Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the US example

The risk relationships between alcohol consumption, alcohol use disorder and alcohol use disorder mortality: A systematic review and meta-analysis

BACKGROUND AND AIMS

Increasing levels of alcohol use are associated with a risk of developing an alcohol use disorder (AUD), which, in turn, is associated with considerable burden. Our aim was to estimate the risk relationships between alcohol consumption and AUD incidence and mortality.

METHOD

A systematic literature search was conducted, using Medline, Embase, PsycINFO and Web of Science for case-control or cohort studies published between 1 January 2000 and 8 July 2022. These were required to report alcohol consumption, AUD incidence and/or AUD mortality (including 100% alcohol-attributable deaths). The protocol was registered with PROSPERO (CRD42022343201). Dose-response and random-effects meta-analyses were used to determine the risk relationships between alcohol consumption and AUD incidence and mortality and mortality rates in AUD patients, respectively.

RESULTS

Of the 5904 reports identified, seven and three studies from high-income countries and Brazil met the inclusion criteria for quantitative and qualitative syntheses, respectively. In addition, two primary US data sources were analyzed. Higher levels of alcohol consumption increased the risk of developing or dying from an AUD exponentially. At an average consumption of four standard drinks (assuming 10 g of pure alcohol/standard drink) per day, the risk of developing an AUD was increased sevenfold [relative risk (RR) = 7.14, 95% confidence interval (CI) = 5.13-9.93] and the risk of dying fourfold (RR = 3.94, 95% CI = 3.53-4.40) compared with current non-drinkers. The mortality rate in AUD patients was 3.13 (95% CI = 1.07-9.13) per 1000 person-years.

CONCLUSIONS

There are exponential positive risk relationships between alcohol use and both alcohol use disorder incidence and mortality. Even at an average consumption of 20 g/day (about one large beer), the risk of developing an alcohol use disorder (AUD) is nearly threefold that of current non-drinkers and the risk of dying from an AUD is approximately double that of current non-drinkers.

Trends of alcohol-attributable deaths in Lithuania 2001-2021: epidemiology and policy conclusions

BACKGROUND

Lithuania, a Baltic country in the European Union, can be characterized by high alcohol consumption and attributable burden. The aim of this contribution is to estimate the mortality burden due to alcohol use for the past two decades based on different relative risk functions, identify trends, and analyse the associations of alcohol-attributable burden with alcohol control policies and life expectancy.

METHODS

The standard methodology used by the World Health Organization for estimating alcohol-attributable mortality was employed to generate mortality rates for alcohol-attributable mortality, standardized for Lithuania's 2021 population distribution. Joinpoint analysis, T-tests, correlations, and regression analyses including meta-regressions were used to describe trends and associations.

RESULTS

Age-standardized alcohol-attributable mortality was high in Lithuania during the two decades between 2001 and 2021, irrespective of which relative risks were used for the estimates. Overall, there was a downward trend, mainly in males, which was associated with four years of intensive implementation of alcohol control policies in 2008, 2009, 2017, and 2018. For the remaining years, the rates of alcohol-attributable mortality were stagnant. Among males, the correlations between alcohol-attributable mortality and life expectancy were 0.90 and 0.76 for Russian and global relative risks respectively, and regression analyses indicated a significant association between changes in alcohol-attributable mortality and life expectancy, after controlling for gross domestic product.

CONCLUSIONS

Male mortality and life expectancy in Lithuania were closely linked to alcohol-attributable mortality and markedly associated with strong alcohol control policies. Further implementation of such policies is predicted to lead to further improvements in life expectancy.

ALDH2 polymorphism, alcohol intake and the attributable burden of cancer in East Asia: systematic review, meta-analysis, and modeling study

PURPOSE

To estimate the burden of alcohol-attributable cancer in East Asian populations accounting for aldehyde dehydrogenase-2 (ALDH2) genotype-specific cancer risk and alcohol exposure.

METHODS

We conducted a systematic review and meta-analysis of eight databases on cancer risk to derive alcohol dose-response curves by ALDH2 genotype. A simulation-based approach using the Global Burden of Disease (GBD) modeling framework was applied to estimate the population attributable fraction, incidence, and disability-adjusted life-years (DALYs) lost to alcohol-attributable cancer.

RESULTS

We included 34 studies (66,655 participants) from China, Japan, and South Korea in the meta-analysis. Alcohol dose-response curves for liver, esophageal, and oral cavity/pharynx cancer showed an increased risk for people with the inactivated ALDH2 genetic polymorphism, resulting in a higher burden of alcohol-attributable cancer compared to GBD estimates. Our methods estimated annual incidence of cancer of 230,177 cases, an underestimate of 69,596 cases compared to GBD estimates. Similarly, total DALYs lost annually were underestimated by 1.20 million.

CONCLUSIONS

The burden of liver, esophageal, and oral cavity/pharynx cancer attributable to alcohol is underestimated in populations with the ALDH2 genetic polymorphism when compared to current estimates.

The cost of premature death from cancer attributable to alcohol: Productivity losses in Europe in 2018

BACKGROUND

More than 1.9 million people die from cancer each year in Europe. Alcohol use is a major modifiable risk factor for cancer and poses an economic burden on society. We estimated the cost of productivity lost due to premature death (under 65 years of age) from alcohol-attributable cancer in the European Union (EU) plus Iceland, Norway, Switzerland, and the United Kingdom (UK) in 2018.

METHODS

We estimated cancer deaths attributable to alcohol using a Levin-based population attributable fractions method and cancer deaths in 2018 from the Global Cancer Observatory. Lost productivity was estimated for all alcohol-attributable cancer deaths by sex, cancer site, and country. Productivity losses were valued using the human capital approach.

RESULTS

An estimated 23,300 cancer deaths among people aged less than 65 in the EU plus Iceland, Norway, Switzerland and the UK in 2018 were attributable to alcohol (18,200 males, 5100 females). This equated to €4.58 billion in total productivity losses in the region and 0.027 % of the European Gross Domestic Product (GDP). The average cost per alcohol-attributable cancer death was €196,000. Productivity lost to alcohol-attributable cancer per capita was highest in Western Europe. Hungary, Romania, Slovakia, Latvia, Lithuania, and Portugal had the highest rate of premature mortality from alcohol-attributable cancer and the highest productivity lost as a share of national GDP.

CONCLUSION

Our study provides estimates of lost productivity from alcohol-attributable cancer death in Europe. Cost-effective strategies to prevent alcohol-attributable cancer deaths could result in economic benefits for society and must be prioritised.

Reduction of Alcoholic Strength: Does It Matter for Public Health?

In this work, reduction of alcoholic strength was discussed as a means to reduce consumption and alcohol-attributable harm. Statistical modelling was conducted to (1) estimate its potential for the largest six Western and Central European countries (France, Germany, Italy, Poland, Spain, UK); (2) calculate the increase in taxation necessary to reach this potential, and (3) estimate the mortality gains achieved with the introduction of no- or low-alcohol beverages in the UK and Spain. The high public health potential of reducing alcoholic strength was demonstrated via modelling a scenario in which the strength of all beverages was reduced by 10%, which would avert thousands of deaths in these six European countries per year. However, methods by which to achieve these gains were not clear, as the alcohol industry has shown no inclination toward reductions in the alcoholic strength of beer, wine, or spirits via a reformulation on a large scale. The increase of excise taxation to achieve the public health gains of such a reduction would result in markedly increasing prices-a situation unlikely to be implemented in Europe. Finally, the introduction of beer and wine with an alcoholic strength below 0.5% led to some substitutions of higher-strength beverages, but did not show a marked public health impact. New taxation initiatives to achieve the potential of a reduction of alcoholic strength will need to be implemented.

Socio-demographic development and burden of mental, substance use disorders, and self-harm: An ecological analysis using the Global Burden of Disease study 2019

OBJECTIVES

Whether a country's level of development is associated with an increased or decreased burden of mental and behavioural problems is an important yet unresolved question. Here, we examined the association between the burden of mental and substance use disorders and self-harm with socio-demographic development along temporal and geographical dimensions.

METHODS

We collected data from the Global Burden of Disease study 2019, which uses robust statistical modelling techniques to calculate disease burden estimates where data are sparse or unavailable. We extracted age-standardized Disability Adjusted Life Year rates as a measure of disease burden for 204 countries and territories, as well as the Socio-Demographic Index, a measure of development reflecting income per capita, fertility rate and level of education. We tested the association between Socio-Demographic Index and Disability Adjusted Life Years for mental and substance use disorders and self-harm, between 1990 and 2019, and across six geographical regions as defined by the World Health Organization.

RESULTS

The association between Socio-Demographic Index and Disability Adjusted Life Years was heterogeneous across world regions for all mental and behavioural conditions. For substance use disorders and self-harm, these regional variations were further moderated by time period. Our findings were robust to down-weighing outlier observations, as well as controlling for other socio-demographic variables, and the number of data sources available in each country.

CONCLUSION

Based on data from the Global Burden of Disease study 2019, we demonstrated that the association between mental and substance use disorders and self-harm with socio-demographic development is dependent on geographical regions and temporal periods. This heterogeneity is likely related to geographical and temporal variations in socio-cultural norms, attitudes towards mental problems, as well as health care and social policies. Better knowledge of this spatial and temporal heterogeneity is crucial to ensure that countries do not develop at the expense of a higher burden of mental and behavioural conditions.

Social, psychological and health characteristics associated with stability and change in adult alcohol consumption

Background

Many studies analyzing health effects of alcohol consumption have operationalized alcohol intake from a single baseline measure without further follow-up. Consequently, there is a lack of knowledge about stability and change in alcohol consumption over the life course and the social, psychological, lifestyle, and health characteristics associated with different alcohol consumption trajectories.

Objectives

The aims of the study were to describe the prevalence of different adult-life alcohol consumption trajectories among Danish men and to analyze social, psychological, lifestyle and health characteristics associated with these trajectories.

Methods

For 2510 Danish men, retrospective decade-based information on alcohol consumption during life period 26–60 years was obtained in late midlife and information on individual characteristics was obtained in young adulthood, late midlife and from national hospital registries. The men were allocated to one of six a priori defined alcohol consumption trajectories.

Results

About 65% of Danish men had a stable moderate consumption, drinking 1–21 units weekly while the five other consumption trajectories were comparatively rare: 3% stable abstainers, 4.7% stable high-risk drinkers, 10.9% with increasing and 12.7% with decreasing consumption. Moderate consumption over the adult life-course was associated with the most favorable social, psychological, lifestyle and health characteristics while the other trajectories were generally associated with less favorable characteristics to varying degrees–e. g. this was the case for the stable abstaining trajectory and in particular the trajectory with decreasing consumption.

Conclusion

The findings suggest that the majority of Danish men drink moderately in the life period from young adulthood to late midlife, and deviance from this ‘normal’ moderate consumption trajectory is associated with less favorable social, psychological, lifestyle and health characteristics. Some of these characteristics may influence alcohol consumption patterns, but for some of the trajectories, alcohol consumption may influence health as well as social and psychological functioning.

Gender-specific risk relationship between heavy alcohol use/alcohol use disorders and suicidal thoughts and behavior among adults in the United States over time

PURPOSE

Suicidal thoughts and behaviors have been on the rise in the recent years in the US. There is a well-known link between heavy alcohol use/alcohol use disorders (AUDs) and suicidal thoughts and behaviors. An increase in the respective risk relationships is one way in which heavy alcohol use/AUDs may be driving the increase in the rate of suicidal thoughts and behaviors. The objective of the current study was to investigate whether the gender-specific risk relationships between heavy alcohol use/AUDs and past-year (1) suicidal thoughts and (2) attempted suicide have increased over time.

METHODS

Individual-level annual data from the National Survey on Drug Use and Health for the past 12 years (2008-2019) were utilized. Year- and gender-specific multivariate binary logistic regression analyses were first conducted. Gender-stratified random-effects meta-regressions across study years were then conducted.

RESULTS

Heavy alcohol use/AUDs were associated with elevated odds of past-year suicidal thoughts and attempted suicide for both men and women; however, a linear increase in the risk relationships over time was not found.

CONCLUSION

Although a temporal increase in the risk relationships of interest was not found, until additional research in this area is conducted, heavy alcohol use/AUDs cannot be ruled out as being a driving force behind the increasing rate of suicidal thoughts and behaviors in the US.

Methodological guidelines for the estimation of attributable mortality using a prevalence-based method: The STREAMS-P tool

BACKGROUND

There is evidence of strong links between exposure to different risk factors and life-threatening diseases. Assessing the burden of a risk factor on the population's mortality due to a given disease provides a clear picture of these links. The estimation of attributable mortality to a risk factor is the most widely used procedure for doing this. Although different methods are available to estimate attributable mortality, the prevalence-based methodology is the most frequent. The main objective of this paper is to develop guidelines and checklists to STrengthen the design and REporting of Attributable-Mortality Studies using a Prevalence-based method (STREAMS-P) and also to assess the quality of an already published study which uses this methodology.

METHODS

The design of the guideline and checklists has been done in two phases. A development phase, where we set recommendations based on the review of the literature; and a validation phase, where we validated our recommendations against other published studies that have estimated attributable mortality using a prevalence-based method.

RESULTS

We have developed and tested a guideline that includes the information required to perform a prevalence-based attributable mortality study to a given risk factor; a checklist of aspects that should be present when a report or a paper on attributable mortality is written or interpreted and a checklist of quality control criteria for reports or papers estimating attributable mortality.

CONCLUSION

To our knowledge, the STREAMS-P is the first set of criteria specifically created to assess the quality of such studies and it could be valuable for authors and readers interested in performing attributable mortality studies or interpreting their reliability.

Predicting the Impact of Alcohol Taxation Increases on Mortality-A Comparison of Different Estimation Techniques

AIMS

To examine how standard analytical approaches to model mortality outcomes of alcohol use compare to the true results using the impact of the March 2017 alcohol taxation increase in Lithuania on all-cause mortality as an example.

METHODS

Four methodologies were used: two direct methodologies: (a) interrupted time-series on mortality and (b) comparing predictions based on time-series modeling with the real number of deaths for the year following the implementation of the tax increase; and two indirect methodologies: (c) combining a regression-based estimate for the impact of taxation on alcohol consumption with attributable-fraction methodology and (d) using price elasticities from meta-analyses to estimate the impact on alcohol consumption before applying attributable-fraction methodology.

RESULTS AND CONCLUSIONS

While all methodologies estimated reductions in all-cause mortality, especially for men, there was substantial variability in the level of mortality reductions predicted. The indirect methodologies had lower predictions as the meta-analyses on elasticities and risk relations seem to underestimate the true values for Lithuania. Directly estimated effects of taxation based on the actual mortalities seem to best represent the true reductions in alcohol-attributable mortality. A significant increase in alcohol excise taxation had a marked impact on all-cause mortality in Lithuania.

Impact of introducing a minimum alcohol tax share in retail prices on alcohol-attributable mortality in the WHO European Region: A modelling study

Background

Alcohol use and its burden constitute one of the largest public health challenges in the WHO European Region. Raising alcohol taxes is a cost-effective "best buy" measure to reduce alcohol consumption, but its implementation remains uneven. This paper provides an overview of existing tax structures in 50 countries and subregions of the Region, estimates their proportions of tax on retail prices of beer, wine, and spirits, and quantifies the number of deaths that could be averted annually if these tax shares were raised to a minimum level.

Methods

Review of databases and statistical reports on taxes and mean retail prices of alcohol beverages in the Region. Affordability was calculated based on alcohol prices, adjusted for differences in purchasing power. Consumption changes and averted mortality were modelled assuming two scenarios. In Scenario 1, a minimum excise tax share level of 25% of the beverage-specific retail price was assumed for all countries. In Scenario 2, in addition to a minimum excise tax share level of 15% it was assumed that per unit of ethanol minimal retail prices were the same irrespective of alcoholic beverages (equalisation). Sensitivity analyses were conducted for different price elasticities.

Findings

Alcohol is very affordable in the Region and alcohol taxes have clearly been under-utilized as a public health measure, constituting on average only 5·7%, 14·0% and 31·3% of the retail prices of wine, beer, and spirits, respectively. Tax shares were higher in the eastern part of the Region compared to the EU, where various countries did not have excise taxes on wine. Annually, the introduction of a minimum tax share of 25% (Scenario 1) could avert 40,033 (95% CI: 38,054-46,097) deaths in the WHO European Region (with 753,454,300 inhabitants older than 15 years of age). If a 15% tax share with equalisation were implemented (Scenario 2), 132,906 (95% CI: (124,691-151,674) deaths could be averted. All sensitivity analyses with different elasticities yielded outcomes close to those of the main analyses.

Interpretation

Similar to tobacco taxes, increasing alcohol taxes should be considered to be a health-based measure aimed at saving lives. Many countries have hesitated to apply higher taxes to alcohol, but the present results show a clear health benefit as a result of implementing a minimum tax share.

Funding

This work was supported by the National Institute on Alcohol Abuse and Alcoholism (1R01AA028224) and the Canadian Institutes of Health Research, Institute of Neurosciences, and Mental Health and Addiction (SMN-13950).

Alcohol taxation, alcohol consumption and cancers in Lithuania: A case study

Aims

The aim of this contribution was to estimate the impact of the last significant alcohol taxation increase in Lithuania in 2017 on alcohol consumption, incident cancer cases, and cancer mortality, as well as the number of cancer outcomes that could have potentially been averted in 2018 had larger increases in alcohol excise taxation been applied.

Design

Statistical modelling was used to estimate the change in alcohol per capita consumption following the tax increase, and alcohol-attributable fraction methodology was then used to estimate the associated cancer incidence and mortality. Potential increases of current excise duties were modelled in two steps. First, beverage-specific price elasticities of demand were used to predict the associated decreases in consumption and cancer outcomes, and second, the outcomes arising from the actual numbers and the modelled numbers were compared.

Method

Data were taken from the following sources: alcohol consumption data from Statistics Lithuania and the WHO, cancer data from the International Agency of Research on Cancer, and risk relations and elasticities of demand from published meta-analyses.

Results

A total of 15,857 new cancer cases (8,031 in women and 7,826 in men) and 8,534 cancer deaths (3,757 in women and 4,777 in men) were recorded in Lithuania in 2018. Using the attributable fraction methodology, we estimate that 4.8% of 761 of these new cancer cases were attributable to alcohol use (284 in women; 477 in men), as well as 5.5% or 466 cancer deaths (115 in women; 351 in men). With the taxation increase of 2017, 45 new cases and 24 deaths will be averted over the next 10 years. Further taxation increases of 100% could double the number of new cancer cases averted or saved.

Conclusion

In a high-consumption European country like Lithuania, alcohol use is an important and avoidable risk factor for cancer. Taxation is an important measure to reduce the alcohol-attributable cancer burden.

Improving Estimates of Alcohol-Attributable Deaths in the United States: Impact of Adjusting for the Underreporting of Alcohol Consumption

OBJECTIVE

Self-reported alcohol consumption in U.S. public health surveys covers only 30%-60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths.

METHOD

Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach.

RESULTS

Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6).

CONCLUSIONS

Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates.

Improving Estimates of Alcohol-Attributable Deaths in the United States: Impact of Adjusting for the Underreporting of Alcohol Consumption

OBJECTIVE

Self-reported alcohol consumption in U.S. public health surveys covers only 30%-60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths.

METHOD

Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach.

RESULTS

Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6).

CONCLUSIONS

Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates.

Improved estimates for individual and population-level alcohol use in the United States, 1984-2020

Aims

While nationally representative alcohol surveys are a mainstay of public health monitoring, they underestimate consumption at the population level. This paper demonstrates how to adjust individual-level survey data using aggregated alcohol per capita (APC) data for improved individual- and population-level consumption estimates.

Design and Methods

For the period 1984-2020, data on self-reported alcohol consumption in the past 30 days were taken from the Behavioral Risk Factor Surveillance System (BRFSS) involving participants (18+ years) in the United States (US). Monthly abstainers were reallocated into lifetime abstainers, former drinkers, and 12-month drinkers using the 2005 National Alcohol Survey data. To correct for under-coverage of alcohol use, we triangulated APC and survey data by upshifting quantity (average grams/day) and frequency (drinking days/week) of alcohol use based on national- and state-level APC data. Results were provided for the US as a whole and for selected states to represent different drinking patterns.

Findings

The corrections described above resulted in improved correspondence between survey and APC data. Following our procedure, national estimates of alcohol quantity increased from 45% to 77% of APC estimates. Both quantity and frequency of alcohol use were upshifted; by upshifting to 90% of APC, we were able to fit trends and distributions in APC patterns for individual states and the US.

Conclusions

An individual-level dataset which more accurately reflects the alcohol use of US citizens was achieved. This dataset will be invaluable as a research tool and for the planning and evaluation of alcohol control policies for the US. The methodology described can also be used to adjust individual-level alcohol survey data in other geographical settings.

An integrated dual process simulation model of alcohol use behaviours in individuals, with application to US population-level consumption, 1984-2012

INTRODUCTION

The Theory of Planned Behaviour (TPB) describes how attitudes, norms and perceived behavioural control guide health behaviour, including alcohol consumption. Dual Process Theories (DPT) suggest that alongside these reasoned pathways, behaviour is influenced by automatic processes that are determined by the frequency of engagement in the health behaviour in the past. We present a computational model integrating TPB and DPT to determine drinking decisions for simulated individuals. We explore whether this model can reproduce historical patterns in US population alcohol use and simulate a hypothetical scenario, "Dry January", to demonstrate the utility of the model for appraising the impact of policy interventions on population alcohol use.

METHOD

Constructs from the TPB pathway were computed using equations from an existing individual-level dynamic simulation model of alcohol use. The DPT pathway was initialised by simulating individuals' past drinking using data from a large US survey. Individuals in the model were from a US population microsimulation that accounts for births, deaths and migration (1984-2015). On each modelled day, for each individual, we calculated standard drinks consumed using the TPB or DPT pathway. In each year we computed total population alcohol use prevalence, frequency and quantity. The model was calibrated to alcohol use data from the Behavioral Risk Factor Surveillance System (1984-2004).

RESULTS

The model was a good fit to prevalence and frequency but a poorer fit to quantity of alcohol consumption, particularly in males. Simulating Dry January in each year led to a small to moderate reduction in annual population drinking.

CONCLUSION

This study provides further evidence, at the whole population level, that a combination of reasoned and implicit processes are important for alcohol use. Alcohol misuse interventions should target both processes. The integrated TPB-DPT simulation model is a useful tool for estimating changes in alcohol consumption following hypothetical population interventions.

Bayesian modelling of population trends in alcohol consumption provides empirically based country estimates for South Africa

Background

Alcohol use has widespread effects on health and contributes to over 200 detrimental conditions. Although the pattern of heavy episodic drinking independently increases the risk for injuries and transmission of some infectious diseases, long-term average consumption is the fundamental predictor of risk for most conditions. Population surveys, which are the main source of data on alcohol exposure, suffer from bias and uncertainty. This article proposes a novel triangulation method to reduce bias by rescaling consumption estimates by sex and age to match country-level consumption from administrative data.

Methods

We used data from 17 population surveys to estimate age- and sex-specific trends in alcohol consumption in the adult population of South Africa between 1998 and 2016. Independently for each survey, we calculated sex- and age-specific estimates of the prevalence of drinkers and the distribution of individuals across consumption categories. We used these aggregated results, together with data on alcohol production, sales and import/export, as inputs of a Bayesian model and generated yearly estimates of the prevalence of drinkers in the population and the parameters that characterise the distribution of the average consumption among drinkers.

Results

Among males, the prevalence of drinkers decreased between 1998 and 2009, from 56.2% (95% CI 53.7%; 58.7%) to 50.6% (49.3%; 52.0%), and increased afterwards to 53.9% (51.5%; 56.2%) in 2016. The average consumption from 52.1 g/day (49.1; 55.6) in 1998 to 42.8 g/day (40.0; 45.7) in 2016. Among females the prevalence of current drinkers rose from 19.0% (17.2%; 20.8%) in 1998 to 20.0% (18.3%; 21.7%) in 2016 while average consumption decreased from 32.7 g/day (30.2; 35.0) to 26.4 g/day (23.8; 28.9).

Conclusions

The methodology provides a viable alternative to current approaches to reconcile survey estimates of individual alcohol consumption patterns with aggregate administrative data. It provides sex- and age-specific estimates of prevalence of drinkers and distribution of average daily consumption among drinkers in populations. Reliance on locally sourced data instead of global and regional trend estimates better reflects local nuances and is adaptable to the inclusion of additional data. This provides a powerful tool to monitor consumption, develop burden of disease estimates and inform and evaluate public health interventions.

Modelling the number of avoidable new cancer cases in France attributable to alcohol consumption by following official recommendations: a simulation study

AIMS

To predict the effects of perfect adherence to the French alcohol consumption guidelines, a maximum of 10 standard alcoholic drinks per week with no more than two standard alcoholic drinks per day, during a 36-year period (2014-50).

DESIGN

This simulation study is an adaption of the Sheffield Alcohol Policy Model. The dose-response relationship between alcohol consumption and alcohol-attributable cancer risks was defined by cancer site-specific risk functions, each modelled as a continuous risk. These estimates were used to compute the potential impact fraction (PIF) associated with alcohol consumption by cancer site.

SETTING

The French general adult population during a 36-year period (2014-50).

PARTICIPANTS

For the baseline scenario, the current distribution of consumption levels, the counterfactual scenario and perfect adherence to the French alcohol consumption guidelines, we generated for each gender and age group 1000 randomly distributed alcohol consumption values from calibrated group-specific gamma distribution.

MEASUREMENTS

The predicted number of new cancer cases among men and women in France between 2015 and 2050 that could have been prevented by following the French government's alcohol consumption guidelines.

FINDINGS

The simulation predicted that perfect adherence to the French government's alcohol consumption guidelines would prevent, on average, an estimated 15 952 cancer cases per year after the PIF reached its full effect, which would have represented 4.5% of new cancer cases in 2015. The number of averted cancer cases over the study period were highest for oral cavity, oropharynx and hypopharynx cancer (respectively, 118 462, 95% CI = 113 803-123 022 and 11 167, 95% CI = 10 149-12 229] for men and women; liver and intrahepatic bile ducts cancer (123 447, 95% CI = 112 581-133 404 and 2825, 95% CI = 2208,4095); colorectal cancer (89 859, 95% CI = 84 651-95 355 and 12 847, 95% CI = 11 545-14 245); and female breast cancer (61 649, 95% CI = 56 330-67 452).

CONCLUSION

This simulation study of the French general population predicted that perfect adherence to the French government's alcohol consumption guidelines (no more than 10 standard alcoholic drinks per week and two per day) would prevent almost 16 000 cancer cases per year.

Alcohol consumption and mortality: The Ludwigshafen Risk and Cardiovascular Health (LURIC) study

BACKGROUND AND AIMS

One of the most important risk factors for morbidity and mortality is the consumption of alcohol. The aim of our study was to examine the effect of alcohol consumption on all-cause mortality and cardiovascular mortality.

METHODS

The Ludwigshafen Risk and Cardiovascular Health (LURIC) study includes 3316 patients hospitalized for coronary angiography at a tertiary care centre in Southwest Germany. Patients were followed-up for a median of 9.9 (range 0.1-11.9 years) years. Total mortality number in the follow-up period was 995, and the number of incident cases, i.e. cardiovascular death, was 622. Information on alcohol consumption assessed by self-report questionnaires was used to calculate intake in grams of ethanol per day. Associations of alcohol consumption with morbidity and mortality were analysed using Cox proportional hazards regression.

RESULTS

We found significantly increased mortality for patients in the highest alcohol intake group age- and sex-adjusted (hazard ratio of 1.59 (95%CI, 0.93-2.72)) and a reduced risk for the group of low-volume drinkers (hazard ratio of 0.75 (95%CI, 0.65-0.86)). After adjustment for cardiovascular risk factors, the risk difference between abstainers and low-volume drinkers was not significant anymore.

CONCLUSIONS

In the LURIC study, the risk of overall mortality and cardiovascular mortality is significantly increased in study participants with very high alcohol consumption and slightly increased in total abstainers as compared to participants with low consumption in unadjusted analysis, replicating the well-known J-curve. Adjusting for cardiovascular risk factors rendered the risk decrease observed for low-volume drinkers insignificant. Therefore, our results do not show a significant health benefit of low-volume alcohol consumption in a cohort of patients at medium-to-high cardiovascular risk.

Estimation of cancers caused by light to moderate alcohol consumption in the European Union

BACKGROUND

Research has identified alcohol to be an important risk factor for several types of cancers. This study estimates the number of incident cancers attributable to alcohol consumption in the European Union (EU) in 2017, with a special focus on those caused by light to moderate drinking levels.

METHODS

The attributable-fraction methodology is used to estimate the number of new cancer cases in the year 2017 in the EU caused by alcohol use, and further examines those due to light to moderate drinking levels, defined here as alcohol consumption of <20 g of pure alcohol per day.

RESULTS

Light to moderate drinking levels of alcohol caused almost 23 000 new cancer cases in the EU in 2017, and accounted for 13.3% of all alcohol-attributable cancers, and 2.3% of all cases of the seven alcohol-related cancer types. Almost half of these (∼11 000 cases) were female breast cancers. Also, more than a third of the cancer cases due to light to moderate drinking resulted from a light drinking level of <1 standard drink per day (total: 37%; women: 40%; men: 32%).

CONCLUSIONS

Alcohol use, including light to moderate drinking, continues to cause considerable cancer burden, and efforts should be made to reduce this burden. In addition to the alcohol control policies suggested by the World Health Organization, public information campaigns and the placement of warning labels on alcohol containers advising of the cancer risk associated with alcohol use should be initiated to increase knowledge about the alcohol-cancer link.

Can alcohol consumption in Germany be reduced by alcohol screening, brief intervention and referral to treatment in primary health care? Results of a simulation study

Background

Screening, brief intervention and referral to treatment (SBIRT) is a programme to reduce alcohol consumption for drinkers with high alcohol consumption levels. Only 2.9% of patients in primary health care (PHC) are screened for their alcohol use in Germany, despite high levels of alcohol consumption and attributable harm. We developed an open-access simulation model to estimate the impact of higher SBIRT delivery rates in German PHC settings on population-level alcohol consumption.

Methods and findings

A hypothetical population of drinkers and non-drinkers was simulated by sex, age, and educational status for the year 2009 based on survey and sales data. Risky drinking persons receiving BI or RT were sampled from this population based on screening coverage and other parameters. Running the simulation model for a ten-year period, drinking levels and heavy episodic drinking (HED) status were changed based on effect sizes from meta-analyses.

In the baseline scenario of 2.9% screening coverage, 2.4% of the adult German population received a subsequent intervention between 2009 and 2018. If every second PHC patient would have been screened for alcohol use, 21% of adult residents in Germany would have received BI or RT by the end of the ten-year simulation period. In this scenario, population-level alcohol consumption would be 11% lower than it was in 2018, without any impact on HED prevalence. Screening coverage rates below 10% were not found to have a measurable effect on drinking levels.

Conclusions

Large-scale implementation of SBIRT in PHC settings can yield substantial reductions of alcohol consumption in Germany. As high screening coverage rates may only be achievable in the long run, other effective alcohol policies are required to achieve short-term reduction of alcohol use and attributable harm in Germany. There is large potential to apply this open-access simulation model to other settings and for other alcohol interventions.

Causality and initiation of alcohol control policy. A response to Allamani

In a recent commentary, Allamani asked how one can establish causality in epidemiological research, and specifically about causality as it relates to alcohol control policy. Epidemiology customarily uses a sufficient-component cause model, where a sufficient cause for an outcome is determined by a set of minimal conditions and events that inevitably produce the stated outcome. While this model is theoretically clear, its operationalisation often involves probabilistic elements. Recent advances in agent-based modelling may improve operationalisation. The implications for alcohol control policy from this model are straightforward: the so-called alcohol-attributable fraction denotes the cases of morbidity or mortality which would not have happened in the absence of alcohol use.

Dose-Response Relationships between Levels of Alcohol Use and Risks of Mortality or Disease, for All People, by Age, Sex, and Specific Risk Factors

Alcohol use has been causally linked to more than 200 disease and injury conditions, as defined by three-digit ICD-10 codes. The understanding of how alcohol use is related to these conditions is essential to public health and policy research. Accordingly, this study presents a narrative review of different dose-response relationships for alcohol use. Relative-risk (RR) functions were obtained from various comparative risk assessments. Two main dimensions of alcohol consumption are used to assess disease and injury risk: (1) volume of consumption, and (2) patterns of drinking, operationalized via frequency of heavy drinking occasions. Lifetime abstention was used as the reference group. Most dose-response relationships between alcohol and outcomes are monotonic, but for diabetes type 2 and ischemic diseases, there are indications of a curvilinear relationship, where light to moderate drinking is associated with lower risk compared with not drinking (i.e., RR < 1). In general, women experience a greater increase in RR per gram of alcohol consumed than men. The RR per gram of alcohol consumed was lower for people of older ages. RRs indicated that alcohol use may interact synergistically with other risk factors, in particular with socioeconomic status and other behavioural risk factors, such as smoking, obesity, or physical inactivity. The literature on the impact of genetic constitution on dose-response curves is underdeveloped, but certain genetic variants are linked to an increased RR per gram of alcohol consumed for some diseases. When developing alcohol policy measures, including low-risk drinking guidelines, dose-response relationships must be taken into consideration.

Validation of a screening test for alcohol use, the Russian Federation

OBJECTIVE

To validate a Russian-language version of the World Health Organization's Alcohol Use Disorders Identification Test (AUDIT).

METHODS

We invited 2173 patients from 21 rural and urban primary health-care centres in nine Russian regions to participate in the study (143 declined and eight were excluded). In a standardized interview, patients who had consumed alcohol in the past 12 months provided information on their sociodemographic characteristics and completed the Russian AUDIT, the Kessler Psychological Distress Scale and the Composite International Diagnostic Interview to identify problem drinking and alcohol use disorders. We assessed the feasibility of administering the test, its internal consistency and its ability to predict hazardous drinking and alcohol use disorders in primary health care in the Russian Federation.

FINDINGS

Of the 2022 patients included in the study, 1497 were current drinkers with Russian AUDIT scores. The test was internally consistent with good psychometric properties (Cronbach's α : 0.842) and accurately predicted alcohol use disorders and other outcomes (area under the curve > 75%). A three-item short form of the test correlated well with the full instrument and had similar predictive power (area under the curve > 80%). We determined sex-specific thresholds for all outcomes, as non-specific thresholds resulted in few women being identified.

CONCLUSION

With the validated Russian AUDIT, there is no longer a barrier to introducing screening and brief interventions into primary health care in the Russian Federation to supplement successful alcohol control policies.

Why Is Per Capita Consumption Underestimated in Alcohol Surveys? Results from 39 Surveys in 23 European Countries

Aims

The aims of the article are (a) to estimate coverage rates (i.e. the proportion of ‘real consumption’ accounted for by a survey compared with more reliable aggregate consumption data) of the total, the recorded and the beverage-specific annual per capita consumption in 23 European countries, and (b) to investigate differences between regions, and other factors which might be associated with low coverage (prevalence of heavy episodic drinking [HED], survey methodology).

Methods

Survey data were derived from the Standardised European Alcohol Survey and Harmonising Alcohol-related Measures in European Surveys (number of surveys: 39, years of survey: 2008–2015, adults aged 20–64 years). Coverage rates were calculated at the aggregated level by dividing consumption estimates derived from the surveys by alcohol per capita estimates from a recent global modelling study. Fractional response regression models were used to examine the relative importance of the predictors.

Results

Large variation in coverage across European countries was observed (average total coverage: 36.5, 95% confidence interval [CI] [33.2; 39.8]), with lowest coverage found for spirits consumption (26.3, 95% CI [21.4; 31.3]). Regarding the second aim, the prevalence of HED was associated with wine- and spirits-specific coverage, explaining 10% in the respective variance. However, neither the consideration of regions nor survey methodology explained much of the variance in coverage estimates, regardless of the scenario.

Conclusion

The results reiterate that alcohol survey data should not be used to compare or estimate aggregate consumption levels, which may be better reflected by statistics on recorded or total per capita consumption.

Determining the sex-specific distributions of average daily alcohol consumption using cluster analysis: is there a separate distribution for people with alcohol dependence?

BACKGROUND

It remains unclear whether alcohol use disorders (AUDs) can be characterized by specific levels of average daily alcohol consumption. The aim of the current study was to model the distributions of average daily alcohol consumption among those who consume alcohol and those with alcohol dependence, the most severe AUD, using various clustering techniques.

METHODS

Data from Wave 1 and Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were used in the current analyses. Clustering algorithms were applied in order to group a set of data points that represent the average daily amount of alcohol consumed. Gaussian Mixture Models (GMMs) were then used to estimate the likelihood of a data point belonging to one of the mixture distributions. Individuals were assigned to the clusters which had the highest posterior probabilities from the GMMs, and their treatment utilization rate was examined for each of the clusters.

RESULTS

Modeling alcohol consumption via clustering techniques was feasible. The clusters identified did not point to alcohol dependence as a separate cluster characterized by a higher level of alcohol consumption. Among both females and males with alcohol dependence, daily alcohol consumption was relatively low.

CONCLUSIONS

Overall, we found little evidence for clusters of people with the same drinking distribution, which could be characterized as clinically relevant for people with alcohol use disorders as currently defined.

Commentary: The COVID-19 Pandemic Is Not a Good Time to Weaken Restrictions on Alcohol Availability

Alcohol use is well established globally as one of the major risk factors for burden of disease and mortality. Although it is not yet clear how the COVID-19 pandemic has impacted the overall level of alcohol use in Canada, we do know that various levels of government have promoted its use - either by designating it essential or by increasing its availability. Such actions may have both an immediate and sustained impact on alcohol-related harm in Canada. We encourage all levels of government to support and prioritize the development and implementation of an evidence-informed framework for both alcohol policy and service delivery to reduce alcohol-related harms during the current pandemic and beyond.

The role of alcohol use in the aetiology and progression of liver disease: A narrative review and a quantification

Issues.

Alcohol use has been shown to impact on various forms of liver disease, not restricted to alcoholic liver disease.

Approach.

We developed a conceptual framework based on a narrative review of the literature to identify causal associations between alcohol use and various forms of liver disease including the complex interactions of alcohol with other major risk factors. Based on this framework, we estimate the identified relations for 2017 for the USA.

Key Findings.

The following pathways were identified and modelled for the USA for the year 2017. Alcohol use caused 35 200 (95% uncertainty interval 32 800–37 800) incident cases of alcoholic liver cirrhosis. There were 1700 (uncertainty interval 1100–2500) acute hepatitis B and C virus (HBV and HCV) infections attributable to heavy-drinking occasions, and 14 000 (uncertainty interval 5900–19 500) chronic HBV and 1700 (uncertainty interval 700–2400) chronic HCV infections due to heavy alcohol use interfering with spontaneous clearance. Alcohol use and its interactions with other risk factors (HBV, HCV, obesity) led to 54 500 (uncertainty interval 50 900–58 400) new cases of liver cirrhosis. In addition, alcohol use caused 6600 (uncertainty interval 4200–9300) liver cancer deaths and 40 700 (uncertainty interval 36 600–44 600) liver cirrhosis deaths.

Implications.

Alcohol use causes a substantial number of incident cases and deaths from chronic liver disease, often in interaction with other risk factors.

Conclusion.

This additional disease burden is not reflected in the current alcoholic liver disease categories. Clinical work and prevention policies need to take this into consideration.

Determinants of educational inequalities in disability-free life expectancy between ages 35 and 80 in Europe

Socioeconomic inequalities in disability-free life expectancy (DFLE) exist across all European countries, yet the driving determinants of these differences are not completely known. We calculated the impact on educational inequalities in DFLE of equalizing the distribution of eight risk factors for mortality and disability using register-based mortality data and survey data from 15 European countries for individuals between 35 and 80 years old. From the selected risk factors, the ones that contribute the most to the educational inequalities in DFLE are low income, high body-weight, smoking (for men), and manual occupation of the father. Potentially large reductions in inequalities can be achieved in Eastern European countries, where educational inequalities in DFLE are also the largest.

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Disability-free life expectancy is lower among low than the high educated in Europe.

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Over-all, the risk factor contributing most to the inequality was low income.

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Other important contributors are high body-weight, smoking and father's manual occupation.

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Size of inequality and contribution of risk factors vary importantly between countries.

Further considerations of the best indicator for the harmful use of alcohol

INTRODUCTION AND AIMS

We discuss the rejoinder of Sherwin to our review which came to the result that adult alcohol per capita consumption is the best indicator for the harmful use of alcohol for the sustainable development goals.

DESIGN AND METHODS

Scientific discourse.

RESULTS

Sherwin suggested two additional indicators, 'age-standardised prevalence of heavy episodic drinking among adolescents and adults' and 'alcohol-related morbidity and mortality among adolescents and adults'. Given that these indicators should be part of the comprehensive sustainable development goals, we do not believe that three indicators for one target make sense. In addition, both suggested indicators are can only be derived using adult alcohol per capita consumption as basis.

DISCUSSION AND CONCLUSIONS

Adult per capita consumption should remain the indicator for the sustainable development goals.

Alcohol and health in Central and Eastern European Union countries - status quo and alcohol policy options

The aim of this narrative review is to give an overview of alcohol consumption, attributable health harm, and potential alcohol control policies to reduce this harm in five Central and Eastern European Union countries: Czech Republic, Estonia, Latvia, Lithuania, and Poland. The overall level of alcohol consumption was high, with the two highest-consuming countries in the world being situated in Central and Eastern Europe (Czech Republic, Latvia), and all five of these countries being in the top 15% of World Health Organization member states with respect to consumption. Accordingly, alcohol-attributable health harm was high. Implementation of alcohol control policies could be improved, especially the implementation of pricing policies such as taxation increases. A moderate increase of the tax share on alcohol could result in thousands of lives being saved in Central and Eastern Europe in a single year. As taxation increases not only save lives, but also increase state revenue, the implementation of this alcohol control measure should be made a priority.

Fewer Cancer Cases in 4 Countries of the WHO European Region in 2018 through Increased Alcohol Excise Taxation: A Modelling Study

INTRODUCTION

Prevention of cancer has been identified as a major public health priority for Europe, and alcohol is a leading risk factor for various types of cancer. This contribution estimates the number of cancer cases that could have potentially been averted in 2018 in 4 European countries if an increase in alcohol excise taxation had been applied.

METHODS

Current country and beverage-specific excise taxation of 4 member states of the WHO European Region (Germany, Italy, Kazakhstan, and Sweden) was used as a baseline, and the potential impacts of increases of 20, 50, and 100% to current excise duties were modelled. A sensitivity analysis was performed, replacing the current tax rates in the 4 countries by those levied in Finland. The resulting increase in tax was assumed to be fully incorporated into the consumer price, and beverage-specific price elasticities of demand were obtained from meta-analyses, assuming less elasticity for heavy drinkers. Model estimates were applied to cancer incidence rates for the year 2018.

RESULTS

In the 4 countries, >35,000 cancer cases in 2018 were caused by alcohol consumption, with the highest rate of alcohol-attributable cancers recorded in Germany and the lowest in Sweden. An increase in excise duties on alcohol would have significantly reduced these numbers, with between 3 and 7% of all alcohol-attributable cancer cases being averted if taxation had been increased by 100%. If the 4 countries were to adopt an excise taxation level equivalent to the one currently imposed in Finland, an even higher proportion of alcohol-attributable cancers could be avoided, with Germany alone experiencing 1,600 fewer cancer cases in 1 year.

DISCUSSION/CONCLUSION

Increasing excise duties can markedly reduce cancer incidence in European countries.

Province-specific alcohol-attributable cancer deaths and years of potential life lost in China

OBJECTIVE

Cancer is a major cause of death in China. As alcohol drinking, a risk factor of cancer, is common in China, we aimed to estimate the alcohol-attributable cancer deaths and years of potential life lost (YPLL) across all provinces in China.

METHODS

We estimated the proportion of cancer deaths and YPLL attributable to alcohol consumption at the province level. Population attributable fraction (PAF) was calculated based on: 1) prevalence of alcohol consumption, obtained from the China National Nutrition and Health Survey 2002; 2) dose-response relative risks (RRs) of alcohol consumption and site-specific cancer, extracted from published meta-analyses; 3) cancer mortality data, originated from the National Program of Cancer Registry 2013.

RESULTS

We estimated that 98,306 cancer deaths were attributable to alcohol consumption and accounted for 4.56 % of the total cancer deaths in China in 2013. Of these deaths, a total of 919,741.57 person-years premature loss of life was caused. Both overall PAF and average YPLL per 100,000 individuals were much higher in men than that in women (7.01 % vs. 0.33 % and 130.55 vs. 4.45, respectively). At the province level, overall PAF ranged from 2.14 % (95 % CI: 1.40 %-2.87 %) in Shanghai to 6.56 % (95 % CI: 4.06 %-9.05 %) in Anhui and the average YPLL per 100,000 individuals ranged from 10.97 in Tibet to 106.52 in Shandong.

CONCLUSIONS

Cancer burden attributable to alcohol consumption varied across provinces in China. Province-level approaches are warranted to decrease alcohol consumption and reduce the alcohol-related cancer burden.

Distribution of Drinks Consumed by U.S. Adults by Average Daily Alcohol Consumption: A Comparison of 2 Nationwide Surveys

INTRODUCTION

Estimates of alcohol consumption in the Behavioral Risk Factor Surveillance System are generally lower than those in other surveys of U.S. adults. This study compares the estimates of adults' drinking patterns and the distribution of drinks consumed by average daily alcohol consumption from 2 nationwide telephone surveys.

METHODS

The 2014-2015 National Alcohol Survey (n=7,067) and the 2015 Behavioral Risk Factor Surveillance System (n=408,069) were used to assess alcohol consumption among adults (≥18 years), analyzed in 2019. The weighted prevalence of binge-level drinking and the distribution of drinks consumed by average daily alcohol consumption (low, medium, high) were assessed for the previous 12 months using the National Alcohol Survey and the previous 30 days using the Behavioral Risk Factor Surveillance System, stratified by respondents' characteristics.

RESULTS

The prevalence of binge-level drinking in a day was 26.1% for the National Alcohol Survey; the binge drinking prevalence was 17.4% for the Behavioral Risk Factor Surveillance System. The prevalence of high average daily alcohol consumption among current drinkers was 8.2% for the National Alcohol Survey, accounting for 51.0% of total drinks consumed, and 3.3% for the Behavioral Risk Factor Surveillance System, accounting for 27.7% of total drinks consumed.

CONCLUSIONS

National Alcohol Survey yearly prevalence estimates of binge-level drinking in a day and high average daily consumption were consistently greater than Behavioral Risk Factor Surveillance System monthly binge drinking and high average daily consumption prevalence estimates. When planning and evaluating prevention strategies, the impact of different survey designs and methods on estimates of excessive drinking and related harms is important to consider.

Future of surveys in the alcohol field

Responding to the commentaries on a recent paper on the elusiveness of representativeness in general population alcohol surveys, we can summarise that there is agreement that the status quo of current alcohol surveys is scientifically no longer defensible. Current surveys cannot per se be assumed to yield representative results for the general populations of countries based on a probabilistic sampling alone. Alternatives are discussed and-as for any survey-creative ideas on validating key results on indicators or hypotheses need to be developed and used. This will inevitably lead away from omnibus surveys to more focused studies requiring more complex methodological tools. While there may not be obvious solutions for every problem related to alcohol use prevention and policy or treatment use disorders, and it may take years to find solutions for some of the issues, continued use of the methodology of the status quo will surely fail to answer the questions posed by modern societies concerning these issues.

The future of alcohol surveys: Between the devil and the deep blue sea

The future of survey research in the alcohol field, as elsewhere, does look gloomy. Even if there is a need to better confront this reality, abandoning traditional survey methods does not guarantee better outcomes and is not an equally burning issue in all countries or surveys and for all objectives. Correcting biases is easier when the aim is to estimate the parameters of a consumption distribution than when the aim is to measure drinking patterns, their changes and subgroup differences. Combining data from various sources requires making assumptions that affect the results but that may be hard to base on evidence. Despite these challenges, alcohol researchers need to take steps in this direction to find out more about the situations and ways in which such new methods would best serve the field.

Introducing CASCADEPOP: an open-source sociodemographic simulation platform for us health policy appraisal

Largescale individual-level and agent-based models are gaining importance in health policy appraisal and evaluation. Such models require the accurate depiction of the jurisdiction's population over extended time periods to enable modeling of the development of non-communicable diseases under consideration of historical, sociodemographic developments. We developed CASCADEPOP to provide a readily available sociodemographic micro-synthesis and microsimulation platform for US populations. The micro-synthesis method used iterative proportional fitting to integrate data from the US Census, the American Community Survey, the Panel Study of Income Dynamics, Multiple Cause of Death Files, and several national surveys to produce a synthetic population aged 12 to 80 years on 01/01/1980 for five states (California, Minnesota, New York, Tennessee, and Texas) and the US. Characteristics include individuals' age, sex, race/ethnicity, marital/employment/parental status, education, income and patterns of alcohol use as an exemplar health behavior. The microsimulation simulates individuals' sociodemographic life trajectories over 35 years to 31/12/2015 accounting for population developments including births, deaths, and migration. Results comparing the 1980 micro-synthesis against observed data shows a successful depiction of state and US population characteristics and of drinking. Comparing the microsimulation over 30 years with Census data also showed the successful simulation of sociodemographic developments. The CASCADEPOP platform enables modelling of health behaviors across individuals' life courses and at a population level. As it contains a large number of relevant sociodemographic characteristics it can be further developed by researchers to build US agent-based models and microsimulations to examine health behaviors, interventions, and policies.

Binge Drinking by Occupation Groups among Currently Employed U.S. Adults in 32 States, 2013-2016

BACKGROUND

Excessive alcohol use, including binge drinking (i.e., ≥5 drinks (males); ≥4 drinks (females), per occasion during the past 30 days), is associated with work-related injuries, absenteeism, and lost productivity. Binge drinking varies by sociodemographic characteristics (e.g., age, sex, income). However, information on binge drinking by occupation is limited. Purpose: This study examined binge drinking prevalence, frequency, intensity, and total binge drinks per binge drinker by sociodemographic characteristics and occupation. Methods: Data were analyzed from 358,355 currently employed U.S. adults who resided in the 32 states that administered the Behavioral Risk Factor Surveillance System industry and occupation questions during 2013-2016. Binge drinking was evaluated using weighted and adjusted prevalence models. Results: Among currently employed adults in the 32 states, 20.8% reported binge drinking, with an average of nearly 49 times per year and an average intensity of 7.4 drinks per binge episode, resulting in 478 total binge drinks per binge drinker. The adjusted binge drinking prevalence ranged from 15.9% among community and social services workers to 26.3% among construction and extraction workers. The total annual binge drinks per binge drinker ranged from 207 drinks among community and social services workers to 749 drinks among construction and extraction workers. Conclusions: One in five employed adults binge drink, and binge drinking varied across occupation groups. Widespread use of effective community-based strategies for preventing excessive alcohol use (e.g., regulating alcohol outlet density), as well as interventions tailored to specific occupation groups, and could reduce binge drinking and improve occupational safety and health.

Alcohol Use and Cancer in the European Union

BACKGROUND

Cancers constitute a major non-communicable disease category globally and in the European Union (EU).

SUMMARY

Alcohol use has been established as a major cause of cancer in humans. Principal cancer agencies agree that the following cancer sites are causally impacted by alcohol: lip and oral cavity, pharynx (excluding nasopharynx), oesophagus, colon and rectum, liver, (female) breast, and larynx. For all of these cancer sites, there is a dose-response relationship with no apparent threshold: the higher the average level of consumption, the higher the risk of cancer incidence. In the EU in 2016, about 80,000 people died of alcohol-attributable cancer, and about 1.9 million years of life were lost due to premature mortality or due to disability. Key messages: Given the above-described impact of alcohol on cancer, public awareness about the alcohol-cancer link needs to be increased. In addition, effective alcohol policy measures should be implemented. As a large part of alcohol-attributable cancers are in low and moderate alcohol users, in particular for females, general population measures such as increases in taxation, restrictions on availability, and bans on marketing and advertisement are best suited to reduce the alcohol-attributable cancer burden.

Improving the Validity of the Behavioral Risk Factor Surveillance System Alcohol Measures

BACKGROUND

Valid measurement of alcohol use can be difficult in surveys, which are subject to biases like underreporting and differential nonresponse. Still, monitoring trends, policy impacts, disparities, and related issues all require valid individual- and state-level drinking data collected over time. Here, we propose a double-adjustment approach for improving the validity of the Behavioral Risk Factor Surveillance System (BRFSS) alcohol measures.

METHODS

Validity analyses of the 1999 to 2016 BRFSS, a general population survey of U.S. adults. Measures are aggregated to state level for N = 918 observations, single-adjusted for BRFSS methodologic changes, and double-adjusted by per capita consumption. Fixed-effects models: (i) assess predictive validity using adjusted BRFSS drink volume to predict mortality outcomes and (ii) assess outcome validity using state-level alcohol taxes to predict adjusted BRFSS volume.

RESULTS

Neither the raw nor the single-adjusted BRFSS drinking measures were related to mortality in the expected direction, while double-adjusted BRFSS volume and 5+ days were significantly positively related to mortality, as expected. Spirits and beer taxes were not related to single-adjusted BRFSS drinking in the expected direction. However, spirits and beer taxes were both significantly related to double-adjusted BRFSS volume in the expected directions.

CONCLUSIONS

Future studies should consider using the double-adjusted BRFSS measures to ensure the validity of drinking survey data in analyses where variation over time is considered.

Alcohol Use and Cancers of the Gastrointestinal Tract. Epidemiology and Preventive Implications

Introduction: Alcohol is a carcinogen for human cancer. This contribution summarizes the relationships between alcohol use and gastrointestinal cancers, and implications for prevention. Methods: Comparative risk assessment and narrative literature review. Results: The following gastrointestinal cancer sites were found to be causally impacted by alcohol use: lip and oral cavity, pharynx other than nasopharynx, esophagus, colon and rectum, and liver. Globally, 368,000 deaths (304,000 men and 64,000 women) and more than 10 million disability-adjusted life years (DALYs) lost (10.1 million; 8.4 million men and 1.6 million women) in 2016 were attributable to alcohol use, making up about 10% of all deaths and DALYs lost due to these cancers, respectively. There are effective and cost-effective alcohol control policies available to reduce this burden, namely the best buys of increasing taxation, reducing availability, and banning advertisement. In addition, public knowledge about the alcohol-cancer link should be increased. Discussion: There are a number of assumptions underlying these estimates, but overall all of them seem to be conservative.

Estimation of the impacts of substance use on workplace productivity: a hybrid human capital and prevalence-based approach applied to Canada

OBJECTIVE

Policy makers require evidence-based estimates of the economic costs of substance use-attributable lost productivity to set strategies aimed at reducing substance use-related harms. Building on a study by Rehm et al. (2006), we provide estimates of workplace costs using updated methods and data sources.

METHODS

We estimated substance use-attributable productivity losses due to premature mortality, long-term disability, and presenteeism/absenteeism in Canada between 2007 and 2014. Lost productivity was estimated using a hybrid prevalence and incidence approach. Substance use prevalence data were drawn from three national self-report surveys. Premature mortality data were from the Canadian Vital Statistics Death Database, and long-term disability and workplace interference data were from the Canadian Community Health Survey.

RESULTS

In 2014, the total cost of lost productivity due to substance use was $15.7 billion, or approximately $440 per Canadian, an increase of 8% from 2007. Substances responsible for the greatest economic costs were alcohol (38% of per capita costs), tobacco (37%), opioids (12%), other central nervous system (CNS) depressants (4%), other CNS stimulants (3%), cannabis (2%), cocaine (2%), and finally other psychoactive substances (2%).

CONCLUSION

In 2014, alcohol and tobacco represent three quarters of substance use-related lost productivity costs in Canada, followed by opioids. These costs provide a valuable baseline that can be used to assess the impact of future substance use policy, practice, and other interventions, especially important given Canada's opioid crisis and recent cannabis legalization.

Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study

BACKGROUND

Alcohol use is a leading risk factor for global disease burden, and data on alcohol exposure are crucial to evaluate progress in achieving global non-communicable disease goals. We present estimates on the main indicators of alcohol exposure for 189 countries from 1990-2017, with forecasts up to 2030.

METHODS

Adult alcohol per-capita consumption (the consumption in L of pure alcohol per adult [≥15 years]) in a given year was based on country-validated data up to 2016. Forecasts up to 2030 were obtained from multivariate log-normal mixture Poisson distribution models. Using survey data from 149 countries, prevalence of lifetime abstinence and current drinking was obtained from Dirichlet regressions. The prevalence of heavy episodic drinking (30-day prevalence of at least one occasion of 60 g of pure alcohol intake among current drinkers) was estimated with fractional response regressions using survey data from 118 countries.

FINDINGS

Between 1990 and 2017, global adult per-capita consumption increased from 5·9 L (95% CI 5·8-6·1) to 6·5 L (6·0-6·9), and is forecasted to reach 7·6 L (6·5-10·2) by 2030. Globally, the prevalence of lifetime abstinence decreased from 46% (42-49) in 1990 to 43% (40-46) in 2017, albeit this was not a significant reduction, while the prevalence of current drinking increased from 45% (41-48) in 1990 to 47% (44-50) in 2017. We forecast both trends to continue, with abstinence decreasing to 40% (37-44) by 2030 (annualised 0·2% decrease) and the proportion of current drinkers increasing to 50% (46-53) by 2030 (annualised 0·2% increase). In 2017, 20% (17-24) of adults were heavy episodic drinkers (compared with 1990 when it was estimated at 18·5% [15·3-21·6%], and this prevalence is expected to increase to 23% (19-27) in 2030.

INTERPRETATION

Based on these data, global goals for reducing the harmful use of alcohol are unlikely to be achieved, and known effective and cost-effective policy measures should be implemented to reduce alcohol exposure.

FUNDING

Centre for Addiction and Mental Health and the WHO Collaborating Center for Addiction and Mental Health at the Centre for Addiction and Mental Health.

Research Protocol to Evaluate the Effects of Alcohol Policy Changes in Lithuania

Aims

To point out the importance for public health to evaluate the past policy changes (2016-2018) in Lithuania. To present a research protocol to conduct this evaluation.

Short summary

The staggered implementation of key alcohol policies in Lithuania over the past two years offers the possibility to evaluate 'best buys' for alcohol policies for this country. Lithuania is the only country where all 'best buys' were implemented over a short period of time, so this evaluation will be unique.

Methods

Quasi-experimental design based on interrupted time-series analysis of monthly routine statistics of morbidity and mortality indicators as well as key variables on the pathway between alcohol exposure and health outcomes.

Conclusions

For the public health community, results of the evaluation of these policy changes will be of critical importance.