1. Jürgen Rehm 1,2,3 & Benjamin Taylor 2
Volume of alcohol consumption, patterns of drinking and burden of disease in the Americas 2002
Jürgen Rehm 1,2,3 & Benjamin Taylor 2
1 Institut für Suchtforschung (ISF - Addiction Research Institute), Zurich, Switzerland
2 Centre for Addiction and Mental Health (CAMH), Toronto, Canada
3 University of Toronto, Canada

2. Causal model of alcohol consumption, intermediate mechanisms, and long-term consequences
* Independent of intoxication or dependence

3. Adult per capita consumption in litre pure alcohol 2000 (based on CRA)

4. Pattern of drinking 2000 (based on CRA)

5. Estimation of AAF for different disease categories
Estimation of AAF for different disease categories
Volume of drinking
Drinking pattern
hazard score
(predominance of
intoxication)
Other chronic
Diseases (except CHD and depression)
Injuries
Coronary
heart
disease
Alcohol-
attributable
conditions (by definition)
Depression from psychiatric surveys

6. Alcohol related disease and injury
Chronic disease:
Cancer: Mouth & oropharyngeal cancer, Esophageal cancer, Liver cancer, Female breast cancer, other neoplasms
Neuropsychiatric diseases: Alcohol use disorders, unipolar major depression, epilepsy
Diabetes
Cardiovascular diseases: Hypertensive diseases, ischemic heart disease, stroke
Gastrointestinal 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

7. Classification of countries in WHO European regions by childhood and adult mortality (WHO, 2000)
America A
America B
America D
very low childhood and very low adult mortality
low high childhood and low adult mortality
high childhood and high adult mortality
USA
Canada
Cuba
Argentina, Barbados, Belize, Brazil, Chile, Colombia, Costa Rica, Dominican republic, El Salvador, Guyana, Honduras, Jamaica, Mexico, Paraguay, Suriname, Trinidad and Tobago, Uruguay, Venezuela
Bolivia, Ecuador, Guatemala, Haiti, Nicaragua, Peru
Definition of regions*: The regional subgroupings used were defined by WHO (World Health Report 2000) on the basis of high, medium or low levels of adult and of infant mortality.

8. Estimates of alcohol-related burden in South America
Epidemiological developments (i.e. changes in distribution of disease such as chronic disease vs. infectious disease)
Changes in drinking (average level and patterns of drinking) => slides with green background

9. Exposure: Characteristics of adult alcohol consumption in different regions of WHO AMRO: based on CRA (i.e. no new data on consumption included) (population weighted averages across countries; cf. Rehm et al., 2003b, 2004; Babor et al., 2003)

10. Adult alcohol consumption in different categories 2000 in % - Americas - males
Abstainer
g/d
Cat.I
Cat II
40-60
Cat III
60 +
Amro-A
27.1
55.2
12.9
4.8
Amro-B
21.1
67.8
3.9
7.1
Amro-D
30.3
67.4
1.6
0.8

11. Adult alcohol consumption in different categories 2000 in % - Americas - females
Abstainer
g/d
Cat.I
Cat II
20-40
Cat III
40 +
Amro-A
42.1
52.8
3.4
1.7
Amro-B
46.0
46.8
2.7
4.5
Amro-D
44.5
2.3
0.8

12. And after GENACIS and World Health Surveys and new per capita estimates (2002)….?
Similar overall consumption rates
Different distributions between ages
Different distributions between drinking categories: => Higher proportions of people with heavy drinking

13. Adult alcohol consumption 2002 in % - Americas - Males
Abstainer
g/d
Cat.I
Cat II
40-60
Cat III
60 +
Amro-A
28.3
39.1
21.7
10.9
Amro-B
18.8
56.6
11.3
13.3
Amro-D
32.0
59.1
2.5
6.5

14. Adult alcohol consumption in 2002 in % - Americas - Females
Abstainer
g/d
Cat.I
Cat II
20-40
Cat III
40 +
Amro-A
38.6
36.8
16.4
8.2
Amro-B
40.2
41.0
10.1
8.7
Amro-D
50.2
47.8
0.6
1.5

15. Changes between 2000 and 2002 estimates in different categories of alcohol consumption
females
males

16. Alcohol-attributable deaths in Americas 2002 by disease and region – epidemiological model
Amro A
Amro B
Amro D
All of America M F
Both
Low birth weight 23 19 78 60 13 10
203
Cancer
10365
6787
11117
7121
802
815
37006
Neuro-psychriatric conditions
6923
1872
14263
1835
2224
374
27492
Vascular conditions
-28231
-38285
45281
13203
3188
1595
-3249
Other non-communicable diseases
9962
1878
25590
5928
2310
988
46657
Unintentional injury
17406
5942
53362
5871
4392
1435
88409
Intentional Injury
7352
1782
53519
3419
1807
299
68180
All alcohol-related deaths
23800
-20003
203210
37438
14736
5515
264697
% alcohol-attributable of all deaths
0.9
-0.7
7.5
1.4
2.7
1.0
4.4
For % alcohol-attributable of all deaths:
Numerator = gender-specific disease category
Denominator = region specific total deaths
Total deaths in America 2002 =

17. % of all alcohol-attributable
Alcohol-attributable mortality 2002 (number of deaths) – America epidemiological model vs. world
America
% of all alcohol-attributable
World
Maternal perinatal conditions
203
0.1%
3,057
0.2%
Cancer
37006
14.0%
377,968
21.2%
Neuro-psychriatric conditions
27492
10.4%
113,603
6.4%
Vascular conditions
-3249
-1.2%
196,646
11.0%
Other non-communicable diseases
46657
17.6%
237,985
13.3%
Unintentional injury
88409
33.4%
585,553
32.8%
Intentional Injury
68180
25.8%
269,155
15.1%
All alcohol-related deaths
264697
100.0%
1,783,567
% alcohol-attributable of all deaths
4.4%
3.1%

18. Comparison of alcohol-related deaths of 2002 to 2000 – epidemiological model only
For all of America, the relative size of mortality of alcohol-related deaths decreased slightly (4.4% in 2002; 4.7% in 2000).
The numbers of alcohol-related deaths -decreased in all three regions, with biggest decreases in America Region D.
For the world, the relative size of alcohol-related deaths stayed at about the same level (3.2% in 2000; 3.1% in 2002).

19. Alcohol-attributable deaths (basis: new alcohol prevalence estimates and epidemiological shifts in COD)
Amro A
Amro B
Amro D
All of America M F
Both
Maternal perinatal conditions 23 19 78 60 13 10
203
Cancer
13012
11210
13114
8961
842
780
47920
Neuro-psychriatric conditions
7036
2096
14774
2174
2314
340
28733
Vascular conditions
-31354
-30331
39009
13841
2278
1404
-5154
Other non-communicable diseases
11005
4709
28272
5081
3119
371
52557
Unintentional injury
19723
5942
53362
5871
7029
733
92661
Intentional Injury
7352
1782
53519
3420
3120
237
69430
All alcohol-related deaths
26797
-4574
202124
39407
18716
3874
286346
% alcohol-attributable of all deaths
1.0
-0.2
7.5
1.5
3.5
0.7
4.8

20. % of all alcohol-attributable
Comparison chart on alcohol-attributable deaths: best estimates 2002 versus 2000 estimates
America
2002 best estimates
% of all alcohol-attributable
2000 CRA estimates
Maternal perinatal conditions
203
0.1%
873
0.3%
Cancer
47920
16.7%
35989
12.9%
Neuro-psychriatric conditions
28733
10.0%
26815
9.6%
Vascular conditions
-5154
-1.8%
1567
0.6%
Other non-communicable diseases
52557
18.4%
45540
16.3%
Unintentional injury
92661
32.4%
96201
34.5%
Intentional Injury
69430
24.3%
71871
25.8%
All alcohol-related deaths
286346
100.0%
278856
% alcohol-attributable of all deaths
4.8%
4.7%

21. Comparison of alcohol-related deaths from 2000 to 2002 – best estimates for 2002
There are no major changes in estimates of alcohol-related mortality from 2000 to 2002
Two developments:
Epidemiological change -> less deaths in alcohol-related categories
More heavy drinking -> more deaths….
Americas continue to have a high mortality burden from alcohol
Please note, that this is a net burden, after subtracting cardio-protective effects

22. Alcohol-attributable BOD in DALYs (basis: new alcohol prevalence estimates and epidemiological shifts in COD)
Amro A
Amro B
Amro D
All of America M F
Both
Maternal perinatal conditions
4.0
3.3
11.0
9.3
1.7
1.3
31.0
Cancer
127.8
138.8
148.4
120.1
9.6
9.5
554.2
Neuro-psychriatric conditions
2209.3
673.8
3115.8
859.7
315.3
77.9
7318.1
Vascular conditions
-192.5
-174.0
386.1
152.0
23.1
12.9
215.8
Other non-communicable diseases
154.6
81.0
562.3
123.6
63.1
8.2
1004.7
Unintentional injury
428.6
106.1
1130.2
160.9
184.7
20.1
2364.7
Intentional Injury
36.2
1065.5
103.3
71.7
5.8
1984.9
All alcohol-related deaths
2884.2
865.3
6408.5
1528.9
669.2
135.6
% alcohol-attributable of all deaths
6.1
1.8
9.1
1.9
0.8

23. % of all alcohol-attributable
Comparison chart on alcohol-attributable DALYs: best estimates 2002 versus 2000 estimates
America
2002 best estimates
% of all alcohol-attributable
2000 CRA estimates
Maternal perinatal conditions
31.0
0.2%
31.6
Cancer
554.2
4.1%
399.5
2.9%
Neuro-psychriatric conditions
7318.1
54.3%
6953.2
50.1%
Vascular conditions
215.8
1.6%
266.3
1.9%
Other non-communicable diseases
1004.7
7.5%
89.6
6.5%
Unintentional injury
2364.7
17.6%
2906.1
20.9%
Intentional Injury
1984.9
14.7%
2430.4
17.5%
All alcohol-related deaths
100.0%
% alcohol-attributable of all deaths
9.3
9.7

24. Comparison of alcohol-related DALYs from 2000 to 2002 – best estimates for 2002
There are no major changes in estimates of alcohol-related burden of disease from 2000 to 2002
Americas continue to have a burden of disease from alcohol
Please note, that this is a net burden, after subtracting cardio-protective effects

25. Relative impact of alcohol for different age groups
For all three regions, for both genders, with one small exception, the relative weight of alcohol on deaths is strongest in the age group years of age
In this age group, there are no beneficial effects of alcohol on mortality

26. Age and sex distribution among alcohol-related deaths in WHO America regions and in World for the year 2002 (own calculations)
0 to 14
15 to 29
30 to 44
45 to 59
60 to 69
70 to 79
80+
Total deaths in 1000
Males
AmrA
2.5%
28.9%
47.7%
48.9%
9.0%
-10.1%
-27.0%
23.8
Amr B
1.1%
24.7%
22.6%
21.4%
13.4%
10.0%
6.8%
203.2
Amr D
2.9%
6.5%
27.2%
22.8%
18.8%
13.2%
8.8%
14.7
World
1.2%
15.2%
20.6%
26.1%
18.6%
12.9%
5.3%
1636
Females
Amr A
Not meaningful, as there was a net beneficial effect, but there were no net gains before age 60
2.1%
9.3%
21.0%
17.5%
17.0%
19.7%
37.4
15.0%
12.8%
18.0%
16.1%
13.1%
5.5
5.4%
21.8%
31.9%
47.1%
31.3%
11.2%
-48.7%
165

27. Conclusion for policy -> main targets based on epidemiology
This is the major aim of this conference, but from an epidemiological side, policies to reduce health burden in the following areas should be considered:
Heavy drinking occasions
Overall level of consumption
Youth
Injury
Alcohol use disorders