The burden caused by alcohol

Presentation at REDUCING THE HARM CAUSED BY ALCOHOL: A COORDINATED EUROPEAN RESPONSE

Tuesday, November 13

Jürgen Rehm

Centre for Addiction and Mental Health, Toronto, Canada

University of Toronto, Canada

Technische Universität Dresden, Deutschland

WHO Collaborating Centre on Substance Abuse, Zürich, Schweiz

Alcohol is different from other risk factors…

• Social harm may outweigh the health harm!

• Acute (e.g. traffic accidents) and chronic (e.g. liver cirrhosis) health consequences

• Beneficial vs. detrimental impacts

• More than 70 different disease outcomes related to alcohol

• Only three important outcomes have beneficial link to alcohol, restricted to certain age groups (40 plus or 50 plus) and patterns

• Different sign and value of impact by different characteristics of alcohol– average volume of alcohol consumption

– patterns of drinking

– Quality of alcoholic beverages

• Alcohol level associated to minimum risk depends on disease

• Impact of other risk factors (e.g. alcohol impact in under-nourished persons is potentiated)

Basic causal model of alcohol consumption, intermediate mechanisms, and long-term consequences (from Rehm

et al., 2003; Babor et al., 2003)

Chronic Disease

Accidents/Injuries

(acute disease)

Acute Social

ChronicSocial

IntoxicationToxic and

benefical biochemical

effects*Dependence

Patterns of drinking Average volume

* Independent of intoxication or dependence

Conditions with alcohol-attributable fractions of 100%

Alcoholic psychoses, Alcohol dependence syndrome,

Harmful alcohol use, Alcoholic polyneuropathy, Alcoholic cardiomyopathy, Alcoholic gastritis, Alcoholic fatty liver,

Acute alcoholic hepatitis, Alcoholic cirrhosis of liver, Alcoholic liver damage, unspecific, Alcoholic hepatic

failure, Fetal alcohol syndrome, Excess blood alcohol,

Accidental poisoning and exposure to alcohol, Ethanol and methanol toxicity

Practically there may be no reliable data in many countries on

some subcategories, and the relation to alcohol may have to be determined based on RR (e.g., for liver cirrhosis as wider

category)

Relation of alcohol to disease in terms of relative risk for average

volume

• Identification of more than 70 diseases by ICD-10 codes related to alcohol based on epidemiological and

biochemical literature (mainly based on relations to

average volume of alcohol consumption applying usual causal criteria with more weight on consistency and

biological plausibility; in total more than 5000 references checked)

• Identification of RR for different levels of average volume

by sex and age by meta-analyses from different groups of researchers

• RR can be < 1 (e.g. CHD), depending on the level of alcohol exposure; risk curves for all except injury codes

Main chronic disease categories related toaverage volume and kind of relative risk

Cancer:• Lip & oropharyngeal

cancer, Esophageal

cancer, Liver cancer,

Laryngeal cancer,

Colorectal cancer, Female breast cancer

• Usual linear risk

relationship between average

volume of alcohol

consumption and risk

• Other cancers show

consistent risk relationships,

but do not qualify for other

criteria of causality

Typical risk curves for cancer(Corrao et al., 2004)

Main chronic disease categories related to average volume and kind of relative risk II

Diabetes:• Curvilinear relationship, partly protective

• may depend on patterns

Gastrointestinal diseases:• Esophageal varices, Gastro-esophageal hemorrhage, Liver

cirrhosis, Cholelithiasis, Acute pancreatitis, Chronic pancreatitits

• Often exponential relationship

Conditions arising during perinatal period:• Spontaneous abortion, Low birth weight, Psoriasis, Prematurity,

Intrauterine growth-retardation

•Deviation from usual model (drinking of mother is causing the disease in children -> different epidemiological model)

Influence of pattern

• 20 grams of pure alcohol per day on average can be achieved by 2dl of wine every day with meals or by 2 bottles of wine every Friday night

���� different impact on disease and injury risk• CHD, other CVD conditions (modeled) • all kinds of injuries, which are influenced by intoxication and

acute drinking before the event (modeled) • Liver cirrhosis (not yet modeled)

• Patterns can be thought of as a weighting factor influencing the outcome of average volume (main effect)

Patterns and acute consequences.... (one example)

Relative risk of accident by blood alcohol concentration

0

2

4

6

8

10

12

0.002 0.025 0.06 0.09 0.13

Blood alcohol concentration

Re

lati

ve

ris

k

Source: Hurst et al. (1994) Accident Analysis and prevention,

26(5): 647-654

Alcohol and injury –more public health relevant problems!

Conclusion on patterns and CHD I

• Alcohol can have detrimental and beneficial effects depending on the pattern and volume of drinking

• Important considerations:– Volume

– Heavy drinking occasions (Binge drinking is not protective for any heart!)

– Regularity

– With or outside of meals

• The overall relation in one country depends on the mix of drinking patterns

Conclusion on patterns and CHD II

• CHD is very important cause of disease and thus important in determining health policy (and influencing

health policy makers)

• Alcohol to CHD relation is complex

• Need to know exactly what proportion of population

drinks how to predict outcome

• Better and standardized pattern measures necessary!

• But conclusions can tentatively be drawn today: alcohol in many parts of the world is consumed in a way that it is

detrimental to CHD

• How to determine patterns weights for CHD for CRA?

Alcohol related disease and injury (major categories)

Chronic disease:Cancer: Mouth & oropharyngeal cancer, esophageal cancer,

liver cancer, female breast cancer, colorectal cancer Neuropsychiatric diseases: Alcohol use disorders, unipolar

major depression, epilepsy

DiabetesCardiovascular diseases: Hypertensive diseases, coronary

heart disease, strokeGastrointestinal diseases: Liver cirrhosis

Conditions arising during perinatal period: Low birth weight

Injury:Unintentional injury: Motor vehicle accidents, drownings, falls, poisonings, other unintentional injuries

Intentional injury: Self-inflicted injuries, homicide, other

intentional injuries

Volume of drinking

Depression was estimated differently based on alcohol dependence and temporal sequence from surveys.

Drinking pattern

hazard score

(predominance of

intoxication)

Other chronicDiseases (except

CHD and depression)

Coronaryheart

diseaseInjuries

100% alcohol-attributableconditions (by definition):e.g. alcohol dependence

Estimation of AAF for different disease categories

Adult per capita consumption inlitre pure alcohol 2002

Average per capita alcohol consumption in litres pure alcohol, 2002

0 - 3

3 - 6

6 - 9

9 - 12

12 - 15

15 - 25

Adult per capita consumption in litres pure alcohol, EU 2002

8Ltr - 10Ltr

10Ltr - 12Ltr

12Ltr - 14Ltr

14Ltr - 16Ltr

15Ltr - 18Ltr

Overall per capita recorded and unrecorded alcohol consumption in litres pure alcohol,

Europe, 2002

• Alcohol consumption in Europe is comparatively

high

• No systematic East-West

differences

• Differences in unrecorded

consumption

• Source: http://www.who.int/global

atlas/default.asp

Patterns of drinking 2002

Patterns of drinking

1 - 2

2 - 2.5

2.5 - 3.5

3.5 - 4

Patterns of drinking in Europe

• Patterns of drinking are different between East

and West

• More irregular binge

drinking in EU10

• More spirits in EU10, but overall beer being the

preferred beverage in EU

• More problems with

quality of beverages in EU10

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Drinking Pattern, EU 2002

1

2

3

Alcohol-attributable global burden of disease

Alcohol-attributable mortality

0.35 to 1.00

1.00 to 4.00

4.00 to 6.00

6.00 to 8.00

8.00 to 20.00

Alcohol-attributable DALYs

All numbers are based on net burden!

Alcohol-attributable mortality in different countries

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Alcohol-attributable deaths, males, 20-64

050100150200250300350400

Netherlands

Greece

Sweden

Italy

Spain

Belgium

United Kingdom

Ireland

EU15

Austria

Portugal

Germany

Luxembourg

Bulgaria

France

Denmark

Czech Republic

Slovenia

Finland

Poland

EU10

Slovakia

Romania

Latvia

Hungary

Lithuania

Estonia

Russia

Rates per 100,000 population

Alcohol-attributable deaths, females, 20-64

0 50 100 150 200 250 300 350 400

Bulgaria

Greece

Sweden

Spain

Italy

Netherlands

Poland

Ireland

Portugal

United Kingdom

Belgium

Czech Republic

EU15

Austria

Luxembourg

France

EU10

Germany

Slovenia

Romania

Finland

Slovakia

Denmark

Latvia

Estonia

Lithuania

Hungary

Russia

Rates per 100,000 population

What are main alcohol-attributable causes of premature death in Europe?

1. Unintentional and intentional injury

2. Liver cirrhosis

3. Cardiovascular diseases (protective effect of regular moderate drinking vs. detrimental effect of binge

drinking)

4. Cancer: Mouth & oropharyngeal cancer, esophageal

cancer, liver cancer, colorectal cancer, breast

cancer

Overall 15.3% all premature deaths in Central and Eastern European countries of the EU (19.1% M, 6.6% F), and 12.5% in EU15 are caused by alcohol (15.1% M, 7.5% F).

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Conclusions

• Alcohol is major risk factor for premature mortality and morbidity in EU, more for men than for women

• Alcohol-attributable deaths and burden of disease are higher in the Central and Eastern European countries than EU 15

• Alcohol-attributable health harm is only one part of overall harm by alcohol

Disease conditions Men Women Total% of all alcohol-

attributable deaths

Maternal and perinatal conditions (low birth weight)

1 1 3 0.1%

Cancer 361 105 466 22.0%

Neuro-psychiatric disorders 106 25 130 6.1%

Cardiovascular diseases 361 -53 308 14.5%

Other non-communicable diseases (diabetes, liver cirrhosis)

285 73 359 16.9%

Unintentional injuries 501 96 597 28.1%

Intentional injuries 220 40 260 12.3%

Alcohol-attributable mortality burden all causes

1,836 287 2,123 100.0%

All deaths 29,891 27,138 57,029 In comparison: estimate for

2000: 3.2%% of all deaths which are alcohol-attributable

6.1% 1.1% 3.7%

Global mortality burden (deaths in 1000s) attributable to alcohol by major disease categories - 2002

Disease conditions Men Women Total% of all alcohol-

attributable DALYs

Maternal and perinatal conditions (low birth weight)

52 42 94 0.1%

Cancer 4,593 1,460 6,054 9.3%

Neuro-psychiatric conditions 19,393 3,722 23,115 35.6%

Cardiovascular diseases 4, 877 -318 4,558 7.0%

Other non-communicable diseases (diabetes, liver cirrhosis)

5,190 1,402 6,592 10.2%

Unintentional injuries 14,499 2,647 17,146 26.4%

Intentional injuries 6,366 1,051 7,417 11.4%

Alcohol-attributable disease burden all causes (DALYs)

54,970 10,006 64,975 100%

All DALYs 772,912 717,213 1,490,126 In comparison: estimate for

2000: 4.0%% of all DALYs which are alcohol-attributable

7.1% 1.4% 4. 4%

Global burden of disease (DALYs in 1000s) attributable to alcohol by major disease categories - 2002