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. 2026 Jul 10;50(7):e70321. doi: 10.1111/acer.70321

Trends in Alcohol–Related Deaths in the United States Over 55 Years: 1968–2023

Mohid Zulfiqar 1, Muhammad Salik Uddin 1, Faizan Abbas 2, Asim Sajjad 1, Ammad Uddin 1, Syed Ahmed Ali Shah 1, Gregg C Fonarow 3, Saad Ahmed Waqas 1, Hermann Yokolo 4,✉, Shaheer Qureshi 1
PMCID: PMC13353243  PMID: 42429647

ABSTRACT

Background

Alcohol consumption is a leading cause of preventable mortality worldwide. We examined long‐term trends in alcohol‐related deaths in the United States over 55 years (1968–2023) and analyzed demographic disparities.

Methods

Using CDC WONDER data, we identified alcohol‐related deaths among adults aged ≥ 25 years. Age‐adjusted mortality rates (AAMRs) per 100,000 population were calculated, and joinpoint regression analyzed temporal trends by sex, race, age, and geographic region.

Results

From 1968 to 2023, 1,321,804 alcohol‐related deaths occurred. AAMRs increased from 13.1 to 19.3 (AAPC: 0.7, p < 0.001), with a sharp acceleration during 2018–2021 (APC: 14.1) followed by a decline during 2021–2023 (APC: −6.9). Males consistently had higher mortality than females, though the gender gap narrowed. A striking racial inversion occurred: mortality among Black individuals declined from 27.7 to 13.5 (AAPC: −1.4), while mortality among White individuals increased from 11.3 to 21.1 (AAPC: 1.1) with older adults (65+) showing the steepest long‐term increase (AAPC: 1.4). Regionally, the Midwest experienced the greatest rise in mortality (AAPC: 1.4), while the Northeast remained stable.

Conclusions

Alcohol‐related mortality has increased substantially over 55 years, with profound demographic shifts including a complete racial disparity inversion and narrowing gender gap. Recent declines (2021–2023) offer cautious optimism, but sustained, targeted interventions are needed for high‐risk populations.

Keywords: age‐adjusted mortality rate, alcohol, CDC WONDER, gender disparities, health disparities, mortality trends, racial disparities

This 55 year analysis of 1.3 million alcohol‐related deaths reveals a profound epidemiological shift. While overall mortality rose from 13.1 to 19.3 per 100,000, the most striking finding is the complete inversion of racial disparities rates among Black Americans declined by half, while White Americans nearly doubled. The gender gap narrowed as female mortality accelerated, and the Midwest emerged as the new epicenter of crisis. These trends, sharply amplified during COVID‐19, underscore the need for targeted, population‐specific interventions.

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1. Introduction

Alcohol consumption poses unique risks as it not only directly has adverse effects on a person's health but also simultaneously increases the risk of over 200 diseases and conditions, including liver disease, heart disease, stroke, and multiple cancers such as breast, liver, colorectal and esophageal, as well as mental disorders, injuries, infectious diseases, and fetal alcohol spectrum disorders (Alcohol 2026). This unique burden is evident in its global impact, as it is reported that alcohol use was the seventh leading risk factor for deaths in 2016 globally, accounting for 2.8 million fatalities, and even more alarmingly, it was the number one leading cause of preventable deaths among people aged 15–49 (Griswold et al. 2018). In the United States, there has been a concerning rise in preventable deaths, largely driven by increases in accidental deaths, suicides, and chronic liver disease or cirrhosis. These trends are primarily driven by substance misuse, notably opioid overdoses and alcohol‐related liver disease (Best et al. 2018). Among these causes of preventable death, those linked to alcohol stand out. For instance, one report indicates that between 1999 and 2020, there were 605,948 alcohol‐related deaths in the United States (Maleki et al. 2023). Aside from its fatal consequences, alcohol use has significant financial consequences. In 2015, the healthcare costs for privately insured Americans with alcohol‐related liver cirrhosis were about $5 billion. On average, the medical bills for each patient in the first year after diagnosis were nearly $45,000 (Julien et al. 2020). Alcohol‐related deaths, often referred to as “deaths of despair,” are particularly prevalent among certain vulnerable populations (Manthey et al. 2019). In light of this, we aim to examine long‐term trends associated with alcohol‐related deaths, utilizing data from the CDC WONDER database. By analyzing over five decades of national mortality records, we aim to provide a comprehensive understanding of how alcohol‐related deaths have evolved over time and explore variations across demographic groups, including age, sex, race, and geographic regions, to identify populations at heightened risk. Additionally, we aim to offer valuable insights for policymakers and public health professionals to design demographic‐specific prevention and intervention strategies to reduce alcohol‐attributable deaths and their associated burden.

2. Methods

2.1. Study Setting and Population

We conducted a descriptive analysis using death certificate data from the Centers for Disease Control and Prevention's Wide‐Ranging Online Data for Epidemiologic Research database. Alcohol‐related deaths were identified in individuals ≥ 25 years of age, with International Classification of Diseases‐8 (ICD‐8‐CM) codes 291, 303, 571.0, and E860 for the years 1968 to 1978, ICD‐9‐CM codes 291, 303, 305.0, 357.5, 425.5, 535.3, 571.0–571.3, 790.3, and E860 for the years 1979 to 1998, and ICD‐10‐CM codes E24.4, F10, G31.2, G62.1, G72.1, I42.6, K29.2, K70, K85.2, K86.0, O35.4, P04.3, Q86.0, R78.0, X45, and Y15 from 1999 onward. We applied a consistent definition of alcohol‐related across ICD revisions.

Our analysis focused on death certificates from the database, capturing cases where Alcohol was listed as a primary cause of death. Institutional review board approval was not required, as we used a de‐identified, publicly available dataset in compliance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (von Elm et al. 2008).

2.2. Data Abstraction

We categorized data by demographic factors, including age, gender, census region, and race/ethnicity. Age groups were categorized as adults aged 25–44 years (younger adults), 45–64 years (middle‐aged adults), and 65+ (older adults). Racial/ethnic groups included White and Black/African American. The United States was further divided into four regions based on the U.S. Census Bureau classification: Northeast, Midwest, South, and West (Klein and Schoenborn 2001).

2.3. Statistical Analysis

To standardize related deaths, age‐adjusted mortality rates (AAMRs) per 100,000 population were calculated using the annual national population totals from the US Census Bureau and the 2000 US standard population, along with the corresponding 95% confidence intervals (CIs) (Bureau 2021). Temporal trends were assessed using the Joinpoint Regression version 5.2.0 (National Cancer Institute) (National Cancer Institute 2026). Annual percentage changes (APCs) with 95% CIs were calculated among intervals identified by the Joinpoint regression. APCs were categorized as increasing or decreasing based on statistical deviation from the null hypothesis of zero change. Statistical significance was determined using a two‐tailed t‐test with a significance threshold of p < 0.05.

3. Results

Between 1968 and 2023, a total of 1,321,804 deaths were recorded in which alcohol was the underlying cause of death. During this period, AAMR increased from 13.1 (95% CI: 12.9 to 13.3) in 1968 to 19.3 (95% CI: 19.1 to 19.5) in 2023, with an AAPC of 0.7 (95% CI: 0.3 to 1.1, p < 0.001). The pattern exhibited multiple distinct phases: an initial rise from 1968 to 1972 (APC: 4.1; 95% CI: 2.5 to 5.8), followed by a non‐significant decline from 1972 to 1980 (APC: −0.5; 95% CI: −1.1 to 0.2). Subsequently, rates decreased more substantially from 1980 to 1983 (APC: −6.0; 95% CI: −10.8 to −0.9), then increased nonsignificantly from 1983 to 1989 (APC: 1.0; 95% CI: −0.2 to 2.3). A decline in mortality trends occurred from 1989 to 2005 (APC: −1.5; 95% CI: −1.8 to −1.3), followed by an increase from 2005 to 2021, more steeply from 2018 to 2021 (APC: 14.1; 95% CI: 9.7 to 18.7), with a subsequent decrease from 2021 to 2023 (APC: −6.9; 95% CI: −10.1 to −3.5) (Tables 1, S1 and S2 Central illustration).

TABLE 1.

Annual percent change (APC) in Alcohol‐related mortality by total population, sex, race, age group, and U.S. Census Region, 1968–2023.

Category Trend 1 year Trend 2 year Trend 3 year Trend 4 year Trend 5 year
Year APC (95% CI) Year APC (95% CI) Year APC (95% CI) Year APC (95% CI) Year APC (95% CI)
Overall 1968–1972 4.15 (2.50 to 5.82) 1972–1980 −0.47 (−1.09 to 0.15) 1980–2005 −1.51 (−1.76 to −1.26) 2005–2021 2.97 (2.62 to 3.31) 2021–2023 −6.87 (−10.08 to −3.55)
Sex
Male 1968–1973 3.84 (1.22 to 6.53) 1973–2006 −1.15 (−1.27 to −1.03) 2006–2018 2.50 (2.27 to 2.77) 2018–2021 12.71 (5.32 to 20.62) 2021–2023 −5.99 (−13.47 to 2.14)
Female 1968–1972 3.82 (1.38 to 6.32) 1972–1980 −0.92 (−1.84 to 0.01) 1980–2005 −1.11 (−1.34 to −0.88) 2005–2018 4.25 (3.78 to 4.73) 2018–2023 14.92 (9.35 to 20.77)
Race
Black or African American 1968–1975 3.8 (1.0 to 6.0) 1975–1985 −3.2 (−5.5 to −0.8) 1985–2000 −5.8 (−6.7 to −4.9) 2000–2015 1.5 (0.7 to 2.3) 2015–2023 5.8 (−3.6 to 14.5)
White 1968–1975 2.7 (1.4 to 4.1) 1975–1985 −2.1 (−2.7 to −1.3) 1985–2005 −0.05 (−0.26 to 0.16) 2005–2018 3.4 (2.9 to 3.9) 2018–2023 4.0 (−2.0 to 9.6)
Age group
Young adults (25–44) 1968–1975 2.96 (0.41 to 5.58) 1975–1990 −2.42 (−3.36 to −1.48) 1990–2005 −2.48 (−2.80 to −2.15) 2005–2018 3.90 (3.21 to 4.60) 2018–2023 −7.50 (−11.29 to −3.55)
Middle‐aged adults (45–64) 1968–1975 3.67 (2.19 to 5.17) 1975–1990 −0.83 (−1.78 to 0.14) 1990–2005 −0.93 (−1.13 to −0.74) 2005–2018 2.62 (2.33 to 2.92) 2018–2023 −8.53 (−12.26 to −4.65)
Older adults (65–85+) 1968–1975 3.91 (2.68 to 5.15) 1975–1990 0.48 (0.21 to 0.76) 1990–2005 −2.83 (−3.89 to −1.75) 2005–2018 4.61 (3.26 to 5.98) 2018–2023 −1.85 (−6.73 to 3.29)
Census region
Census Region 1: Northeast 1968–1978 0.30 (−0.48 to 1.08) 1978–2000 −2.80 (−2.97 to −2.64) 2000–2010 3.34 (2.71 to 3.98) 2010–2020 11.67 (1.10 to 23.35) 2020–2023 −6.43 (−14.60 to 2.53)
Census Region 2: Midwest 1968–1975 1.83 (0.58 to 3.10) 1975–1990 −1.42 (−2.16 to −0.67) 1990–2005 −2.30 (−3.22 to −1.37) 2005–2018 4.39 (3.87 to 4.91) 2018–2023 −6.23 (−10.70 to −1.53)
Census Region 3: South 1968–1975 6.74 (1.69 to 12.05) 1975–1990 −1.23 (−1.37 to −1.10) 1990–2010 4.03 (3.05 to 5.01) 2010–2020 13.25 (6.38 to 20.56) 2020–2023 −7.35 (−12.43 to −1.97)
Census Region 4: West 1968–1975 3.63 (2.09 –to 5.19) 1975–1990 −2.56 (−3.21 to −1.91) 1990–2005 −0.42 (−0.66 to −0.18) 2005–2020 1.83 (1.51 to 2.14) 2020–2023 −6.99 (−10.68 to −3.15)
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3.1. Alcohol‐Related Mortality by Sex

Males exhibited a higher AAMR than females throughout the study period, with AAMR changing from 19.8 (95% CI: 19.4 to 20.2) in 1968 to 27.9 (95% CI: 27.6 to 28.2) in 2023, with an AAPC of 0.6 (95% CI: 0.1 to 1.2, p = 0.022). Male mortality rates initially increased from 1968 to 1973 (APC: 3.8; 95% CI: 1.2 to 6.5), then declined from 1973 to 2006 (APC: −1.1; 95% CI: −1.3 to −1.0), followed by an increase from 2006 to 2018 (APC: 2.5; 95% CI: 2.1 to 2.9). A sharp rise from 2018 to 2021 was observed (APC: 12.7; 95% CI: 5.3 to 20.6) and concluded with a nonsignificant decrease from 2021 to 2023 (APC: −6.0; 95% CI: −13.5 to 2.1). In contrast, among females, the AAMR rose from 7.2 (95% CI: 7.0 to 7.4) in 1968 to 11.2 (95% CI: 11.0 to 11.4) in 2023, with an AAPC of 0.8 (95% CI: 0.3 to 1.4, p = 0.003). In females, mortality pattern showed an initial increase from 1968 to 1972 (APC: 3.8; 95% CI: 1.4 to 6.3), followed by a decline from 1972 to 1983, more pronounced from 1980 to 1983 (APC: −6.5; 95% CI: −13.0 to 0.6), although it was statistically nonsignificant. AAMR declined from 1983 to 2005 (APC: −1.1; 95% CI: −1.3 to −0.9). Subsequently, rates increased from 2005 to 2021, steeper from 2018 to 2021 (APC: 14.9; 95% CI: 9.3 to 20.8), and finally decreased from 2021 to 2023 (APC: −6.4; 95% CI: −10.3 to −2.2) (Figure 1; Table S3).

FIGURE 1.

FIGURE 1

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Sex‐stratified alcohol‐related AAMRs per 100,000 in adults in the United States, 1968–2023 (ICD‐8 codes for 1968–1978, ICD‐9 codes for 1979–1998, and ICD‐10 codes from 1999 onward).

3.2. Alcohol‐Related Mortality by Race

Racial disparities in alcohol‐related mortality revealed contrasting long‐term trends throughout the study period. Among Black or African American individuals, the AAMR decreased from 27.7 (95% CI: 26.7 to 28.7) in 1968 to 13.5 (95% CI: 13.1 to 13.9) in 2023, with an AAPC of −1.4 (95% CI: −2.1 to −0.6, p < 0.001). Conversely, White individuals showed an overall increasing trend, with AAMR rising from 11.3 (95% CI: 11.1 to 11.5) in 1968 to 21.1 (95% CI: 20.9 to 21.3) in 2023, exhibiting an AAPC of 1.1 (95% CI: 0.8 to 1.5, p < 0.001).

Black or African American individuals experienced an initial increase from 1968 to 1972 (APC: 4.3; 95% CI: 1.4 to 7.3), followed by periods of stability, declining and inclining from 1972 to 1989, but none of them reached statistical significance. AAMR declined from 1989 to 2007 (APC: −6.5; 95% CI: −6.8 to −6.3), then a rise was observed from 2007 to 2018 (APC: 1.3; 95% CI: 0.5 to 2.1), followed by a steeper rise from 2018 to 2021 (APC: 17.3; 95% CI: 8.4 to 26.8). Finally, a decline from 2021 to 2023 (APC: −10.1; 95% CI: −16.2 to −3.6) was observed. The White individuals experienced an increase from 1968 to 1974 (APC: 2.7; 95% CI: 1.4 to 4.1), followed by a decline from 1974 to 1984 (APC: −2.0; 95% CI: −2.7 to −1.4). Rates remained relatively stable and did not reach statistical significance from 1984 to 2006 (APC: −0.0; 95% CI: −0.3 to 0.2), then increased from 2006 to 2018 (APC: 3.4; 95% CI: 2.9 to 3.9), followed by a sharper acceleration from 2018 to 2021 (APC: 13.9; 95% CI: 8.7 to 19.2), and concluded with a decrease from 2021 to 2023 (APC: −5.9; 95% CI: −9.6 to −2.0) (Figure 2; Tables 1 and S4).

FIGURE 2.

FIGURE 2

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Alcohol‐related AAMRs per 100,000 stratified by race in adults in the United States, 1968–2023 (ICD‐8 codes for 1968–1978, ICD‐9 codes for 1979–1998, and ICD‐10 codes from 1999 onward).

3.3. Alcohol‐Related Mortality by Age Group

Among younger adults (25–44 years), the AAMR rose from 8.2 (95% CI: 8.0 to 8.5) in 1968 to 11.3 (95% CI: 11.1 to 11.6) in 2023, with an AAPC of 0.6 (95% CI: 0.0 to 1.2, p = 0.061). The middle‐aged adults (45–64 years) also displayed an increasing trend, with AAMR rising from 21.5 (95% CI: 21.1 to 22.0) in 1968 to 29.1 (95% CI: 28.8 to 29.5) in 2023, with an AAPC of 0.5 (95% CI: 0.1 to 1.0, p = 0.018). Among older adults (65+ years), mortality patterns showed the most substantial long‐term increase, with AAMR rising from 9.9 (95% CI: 9.4 to 10.3) in 1968 to 20.9 (95% CI: 20.6 to 21.3) in 2023, and an AAPC of 1.4 (95% CI: 0.9 to 1.9, p < 0.001).

Younger adults (25–44 years) experienced an initial increase from 1968 to 1972 (APC: 3.0; 95% CI: 0.4 to 5.6), followed by a decline from 1972 to 1983, more pronounced decrease from 1980 to 1983 (APC: −7.0; 95% CI: −13.5 to 0.0). Subsequently, rates increased from 1983 to 1990 (APC: 1.7; 95% CI: 0.4 to 3.0), then declined from 1990 to 2007 (APC: −2.5; 95% CI: −2.8 to −2.1), followed by incline from 2007 to 2021, more sharply from 2018 to 2021 (APC: 24.2; 95% CI: 17.8 to 31.0), concluding with a decrease from 2021 to 2023 (APC: −7.5; 95% CI: −11.3 to −3.5). Middle‐aged adults (45–64 years) showed an initial increase from 1968 to 1973 (APC: 3.7; 95% CI: 2.2 to 5.2), followed by a statistically nonsignificant decline from 1973 to 1983. A relatively stable period was observed from 1983 to 2003 (APC: −0.9; 95% CI: −1.1 to −0.7), followed by a rise in AAMR from 2003 to 2021, more steeply from 2018 to 2021 (APC: 11.2; 95% CI: 6.4 to 16.2), and concluded with a decrease from 2021 to 2023 (APC: −8.5; 95% CI: −12.3 to −4.6). Older adults (65+ years) displayed similar trends; however, the increase was more pronounced and sustained than in middle‐aged adults (45–64 years), showing a steeper rise throughout the study period (Figure S1; Tables 1 and S5).

3.4. Alcohol‐Related Mortality by Census Region

The Midwest exhibited the steepest upward trajectory, with an AAPC of 1.4 (95% CI: 0.7 to 2.1, p < 0.001), as AAMR increased from 9.8 (95% CI: 9.5 to 10.2) in 1968 to 20.4 (95% CI: 20.0 to 20.9) in 2023. The South showed the next most pronounced rise, with an AAPC of 0.7 (95% CI: 0.1 to 1.2, p = 0.014), as mortality increased from 11.5 (95% CI: 11.1 to 11.9) in 1968 to 16.8 (95% CI: 16.6 to 16.8) in 2023. The West demonstrated a more modest upward trend, with an AAPC of 0.6 (95% CI: 0.2 to 1.0, p = 0.001), as AAMR rose from 19.5 (95% CI: 18.9 to 20.2) in 1968 to 26.6 (95% CI: 26.2 to 27.0) in 2023. In contrast, the Northeast displayed the most stable long‐term pattern, with an AAPC of −0.2 (95% CI: −0.9 to 0.5, p = 0.539), showing little change from 14.5 (95% CI: 14.1 to 15.0) in 1968 to 13.8 (95% CI: 13.4 to 14.2) in 2023.

The Northeast region experienced an increase from 1968 to 1978 (APC: 0.3; 95% CI: −0.5 to 1.1), but it did not reach statistical significance. A decline was seen from 1978 to 2005 (APC: −2.8; 95% CI: −3.0 to −2.6), followed by an increase from 2005 to 2021, more sharply from 2018 to 2021 (APC: 11.7; 95% CI: 1.1 to 23.4), and a recent nonsignificant decrease from 2021 to 2023 (APC: −6.4; 95% CI: −14.6 to 2.5). The South showed similar trends, but the increasing trends were more pronounced than in the Northeast. The Midwest showed an initial rise from 1968 to 1975 (APC: 1.8; 95% CI: 0.6 to 3.1), followed by a decline from 1975 to 1986 (APC: −1.4; 95% CI: −2.2 to −0.7). Subsequent periods included modest increases but were not statistically significant. From 1989 to 1999, a decline was seen (APC: −2.3; 95% CI: −3.2 to −1.4), followed by an increase from 1999 to 2021, a more steep increase from 2018 to 2021 (APC: 16.7; 95% CI: 10.1 to 23.7), and a recent decrease from 2021 to 2023 (APC: −6.2; 95% CI: −10.7 to −1.5). The West demonstrated similar trends from 1968 to 2023 (Figure S2; Tables 1 and S6).

3.5. Alcohol‐Related Mortality by States

States that showed the highest AAMRs in 2023 were New Mexico, Alaska and South Dakota with AAMRs 56.1, 52.7, and 43.1, respectively. The states with the greatest increases in AAMRs were South Dakota 580.9%, Iowa 406.2%, and Idaho 272.2%. Conversely, the smallest increases were seen in Georgia 0.1%, California 4.5%, and Connecticut 8.3% with four states showing decline in AAMRs, District of Columbia −56.3%, New York −39.2%, Virginia −17.4%, and New Jersey −14.7%. In the 25–45 age group, New Mexico (51.2), Alaska (44.7), and South Dakota (40.5) had the highest AAMRs in 2023, with South Dakota (1250.0%), North Dakota (916.0%), and Hawaii (750.0%) showing the greatest increases, while we observed that District of Columbia (−71.6%), New York (−48.7%), Georgia (−41.0%), and North Carolina (−31.7%) experienced declines. For the 45–65 age group, New Mexico (79.6), Alaska (64.2), and South Dakota (60.8) had the highest rates, with South Dakota (428.7%), Iowa (357.3%), and Mississippi (194.2%) demonstrating the largest increases, whereas District of Columbia (−52.9%), New York (−36.5%), Virginia (−30.6%), New Jersey (−22.1%), and Georgia (−13.1%) showed decreases. Among those aged 65–85+, Oregon (49.0), Alaska (43.3), and Nevada (39.1) had the highest AAMRs, with South Carolina (574.3%), Tennessee (528.2%), and Arkansas (500.0%) exhibiting the most substantial increases, while Alaska (−51.2%), New Jersey (−28.6%), Hawaii (−25.4%), and New York (−22.7%) demonstrated decline (Figure 3; Table S7).

FIGURE 3.

FIGURE 3

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Geographic percentage change in alcohol‐related AAMR across age groups (25–45 years, 45–65 years, 65–85+ years, and overall adults aged 25–85+) in the United States, 1968–2023.

4. Discussion

This longitudinal analysis of United States mortality data reveals a sustained, upward trend in alcohol‐related deaths over more than half a century, signifying an escalating public health concern. The historical trajectory was notably marked by a period of sharp escalation in recent years, a time frame that corresponds with the COVID‐19 pandemic (White et al. 2022). This overall mortality pattern is further characterized by profound and evolving demographic disparities. While males consistently experienced higher mortality rates than females, the most significant historical dynamic observed was a pronounced racial divergence. Throughout the study's time frame, mortality rates demonstrated opposing trajectories, with a substantial decline among Black individuals and a considerable increase among White individuals, resulting in a reversal of the mortality burden by the end of the observation period.

The 55‐year historical trend in alcohol‐related mortality was not linear but characterized by distinct epochs reflecting shifts in demographics, policy, and clinical practice as well as economic forces. Among these, economic factors play a central role. Per capita alcohol consumption is strongly influenced by affordability, which is determined by the interaction between alcohol prices and income trends (Kerr et al. 2013). Fluctuations in real prices, taxation policies, and disposable income over time likely contributed to corresponding changes in consumption patterns and, ultimately, alcohol‐attributable mortality. Historical data demonstrate substantial shifts in affordability over time. For example, in 1950, purchasing one daily drink of the least expensive spirits required approximately 4.46% of per capita disposable income; by 1970, this share had declined to 2.24%, effectively reducing the income burden by nearly half. Such a marked decline in the real cost of alcohol during the 1970s represents a dramatic increase in affordability, which likely facilitated higher per capita consumption and may have contributed to subsequent increases in alcohol‐attributable mortality observed during our analysis (Kerr et al. 2013). The sharp decline in mortality in the early 1980s coincides with the double‐dip recessions (1980, 1981–1982), when disposable income contracted while alcohol prices remained elevated, sharply reducing affordability. The sustained 1989–2005 decrease aligns with accelerating price index increases, reducing affordability through higher real costs during a period of economic expansion (U.S. Bureau of Labor Statistics 2026).

However, this progress reversed in the mid‐2000s as mortality rates began to climb steadily. This era aligns with growing socioeconomic pressures linked to “deaths of despair” (Beseran et al. 2022) and was likely worsened by a changing alcohol landscape, including the aggressive marketing of higher potency beverages (Babor 2010) and a cultural normalization of high‐risk drinking that narrowed the gender gap in consumption and harms (Carlini et al. 2026). This upward trajectory culminated in an unprecedented acceleration during the COVID‐19 pandemic, a crisis that amplified risk factors like psychological distress (Rodriguez et al. 2020) while a shift to at‐home consumption weakened informal social controls on drinking (Acuti Martellucci et al. 2021). While the recent downturn from 2021 to 2023 is a positive signal, it must be interpreted with caution as a potential short‐term stabilization rather than a durable reversal of the multi‐decade upward trend.

The sex gap in alcohol‐related mortality has fundamentally transformed over the past half‐century, shifting from a large, stable divide into a dynamic and alarming convergence. Starting from a vast disparity in 1968, when men's mortality rate was nearly three times higher, this was followed by a subsequent decline in rates for both sexes without significantly altering this gap for decades; this may in part be due to successful public health policies, although economic forces as mentioned earlier likely play a part as well (Wagenaar and Toomey 2002). This shared progress, however, unraveled for both genders after the mid‐2000s amid rising “deaths of despair” (Beseran et al. 2022). Here, a critical divergence began, which was rooted in a profound cultural shift where women were transformed from an overlooked demographic into a prime target market for the alcohol industry. Combined with the normalization of alcohol as a primary tool for managing modern stressors, powerfully seen in phenomena like “Mommy Wine Culture” (Reisdorfer et al. 2023), a rapid increase in high‐risk drinking among women was observed, causing the relative gender gap to progressively narrow (White 2020). The COVID‐19 pandemic acted as a powerful accelerator for this trend, as the resulting mortality spike was sharpest among women, confirming their unique vulnerability to the crisis's disproportionate burdens (Pollard et al. 2020). Thus, the narrowing of this long‐standing gender gap is not a story of progress, but a clear warning of a worsening and increasingly female‐centric public health crisis.

While the gender disparities observed are significant, another striking epidemiological transition we document in our analysis is the complete inversion of the racial mortality burden over the past five decades. The historical narrative began in 1968 with Black individuals facing a mortality rate more than double that of their White counterparts. This disparity, rooted in systemic inequities like the targeted marketing of high‐potency alcohol (Alaniz 1998) and in complex drinking patterns where higher rates of abstinence in Black communities coexisted with more severe consequences for those who did engage in high‐risk drinking, caused this observed significant difference in historical mortality rates (Hasin et al. 2007). However, a remarkable reversal unfolded when a sustained decline in mortality among Black Americans was observed, particularly from 1989 to 2007. This may in part be due to public health policies as well as quality of substance use treatment (Saloner and Cook 2013). In stark contrast, a persistent and accelerating rise in mortality began to afflict White individuals. This trend, a central feature of the “deaths of despair” crisis (Case and Deaton 2015), is not only linked to economic precarity but is also deeply intertwined with the opioid epidemic and a documented decline in social cohesion and community engagement in many parts of America (Siddiqi et al. 2019). While both groups experienced a sharp spike in mortality during the COVID‐19 pandemic, recent data shows that the long‐term trend of declining mortality for Black individuals and rising mortality for White individuals has resumed, thus resulting in a complete reversal of the observed 1968 disparity by 2023.

Age group disparities were also observed in this analysis and revealed distinct crises of cumulative, late‐life, and acute harm. Middle‐aged adults (45–64) consistently bear the highest mortality burden, representing the fatal culmination of chronic drinking and serving as the epicenter for the “deaths of despair” crisis, with their mortality rates beginning a sustained increase after 2003 (Case and Deaton 2017). The most rapid long‐term increase, however, is among older adults (65+), where the cohort effect of the heavy‐drinking Baby Boomer generation (Barak et al. 2025) converges with the physiological vulnerabilities of aging (Heuberger 2009) and psychosocial stressors like social isolation (Purser 2020). In contrast, younger adults (25–44), after experiencing a significant period of declining mortality from 1990 to 2007, have seen a dramatic reversal. Their unique vulnerability to acute stressors was starkly illustrated during the pandemic, when they experienced an astounding 24.2% annual increase in mortality, the sharpest recorded for any demographic. This extreme volatility is explained by their high prevalence of binge drinking, a pattern associated with immediate, rather than chronic, fatal outcomes (Bohm et al. 2025). This reveals a multifaceted challenge, requiring distinct strategies for the chronic crisis in mid‐life, the accelerating problem in old age, and the acute‐risk behaviors of the young.

Geographic analysis of alcohol‐related mortality reveals four distinct regional narratives: a long‐standing crisis in the West, a rapid escalation in the Midwest, a relative stability in the Northeast, and a moderate increase in the South. The West has persistently served as the crisis's historical epicenter, burdened by long‐standing cultural patterns of heavy drinking (Hilton 1988). In stark contrast, the Midwest experienced the most dramatic escalation, transforming from the lowest‐mortality region into the heartland of the “deaths of despair” crisis, where deindustrialization fueled a steep rise in alcohol‐related deaths (Knapp et al. 2019; Song et al. 2023). The Northeast stands as a notable outlier, demonstrating relative stability likely attributable to stronger state‐level alcohol control policies and more robust public health infrastructure (Campbell et al. 2009). Meanwhile, the South follows an intermediate trajectory, where the impacts of socioeconomic disadvantage are likely moderated by cultural and religious proscriptions against heavy drinking (Holt et al. 2006). These divergent and long‐term patterns highlight the powerful role that local economies, cultures, and policies play in shaping this national crisis.

Recent polls show a shift after 2023 in US attitudes toward alcohol. The percentage of adults who believe moderate drinking is harmful rose from 39% in 2023 to a majority in 2025, which is the highest level recorded. Over the same period, self‐reported alcohol consumption declined from 2023 to 2025, reaching a historic low. Additionally, drinkers also report consuming fewer drinks per week as well as drinking less frequently (Gallup 2025). While these trends are encouraging, our 55‐year historical analysis highlights the need for caution while interpreting short‐term declines as sustainable reversals. Our study demonstrates that alcohol‐related mortality has repeatedly shown that periods of decline can be followed by renewed increases when economic, social, or policy environments change. Sustained public health efforts as well as tax policies targeted toward alcoholic drinks are therefore essential to ensure that recent improvements translate into long‐term reductions in alcohol‐related harm.

For clinicians, this requires a shift toward proactive and risk‐based screening with a particular focus on middle‐aged and older White male patients, and a wider implementation of critically underutilized interventions like medication‐assisted treatment for alcohol use disorder (McPheeters et al. 2023). Policymakers must move beyond universal messaging and implement evidence‐based, population‐level policies such as increasing alcohol taxes and limiting outlet density, which are proven to reduce overall consumption and harm, especially in the highest‐risk regions like the West and Midwest (Elder et al. 2010). Finally, researchers are tasked with a dual priority: elucidating the specific socioeconomic and cultural drivers of the escalating crisis among White Americans, while simultaneously identifying the protective factors and successful interventions that can be learned from the Black community's resilient, downward trend.

4.1. Limitations

It is important to acknowledge several limitations inherent in this analysis. First, our reliance on CDC WONDER death certificate data is subject to potential misclassification, a challenge compounded by the need to bridge definitions of alcohol‐related death across three different ICD revisions (ICD‐8, −9, and −10) over the 55‐year period. More significantly, by restricting our analysis to cases where alcohol was the primary cause of death, this study almost certainly underestimates the true total mortality burden of alcohol, as it excludes numerous cases where alcohol was a significant contributing factor (Alcohol‐Related Disease Impact). Furthermore, our analysis was limited to White and Black/African American populations, meaning our findings are not generalizable to other racial and ethnic groups, such as American Indian/Alaska Native populations, who are known to experience a disproportionately high burden of alcohol‐related harm. Additionally, while our study associates decreases and increases in alcohol‐related mortality with economic forces, prices, as well as public health policies, it is important to note that the extent to which these forces caused a shift in mortality trends remains speculative within the scope of the present study.

5. Conclusion

Historically, the most significant development has been the complete inversion of the long‐standing racial disparity, with mortality rates among White Americans now far exceeding those of Black Americans, alongside a narrowing of the gender gap that signals a growing crisis for women. These trends intensified dramatically during the COVID‐19 pandemic, though recent declines from 2021 to 2023 offer cautious optimism. Addressing this crisis requires targeted interventions for high‐risk populations, evidence‐based alcohol policies, and sustained public health efforts to ensure recent improvements translate into lasting reductions in alcohol‐attributable mortality.

Author Contributions

Mohid Zulfiqar: conceptualization, software, data curation, investigation, validation, formal analysis, supervision, visualization, writing – original draft, and writing – review and editing. Muhammad Salik Uddin: writing – review and editing. Faizan Abbas: software, data curation, formal analysis, and writing – review and editing. Asim Sajjad: methodology, and writing – review and editing. Ammad Uddin: data curation and writing – review and editing. Syed Ahmed Ali Shah: writing – review and editing. Gregg C. Fonarow: validation, and writing – review and editing. Saad Ahmed Waqas: validation, and writing – review and editing. Hermann Yokolo: writing – review and editing. Shaheer Qureshi: validation, and writing – review and editing.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

Dr. Fonarow reports consulting for Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly, Johnson & Johnson, Medtronic, Merck, Novartis, and Pfizer. All other authors declare no conflicts of interest.

Supporting information

Figure S1: Alcohol‐related AAMRs per 100,000 stratified by age group in the United States, 1968–2023 (ICD‐8 codes for 1968–1978, ICD‐9 codes for 1979–1998, and ICD‐10 codes from 1999 onward).

Figure S2: Alcohol‐related AAMRs per 100,000 stratified by census region in the United States, 1968–2023 (ICD‐8 codes for 1968–1978, ICD‐9 codes for 1979–1998, and ICD‐10 codes from 1999 onward).

Table S1: Alcohol‐related mortalities in adults, stratified by sex and race, in the United States, 1968–2023.

Table S2: Annual percent change (APC) and average annual percentage change (AAPC) of alcohol‐related age‐adjusted mortality rates per 100,000, in adults, in the United States, 1968–2023.

Table S3: Overall and sex‐stratified alcohol‐related age‐adjusted mortality rates per 100,000, in Adults, in the United States, 1968–2023.

Table S4: Race‐stratified alcohol‐related age‐adjusted mortality rates per 100,000 in adults, in the United States, 1968–2023.

Table S5: Age‐stratified alcohol‐related age‐adjusted mortality rates per 100,000, in adults, in the United States, 1968–2023.

Table S6: Alcohol‐related age‐adjusted mortality rates per 100,000, stratified by census region, in adults, in the United States, 1968–2023.

Table S7: Alcohol‐related age‐adjusted mortality Rates per 100,000, stratified by states and age groups (25–45, 45–65, 65–85, and 85+ years), in the United States, 1968–2023.

ACER-50-0-s001.docx (285.7KB, docx)

Data Availability Statement

The data supporting the findings of this study were obtained from the CDC WONDER online database (Centers for Disease Control and Prevention Wide‐ranging Online Data for Epidemiologic Research). The datasets used and analyzed during the current study are publicly available and can be accessed at https://wonder.cdc.gov.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Figure S1: Alcohol‐related AAMRs per 100,000 stratified by age group in the United States, 1968–2023 (ICD‐8 codes for 1968–1978, ICD‐9 codes for 1979–1998, and ICD‐10 codes from 1999 onward).

Figure S2: Alcohol‐related AAMRs per 100,000 stratified by census region in the United States, 1968–2023 (ICD‐8 codes for 1968–1978, ICD‐9 codes for 1979–1998, and ICD‐10 codes from 1999 onward).

Table S1: Alcohol‐related mortalities in adults, stratified by sex and race, in the United States, 1968–2023.

Table S2: Annual percent change (APC) and average annual percentage change (AAPC) of alcohol‐related age‐adjusted mortality rates per 100,000, in adults, in the United States, 1968–2023.

Table S3: Overall and sex‐stratified alcohol‐related age‐adjusted mortality rates per 100,000, in Adults, in the United States, 1968–2023.

Table S4: Race‐stratified alcohol‐related age‐adjusted mortality rates per 100,000 in adults, in the United States, 1968–2023.

Table S5: Age‐stratified alcohol‐related age‐adjusted mortality rates per 100,000, in adults, in the United States, 1968–2023.

Table S6: Alcohol‐related age‐adjusted mortality rates per 100,000, stratified by census region, in adults, in the United States, 1968–2023.

Table S7: Alcohol‐related age‐adjusted mortality Rates per 100,000, stratified by states and age groups (25–45, 45–65, 65–85, and 85+ years), in the United States, 1968–2023.

ACER-50-0-s001.docx (285.7KB, docx)

Data Availability Statement

The data supporting the findings of this study were obtained from the CDC WONDER online database (Centers for Disease Control and Prevention Wide‐ranging Online Data for Epidemiologic Research). The datasets used and analyzed during the current study are publicly available and can be accessed at https://wonder.cdc.gov.

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