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

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 AAmerica BAmerica 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 2000 (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 Males Abstainer 0-0.25 g/d Cat.I 0.25-40 Cat II 40-60 Cat III 60 + Amro-A 27.155.212.94.8 Amro-B 21.167.83.97.1 Amro-D 30.367.41.60.8

11. Adult alcohol consumption in different categories 2000 in % - Americas - females Males Abstainer 0-0.25 g/d Cat.I 0.25-20 Cat II 20-40 Cat III 40 + Amro-A 42.152.83.41.7 Amro-B 46.046.82.74.5 Amro-D 44.552.82.30.8

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 MalesAbstainer 0-0.25 g/d Cat.I 0.25-40 Cat II 40-60 Cat III 60 + Amro-A 28.339.121.710.9 Amro-B 18.856.611.313.3 Amro-D 32.059.12.56.5

14. Adult alcohol consumption in 2002 in % - Americas - Females Females Abstainer 0-0.25 g/d Cat.I 0.25-20 Cat II 20-40 Cat III 40 + Amro-A 38.636.816.48.2 Amro-B 40.241.010.18.7 Amro-D 50.247.80.61.5

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

16. Alcohol-attributable deaths in Americas 2002 by disease and region – epidemiological model Amro AAmro BAmro DAll of America MFMFMFBoth Low birth weight 231978601310203 Cancer 10365678711117712180281537006 Neuro-psychriatric conditions 69231872142631835222437427492 Vascular conditions -28231-38285452811320331881595-3249 Other non- communicable diseases 99621878255905928231098846657 Unintentional injury 1740659425336258714392143588409 Intentional Injury 73521782535193419180729968180 All alcohol-related deaths 23800-2000320321037438147365515264697 % alcohol- attributable of all deaths 0.9-0.77.51.42.71.04.4

17. Alcohol-attributable mortality 2002 (number of deaths) – America epidemiological model vs. world America% of all alcohol- attributable World% of all alcohol- attributable Maternal perinatal conditions 2030.1%3,0570.2% Cancer 3700614.0%377,96821.2% Neuro-psychriatric conditions 2749210.4%113,6036.4% Vascular conditions -3249-1.2%196,64611.0% Other non-communicable diseases 4665717.6%237,98513.3% Unintentional injury 8840933.4%585,55332.8% Intentional Injury 6818025.8%269,15515.1% All alcohol-related deaths 264697100.0%1,783,567100.0% % 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 2002 (basis: new alcohol prevalence estimates and epidemiological shifts in COD) Amro AAmro BAmro DAll of America MFMFMFBoth Maternal perinatal conditions 231978601310203 Cancer 130121121013114896184278047920 Neuro-psychriatric conditions 70362096147742174231434028733 Vascular conditions -31354-30331390091384122781404-5154 Other non- communicable diseases 110054709282725081311937152557 Unintentional injury 197235942533625871702973392661 Intentional Injury 73521782535193420312023769430 All alcohol-related deaths 26797-457420212439407187163874286346 % alcohol- attributable of all deaths 1.0-0.27.51.53.50.74.8

20. Comparison chart on alcohol- attributable deaths: best estimates 2002 versus 2000 estimates America 2002 best estimates % of all alcohol- attributable America 2000 CRA estimates % of all alcohol- attributable Maternal perinatal conditions 2030.1%8730.3% Cancer 4792016.7%3598912.9% Neuro-psychriatric conditions 2873310.0%268159.6% Vascular conditions -5154-1.8%15670.6% Other non-communicable diseases 5255718.4%4554016.3% Unintentional injury 9266132.4%9620134.5% Intentional Injury 6943024.3%7187125.8% All alcohol-related deaths 286346100.0%278856100.0% % 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 2002 (basis: new alcohol prevalence estimates and epidemiological shifts in COD) Amro AAmro BAmro DAll of America MFMFMFBoth Maternal perinatal conditions 4.03.311.09.31.71.331.0 Cancer 127.8138.8148.4120.19.69.5554.2 Neuro-psychriatric conditions 2209.3673.83115.8859.7315.377.97318.1 Vascular conditions -192.5-174.0386.1152.023.112.9215.8 Other non- communicable diseases 154.681.0562.3123.663.18.21004.7 Unintentional injury 428.6106.11130.2160.9184.720.12364.7 Intentional Injury 154.636.21065.5103.371.75.81984.9 All alcohol-related deaths 2884.2865.36408.51528.9669.2135.613473.4 % alcohol- attributable of all deaths 6.11.89.11.94.00.89.3

23. Comparison chart on alcohol- attributable DALYs: best estimates 2002 versus 2000 estimates America 2002 best estimates % of all alcohol- attributable America 2000 CRA estimates % of all alcohol- attributable Maternal perinatal conditions 31.00.2%31.60.2% Cancer 554.24.1%399.52.9% Neuro-psychriatric conditions 7318.154.3%6953.250.1% Vascular conditions 215.81.6%266.31.9% Other non-communicable diseases 1004.77.5%89.66.5% Unintentional injury 2364.717.6%2906.120.9% Intentional Injury 1984.914.7%2430.417.5% All alcohol-related deaths 13473.4100.0%13883.3100.0% % alcohol-attributable of all deaths 9.39.7

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 15-29 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 1415 to 2930 to 4445 to 5960 to 6970 to 7980+ 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 Amr B 2.1%9.3%13.4%21.0%17.5%17.0%19.7%37.4 Amr D 15.0%6.8%12.8%17.5%18.0%16.1%13.1%5.5 World 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