$3.3 billion worth of alcohol sale in one state in
Chennai is the capital
of the Tamil Nadu state which is one of the 28 states in India. The
population of Tamil Nadu (72.1 million)1 is slightly
higher than that of the UK (62.2 million)2, but the
total area of Tamil Nadu (50,216 sq miles) is nearly half the size
of the UK (94,060 sq miles)!
India is traditionally viewed as a
‘dry’ or ‘abstaining culture’3. Those who drink alcohol
are looked upon as ‘outcasts’ in society. In 2004, the per capita
alcohol consumption for the UK was 10.39 compared with 0.82 for
India4. The National Household Survey of Drug and
Alcohol Abuse (India) showed in 2001 that the prevalence of men
using alcohol was about 21% and it was only between 2% and 5% among
"...alcohol consumption is still considered a taboo in Tamil
Nadu. The society does not accept any form of drinking...".
But in recent years things have
changed. The change is visible especially in major cities like
Mumbai, Delhi, Pune, Chandigarh, and Bangalore. Women-only Alcohol
Anonymous (AA) meetings held in these areas have found an increase
in the number of women who drink in India7. Also the
average age of first time alcohol use in general has reduced from
28 in 1980s to 18 years in 20108.
However, alcohol consumption is still
considered a taboo in Tamil Nadu. The society does not accept any
form of drinking (either ‘social drinking’ or ‘binge drinking’).
Local magazines reported that bar workers lack social
dignity9 and hence many of them remain unmarried as the
parents are hesitant to give their daughter in marriage to
The Indian government has given rights
to individual states to develop their own rules in terms of alcohol
production, sale and taxation. Historically, consumption of alcohol
was totally banned in Tamil Nadu state between 1937 to 1991 and the
ban was lifted only 3 times during those periods11. The
whole production and sale of alcohol is controlled by the
Government company called TASMAC (Tamil Nadu State Marketing
Corporation) which has nearly 7000 sale outlets and about 30,000
employees11. There has been a steady profit over the
years. Reports suggest that in 2005-06, the annual revenue was
about 7,335 crores of Indian rupees (73.35 billion rupees,
equivalent to $1336 million). The most recent data (2011-12) showed
annual revenue of an astonishing 18,018 crores of Indian
rupees12 (180.18 billion rupees, roughly equivalent to
With the sale of alcoholic beverages
soaring high over the last decade, I believe that alcohol-related
morbidity and mortality have been on the rise. Hence there is a
great demand for alcohol treatment services. Let me give a brief
account on the treatment model at the CSI Rainy Hospital, Chennai,
Tamil Nadu. There are some striking contrasts from the western
First, the referral system is entirely
different. Anyone can self refer to the psychiatric out-patient
clinic. There are no waiting lists and the patients are seen on the
same day of referral. Frequently, those who are already undergoing
treatment bring their friends or relatives who have alcohol or
mental health problems.
Secondly, the patients are always seen with their family members
(mother, spouse etc), and counselling forms an inevitable part of
the treatment process. Thirdly, there is striking gender difference
- only male patients access the service! As for the possible
reasons, a local report suggests female drinkers are less in
number13. But apart from this, I believe it is due to
the stigma attached to drinking. The initial assessment consists of
history taking, administration of questionnaires (such as Addiction
Severity Index) and alcohol withdrawal scale (CIWA-AR) and blood
tests. If the patient presents with severe withdrawal symptoms, he
would be admitted to the medical ward for detoxification. However,
those with minimal or no withdrawal symptoms are assessed for the
suitability of initiating disulfiram (about 12 to 24 hours after
their last drink). If there are no contraindications, the patient
is started on disulfiram after giving information about the
medication and obtaining consent. This process constantly involved
the participation from the family. As a rule of thumb disulfiram
would not be commenced if there are no carers available at the time
of the assessment.
"The patients (and the carers) are then given weekly
appointments for up to a month – during which time an intense short
term (both individual and family) counselling sessions takes
It has become the responsibility of the carer to supervise this
medication and it is done meticulously. The patients (and the
carers) are then given weekly appointments for up to a month –
during which time an intense short term (both individual and
family) counselling sessions takes place. Emphasis is given to
restoration of marital relationship during recovery. It is
interesting to note that these sessions are based on ‘Steps to
Freedom’, a faith-based intervention in resolving personal issues
such as anger, ego defences, dysfunctional coping, pseudo
self-esteem, sexuality and genetic traits.
This was tried by Hurst et al14 and found to produce
positive results for depression, anxiety and other mental
disturbances. The same version is currently applied for patients
with alcohol dependence. One of the remarkable differences I noted
is that there are no set time limits for these sessions. They are
so flexible and each session could carry on for few hours!
A short review of patients with history of
alcohol use was done at the CSI Rainy Hospital:
Of those 33 patients with history of alcohol
use 11 attended for the first time for assessment.The rest of the
22 patients are currently abstinent and attending regular follow
ups.Their case notes were analysed to check how long they were in
treatment and abstinent.
The table is as follows:
In conclusion, the sale and consumption of alcohol in Tamil Nadu is
escalating day by day and it raises alarm bells. This has become a
major public health concern. The available alcohol treatment
services are too few in number and the country is ill equipped with
resources to address the issues. However, there are pockets of
excellence where a tiny unit such as the CSI Rainy hospital in
Chennai shines like a lode star in the dark!
India 2011 www.census.tn.nic.in/whatsnew/ppt_total2011.pdf
- The World Bank data
- Bennet et al, 1993.
WHO Global status report on alcohol 2004. Page 17-18.
Prasad R. Alcohol use on the rise in India. The Lancet,
Volume 373, Issue 9657, Pages 17 - 18, 3 January 2009.
Benegal V, Nayak M, Murthy P, Gururaj G et al. Alcohol, gender and
drinking problems – perspectives from the low and middle income
countries. Chapter 5: Women and alcohol use in India. World Health
Suryanarayan D. A dubious high for ‘spirited’ women in India’s
cities. Daily News and Analysis. Published: Wednesday, May 26,
Gururaj G, Murthy P, Rao G N, Benegal V et al. Alcohol related
harm: Implications for public health and policy in India.
Publication No. 73, National Institute of Mental Health and Neuro
Sciences (NIMHANS), Bangalore, India. ISBN No:
The Hindu: TASMAC staff request CM to make them full-fledged
government employees. 18 July 2012.
- D.L.Sanjeevi Kumar. Junior Vikadan article: Mayakkam Enna. 24
Wikipedia, the free encyclopedia: TASMAC.
The Times of India. Tamil Nadu's liquor revenue rises to Rs 18K cr.
27 April 2012.
- Linda A.
Bennett, Carlos Campillo, C.R. Chandrashekar and Oye Gureje.
Alcoholic beverage consumption beverage in India, Mexico and
Nigeria – a cross cultural comparison.
George A. Hurst, Marion G. Williams, Judith E. King and Richard
Viken. Faith-based intervention in depression, anxiety and other
mental disturbances. Southern Medical Journal: - Volume 101 - Issue
4 - pp 388-392 April 2008