Burden of Disease and Injury Caused by Alcohol

Burden of Disease and Injury Caused by Alcohol Kevin D Shield, Svetlana Popova, and Ju¨rgen Rehm, Centre for Addiction and Mental Health, Toronto, ON, Canada Ó 2017 Elsevier Inc. All rights reserved. This article is an updated version of the previous edition article by Jürgen Rehm, Jayadeep Patra, Dolly Baliunas, Svetlana Popova, Michael Roerecke, Benjamin Taylor, volume 1, pp. 135–151, Ó 2008, Elsevier Inc.

Introduction

burden of disease and injury attributable to alcohol consumption in 2012.

The consumption of alcohol impacts various parts of the human body, with alcohol now being causally linked to over 200 three-digit International Classification of Diseases (ICD) revision 10 codes (Rehm et al., 2010a). Historically, the harmful consumption of alcohol has been also widespread globally, and therefore alcohol consumption has caused, and continues to cause, a large burden of disease and injury (measured in disability-adjusted life years (DALYs) lost; a measure that combines premature mortality with morbidity). In fact, alcohol consumption is currently estimated to be the fifth most important risk factor globally for the burden of disease and injury (Lim et al., 2012; World Health Organization, 2014b); however, the burden caused by alcohol consumption is not equal in all regions, and in some regions, such as eastern Europe and South America, alcohol is the number one risk factor for the burden of disease and injury (Lim et al., 2012). The burdens caused by alcohol consumption are not limited to mortality and morbidity; the consumption of alcohol also causes a large societal burden to the drinker’s family and friends and to society in general (Laslett et al., 2010). Additionally, alcohol consumption has a large economic impact stemming from costs related to (1) health care, (2) crime and public disorder, (3) prevention and research, (4) the drinker, their family, other people within their social network, and strangers, and (5) workplace and productivity losses (Laslett et al., 2010). The economic costs caused by alcohol consumption have been estimated to amount to more than 1% of the gross national product in high-and middle-income countries (Rehm et al., 2009a). Therefore, when analyzing the burden of alcohol consumption, the social and economic burdens should also be considered as the magnitudes of these problems are great (Laslett et al., 2010). Furthermore, these burdens caused by alcohol consumption are modifiable and could be reduced by the implementation of cost-effective policy interventions (Anderson et al., 2009; Babor et al., 2010, 2003). Given the large health burden caused by alcohol consumption, and the fact that this burden could be decreased by the implementation of effective interventions, this article describes the calculation of the burden of disease and injury caused by alcohol consumption. Specifically, this article (1) summarizes alcohol consumption measures from around the world for 2012 as obtained from the Global Information System on Alcohol and Health (GISAH) database (see Relevant Website), (2) outlines current knowledge about the relationships between the consumption of alcohol and disease and injury outcomes, (3) describes the methods used to calculate the burden of disease and injury caused by alcohol consumption as provided in the latest World Health Organization (WHO) Global Status Report on Alcohol and Health (GSRAH) 2014 (World Health Organization, 2014b), and (4) outlines the

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Alcohol as a Risk Factor for Diseases and Injuries Dimensions of Alcohol Relevant to the Burden of Disease and Injury The relationship between alcohol consumption, and health and social outcomes is complex and multidimensional. Three dimensions of alcohol consumption lead to mortality and morbidity, namely (1) average volume of consumption, (2) patterns of alcohol consumption, and (3) the quality of alcohol consumed (Rehm et al., 2009b). Furthermore, three main mechanisms of alcohol consumption impact disease, namely (1) toxic and beneficial biological effects of alcohol on organs and tissues, (2) intoxication, and (3) dependence (Rehm et al., 2003b). Figure 1 provides an overview of how the above-described dimensions of alcohol consumption affect health outcomes, result in harms to others, and have socioeconomic consequences. The average volume of alcohol consumption (in liters of pure alcohol) predicts the burden of disease and injury caused by alcohol for numerous diseases (primarily long-term consequences and alcohol dependence) (see Rehm et al., 2010a) for a systematic overview of the relationship between alcohol consumption and causally related diseases and injuries). Although average volume of alcohol consumption is also related to ischemic heart disease, ischemic stroke, and injuries (Roerecke and Rehm, 2010; Taylor et al., 2010), the ability to predict the harm caused by alcohol for ischemic diseases and for injuries is increased when the pattern of alcohol consumption is taken into account (MacDonald et al., 2013; Rehm et al., 1996) due to differences in the way people consume alcohol. For example, when a person has an average consumption of seven international standard drinks (84 g of pure alcohol) over a 7-day period, they might be consuming a standard drink per day over the 7 days, or they might be consuming seven international standard drinks in 1 day and no alcohol on the other 6 days. The health outcomes of these two drinking patterns are very different, especially for ischemic diseases and for injuries, even though the average consumption of alcohol is the same. Patterns of alcohol consumption affect the health burden caused by alcohol in two main ways. The acute intoxicating effects of alcohol have a casual impact on injuries (Taylor et al., 2010). The impact of alcohol on injury is primarily due to alcohol’s effect on the central nervous system, causing symptoms of intoxication, which can be experienced and measured even at low consumption levels (Eckhardt and Crane, 2008). Alcohol intoxication is also causally related to harms caused by the alcohol consumption of others (Laslett et al., 2011; see Rehm et al., 2010a) for a systematic overview of the

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Figure 1 Model of alcohol consumption, intermediate outcomes, and long-term consequences. Source: World Health Organization, 2014b. Global Status Report on Alcohol and Health, World Health Organization, Geneva, Switzerland.

relationship between alcohol intoxication and causally related diseases and injuries). Second, heavy alcohol consumption impacts ischemic diseases by affecting risk factors such as blood pressure. These effects counteract the effects of low alcohol consumption (Beulens et al., 2007), which increase protective factors such as high-density lipoprotein (Rimm et al., 1999). The quality of an alcoholic beverage, particularly illegally produced or homemade beverages, can have a large health effect on the drinker, especially when these beverages are contaminated with methanol, heavy metals, or other toxic substances, and can contribute also to mortality caused by alcohol in cases such as methanol poisoning through the use of some surrogate alcoholic beverages. However, the overall impact of the quality of the alcohol consumed is not large and accounts for less than 1% of all alcohol-attributable deaths (Rehm et al., 2014, 2010b), with methanol deaths in particular typically accounting for fewer than 1000 deaths per year (Rehm et al., 2014). Given the relatively low amount of harm caused by the quality of alcoholic beverages, quality is not a focus when evaluating the harms caused by alcohol consumption.

a person has the aldehyde dehydrogenase allele ADH1B*2 and a resulting decreased ability to metabolize acetaldehyde into acetate, causing a buildup of acetate (Seitz and Becker, 2007). The buildup of acetate causes an increased risk of cancer; however, people with this allele also experience an increase in the negative short-term effects of alcohol consumption, such as nausea and, therefore, on average tend to have a lower risk of alcohol dependence (Luczak et al., 2004).

Measuring Alcohol Exposure: Key Indicators of Alcohol Consumption The following key indicators of exposure are involved in the estimation of the alcohol-attributable burden of disease and injury (World Health Organization, 2014b): (1) adult per capita consumption of alcohol (recorded, unrecorded, and tourist), (2) prevalence of different drinking statuses by age and sex, (3) distribution of average daily alcohol consumption by age and sex, and (4) data on the prevalence, frequency, and severity of heavy episodic drinking occasions.

Adult Per Capita Consumption of Alcohol Factors Affecting Alcohol Consumption Many factors predict and have a direct impact on alcohol consumption and consumption patterns. Many social vulnerability factors (such as the level of a country’s development, the cultural drinking context, and alcohol production and distribution in a country) affect alcohol consumption, while individual level factors such as age, gender, familial factors (genetics), and socioeconomic status affect both alcohol consumption and its related health outcomes (World Health Organization, 2014b). For example, familial factors play a role in alcohol consumption and the increased risk of mortality associated with an average volume of alcohol consumed (Sun et al., 1999, 2002; Takeshita and Morimoto, 1999), such as in the case where

Adult per capita consumption, that is, alcohol consumption by every person aged 15 years and older, is based on population level statistics concerning recorded alcohol consumption, unrecorded alcohol consumption, and tourist alcohol consumption. These statistics are preferable to population alcohol consumption estimates based on population survey data, as population surveys often underestimate consumption (Shield and Rehm, 2012). Furthermore, the extent of the underestimation of alcohol consumption by survey data differs between countries and surveys. For more information and guidance on estimating per capita consumption, see the WHO GSRAH (2014b); for a concise description of the data collection, see Poznyak et al. (2013).

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Burden of Disease and Injury Caused by Alcohol

Adult Per Capita Consumption of Recorded Alcohol There are three principal sources of data for estimates of the adult per capita consumption of recorded alcohol: national government data, data from the Food and Agriculture Organization of the United Nations (FAO), and data from the alcohol industry (Poznyak et al., 2013; Rehm et al., 2003c; World Health Organization, 2014b). These data are used in combination with United Nations (UN) population data to estimate the per capita consumption of alcohol for a country (United Nations, 2013). Data collected on recorded consumption are usually reported in the following categories: beer, wine, distilled spirits, and all other alcoholic beverages. In many developing countries the category of all other alcoholic beverages is made up of local beverages, such as cider and fruit wines, which may comprise more of the alcohol market by volume of pure alcohol than do beer, wine, or distilled spirits. Where available, the best and most reliable data generally come from national governments. Governments usually collect alcohol data based on sales figures, tax revenue, and/or production data. Taxation and sales data are usually considered the most accurate, as they include both home-produced and imported alcoholic beverages; however, in some countries certain beverages are not taxed (e.g., wine in some wineproducing countries), the sales of alcoholic beverages cannot be separated from sales of other items sold at a given location, and sales data are not beverage-specific. Additionally, accurate export and import data are needed to accurately measure recorded per capita alcohol consumption. These problems with government data can lead to underestimation or overestimation of the adult per capita consumption of alcohol. The most complete and comprehensive international data set on per capita consumption is published by the UN’s FAO. FAOSTAT, the database of the FAO, publishes production and trade data for almost 200 countries for different types of alcoholic beverages. The estimates are based on official reports of production and/or raw materials by national governments, primarily as reported by each country’s agriculture ministry in response to an annual FAO questionnaire. Statistics on imports and exports are derived mainly from customs departments. If these sources are not available, other government data, such as statistical yearbooks, are consulted. The accuracy of the FAO data relies on member nations reporting the data in a reliable and valid manner. The data reported by the countries may include some unrecorded alcohol production; however, these data likely underestimate the actual informal, home and illegal production. The third main source of data is the alcohol industry (Poznyak et al., 2013; World Health Organization, 2014b). Market research firms serving the alcoholic beverage industry or industry associations (such as Impact Databank and Euromonitor) are accurate sources of alcohol consumption data; however, these data are expensive to obtain. Furthermore, publications of these market research firms do not cover all countries, especially low- and middle-income countries, and the information is often not reliable when provided for these countries. Therefore, in the absence of any other more reliable source of information, alcohol consumption data obtained from market research firms can be used to supplement data at country and international levels.

The GISAH (see Relevant Website) systematically collects and compares recorded per capita consumption data from different sources on a regular basis (for procedures and further information, see Rehm et al., 2003a; World Health Organization, 2004; World Health Organization, 2009). There are limitations that are common to all sources of recorded alcohol consumption data. The main limitations of recorded adult per capita estimates are twofold: (1) by their very nature, they do not incorporate unrecorded consumption or tourist consumption and (2) they are only aggregate statistics that cannot easily be disaggregated into sex and age groups. Thus, the triangulation of survey data is needed for an analysis of the burden of disease and injury attributable to alcohol consumption.

Adult Per Capita Consumption of Unrecorded Alcohol Unrecorded alcohol consumption is more difficult to estimate than recorded consumption, with only a few countries regularly collecting data on unrecorded alcohol consumption. Unrecorded alcohol consumption stems from five main sources (for an overview of unrecorded consumption see Lachenmeier et al., 2013; Rehm et al., 2014): (1) legal but unrecorded alcohol products (such as home brews or wine production for one’s family in countries where such production is legal), (2) recorded alcohol products, but consumed in another country (e.g., cross-border shopping), (3) surrogate alcohol (alcohol not officially intended for human consumption), (4) illegal homemade artisanal alcohol production, and (5) illegal production and smuggling on a commercial (industrial) scale. Currently, government data and survey data (including data obtained from the 2012 Global Survey on Alcohol and Health) are the most widely used sources for estimating unrecorded consumption; however, indirect calculations can be based on the use of raw materials for alcohol production (e.g., sugar or fruits), or based on indicators strongly related to overall alcohol consumption, namely alcohol-related harms such as poisoning (Poznyak et al., 2013; World Health Organization, 2014b). However, basing unrecorded alcohol consumption on alcohol-related harms is not feasible for a study that uses alcohol consumption to estimate the alcohol-attributable burden of disease and injury on alcohol consumption as it leads to circular reasoning.

Adult Tourist Per Capita Consumption of Alcohol In most cases the per capita consumption of alcohol consumed by foreign tourists is approximately equal to the amount of alcohol consumed by the country’s inhabitants when they travel outside of their own country, and thus for most countries adult tourist per capita consumption of alcohol does not need to be taken into account when estimating total adult per capita consumption of alcohol. For countries with a small population and a large amount of tourism, tourist consumption is likely to bias recorded and unrecorded adult per capita consumption measurements, and if not taken into account will lead to an overestimation of both alcohol consumption and the burden of disease and injury attributable to alcohol consumption. Accordingly, adult tourist per capita consumption has been estimated for only those countries where the number of tourists

Burden of Disease and Injury Caused by Alcohol

exceeded the number of inhabitants, and for countries such as Estonia, Luxembourg, the Republic of Moldova, and Singapore, where cross-border shopping affects per capita consumption estimates and needs to be taken into account.

Prevalence of Current Drinkers, Former Drinkers, and Lifetime Abstainers The prevalence of current drinkers (those who have consumed at least one standard drink of alcohol within the past year), former drinkers (those who have consumed at least one standard drink of alcohol within their lifetime, but who have not consumed a standard drink of alcohol in the past year), and lifetime abstainers (those who have not consumed at least a standard drink of alcohol in their lifetime) was assessed by either population surveys or regression analyses where survey data were not available (World Health Organization, 2014b). Drinking status information is part of many population surveys, and questions concerning drinking status are included often in population surveys that are not alcohol- or health-focused. However, these estimates have biases that stem from survey design and coverage which currently cannot be corrected for (Shield and Rehm, 2012). For the global estimates of the alcohol-attributable burden for 2012, large, representative population surveys, which were conducted closest to the year 2012, were used to obtain data on the prevalence of different drinking statuses. For years where data were not available, regressions were used to estimate the prevalence of the different drinking statuses.

Modeling Average Volume of Alcohol Consumption As population surveys almost always systematically underestimate alcohol consumption, and population level data do not provide information on alcohol consumption by age and sex, the distribution of average daily consumption of alcohol needs to be modeled by triangulating population level data with survey data (Kehoe et al., 2012; Rehm et al., 2010a). This triangulation is possible due to two different aspects of the distribution of alcohol consumption as observed using data from numerous population surveys. First, Rehm et al. (2010a) and Kehoe et al. (2012) have shown by analyzing data from 41 population surveys that alcohol consumption is best modeled using the gamma distribution. Furthermore, by analyzing 851-point estimates on alcohol consumption and the standard deviation of alcohol consumption obtained from numerous countries’ surveys, Rehm et al. (2010a) and Kehoe et al. (2012) determined that the standard deviation of alcohol consumption could be predicted from the mean alcohol consumption. Therefore, by triangulating data from population surveys with population level data on alcohol consumption, it is possible to accurately model alcohol consumption at the population level. This triangulation of data from surveys corrects for undercoverage of alcohol consumption and allows for the comparability of alcohol consumption by age and sex across time and across countries.

Heavy Episodic Drinking The relationship between patterns of drinking and the harms caused by these patterns is best measured using the prevalence and severity of heavy episodic drinking occasions (drinking five or more international standard drinks (60 g of pure alcohol or more) during one drinking occasion). Population surveys

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were used to estimate the prevalence of people who engaged in heavy episodic drinking occasions, the average frequency of these occasions, and the average amount of alcohol consumed during these drinking occasions (World Health Organization, 2014b).

Which Diseases and Injuries Are Causally Related to Alcohol Consumption? Two general categories of disease and injury conditions exist which are causally related to alcohol consumption (Rehm et al., 2010a, 2003b): (1) disease and injury conditions where alcohol is necessary in their development or occurrence (e.g., alcohol dependence or alcohol intoxication) and, therefore, they would not occur if every person was a lifetime abstainer and (2) disease and injury conditions where alcohol increases the risk of development or occurrence, but it is not a necessary component (i.e., where alcohol can be a contributory cause and the disease develops or the injury occurs when a sufficient number and magnitude of factors come together). In identifying the latter category of conditions, standard epidemiological criteria for causality were applied. Thus, to establish sufficient evidence of causality, (1) there had to be consistent evidence of an association (positive or negative) between alcohol consumption and the disease or injury, (2) chance, confounding variables, and other biases could be ruled out with reasonable confidence as factors in the causal association, and (3) there was evidence of a plausible mediating process (English et al., 1995). These judgments were made using the usual criteria for establishing causality in epidemiology, with the most weight placed on the following four criteria: (1) consistency across studies, (2) established experimental biological evidence of mediating processes or at least physiological plausibility (biological mechanisms), (3) strength of the association (effect size), and (4) temporality (i.e., cause before effect).

Diseases and Injuries Where Alcohol Is a Necessary Cause With regard to the attribution of alcohol-relatedness, the conditions shown in Table 1 are, by definition, wholly attributable to alcohol and, thus, have an alcohol population-attributable fraction (PAF) of 100%. In other words, in a counterfactual scenario of the presence of no alcohol, these disease and injury conditions would not exist. For these conditions, no statistical procedures are necessary to estimate risk relationships. This does not mean that the underlying data are always free of measurement error, that is, all diagnoses of ‘alcoholic cirrhosis of the liver’ are in fact caused by alcohol. Measurement error may also work in the opposite direction, where alcoholic liver cirrhosis is not identified as such and is erroneously classified as another form of liver cirrhosis. Alcohol use disorders and, in particular, alcohol dependence are the most severe wholly attributable diseases caused by alcohol consumption. Alcohol dependence is a disorder in itself, but is also a powerful mechanism sustaining alcohol consumption and mediating its impact on both the chronic and acute physiological as well as social consequences of alcohol (Rehm et al., 2004; Samokhvalov et al., 2010d). In burden of disease and injury studies such as those performed by the WHO (World Health Organization, 2014b), causes that are 100% attributable to alcohol consumption

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Table 1 Disease and injury conditions which are by definition alcohol-related (population-attributable fraction (PAF) ¼ 1 or 100%) Disease or injury condition

ICD 10 code

Alcohol-induced pseudo-Cushing’s syndrome Mental and behavioral disorders due to use of alcohol Acute intoxication Alcohol abuse Alcohol dependence syndrome Withdrawal state Withdrawal state with delirium Psychotic disorder Amnesic syndrome Residual and late-onset psychotic disorder Other mental and behavioral disorders Unspecified mental and behavioral disorder Degeneration of nervous system due to alcohol Alcoholic polyneuropathy Alcoholic myopathy Alcoholic cardiomyopathy Alcoholic gastritis Alcoholic fatty liver Alcoholic hepatitis Alcoholic fibrosis and sclerosis of liver Alcoholic cirrhosis of the liver Alcoholic hepatic failure Alcoholic liver disease, unspecified Alcohol-induced chronic pancreatitis Maternal care of (suspected) damage to fetus from alcohol Fetus and newborn affected by maternal use of alcohol Fetal alcohol syndrome (dysmorphic) Finding of alcohol in blood Toxic effect of alcohol Ethanol Methanol Other alcohols Alcohol unspecified Accidental poisoning by and exposure to alcohol Intentional self-poisoning by and exposure to alcohol Poisoning by and exposure to alcohol, undetermined intent Evidence of alcohol involvement determined by blood alcohol level Evidence of alcohol involvement determined by level of intoxication Problems related to lifestyle: alcohol use

E24.4 F10 F10.0 F10.1 F10.2 F10.3 F10.4 F10.5 F10.6 F10.7 F10.8 F10.9 G31.2 G62.1 G72.1 I42.6 K29.2 K70.0 K70.1 K70.2 K70.3 K70.4 K70.9 K86.0 O35.4 P04.3 Q86.0 R78.0 T51 T51.0 T51.1 T51.8 T51.9 X45 X65 Y15 Y90 Y91 Z72.1

(other than alcohol use disorders) are not modeled due to (1) data on these causes of death and disability not being available and (2) the alcohol relative risk (RR) of diseases such as liver cirrhosis incorporating conditions such as ‘alcoholic cirrhosis of the liver’ into the alcohol RR for the broad category of liver cirrhosis (Rehm et al., 2010c).

Diseases and Injuries Where Alcohol Is a Contributory Cause Table 2 provides an overview of the diseases and injuries where alcohol is a contributory cause and which are used when calculating the global burden of alcohol consumption (based on the above criteria). Table 2 also outlines the diseases that are 100% attributable to alcohol and which are also used when calculating the global burden of alcohol consumption. Furthermore, Table 2 presents the sources of the RR functions used when modeling the burden of disease and injury attributable to alcohol

consumption. These RR functions come from systematic reviews and meta-analyses that, in most cases, describe the relationship between alcohol consumption and the disease/injury as a continuous function. For Russia and other countries with a similar hazardous drinking pattern (see World Health Organization, 2014b), RRs (based on average alcohol consumption) from Zaridze et al. (2009) were used to model the relationship between alcohol consumption and pancreatitis, lower respiratory infections, liver cirrhosis, ischemic heart disease, ischemic stroke, and injuries, as the alcohol RRs of such diseases and injuries are hypothesized to be different in these countries due to their inhabitants’ extremely harmful drinking patterns.

Burden of Disease and Injury Data Both event-based and time-based measures indicating population health status are used in the usual analyses of the burden of disease and injury. This section presents the burden of alcohol for 2012. Mortality, as measured by the number of deaths, was the event measure. Years of life lost (YLLs) due to premature mortality and the burden of disease and injury, as measured in DALYs lost, constituted the time-based measures (Murray et al., 2002; Rehm et al., 2004). YLLs is a summary measure that takes into account the age at which death occurs, thereby giving greater weight to deaths that occur among younger aged populations (i.e., where a higher number of years of life are lost). The DALYs lost measure combines YLLs with years of life lost to living with a disability (YLDs). Population data were obtained from the UN’s population division. Age groups were categorized as follows: 0–14 years of age, 15–34 years of age, 35–64 years of age, and 65 years of age and older. The allocation of countries into the various WHO regions is found in Table 3.

Relating Alcohol Exposure to Disease and Injury Outcomes Alcohol PAFs, interpreted as reflecting the proportion of disease that would not exist if there had been no alcohol consumption (i.e., where lifetime abstention is considered the theoreticalminimum-risk exposure) (Rockhill and Newman, 1998), are applied to mortality and morbidity data to assess the burden of disease and injury caused by alcohol consumption.

Defining Alcohol-Attributable Diseases Average volume of alcohol consumption was found to predict mortality and morbidity for the following WHO global burden of disease (GBD) categories: infectious diseases, neonatal conditions, several types of cancer, cardiovascular diseases, diabetes, neuropsychiatric disorders, gastrointestinal diseases, and unintentional and intentional injuries. The alcohol RR for the GBD estimates for 2012 were used to model the burden of disease and injury attributable to alcohol consumption; see (World Health Organization, 2014b) and Table 2. Exposure and RR data were combined to estimate the alcohol PAF using eqn [1]. Z 150 Pabs þ Pform RR form þ Pcurrent ðxÞRR current ðxÞdx  1 >0 PAF ¼ Z 150 Pabs þ Pform RR form þ Pcurrent ðxÞRR current ðxÞdx >0

[1]

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Table 2 Relative risks for alcohol-attributable diseases and injuries by consumption stratum (reference group is ‘current abstainers’) for globally available disease categories

Condition

ICD 10 code

New WHO code

Old WHO code

Infectious and parasitic diseases Tuberculosis

A15-A19

3

IA1

B20-B24

10

IA3

Lönnroth et al. (2008), for causal relationship see Rehm et al. (2009b) Gmel et al. (2011)

61 62 63 66 78 70 65

IIA IIA1 IIA2 IIA5

Baan et al. (2007), International Agency for Research on Cancer, (2010) (based on relative risks from Corrao et al. (2004))

E10-E14

80

IIC

Baliunas et al. (2009)

F10.0, F10.3-F10.9 F10.1 F10.2 G40-G41

86

IIE4

I10-I15 I20-I25

97 110 112 113

IIF3 IIH IIH2 IIH3

100% AAF per definition 100% AAF per definition 100% AAF per definition Samokhvalov et al. (2010a)

I47-I49 I60-I62 I63-I66

116 114 114

IIH6 IIH4 IIH4

K70, K74 K85, K86.1

121 123 125

IIJ IIJ2

J10.0, J11.0, J12-J15, J18

39

IB1

Samokhvalov et al. (2010c)

P05-P07

50

ID1

Patra et al. (2011)

152 153 154 155 156 157 159

IIIA IIIA1 IIIA2 IIIA3 IIIA4 IIIA5 IIIA7

160 161 162

IIIB IIIB1 IIIB2

Human immunodeficiency virus/acquired immune deficiency syndrome Malignant neoplasms Mouth and oropharynx cancers Esophageal cancer Liver cancer Laryngeal cancer Breast cancer Colon cancer Rectal cancer Diabetes Diabetes mellitus Neuropsychiatric conditions Alcoholic psychoses (part of AUD) Alcohol abuse (part of AUD) Alcohol dependence (part of AUD) Epilepsy Cardiovascular disease Hypertensive disease Ischemic heart disease Cardiac arrhythmias Ischemic stroke Hemorrhagic and other nonischemic stroke Digestive diseases Cirrhosis of the liver Acute and chronic pancreatitis Respiratory infections Pneumonia Conditions arising during the prenatal period Low birth weight: as defined by the global burden of disease Unintentional injuries Motor vehicle accidents Poisonings Falls Fire Drowning Other unintentional injuries

Intentional injuries Self-inflicted injuries Homicide

a

C00-C14 C15 C22 C32 C50 C18 C20

a

X40-X49 W00-W19 X00-X09 W65-W74 b Rest of V-series and W20-W64, W 75-W99, X10-X39, X50-X59, Y40-Y86, Y88, and Y89 X60-X84 and Y87.0 X85-Y09, Y87.1

Sources for relative risks

IIA9 IIA4

Taylor et al. (2009) Roerecke and Rehm, (2012) for volume, Roerecke and Rehm, (2010) for pattern Samokhvalov et al. (2010b) Patra et al. (2010) Patra et al. (2010)

Rehm et al. (2010c) Irving et al. (2009)

Taylor et al. (2010) for relative risk, methodology adopted from Taylor et al. (2011)

Taylor et al. (2010) for relative risk, methodology adopted from Taylor et al. (2011)

V021–V029, V031–V039, V041–V049, V092, V093, V123–V129, V133–V139, V143–V149, V194–V196, V203–V209, V213–V219, V223–V229, V233–V239, V243–V249,V253–V259, V263–V269, V273– V279, V283–V289, V294–V299, V304–V309, V314–V319, V324–V329, V334–V339, V344–V349, V354–V359, V364–V369, V374–V379, V384–V389, V394–V399, V404–V409, V414–V419, V424–V429, V434–V439, V444–V449, V454–V459, V464– V469, V474–V479, V484–V489, V494–V499, V504–V509, V514–V519, V524–V529, V534–V539, V544–V549, V554–V559, V564–V569, V574–V579, V584–V589, V594–V599, V604–V609, V614–V619, V624–V629, V634–V639, V644–V649, V654– V659, V664–V669, V674–V679, V684–V689, V694–V699, V704–V709, V714–V719, V724–V729, V734–V739, V744–V749, V754–V759, V764–V769, V774–V779, V784–V789, V794–V799, V803–V805, V811, V821, V830–V833, V840–V843, V850– V853, V860–V863, V870–V878, V892. b Rest of V ¼ V-series minus the ICD 10 codes present in motor vehicle accidents; AUD ¼ alcohol use disorder.

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Table 3

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Countries of the WHO regions

Region

Countries

African Region (AFR)

Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cabo Verde, Cameroon, Central African Republic, Chad, Comoros, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, South Africa, Swaziland, Togo, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia (Plurinational State of), Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, United States of America, Uruguay, and Venezuela (Bolivarian Republic of) Afghanistan, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, South Sudan, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Monaco, Montenegro, Netherlands, Norway, Poland, Portugal, Republic of Moldova, Romania, Russian Federation, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, the former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, United Kingdom, and Uzbekistan Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste Australia, Brunei Darussalam, Cambodia, China, Cook Islands, Fiji, Japan, Kiribati, Lao People’s Democratic Republic, Malaysia, Marshall Islands, Micronesia (Federated States of), Mongolia, Nauru, New Zealand, Niue, Palau, Papua New Guinea, Philippines, Republic of Korea, Samoa, Singapore, Solomon Islands, Tonga, Tuvalu, Vanuatu, and Vietnam

Region of the Americas (AMR)

Eastern Mediterranean Region (EMR)

European Region (EUR)

South-East Asia Region (SEAR) Western Pacific Region (WPR)

where Pabs represents the proportion of ‘lifetime abstainers,’ Pform the proportion of ‘former drinkers,’ and Pcurrent(x) the probability distribution (grams of pure alcohol per day) function for current drinkers. RRform represents the RR for ‘former drinkers’ and RRcurrent(x) the RR function for a given average daily alcohol consumption in grams per day. A cap at an exposure of 150 g of pure alcohol was used as a conservative measure, as very few individuals consume more than this amount on a daily basis for an extended period of time.

Alcohol and the Risk of Ischemic Heart Disease The alcohol PAF for ischemic heart disease takes into consideration binge alcohol consumption and is calculated using the same formula as the one used for an average volume of alcohol consumption. However, for current drinkers who are also heavy episodic consumers (both chronic heavy episodic drinkers (people who consume five or more international standard alcoholic drinks per day (60 g of pure alcohol or more)) or nonchronic heavy episodic drinkers (people who do not consume on average five or more international standard drinks per day, but do so on at least one occasion monthly)) the RR for ischemic heart disease is 1 when compared to lifetime abstainers.

Alcohol and the Risk of Injury The alcohol PAFs for injuries were based on a time-at-risk model, taking into account the prevalence of current drinkers and the average alcohol consumption and binge alcohol consumption among current drinkers (see Shield et al., 2012). This model calculated the time a person was at risk

during both average drinking days and heavy drinking days (based on how much the person consumed during those days and on metabolism data (Shield et al., 2012)) and combined this calculation with the severity of the risk of an injury, compared to if the person did not drink (based on how much the person consumed during those days). The alcohol PAFs for injuries was then calculated based on the risk of injury for the entire population (using the risk information estimated as outlined above) as compared to a population where no one consumed alcohol. With respect to the WHO estimates of the burden of alcohol consumption (World Health Organization, 2014b), injuries to others caused by motor vehicle accidents were not calculated as data on passengers killed in motor vehicle accidents were not available.

Alcohol and Mortality from HIV/AIDS Alcohol has been shown to decrease adherence to highly active antiretroviral therapy (HAART) among people who have HIV/AIDS (Hendershot et al., 2009) and, therefore, the mortality from HIV/AIDS attributable to alcohol consumption was estimated based on the increased mortality that occurs when people do not adhere to their HAART. This calculation used data on the mortality rates of people who have HIV/AIDS who either adhered or did not adhere to their medication regimes, the percentage of people who were in need of HAART and received HAART, and the mortality rate of people who received HAART compared to those who did not receive HAART (see Gmel et al., 2011) for more information on the estimation of the alcohol PAF for HIV/AIDs mortality).

Burden of Disease and Injury Caused by Alcohol

Estimating the Alcohol-Attributable Burden of Disease and Injury The alcohol-attributable burden of disease and injury was derived using eqn [2]. AA burden ¼

nðzÞ X nðyÞ X nðiÞ X z¼1 y¼1 i¼1

PAFzyi  Burdenzyi

[2]

where AAburden represents the burden caused by alcohol consumption (either deaths, YLLs or YLDs); PAFzyi represents the alcohol PAF for gender z (male or female), age group y, and disease i; and Burdenzyi represents the burden (in either deaths, YLLs, or YLDs) of gender z, age group y, and disease i. The AAburden estimates were summed across countries to estimate the alcohol-attributable burden for both WHO regions and globally (World Health Organization, 2014a). All estimates of the alcohol-attributable burden are for 2012, using predicted country-level 2012 per capita alcohol consumption data. Most countries did not have data for the estimation of alcohol consumption and, therefore, predictions were based on per capita alcohol data from 2000 to 2010 using fractional polynomial regression with the year as the independent variable.

Consumption and the Alcohol-Attributable Burden: A Global Overview Global Patterns of Drinking Table 4 provides an overview of adult per capita consumption for 2012 by WHO region. There is wide variation in alcohol consumption from the global average of 6.8 l of pure alcohol consumed per adult per year (the equivalent of 14.7 g of pure alcohol per day). The countries with the highest overall consumption are Belarus, Moldova, Russia, and Ukraine, but other areas of Europe (EUR) also have high overall consumption. The Americas region (AMR) has the next highest overall consumption. Intermediate levels of consumption are found in the Western Pacific Region (WPR) and the African Region (AFR), while the lowest consumption levels are found in the South-East Asia Region (SEAR) and particularly in the Eastern

Table 4

303

Mediterranean Region (EMR). Furthermore, worldwide, almost one-quarter (22.8%) of all alcohol consumed is in the form of unrecorded alcohol. The percentage of all alcohol consumption from unrecorded sources also varied by region, with the EMR having the greatest proportion of all such alcohol (52.3%), followed by the SEAR (41.0%). In 2012, 61.9% of all adults globally (53.0% of men and 70.9% of women) did not consume alcohol in the past 12 months (Table 4). Furthermore, almost one-half of the global adult population (48.3%) had never consumed alcohol, while 38.1% of the global adult population had consumed alcohol within the past year. The prevalence of abstainers, former drinkers, and current drinkers varied by region, with Belarus, Moldova, Russia, and Ukraine having the highest prevalence of current drinkers, followed by EUR (excluding Belarus, Moldova, Russia, and Ukraine), and the AMR. The prevalence of past year abstention was the highest in the EMR, with 94.5% of adults abstaining from alcohol in the past year, followed by the SEAR, with 86.5% of adults abstaining from alcohol in the past year. Table 5 outlines the prevalence of heavy episodic drinkers by WHO region among adults in 2012. Worldwide, approximately 11.4% of adult drinkers engaged in heavy episodic drinking and approximately 4.3% of all adults engaged in heavy episodic drinking. Belarus, Moldova, Russia, and Ukraine had the highest prevalence of heavy episodic drinking, with 14.0% of all adults and 20.5% of all adult drinkers engaging in heavy episodic drinking, followed by EUR (excluding Belarus, Moldova, Russia, and Ukraine) and by the AMR. The EMR had the lowest prevalence of heavy episodic drinking, with less than 0.1% of all adult drinkers and less than 0.01% of all adults engaging in heavy episodic drinking.

Burden of Disease and Injury Attributable to Alcohol Consumption In 2012 the number of deaths caused by alcohol consumption far exceeded the number prevented. Table 6 outlines the deaths attributable to alcohol consumption by cause for 2012. While 5.9% of all global deaths in 2012 were attributable to alcohol,

Per capita consumption of alcohol and prevalence of lifetime abstainers, former drinkers, and current drinkers for 2012 by WHO region Percentage of lifetime abstainers

WHO region Africa Americas Eastern Mediterranean Europe Excluding (BLR, MDA, RUS, and UKR) Only (BLR, MDA, RUS and UKR) South-East Asia Western Pacific World

Percentage of former drinkers

Percentage of current drinkers

Adult total per capita alcohol consumption (in liters of pure alcohol)

Unrecorded consumption (In liters of pure alcohol)

Adult population (1000s)

Men

513 073 723 380 402 642

45.8% 68.9% 10.8% 26.7% 86.5% 93.3%

57.5% 14.0% 11.5% 19.0% 18.5% 20.6% 89.8% 6.0% 3.4%

12.7% 40.2% 19.6% 19.6% 70.7% 52.7% 4.8% 7.5% 3.3%

29.8% 5.9 61.4% 8.4 5.5% 0.7

1.8 1.2 0.4

574 673

15.9% 29.9%

23.2% 11.3% 11.2%

11.3% 72.7% 58.8%

65.6% 9.3

1.2

171 044

6.9%

18.0%

13.0% 18.0% 19.1%

18.6% 75.2% 62.8%

68.4% 14.8

4.0

1 302 773 1 492 484 5 186 326

63.8% 89.9% 24.9% 49.8% 38.4% 58.2%

76.7% 14.5% 5.1% 37.2% 16.3% 17.9% 48.3% 14.6% 12.7%

9.9% 21.7% 5.0% 17.1% 58.8% 32.3% 13.6% 47.0% 29.1%

13.5% 4.0 45.7% 8.4 38.1% 6.8

1.6 1.7 1.5

Women Total

Men

Women Total

Men

Women Total

304

Burden of Disease and Injury Caused by Alcohol

Prevalence of heavy episodic drinkers by WHO region for 2012

Table 5

WHO region Africa Americas Eastern Mediterranean Europe Excluding (BLR, MDA, RUS, and UKR) Only (BLR, MDA, RUS, and UKR) South-East Asia Western Pacific World

Table 6

Heavy episodic drinkers among current drinkers

Heavy episodic drinkers (total population)

Adult population (1000s)

Men

Women

Total

Men

Women

Total

513 073 723 380 402 642

11.6% 21.2% 0.1%

3.1% 7.5% 0.0%

7.3% 14.1% 0.1%

4.7% 15.0% 0.0%

0.6% 3.9% 0.0%

2.2% 8.7% 0.0%

574 673 171 044 1 302 773 1 492 484 5 186 326

25.3% 32.3% 3.2% 14.5% 16.8%

10.8% 10.7% 0.1% 1.9% 6.1%

17.9% 20.5% 1.7% 8.2% 11.4%

18.4% 24.3% 0.7% 8.5% 7.9%

6.3% 6.7% 0.0% 0.6% 1.8%

11.7% 14.0% 0.2% 3.8% 4.3%

Deaths (in 1000) attributable to alcohol consumption globally in 2012

Disease category

Men

Women

Total

Tuberculosis HIV/AIDS Lower respiratory infections Preterm birth complications Neoplasms Mouth and oropharynx cancers Esophagus cancer Colon and rectum cancers Liver cancer Pancreas cancer Breast cancer Other malignant neoplasms Diabetes mellitus Alcohol use disorders Epilepsy Cardiovascular diseases Hypertensive heart disease Ischemic heart disease Hemorrhagic stroke Ischemic stroke Other circulatory diseases Digestive diseases Cirrhosis of the liver Other digestive diseases Injuries Road injury Poisonings Falls Fire Drowning Other unintentional Self-harm Interpersonal violence Total alcohol-attributable deaths ‘caused’ Total alcohol-related deaths ‘prevented’ Net alcohol-attributable deaths ‘caused’

93 18 81 2 306 80 78 50 72 9 0 17 2 86 18 499 70 112 246 64 7 375 355 20 778 174 30 101 24 46 138 161 104 2257 2 2255

16 4 50 2 103 10 11 22 15 4 41 1 29 21 5 629 25 417 133 46 8 158 154 4 70 13 4 9 5 4 15 14 7 1059 29 1031

109 22 132 3 410 90 89 72 86 13 41 18 31 107 24 1128 95 529 379 110 15 533 509 24 849 187 34 109 29 50 154 175 111 3316 31 3285

the percentage of such deaths was higher among men (7.6%) than among women (4.0%). This difference in mortality between men and women is expected given the differences observed in the average volume of consumption and the

Men % of all AA deaths

Women % of all AA deaths

Total % of all AA deaths

4.1% 0.8% 3.6% 0.1% 13.6% 3.6% 3.5% 2.2% 3.2% 0.4% 0.0% 0.8% 0.1% 3.8% 0.8% 22.2% 3.1% 5.0% 10.9% 2.9% 0.3% 16.6% 15.8% 0.9% 34.5% 7.7% 1.4% 4.5% 1.1% 2.0% 6.1% 7.1% 4.6%

1.6% 0.4% 4.9% 0.1% 10.0% 0.9% 1.1% 2.1% 1.4% 0.4% 4.0% 0.1% 2.8% 2.1% 0.5% 61.0% 2.4% 40.5% 12.9% 4.5% 0.8% 15.3% 14.9% 0.4% 6.8% 1.3% 0.4% 0.9% 0.4% 0.3% 1.5% 1.4% 0.6%

3.3% 0.7% 4.0% 0.1% 12.5% 2.7% 2.7% 2.2% 2.6% 0.4% 1.3% 0.6% 0.9% 3.3% 0.7% 34.3% 2.9% 16.1% 11.5% 3.4% 0.5% 16.2% 15.5% 0.7% 25.8% 5.7% 1.0% 3.3% 0.9% 1.5% 4.7% 5.3% 3.4%

prevalence of heavy episodic drinking; men consumed more alcohol than did women and in a much more harmful manner. The top contributors to the mortality burden caused by alcohol were cardiovascular diseases (34.3%), injuries (25.8%),

Burden of Disease and Injury Caused by Alcohol

Table 7

305

Years of life lost (YLLs) (in 1000) attributable to alcohol consumption globally in 2012

Disease category

Men

Women

Total

Tuberculosis HIV/AIDS Lower respiratory infections Preterm birth complications Neoplasms Mouth and oropharynx cancers Esophagus cancer Colon and rectum cancers Liver cancer Pancreas cancer Breast cancer Other malignant neoplasms Diabetes mellitus Alcohol use disorders Epilepsy Cardiovascular diseases Hypertensive heart disease Ischemic heart disease Hemorrhagic stroke Ischemic stroke Other circulatory diseases Digestive diseases Cirrhosis of the liver Other digestive diseases Injuries Road injury Poisonings Falls Fire Drowning Other unintentional Self-harm Interpersonal violence Total alcohol-attributable YLLs ‘caused’ Total alcohol-related YLLs ‘prevented’ Net alcohol-attributable YLLs ‘caused’

3 382 870 2 119 178 8 904 2 624 2 081 1 241 2 220 238 0 500 37 3 339 891 11 720 1 628 2 365 6 330 1 288 108 13 562 12 793 769 35 060 8 156 1 335 3 314 1 067 2 154 5 861 7 393 5 781 37 80 026 79 989

630 206 1 096 139 2 861 300 255 507 385 88 1 304 22 649 777 235 11 153 635 6 407 3 308 714 89 5 043 4 909 134 2 789 587 151 239 179 151 575 585 323 649 24 929 24 280

4 012 1 076 3 216 317 11 764 2 924 2 336 1 748 2 605 326 1 304 523 686 4 116 1 126 22 873 2 263 8 772 9 638 2 002 197 18 605 17 702 903 37 850 8 743 1 486 3 553 1 245 2 305 6 436 7 978 6 104 686 104 955 104 269

digestive diseases (16.2%), and neoplasms (12.5%); however, the amount each cause of death contributed to the total mortality burden attributable to alcohol differed by sex, with cardiovascular deaths accounting for the most alcoholattributable deaths among women (61.0%) and injury deaths accounting for the most alcohol-attributable deaths among men (34.5%). The global burden of alcohol-attributable YLLs for 2012 is outlined in Table 7. In 2012, 5.2% of all YLLs were attributable to alcohol consumption, with 7.1% of all YLLs attributable to alcohol consumption among men and 2.8% of all YLLs attributable to alcohol consumption among women. Furthermore, the top contributing causes to the burden of alcoholattributable YLLs in 2012 differed from the top contributing causes for alcohol-attributable deaths. In 2012, injuries were the leading causes of all alcohol-attributable YLLs (36.3%), followed by cardiovascular diseases (21.9%), digestive diseases (17.8%), and neoplasms (11.3%). The differing contributions of these causes to the burden of alcohol-attributable YLLs are dependent on the time of death; injuries due to alcohol tend

Men % of all AA YLLs

Women % of all AA YLLs

Total % of all AA YLLs

4.2% 1.1% 2.6% 0.2% 11.1% 3.3% 2.6% 1.6% 2.8% 0.3% 0.0% 0.6% 0.0% 4.2% 1.1% 14.7% 2.0% 3.0% 7.9% 1.6% 0.1% 17.0% 16.0% 1.0% 43.8% 10.2% 1.7% 4.1% 1.3% 2.7% 7.3% 9.2% 7.2%

2.6% 0.8% 4.5% 0.6% 11.8% 1.2% 1.1% 2.1% 1.6% 0.4% 5.4% 0.1% 2.7% 3.2% 1.0% 45.9% 2.6% 26.4% 13.6% 2.9% 0.4% 20.8% 20.2% 0.6% 11.5% 2.4% 0.6% 1.0% 0.7% 0.6% 2.4% 2.4% 1.3%

3.8% 1.0% 3.1% 0.3% 11.3% 2.8% 2.2% 1.7% 2.5% 0.3% 1.3% 0.5% 0.7% 3.9% 1.1% 21.9% 2.2% 8.4% 9.2% 1.9% 0.2% 17.8% 17.0% 0.9% 36.3% 8.4% 1.4% 3.4% 1.2% 2.2% 6.2% 7.7% 5.9%

to occur in people who are relatively young, and cardiovascular diseases due to alcohol typically affect people who are older. In 2012, men experienced approximately 3.3 times more alcohol-attributable YLLs than did women. There are, however, also proportional variations by sex in how much each disease category contributed to the overall alcohol-attributable burden of YLLs. Specifically, cardiovascular diseases, liver cirrhosis, and lower respiratory infections contributed proportionally more to the alcohol-attributable burden of YLLs for women than these causes contributed to the burden of YLLs for men. This difference is due to the burden of injuries in men contributing proportionally much more to the alcohol-attributable burden of disease and injury among men than this cause did among women. Additionally, the amount of YLLs prevented among women in 2012 was over 10 times the number of YLLs prevented among men. In 2012, 5.1% of DALYs lost were attributable to alcohol, with 7.4% of all DALYs lost among men being attributable to alcohol and 2.3% of all DALYs lost among women being attributable to alcohol. Table 8 outlines the global

306

Burden of Disease and Injury Caused by Alcohol

Table 8

Disability-adjusted life years (DALYs) lost (in 1000) attributable to alcohol consumption globally in 2012

Disease category

Men

Women

Total

Tuberculosis HIV/AIDS Lower respiratory infections Preterm birth complications Neoplasms Mouth and oropharynx cancers Esophagus cancer Colon and rectum cancers Liver cancer Pancreas cancer Breast cancer Other malignant neoplasms Diabetes mellitus Alcohol use disorders Epilepsy Cardiovascular diseases Hypertensive heart disease Ischemic heart disease Hemorrhagic stroke Ischemic stroke Other circulatory diseases Digestive diseases Cirrhosis of the liver Other digestive diseases Injuries Road injury Poisonings Falls Fire Drowning Other unintentional Self-harm Interpersonal violence Total alcohol-attributable DALYs ‘caused’ Total alcohol-related DALYs ‘prevented’ Net alcohol-attributable DALYs ‘caused’

4 238 928 2 178 184 9 047 2 675 2 097 1 284 2 236 239 0 516 90 27 021 1 621 11 776 1 655 2 094 6 417 1 344 267 13 742 12 927 815 39 136 9 423 1 379 4 975 1 183 2 182 6 608 7 431 5 954 90 109 871 109 781

761 220 1 135 145 2 976 307 257 526 388 89 1 387 23 1,261 4 986 521 11 087 651 6 278 3 286 719 154 5 157 5 011 146 3 502 758 157 600 202 155 703 592 336 1,261 30 490 29 230

4 999 1 148 3 313 329 12 023 2 982 2 354 1 810 2 623 328 1 387 539 1,351 32 007 2 142 22 863 2 306 8 372 9 703 2 063 420 18 899 17 938 961 42 638 10 181 1 537 5 575 1 385 2 337 7 310 8 022 6 291 1,351 140 361 139 011

alcohol-attributable DALYs lost by cause for 2012. The greatest difference between alcohol-attributable deaths, YLLs, and DALYs lost is the high contribution of alcohol use disorders to the overall alcohol-attributable burden of DALYs lost. Alcohol use disorders are the second greatest contributor to the alcohol-attributable burden of DALYs lost (23.0% of all alcohol-attributable DALYs lost were due to injuries: 24.6% of all alcohol-attributable DALYs lost among men and 17.1% of all alcohol-attributable DALYs lost among women), with injuries being the top contributor. However, it should be noted that the number of DALYs lost due to alcohol use disorders among men was 5.4 times the number of DALYs lost caused by alcohol use disorders among women.

Burden by WHO Region Among people of all ages, Belarus, Moldova, Russia, and Ukraine in 2012 had the greatest percentage of all deaths, YLLs, and DALYs that were attributable to alcohol consumption, with 31.6% of all deaths, 30.2% of all YLLs, and 34.9% of all DALYs lost being attributable to alcohol consumption

Men % of all AA DALYs

Women % of all AA DALYs

Total % of all AA DALYs

3.9% 0.8% 2.0% 0.2% 8.2% 2.4% 1.9% 1.2% 2.0% 0.2% 0.0% 0.5% 0.1% 24.6% 1.5% 10.7% 1.5% 1.9% 5.8% 1.2% 0.2% 12.5% 11.8% 0.7% 35.6% 8.6% 1.3% 4.5% 1.1% 2.0% 6.0% 6.8% 5.4%

2.6% 0.8% 3.9% 0.5% 10.2% 1.0% 0.9% 1.8% 1.3% 0.3% 4.7% 0.1% 4.3% 17.1% 1.8% 37.9% 2.2% 21.5% 11.2% 2.5% 0.5% 17.6% 17.1% 0.5% 12.0% 2.6% 0.5% 2.1% 0.7% 0.5% 2.4% 2.0% 1.2%

3.6% 0.8% 2.4% 0.2% 8.6% 2.1% 1.7% 1.3% 1.9% 0.2% 1.0% 0.4% 1.0% 23.0% 1.5% 16.4% 1.7% 6.0% 7.0% 1.5% 0.3% 13.6% 12.9% 0.7% 30.7% 7.3% 1.1% 4.0% 1.0% 1.7% 5.3% 5.8% 4.5%

in these countries. The burden in these countries was far greater than the alcohol-attributable burden globally, where in 2012, 5.9% of all deaths, 5.2% of all YLLs, and 5.1% of all DALYs lost were caused by alcohol consumption. Figure 2 outlines the percentage of all deaths, YLLs, and DALYs lost attributable to alcohol consumption by WHO region for 2012. The EMR had the lowest percentage of all deaths, YLLs, and DALYs lost attributable to alcohol consumption, with 0.9% of all deaths, 0.7% of all YLLs, and 0.6% of all DALYs lost in 2012 being attributable to alcohol consumption. Proportionally, the percentage of the total burden of deaths, YLLs, and DALYs lost that were attributable to alcohol consumption in 2012 was higher among people 0–69 years of age than it was for people of all ages, particularly in the case of deaths attributable to alcohol consumption, with 6.7% of all deaths, 5.2% of all YLLs, and 5.2% of all DALYs lost among people 0–69 years of age being attributable to alcohol consumption. Figure 3 outlines the percentage of all deaths, YLLs, and DALYs attributable to alcohol consumption by region for 2012 for people 0–69 years of age. The difference in the percentage of all deaths attributable to alcohol

307

Burden of Disease and Injury Caused by Alcohol

Percent of burden aributable to alcohol consumpon

40.0% 34.9% 35.0% 31.6%

30.2%

30.0% 25.0% 20.0% 15.0% 10.0% 5.9% 3.3%

5.0%

4.7%

4.6%

4.6%

5.9%

7.1%

Figure 2

2.4% 0.6%

YLLs AMR

AFR

EMR

DALYs

EUR (except BLR, MDA, RUS and UKR)

BLR, MDA, RUS and UKR

SEAR

WPR

Percentage of total health burden attributable to alcohol consumption by WHO region in 2012.

40.0% Percent of burden aributable to alcohol consumpon

6.6%

5.6% 4.0%

0.7%

Deaths World

6.7% 5.1%

4.4% 2.4%

0.9% 0.0%

6.8%

6.7%

5.2%

36.5%

35.0% 29.3%

28.9%

30.0% 25.0% 20.0% 15.0% 10.0% 5.0%

9.6%

8.6% 6.7%

8.9% 5.6%

9.4%

8.9% 5.2%

3.3%

4.6% 2.3%

0.9%

8.1%

8.0%

7.7%

7.2%

5.2%

4.2% 2.4%

0.7%

0.6%

0.0% Deaths

YLLs

DALYs

Burden World

Figure 3

AFR

AMR

EMR

EUR (except BLR, MDA, RUS and UKR)

BLR, MDA, RUS and UKR

SEAR

WPR

Percentage of total health burden attributable to alcohol consumption by WHO region for those 0–69 years of age in 2012.

consumption among those 0–69 years of age was the most pronounced in EUR (excluding Belarus, Moldova, Russia, and Ukraine), where the percentage of all alcohol-attributable deaths in this age group was 2.1 times the percentage of all alcohol-attributable deaths among people of all ages, followed by the AMR where the percentage of all alcohol-attributable deaths among people 0–69 years of age was 1.8 times the percentage of all alcohol-attributable deaths among people of all ages.

Conclusions and Implications Alcohol creates a large burden of deaths, YLLs, and DALYs lost globally, and its role as one of the most important risk factors for the global burden of disease and injury needs to be addressed. The burden of alcohol consumption in 2012 was caused primarily by injuries, cardiovascular diseases, digestive

diseases, neoplasms, and alcohol use disorders. The average volume of alcohol consumption and heavy episodic drinking show wide variations by gender and by region. Additionally, the resulting health burden caused by alcohol consumption shows wide variation by cause of death, YLLs, and DALYs lost, and by gender and region. Given current trends in exposure, with expected increases in alcohol consumption in developing countries (Shield et al., 2011), and increases in the burden of outcomes that are causally related to alcohol consumption, such as the burden caused by noncommunicable diseases (Parry et al., 2011; World Health Organization, 2011), the detrimental impact of alcohol is expected to increase in the future in developing countries and effective interventions should be introduced in these countries.

See also: Alcohol Consumption: An Overview of International Trends; Alcohol Consumption: The Social and Economic Impacts; Alcohol Industry; Alcohol: Treatment.

308

Burden of Disease and Injury Caused by Alcohol

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Further Reading English, D., Holman, C., Milne, E., et al., 1995. The Quantification of Drug Caused Morbidity and Mortality in Australia 1995. Commonwealth Department of Human Services and Health, Canberra, Australia. Ezzati, M., Lopez, A.D., Rodgers, A., et al., 2004. Comparative Quantification of Health Risks. Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. WHO, Geneva. Lopez, A.D., Mathers, C.D., Ezzati, M., et al., 2006. Global Burden of Disease and Risk Factors. Oxford University Press and The World Bank, New York & Washington. Rehm, J., Room, R., Monteiro, M., et al., 2004. Alcohol use. In: Ezzati, M., Lopez, A., Rodgers, A., Murray, C. (Eds.), Comparative Quantification of Health Risks, Global and Regional Burden of Disease Attributable to Selected Major Risk Factors, vol. 1. WHO, Geneva, pp. 959–1108. Ridolfo, B., Stevenson, C., 2001. The Quantification of Drug-Caused Mortality and Morbidity in Australia 1998. Australian Institute of Health and Welfare, Canberra.

Relevant Website www.who.int/globalatlas/alcohol – WHO, Global Atlas, Alcohol.