Global health. The current scenario and future perspectives

208 The global mortality rate attributable to alcohol use was 38.8 per 100,000 people during the year 2016, with significant regional variations: in Africa, the (age-adjusted) mortality rate reached 70.6 per 100,000 people, followed by Europe with 62.8 per 100,000 people; in the Americas region, the rate was below the global average at a value of 34.1 per 100,000 people. In the Americas region, the report from the PAHO attributes around 380 thousand deaths to alcohol in 2016 and accounts for 6.7% of disability- adjusted life years. The main causes of death attributable to alcohol are digestive disorders (almost 96 thousand), malignant neoplasms (61.7 thousand), self-harm and interpersonal violence (58.6 thousand) and traffic injuries (52.6 thousand). Additionally, about 32 thousand deaths were attributable to alcohol use disorders. Of total deaths, 84.6% correspond to men. The report also indicates that mortality rates attributable to alcohol use vary greatly between countries in the region. The indicators associated with substance use as well as its consequences presented in this section show a quite complex panorama, regardless of whether these substances are legal or illegal; therefore it remains a major challenge for public policies across countries. As is true for all matters, there have been advances and setbacks. A good example of progress at a global level is tobacco, where prevalence and incidence indicators have been declining over recent years. But besides the above, there are other issues that must be addressed within a comprehensive drug policy. In fact, when referring to illegal substances the consequences associated with an illicit market are to be taken into consideration; that is, all those activities related to production and marketing of those products including drug trafficking (which will be discussed later). Elements that make up the trade of an illegal product are obviously not present when it comes to legal substances. For example, the production and commercialization of tobacco or alcohol do not generate the same negative consequences as the production and commercialization of cocaine or marijuana, or in general any substance subject to control. This can be a central element that must be considered when discussing new strategies associated with drug policies. There is still something else: an inherent health risk of the use of drugs obtained from the illegal market is the lack of quality control, when contents are unpredictable. This likely generates inequality in risks because “quality” can be associated with price and, therefore, with access opportunities. The adulteration of drugs, i.e., adding other substances besides the expected ones, is part of the illegal business. When someone buys an ecstasy pill, do they really know what that pill contains? Or when