Group on Social Issues and Harms was held on Monday, 1 Azar 1395 (November 21, 2016) with the presence of three experts in this field and was well received by attendees and the media. At this panel, Dr. Alireza Norouzi (psychiatrist) spoke on the topic of a look at alcoholism from a psychiatric perspective, Dr. Simin Kazemi (physician and sociologist) with the title “Alcohol Consumption as a Social Problem?”, and Engineer Hossein Dezhakam (Secretary General of the Congress for Human Revival) presented their views on the discussion of “Treatment of Alcohol Consumption in Congress 60.”

Dr. Norouzi was the first speaker of this session, who analyzed alcohol consumption from a psychiatric perspective and stated: “Alcoholism” was a general term used for years for problematic alcohol use, but now this term is not used in classifications of psychiatric disorders, yet it still exists in popular culture and people say an individual is an alcoholic. In classifications of psychiatric disorders, terms such as alcohol use disorder, harmful and hazardous alcohol use, and alcohol dependence are used. In scientific reports on alcohol, they say that this substance is among psychoactive substances, meaning substances that have effects on the brain and cause experiences of euphoria and pleasure, and alcohol is also considered one of these substances. Alcohol is the most problematic substance for humanity. In psychiatric classifications, 10 different classes are defined in order of the impact of substances; tobacco, alcohol, cannabis, etc.

He continued: After caffeine, alcohol is the most common psychoactive substance used in the world and is the most common substance with which a use disorder is defined, whereas a use disorder is not defined with caffeine. When addiction experts wanted to rank this issue and see whether methamphetamine (crystal meth) is more problematic or heroin, a group of experts in the world actually identified alcohol. Of course, when an individual uses heroin or methamphetamine (crystal meth), it causes more individual destruction in a short time compared to alcohol. In our country, reports related to alcohol consumption emerged to some extent following the occurrence of some mass poisoning epidemics with methanol in some of our cities, meaning individuals who did not intend to engage with methanol, which is a wood alcohol, toxic, and has serious side effects. During holidays when the demand for alcohol consumption usually rises, individuals operating in illegal alcohol networks supplied wood alcohol or methanol, and serious side effects such as blurred vision, kidney failure, blindness, and even mortality were seen, which was a wake-up call for the public health system. In terms of the prevalence of alcohol dependence in the world, international reports say that 140 million people are dependent on alcohol consumption, and in Western European countries and America, this prevalence is high; for example, 4 percent of the adult population between 15 and 64 years in America and England have alcohol dependence. Historically, humanity has been familiar with alcohol fermentation since the past, and the point about alcohol has been that every 1 gram of alcohol has 7 kilocalories of energy, and surplus agricultural products, when turned into alcohol, gained longer shelf life, and in parallel, in eras when there was no public health and clean water, alcohol was a beverage that had less contamination. For example, in Greece, sages told people not to drink water, that they would get sick, and to use fermented beverages. In parallel with this phenomenon, human experience also takes shape. In this regard, individuals who used alcohol exhibited disinhibited behaviors that were sometimes far from the decorum and character of human beings and became aggressive. Now, in some Western countries, alcohol consumption is prohibited for individuals under 18, and Plato also recommended that young people and women should not use alcohol, because they lose control over their behavior.

Dr. Norouzi said: In the history of alcohol consumption, one of the turning points is the discovery of distilled alcohol. We are indebted to Iranian scientists who managed to heat wine and obtain pure alcohol, and the Crusaders mention this discovery by Muslims with great astonishment in their books, saying that Muslims do something that makes wine as clear as rainwater, and if someone consumes it, their ribs ache, and this encounter was extraordinarily significant for them. In the modern era, we see that there was a tradition of alcohol consumption in Christianity, and now various types of fermented and distilled alcohols are produced in countries around the world, and large alcohol production factories strive to find markets. Just as in the tobacco industry, some of the efforts of health systems in the world are, in fact, to create restrictions for these unbridled efforts. In the 2014 UN report, the only place in the world that managed to reduce its per capita alcohol consumption compared to 5 years prior was Western Europe. In comparison, countries like India and China, which lacked sufficient laws to protect their populations from alcohol, reported an increase in alcohol consumption.

Posing the question of what causes individuals to become caught up in alcohol consumption, Dr. Norouzi added: Compared to other substances, the time interval between when individuals start alcohol and when their consumption becomes compulsive is relatively longer; but the role of genetics is very serious; that is, in studies of identical twins, 30 to 50 percent of the time, if one person is an alcoholic, the other will also become an alcoholic. Among psychological factors, the reinforcing and euphoric effects of alcohol, which lead to continued use and gradually to compulsive consumption, have been mentioned, and in the context of social learning, personality factors such as novelty-seeking and risk-taking have been cited. On the other hand, underlying psychiatric problems such as insomnia and anxiety can turn alcohol consumption into a problem for individuals.

The psychiatrist continued his discussion by posing another question, saying: How much alcohol is used in Iran? Regarding the prevalence of alcohol, in a study conducted by the Ministry of Health in the year 2010-2011, 6.3 percent of individuals aged 15 to 64 confirmed its use, which was higher compared to other substances; however, among those whose use was at the level of a use disorder, only 1 percent was reported.

Raising the subject of the health consequences of alcohol consumption, Dr. Norouzi said: In principle, diseases are divided into three categories: 1 – communicable and non-communicable, 2 – accidents, and 3 – injuries. Alcohol consumption increases all types of intentional and unintentional injuries through accidents. It exacerbates the risk of various non-communicable diseases such as cancers, cardiovascular diseases, and hypertension, and ultimately, it has been observed to have a causal effect on certain infectious diseases; that is, it makes individuals susceptible to tuberculosis. Also, through increasing high-risk sexual behaviors, it can affect the increase in the prevalence of HIV; therefore, it increases communicable diseases, non-communicable diseases, and accidents and injuries alike.

He said: Among the indicators by which the impact of alcohol-related harm on populations is measured are the volume of consumption, the pattern of consumption, and the quality of the alcohol consumed. The volume of alcohol predicts various cancers and liver failure. In any country where per capita alcohol consumption is higher, the prevalence of liver failure is greater. Regarding the pattern of alcohol consumption, this refers to heavy episodic drinking and consumption to the point of intoxication, which increases the risk of accidents and aggression. In the discussion of alcohol quality, the risk of blindness rises. In fact, in terms of importance, volume comes first, then pattern, and then quality. Regarding quality, there are reports in our country; information about the pattern of consumption in our country is insufficient. Heavy episodic drinking means consuming more than 60 grams of alcohol in a single drinking session and occasion, and 60 grams of alcohol from distilled spirits is approximately 6 cans of beer or 6 small glasses of a distilled product. Someone who consumes more than this is at risk of poisoning, accidents, and aggression. Finally, the volume of consumption, or per capita alcohol consumption, is calculated based on the volume of pure alcohol consumed by the population over 15 years of age in a country, which is very low in Iran, because the number of patients with alcoholic liver cirrhosis in our country is very low. The regions with the highest alcohol consumption in the world are in Eastern Europe and Russia, where per capita alcohol consumption is above 12.5 liters of pure alcohol. In the West Asia and North Africa region, the lowest per capita alcohol consumption has been reported. In terms of the type of alcohol consumed, the more this net volume of consumption comes from fermented alcohols, the less the harm, and if it comes from distilled alcohols, the harm is greater. Regarding the amount of consumption in the region, research shows that 89.8 percent have never used it in their lifetime, 4.8 percent have used it in their lifetime but not in the past year, which is roughly the situation in our country as well, based on a household survey, and you know that all studies of sensitive behaviors and behaviors that carry social stigma and social unacceptability and face legal restrictions may have certain shortcomings.

Dr. Nowruzi said: Regarding the indicator for individuals who have consumed more than 60 grams of pure alcohol in a single sitting at least once a month, domestic experts believe that our country's APC is not high; we do not see many alcoholics among our cancer patients, but the HED is probably high. That is, our people either do not consume alcohol, or if they do, they may consume more than 60 grams of pure alcohol in one sitting, which probably increases the risk of accidents. But again, information is limited on how many accidents are due to alcohol consumption. In our country, one of the leading causes of death is road accidents. The extent to which an individual has consumed alcohol or other psychotropic substances is, in fact, unclear. The definition of 10 grams of pure alcohol is such that it is called one standard drink. One of the controversial topics in the field of alcohol consumption is that the health ministries of various countries have determined relatively safer amounts of alcohol consumption; for example, one of the most conservative is that of the World Health Organization, which states no more than 2 drinks per day and no more than 5 days per week. That is, someone who consumes more than 2 drinks per day and more than 5 days per week is someone whose consumption has exceeded the relatively low-risk level. Of course, it is emphasized that even very small amounts of alcohol have caused cancer in women. The course of alcohol consumption is longer compared to other substances. Individuals who use narcotics seek treatment at age 30 or 32, but individuals who consume alcohol seek treatment at an average age of 40 or 45. Part of this is due to the fact that alcohol disables individuals later. Another part of this reason in our country is due to the limitation of services. If we want to reduce per capita alcohol consumption, the rate of heavy episodic drinking, and the complications resulting from alcohol consumption in a population, we must know that alcohol, like many psychotropic substances, affects the brain's reward circuit. The brain's reward circuit is the same circuit that is stimulated when an individual experiences physiological pleasures. Physiological pleasures have survival value for mammals. When a creature eats, when it has sexual relations, the reward circuit, which is in the midbrain, is stimulated. Alcohol affects that same circuit and creates an abnormal feeling of euphoria in the individual and gradually causes it to gain an abnormal importance and salience for the individual, and gradually the importance of other important life matters, such as one's own health, life, and family, diminishes. All psychotropic substances, including alcohol, regardless of the mechanisms through which they affect the brain, ultimately exert their effects through the release of dopamine in the midbrain, and in the early stages, they cause behavioral reinforcement and euphoria, but subsequently, the dark side, the compulsion to consume, and the continuation of consumption will become problematic. The 2014 World Health Organization report indicated that there is a relationship between alcohol consumption, the APC rate, and the income of countries. Countries that are wealthier have higher alcohol consumption. This matter can be controversial: is this a causal relationship, or has it happened by chance?

Continuing the session, Dr. Simin Kazemi (physician and sociologist), as the second speaker, addressed the question, “Is alcohol consumption in Iran a problem?” She stated: The existence of religious and legal prohibitions on alcohol consumption in our country distinguishes Iran from other countries in the world. In Iran, we encounter alcohol consumption both as a deviance and as an illness; therefore, we must approach it from medical, psychological, and sociological perspectives, though unfortunately, the least attention is paid to this issue by sociology. The reality is that in the realm of alcohol consumption, we face a kind of abandonment; even in the medical field, not much attention has been paid to this issue. Access to alcohol in the country is very easy, and despite legal and religious prohibitions, alcohol can be easily obtained. In fact, individuals in both the lower and upper classes of society can use alcohol. Although a study once stated that substance addiction is seen at lower levels and alcohol addiction at higher levels of society, this is not the case, and any individual in society uses it according to the money they can spend. Standard alcohol, which is of high quality, is used among the upper classes, but counterfeit and homemade alcohol, which causes more harm, is consumed by the lower classes of society and, of course, poses a greater danger to them; meanwhile, there is no oversight other than the punishment of 80 lashes in the law for alcohol consumption, and the seller has no obligation to restrict sales to adolescents under 18.

She said: The increase in alcohol consumption can be explained by weak social bonds and social pressures. Social bond means the relationship between the individual and society, which is established through social institutions, and if socialization has taken place desirably, the individual's bonds with society will be strong. In deviant behavior, there are no strong bonds between the individual and society or social institutions, or the person does not believe in the legitimacy and correctness of the laws. On the other hand, the cause of deviant behaviors is the social pressures that a person faces in life. If the person is unable to bear the pressures, deviant behaviors occur. Alcohol consumption may be a strategy for coping with social pressures. If we want to provide a sociological analysis of alcohol consumption, it must be said that in the aggregation of weak and fragile social bonds and existing social pressures, the individual's inclination toward alcohol is strengthened. Given that everyone uses alcohol privately at home, this question arises: Is alcohol a personal issue or a social one? First, we must define a social problem. If we want to provide a minimal definition of a social problem, we say that a social problem is a threat that exists to the desirable state of society and can affect a large number of people, in such a way that it creates a gap between the existing situation and the desirable situation. A social problem has both subjective and objective dimensions, and society is also concerned about it. But whether alcohol is truly a social problem or not, we must see what social consequences it actually entails. Alcohol, besides the physical and mental disorders it creates, also has negative social consequences, and these negative social consequences can exist for both citizens and society. Negative consequences such as job loss, unemployment, and family problems, and negative social consequences such as crime, homicide, rape, and the most common of them, traffic accidents.

Dr. Kazemi added: Sociologists always criticize the medicalization of society and say that medicine has encroached upon areas such as alcohol consumption and alcoholism, which are not within medical expertise, but sociologists themselves have also not paid much attention to this area so far, one of the most important reasons for which can be pointed to its being taboo and the lack of interest among sociologists in this area. Therefore, in Iran, we face the abandonment of the alcohol issue, which has no place in prevention programs, and unfortunately, regarding its treatment and even in the medical field, no specific action has been taken, and there is only one National Center for Studies in Iran, which alone is not sufficient, and according to law enforcement statistics, there are at least two hundred thousand alcoholics, and if they were to refer to that center with its limited facilities, it would practically lack the necessary efficiency.

The second speaker of this session, emphasizing the abandonment of the alcohol issue in Iranian society, presented a summary of the state of alcohol consumption in Iran and stated: In one study conducted at Shahid Beheshti University, about 6 percent of Iranians have consumed alcohol at least once, and currently, the rate of alcohol consumption in Iran is one percent, although other statistics suggesting ten percent have also been presented. Given the religious prohibitions regarding alcohol consumption in Iranian society, many individuals who consume alcohol do not openly admit it. Another issue concerning alcohol is its illegal entry and smuggling into the country, one of the most important reasons for which can be cited as its annual financial turnover of 6,580 billion tomans. According to statistics from the Anti-Narcotics Headquarters and the Anti-Smuggling Headquarters, about 80 million liters of alcoholic beverages worth 730 million dollars enter Iran annually, of which 25 percent is seized and the rest is consumed in society. Another issue raised in this regard, which has turned it into a threat, is the annual mortality caused by alcohol consumption, including traffic accidents caused by excessive alcohol consumption. According to the Tehran Prosecutor, last year there were about three thousand cases of drunk driving. Among other worrying issues that can be mentioned in this regard is consumption among children, citing the head of Tehran's Shahid Fahmideh Educational Complex, according to 2015 statistics, drinking alcohol was the fifth most common crime among ten crimes in the children's domain, to which the statistic of children transporting alcoholic beverages must also be added. Another issue is the easy access to obtain alcohol, which, despite the legal and religious prohibition in society, is still easily obtainable. Among the ways of accessing alcohol in our society are obtaining homemade alcohol, obtaining alcohol through religious minorities, and also its import from abroad; an important point about imported alcohol is its very low price, making it easily accessible and obtainable not only for the upper classes but also for the lower classes. Another matter that should be noted is that, unfortunately, some alcohol is also supplied through pharmacies.

Referring to counterfeit and standard alcohol, Kazemi said: Consumption of counterfeit alcohol among the lower classes is unfortunately high and its consumption is also very dangerous. Another issue that can be pointed out is the lack of commitment on the part of the alcohol seller, who sells alcohol to anyone who approaches them regardless of age conditions, especially concerning adolescents under 18, which is truly worrying. The results of a study conducted at Shahid Beheshti University in 2004 show that 27.6 percent of male students and 1.1 percent of female students have consumed alcoholic beverages at least once. In 2006, alcohol consumption in Hamadan among 12 to 25-year-olds was the second most consumed substance after cigarettes, meaning cigarettes were the highest consumed substance at 93 percent and alcohol at 92.5 percent, and the critical age for alcohol consumption in this study was assessed to be between 12 and 18 years. Another study conducted in the field of social sciences at the Faculty of Social Sciences of Tehran shows that 46.8 percent of students had a moderate tendency and 13.8 percent had a high tendency toward alcohol consumption. At Mazandaran University in 2014, 63.3 percent of male students and 45.1 percent of female students had a neutral attitude toward alcohol consumption, and also 6.2 percent of male students and 0.4 percent of female students had a positive tendency toward alcohol consumption. In another study conducted at Mazandaran University, the results showed that 59.6 percent had never consumed alcohol at all. From 1995 to 2013, the statistics for alcohol addiction progressed with an almost constant slope, and after cigarettes and hookah, alcohol was the second most consumed substance.

Dr. Simin Kazemi continued: In the findings obtained from various studies, contradictory results are also observed; for instance, one study stated that satellite television is an effective factor in alcohol consumption, while another study found satellite television to have no effect on alcohol consumption. Among other factors influencing alcohol consumption, one can point to the degree of an individual's bond with family, abandonment of religiosity, self-control, the level of each person's beliefs and convictions, academic commitment, and peer and friend groups. Among the social factors that lead to alcohol dependence, one is the role and influence of culture and society, such as the abnormalities and anomie that exist in society. Other factors affecting alcohol dependence include the degree of access individuals in society have to it, as well as the extent of economic deprivation. Family is also among the influential factors in the tendency toward alcohol consumption, playing a contradictory role. For example, a close relationship with one's family can be mentioned as a protective factor against the tendency toward alcohol. However, if there is an alcoholic in the family or if there is a positive attitude toward alcohol within the family, these can be cited as factors influencing an individual's tendency toward alcohol.

She said: Among the most important theories that serve as a suitable explanation for this issue in Iran are social bond theory and general strain theory. In social bond theory, the relationship between the individual and society is established through social institutions, which is effective in the discussion of deviance and delinquency, and in which socialization plays a very important role. Because if socialization has been carried out properly, a strong moral bond is created between the individual and society, the results of which include attachment and commitment to others, commitment to conventional lines of action in a society, involvement in activities that are customary in society, and belief in the moral and legal order of society. The behavior of a deviant individual also arises under conditions where, for example, there is no connection between home and school, and the person has no commitment to educational and occupational positions and does not participate in society's activities. Other factors include the individual's withdrawal from society, isolation, and lack of belief in the legitimacy and morality of laws. In our society, despite the prohibition on alcohol consumption and the punishments prescribed for it, it is still neither taken seriously nor considered fair by youth and adolescents, and for these reasons, they do not feel obligated to observe the laws in these cases. General strain theory also points to the reasons for committing deviant behaviors and the social pressures that an individual endures in their life. In fact, this social pressure and tension, which is currently very high in our lives, leads to an increase in the stress levels of members of society, and if a person cannot control these pressures and stresses, the likelihood of turning to deviant behavior increases, with the tendency toward alcohol consumption being one of these deviant behaviors in such situations.

Continuing the panel, Engineer Hossein Dezhakam, Secretary-General of the Society for Human Revival, as the third and final speaker, expressed his views on strategies for combating alcohol abuse in Congress 60, stating: There is a point that may surprise you or be interpreted differently, but I say today that no human being consumes alcohol or drugs for futility. These individuals do not consume alcohol or drugs merely for pleasure. Because alcohol and drugs perform a function for human beings, but unfortunately, this function they perform for the human comes at a heavy and crippling cost. Yet, at the moment it performs that function, the person never thinks they will have to pay the price for it. Now, let me mention a few of its uses: A person wants to have sexual intercourse but falls short or suffers from premature ejaculation, so they use alcohol and their problem is solved to a usual extent. They want to fight but are afraid, so they use alcohol and fight. They want to drive at night and, to avoid falling asleep, they consume drugs and drive until morning. They want to wrestle but have anxiety, so they consume opium, step onto the mat, and wrestle. They want to stay awake all night to study, so they either consume opium, or Ritalin, or another drug to accomplish this; or they are very sad, and by consuming alcohol, they cover up that sadness; or they want to be happy and use alcohol. In general, the point is that one should not imagine that humans are ignorant and unaware and that we must tell them not to consume alcohol and guide them to the straight path. They themselves know everything, but alcohol or drugs enter gradually and then drag the human into this trap. Alcohol consumption is a hidden matter, and you cannot easily gather statistics on a hidden issue. For instance, a person who has been consuming opium for 10 years, yet their spouse is unaware of it—how are we supposed to know! Making alcohol is easier than anything else. You cannot make hashish and opium. As for medications, you have to buy them ready-made. The easiest thing to procure is alcohol. One buys some raisins, puts them in a container, pours some water over them, and after fifteen days, it yields alcohol. It requires no laboratory whatsoever. It is not the case that you should think alcohol must necessarily be smuggled and imported across the border. In the old days, when people drank alcohol, there were specific customs and traditions, and these traditions in society provided a degree of control; firstly, they did not drink every day, but rather it was consumed collectively on certain occasions. However, today this matter has been drawn into the home, and instead of small cups, 4-liter jugs are used, and you can no longer have statistics on this. The alcohol consumer is aggressive. Today, it is a good thing that the person who consumes alcohol does not leave the house, because in the old days when they came out, we were faced with stabbings every night, we were faced with car accidents, and many other issues that have become far less frequent today. But this has caused the burden of alcohol to be shifted onto opium. In the past, for example, they drank beer; today, instead, they obtain and consume crack, crystal meth, or opium.

Engineer Dezhakam added: In our body, there are dopamine neurotransmitters in the nervous system; when they rise, a person becomes euphoric, and if they fall, one develops Parkinson's disease, or if serotonin falls, a person becomes depressed, and these substances disrupt this balance. For example, a substance called dynorphin is produced in our body—we have three types of dynorphin, which they say is forty to fifty times more potent than morphine—or endorphin, which is several times more potent than morphine, but with the displacement of these, our body's system becomes disrupted. Until now, substances were produced naturally in a person's body; now they must be introduced from outside through narcotics, and if we cut off the entry of substances from outside, the body's system becomes impaired, and this impairment must return to its natural state, and the return of this system to natural equilibrium is not possible in one week, two weeks, or one month. We must act with a calculated process for at least a year to be able to restore this system to its original state. Alcohol and narcotics have a destructive effect on three parts: on the body, where they interfere with neurotransmitters; on thinking and worldview, they cause complete destruction—a person's thinking becomes opiate thinking; and they also have a destructive impact on the psyche. If we want to know how treatment is carried out in Congress 60, we must first understand what has been destroyed: narcotics and alcohol destroy the body, worldview, and psyche. If we also want to carry out treatment, all three of these must be corrected; it is not just about cutting off the substances. It is not just about imprisoning someone in a camp for two months. Prison is not the answer for treating narcotics and does not cure the addict. In the discussion of treatment in Congress 60, we work on three subjects. We must correct the body, psyche, and worldview. Worldview is thinking. The psyche, from Congress 60's perspective, means temperament. One person is good-tempered, another is capricious, another is delusional;... everyone is of a certain disposition, and we call this "temperament." The psyche arises from two things: one from the body and one from thoughts (worldview). The body involves neurotransmitters: dynorphin, endorphin, dopamine... If there is a problem with these, they play a role not only in the issue of addiction but in all illnesses. Congress 60 works on thinking. The thinking of a nihilistic individual, a person who says the world is but two days and I am going to die tomorrow, and this body will be eaten by termites and locusts in the grave—I will destroy it myself with alcohol and opium! This thinking must be corrected, and Congress 60, in order to correct thinking, when it saw it could not influence society, placed everything on the individual and educates the person in the Fourteen Valleys. The first valley says: With thinking, structures begin; without thinking, that which exists moves toward decay. Second, one must know that no creature steps into life for futility; none of us humans move toward nothingness and void, even if we ourselves think of nothing. Third, one must know that no creature thinks about its own self as much as the human being does. Fourth, in vital matters, assigning responsibility to God means absolving oneself of responsibility. In vital matters and life, if you assign responsibility to God, it is an absolution of responsibility from oneself. From the fifth valley to the fourteenth valley, matters such as action coupled with thought, rationalism, finding the path, correct perception of the route, the path being visible, and perseverance until the phenomenon of love are discussed. In the meantime, the end of each valley is the beginning of another line, and it is never the case that something in existence comes to an end.

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Audio files of the speeches presented at the Alcohol Consumption in Iran conference:

Audio file of Dr. Noroozi's speech

Audio file of the Engineer's speech

Audio file of Dr. Simin Kazemi's speech

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Source: Iranian Sociological Association

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