Mind the gap: rethinking global alcohol metrics in high-abstention low-income and middle-income countries

Alcohol per capita consumption (APC; total pure alcohol consumed per person 15 years or older per year) is the primary indicator used to track global progress in reducing harms associated with alcohol use. However, in many low-income and middle-income countries (LMICs), where most of the population abstain from alcohol and risk of alcohol-associated harm is concentrated in a heavy-drinking minority, APC can misrepresent both exposure and risk. This Viewpoint argues for the routine inclusion of drinker-adjusted metrics, specifically litres of alcohol consumed per drinker (alcohol per drinker), alongside the standard APC indicator. By use of data from WHO's Global Information System on Alcohol and Health, we show how alcohol per drinker reveals patterns hidden by population averages, particularly in high-abstention LMICs. For example, South Africa and the UK have similar APC but starkly different alcohol-attributable harm profiles, which are better explained by differences in alcohol per drinker. Although APC remains valuable, relying on this metric alone risks misinterpreting progress and misdirecting policy in contexts where drinking is concentrated among a minority of the population who drink heavily. As global monitoring evolves, we call for the inclusion of additional metrics that better reflect risk in diverse contexts.