Ideology, history and changing models of liver cirrhosis epidemiology

Pathogenesis of Alcohol-Associated Liver Disease

Excessive alcohol consumption is a global healthcare problem with enormous social, economic, and clinical consequences. While chronic, heavy alcohol consumption causes structural damage and/or disrupts normal organ function in virtually every tissue of the body, the liver sustains the greatest damage. This is primarily because the liver is the first to see alcohol absorbed from the gastrointestinal tract via the portal circulation and second, because the liver is the principal site of ethanol metabolism. Alcohol-induced damage remains one of the most prevalent disorders of the liver and a leading cause of death or transplantation from liver disease. Despite extensive research on the pathophysiology of this disease, there are still no targeted therapies available. Given the multifactorial mechanisms for alcohol-associated liver disease pathogenesis, it is conceivable that a multitherapeutic regimen is needed to treat different stages in the spectrum of this disease.

Conceptual and Methodological Issues in Studying Alcohol's Harm to Others1

While there is a longer history of concern about alcohol's harm to others, researchers' interest has intensified in the last few years. The background of variation in concern over time in different societies is outlined. Three main traditions of research have emerged: population survey studies of such harm from the perspective of the ‘other’; analysis of register or case-record data which includes information on the involvement of another's drinking in the case; and qualitative studies of interactions and experiences involved in particular harms from others' drinking. In the course of the new spate of studies, many conceptual and methodological issues have arisen, some of which are considered in the paper. The diverse types of harms which have been studied are discussed. The social and personal nature of many of the harms means they do not ft easily into a disability or costing model, raising questions about how they might best be counted and aggregated. Harm from others' drinking is inherently interactional, and subject to varying definitions of what counts as harm. The attribution to drinking, in the usual situation of conditional causation, is also subject to variation, with moral politics potentially coming into play. For measurement and comparison, account needs to be taken of cultural and individual variations in perceptions and thresholds of what counts as a harm, and attribution to alcohol. The view from the windows of a population survey and of a response agency case register are often starkly different, and research is needed, as an input and spur to policy initiatives, on what influences this difference and whether and how the views might be reconciled.

Overlooking Terris: A Speculative Reconsideration of a Curious Spot-Blindness in the History of Alcohol-Control Science

The authors argue that the overlooking or forgetting of a beverage-specific element of Milton Terris's classic 1967 paper linking per capita alcohol consumption with cirrhosis mortality trends sheds new light on the subsequent paradigmatic history of alcohol epidemiology. The historical standing and subsequent citation of Terris's paper are re-examined, and Terris's reasons for not reminding the alcohol epidemiology literature of this aspect of his paper are explored. Aspects of presentation and content of the 1967 paper are also discussed with respect to the explanation of the subsequently lost beverage-specific element of Terris's article. The authors suggest that an evolutionary aspect of the relationship and competition between the modern alcoholism and alcohol controls paradigms in alcohol epidemiology may offer the key to accounting for this historical-forgetting puzzle.

Alcohol consumption and liver disease in Australia: a time series analysis of the period 1935-2006

AIMS

The aim of the study was to examine for Australia whether the link between population alcohol consumption and liver disease mortality varies over time, using 71 years of data.

METHODS

Overall and gender-specific rates of liver disease mortality were analysed in relation to total alcohol consumption as well as for different beverage types by using autoregressive integrated moving average (ARIMA) time series methods. Separate models were developed for the entire time period and for two sub-periods (1935-1975, 1976-2006).

RESULTS

A 1-l increase in adult per capita consumption of pure alcohol led to a rise of ∼10% in overall liver disease mortality rates and a 11 and 9% increase in female and male liver disease mortality, respectively. The strength of the relationship between per capita consumption and liver disease mortality diminished over time. Spirits consumption was found to be the main driving factor in liver mortality rates between 1935 and 1975, while beer consumption was found to be the most significant predictor in liver diseases in the last three decades. In a comparative perspective, the effect of per capita alcohol consumption on liver disease in Australia is similar to the USA, Southern and Eastern Europe countries, but weaker than in Canada and western European countries.

CONCLUSION

An increase in per capita alcohol consumption in Australia is likely to lead to an increase in liver disease. Changes in the most important beverage over the study period suggest substantial shifts in drinking patterns and preferences among the heaviest Australian drinkers.

The drinker's effect on the social environment: a conceptual framework for studying alcohol's harm to others

The paper considers conceptual and methodological issues in studying the scope of alcohol’s harm to others. Reasons are suggested for the relative neglect of the topic. The approaches in two relevant research traditions are considered: population surveys on alcohol problems, and economic cost of alcohol studies. Ways of conceptualizing and measuring aspects of the drinker’s effects on others are considered, in terms of main types of relationship with the other, and in terms of major societal response institutions. The main types of data tend to measure different levels of severity, with population survey data dominated by less severe problems, and response institution data by more severe problems; so both are needed for a three-dimensional view. Research questions for the field and its policy significance are noted.

Cirrhosis mortality and per capita consumption of distilled spirits, United States, 1949-94: trend analysis

OBJECTIVE

To describe, evaluate, and suggest interpretations for an observed aggregate level relation between trends in mortality from cirrhosis and per capita consumption of distilled spirits in the United States.

DESIGN

Trend analysis using data on US cirrhosis mortality and per capita alcohol consumption.

RESULTS

There is a consistent long term trend relation between mortality from cirrhosis and per capita consumption of distilled spirits in the United States from 1949 to 1994. Two instances of comparatively sharp drops in the consumption of spirits earlier in the 1940s generated mixed results in predicting changes in cirrhosis mortality.

CONCLUSIONS

An aggregate level relation between trends in long term cirrhosis mortality and the consumption of spirits falls considerably short of establishing a direct causal link between the two for individuals. Moreover, two sharp drops in the consumption of spirits generated only mixed results with respect to the short term trend in cirrhosis. Nevertheless, the observed relation between the consumption of spirits and cirrhosis mortality merits further investigation.

Epidemiology of alcoholic liver disease

Although mortality from alcoholic liver disease has declined in some Western countries in recent years, elsewhere it is increasing and overall it remains a major health problem. Deaths are predominantly seen in patients with alcoholic hepatitis or cirrhosis, and when they occur in patients with fatty liver are usually unrelated to liver disease. Progression to cirrhosis is correlated with the severity of fatty liver and particularly with the presence of alcoholic hepatitis. Mortality from cirrhosis is strongly correlated with per capita alcohol consumption. The decline in cirrhosis mortality rates seen recently is related in part to decreases in per capita consumption, but probably also to the growth of self-help organizations which facilitate abstinence from alcohol. Recent studies suggest there is not an invariable dose-response relationship between alcohol intake and the severity of liver disease and that alcohol has a permissive effect which allows other aetiological factors to operate. Factors that influence susceptibility to alcoholic liver disease include gender (women develop alcoholic cirrhosis more readily than men), concomitant hepatitis C infection and possibly hepatitis B infection. It is uncertain whether HLA status or immune mechanisms are implicated. The systematic use of screening tests for hazardous consumption combined with early intervention therapies offers a good prospect of reducing morbidity and mortality from alcoholic liver disease.

Benjamin Rush's educational campaign against hard drinking

More than 200 years ago, during a period of unprecedented production and consumption of distilled alcoholic beverages in the United States, Benjamin Rush launched a health education campaign that warned the public about the hazards of such beverages. He corrected erroneous notions about their presumed beneficial effects and accurately described more than a dozen alcohol-related health problems. Although the temperance movement has had a tumultuous history in the United States, the origin and long-standing tradition of temperance as a health promotion activity needs to be recognized.