Estimating alcohol’s role in disease & disability: the alcohol component in WHO’s Global Burden of Disease analysis for 2000 David Jernigan Center on Alcohol Marketing and Youth Georgetown University

WHO’s Comparative Risk Assessment Collaborating Group 27 groups: 27 groups: Core, metholodology, etc. GroupCore, metholodology, etc. Group 26 risk factor groups26 risk factor groups Alcohol group: Alcohol group: J Rehm, R Room, M Monteiro, G Gmel, K Graham, N Rehn, C T Sempos, U Frick, D JerniganJ Rehm, R Room, M Monteiro, G Gmel, K Graham, N Rehn, C T Sempos, U Frick, D Jernigan

The 26 risk factors, roughly grouped Childhood and maternal undernutrition: underweight, iron deficiency, vitamin A deficiency, zinc deficiency; Childhood and maternal undernutrition: underweight, iron deficiency, vitamin A deficiency, zinc deficiency; Other diet-related risks and physical inactivity: blood pressure, cholesterol, overweight, low fruit and vegetable intake, physical inactivity; Other diet-related risks and physical inactivity: blood pressure, cholesterol, overweight, low fruit and vegetable intake, physical inactivity; Sexual and reproductive health risks: unsafe sex, lack of contraception; Sexual and reproductive health risks: unsafe sex, lack of contraception; Addictive substance use: tobacco, alcohol, illicit drugs; Addictive substance use: tobacco, alcohol, illicit drugs; Environmental risks: unsafe water, sanitation and hygiene, urban air pollution, indoor smoke from solid fuels, lead exposure, climate change; Environmental risks: unsafe water, sanitation and hygiene, urban air pollution, indoor smoke from solid fuels, lead exposure, climate change; Occupational risks: risk factors for injury, carcinogens, airborne particulates, ergonomic stressors, noise; Occupational risks: risk factors for injury, carcinogens, airborne particulates, ergonomic stressors, noise; Other selected risks to health: unsafe health care injections, childhood sexual abuse. Other selected risks to health: unsafe health care injections, childhood sexual abuse.

The epidemiological model Attributable fractions =f(prevalence,pattern weight,relative risk) Defined as: With a given outcome exposure factor, and population, the attributable fraction is the proportion by which the incidence rate of the outcome would be reduced if the distribution of exposure would change to an alternative distribution: “When an exposure is believed to be a cause of a given disease, the attributable fraction is the proportion of the disease in the specific population that would be eliminated in the absence of the exposure.” Four drinking categories (old English et al. terminology: abstainer, moderate, hazardous, harmful) are distinguished. Prevalence for all four categories are taken from surveys Steps to derive at pattern weight: 1. Determine pattern value from survey of key informants, and/or survey data where available. 2. Conduct hierarchical linear analyses on mortality using per capita consumption gross-national product, year (level 1 variables) and pattern values (level 2 variable) as determining factors (separate by age and sex). 3. Construct pattern weight based on intercept and regression weight for patterns. Relative Risk estimates for each drinking category are either taken directly from meta- analyses (chronic diseases) or indirectly from meta-analyses of attributable fractions (injuries)

Patterns of drinking Countries assigned hazardous drinking scores, a numeric indicator of hazard per litre of alcohol consumed Countries assigned hazardous drinking scores, a numeric indicator of hazard per litre of alcohol consumed Information drawn from research literature supplemented by key informant questionnaires Information drawn from research literature supplemented by key informant questionnaires Applied to two areas: injuries and CHD. Applied to two areas: injuries and CHD.

Dimensions of patterns of drinking High usual quantity of alcohol per occasion Festive drinking common – at fiestas or community celebrations Proportion of drinking occasions when drinkers get drunk Low proportion of drinkers who drink daily or nearly daily Less common to drink with meals Common to drink in public places

Pattern of drinking 2000 (based on CRA) Patterns of drinking 1.00 to to to to 4.00

Volume of drinking Drinking pattern hazard score (predominance of intoxication) Prior alcohol dependence Depression Injuries Coronary heart disease Physical diseases (except CHD) Alcohol- attributable conditions* Aspects of alcohol used in estimating alcohol attributable fraction (AAF) for different conditions *AAF = 1 by definition

Alcohol-related disorders Chronic disease: Chronic disease: Conditions arising during perinatal period*: low birth weightConditions arising during perinatal period*: low birth weight Cancer*: lip & oropharyngeal cancer, esophageal cancer, liver cancer, laryngeal cancer, female breast cancerCancer*: lip & oropharyngeal cancer, esophageal cancer, liver cancer, laryngeal cancer, female breast cancer Neuropsychiatric diseases: alcohol use disorders, unipolar major depression, epilepsyNeuropsychiatric diseases: alcohol use disorders, unipolar major depression, epilepsy Diabetes*Diabetes* Cardiovascular diseases: hypertension, coronary heart disease, strokeCardiovascular diseases: hypertension, coronary heart disease, stroke Gastrointestinal diseases*: liver cirrhosisGastrointestinal diseases*: liver cirrhosis Injury: Injury: Unintentional injury: motor vehicle accidents, drownings, falls, poisonings, other unintentional injuriesUnintentional injury: motor vehicle accidents, drownings, falls, poisonings, other unintentional injuries Intentional injury: self-inflicted injuries, homicide, other intentional injuriesIntentional injury: self-inflicted injuries, homicide, other intentional injuries * AAF based on volume of drinking only

Estimating AAFs 1. Alcohol-specific categories 2. Chronic health conditions 3. CHD 4. Depression 5. Injuries

Alcohol-related global burden of disease Alcohol-attributable mortality 0.35 to to to to to 20.00

Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS) Developing countries Developed countries High mortality Low mortality Underweight14.9%Alcohol 6.2 % Tobacco 12.2 % Unsafe sex 10.2 % Blood pressure 5.0 % Blood pressure 10.9 % Unsafe water & sanitation 5.5 % Tobacco 4.0 % Alcohol 9.2 % Indoor smoke (solid fuels) 3.6 % Underweight 3.1 % Cholesterol 7.6 % Zinc deficiency 3.2 % Body mass index 2.7 % Body mass index 7.4 % Iron deficiency 3.1 % Cholesterol 2.1 % Low fruit & vegetable intake 3.9 % Vitamin A deficiency 3.0 % Low fruit & vegetable intake 1.9 % Physical inactivity 3.3 % Blood pressure 2.5 % Indoor smoke from solid fuels 1.9 % Illicit drugs 1.8 % Tobacco 2.0 % Iron deficiency 1.8 % Unsafe sex 0.8 % Cholesterol 1.9 % Unsafe water & sanitation 1.8 % Iron deficiency 0.7 %

Disease conditionsMales Females Total % of all alcohol- attributable deaths Conditions arising during the perinatal period 2130% Malignant neoplasm % Neuro-psychiatric conditions % Cardiovascular diseases % Other non-communicable diseases (diabetes, liver cirrhosis) % Unintentional injuries % Intentional injuries % Alcohol-related mortality burden all causes 1, , % All deaths29,23226,62955,861 In comparison: estimate for 1990: 1.5% % of all deaths which are alcohol-attributable 5.6%0.6%3.2% Global mortality burden (deaths in 1000s) attributable to alcohol by major disease categories

Disease conditionsMales Females Total % of all alcohol- attributable DALYs Conditions arising during the perinatal period % Malignant neoplasm3,1801,0214,2017% Neuro-psychiatric conditions18,0903,81421,90438% Cardiovascular diseases4, ,9837% Other non-communicable diseases (diabetes, liver cirrhosis) 3, ,5558% Unintentional injuries14,0082,48716,49528% Intentional injuries5,9451,1177,06212% Alcohol-related disease burden all causes (DALYs) 49,3978,92658,323100% All DALYs755,176689,993 1,445,169 In comparison: estimate for 1990: 3.5% % of all DALYs which are alcohol-attributable 6.5%1.3% 4.0% Global burden of disease (DALYs in 1000s) attributable to alcohol by major disease categories

Future Increase in alcohol-related burden for two reasons: –The disease categories related to alcohol are relatively increasing: chronic disease, accidents and injuries –Alcohol consumption is increasing in the most populous parts of the world –Patterns are stable if not getting worse If there are no interventions!!!