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. 2021 Sep 9;13(9):3145. doi: 10.3390/nu13093145

The Global Impact of Alcohol Consumption on Premature Mortality and Health in 2016

Ivneet Sohi 1,*, Ari Franklin 1, Bethany Chrystoja 1,2,3, Ashley Wettlaufer 1, Jürgen Rehm 1,2,3,4,5,6,7,8, Kevin Shield 1,2,4
Editor: Rosa Casas
PMCID: PMC8470338  PMID: 34579021

Abstract

This study aimed to estimate the impact of alcohol use on mortality and health among people 69 years of age and younger in 2016. A comparative risk assessment approach was utilized, with population-attributable fractions being estimated by combining alcohol use data from the Global Information System on Alcohol and Health with corresponding relative risk estimates from meta-analyses. The mortality and health data were obtained from the Global Health Observatory. Among people 69 years of age and younger in 2016, 2.0 million deaths and 117.2 million Disability Adjusted Life Years (DALYs) lost were attributable to alcohol consumption, representing 7.1% and 5.5% of all deaths and DALYs lost in that year, respectively. The leading causes of the burden of alcohol-attributable deaths were cirrhosis of the liver (457,000 deaths), road injuries (338,000 deaths), and tuberculosis (190,000 deaths). The numbers of premature deaths per 100,000 people were highest in Eastern Europe (155.8 deaths per 100,000), Central Europe (52.3 deaths per 100,000 people), and Western sub-Saharan Africa (48.7 deaths per 100,000). A large portion of the burden of disease caused by alcohol among people 69 years of age and younger is preventable through the implementation of cost-effective alcohol policies such as increases in taxation.

Keywords: alcohol, burden of disease, death, disability, infectious diseases, non-communicable diseases, injuries, global, policy

1. Introduction

Alcohol consumption is a leading risk factor for premature mortality and the burden of disease worldwide. Research in developed and developing countries has found that individuals of younger ages are disproportionately affected by alcohol [1,2,3]. For instance, alcohol is estimated to be the leading risk factor for the burden of disease among people 15 to 49 years of age, followed by high body mass index, high blood pressure, and dietary risks [3]. This population also has a large proportion of their expected lifespans remaining, contributes relatively more to the economy, and plays important roles in caring for their families [4].

In response to the burden of disease caused by alcohol, the World Health Organization (WHO), through its Global strategy to reduce the harmful use of alcohol and its Global Action Plan for the prevention and control of NCDs (2013–2020), agreed at the 2010 World Health Assembly to aim for a 10% relative reduction in harmful alcohol use by 2025 [5,6]. Furthermore, the WHO’s Sustainable Development Goals (SDG) 3.4 outlines a targeted one-third reduction by 2030 of premature mortality (i.e., deaths among people 69 years of age and younger) due to noncommunicable diseases, with reductions in alcohol-attributable diseases being key to achieving this goal [7,8]. There is a distinct spectrum of alcohol-attributable diseases and injuries which affect people 69 years of age and younger compared to people 70 years of age and older. Therefore, it is necessary to characterize the disease-specific health impacts of alcohol for the purposes of structuring disease-specific health efforts, for example to inform cancer prevention programs [9].

Given the impact of alcohol consumption on premature mortality, the objective of this study was to estimate the alcohol-attributable mortality and burden of disease globally in 2016, and to examine variations in the alcohol-attributable burden over time, by global burden of disease (GBD) region, age, and sex.

2. Materials and Methods

A comparative risk assessment methodology was utilized to estimate the burden of disease attributable to alcohol use in 2016. These estimations were based on the theoretical minimum risk exposure level (TMREL) of lifetime abstention. Lifetime abstention was utilized as a TMREL based on historical precedent, and the observation that lifetime abstainers may have the lowest risk of overall health loss [10]. The population-attributable fraction (PAF) for alcohol use was estimated based on a Levin-based method which combines data on alcohol exposure with corresponding relative risk (RR) estimates [11,12]. Information regarding the methods utilized and the data sources can be found in the Supplemental Material and in the paper by Shield et al. [1].

2.1. Relative Risk Estimates

Alcohol RR estimates for chronic disease outcomes (except from ischemic diseases) were obtained from meta-analyses and based on average drinking (in grams per day) [13]. The lag time between alcohol use and disease occurrence was only modelled for cancer (based on the estimate that there is a 10 year period between exposure and disease outcomes [14]). Heavy episodic drinking (HED) was utilized in the modelling for the RRs for ischemic diseases and injuries [1]. All RR estimates were reviewed and approved by the WHO Technical Advisory Group on Alcohol and Drug Epidemiology. The sources of RR estimates are outlined in Supplemental Material Table S1.

2.2. Mortality, Morbidity, and Population Data

Data on mortality, Years of Life Lost (YLL), morbidity measured using Years Lived with Disability (YLD), age, sex, country, year, and by cause of mortality and/or morbidity were obtained from the WHO’s Global Health Estimates [15]. The total burden of disease was measured using Disability Adjusted Life Years (DALYs) lost. Estimates of premature mortality were based on a cut off of deaths which occurred among people 69 years of age and younger [4,16].

Alcoholic cardiomyopathy deaths, YLL, and YLD were estimated using the methods of Manthey and colleagues [17] as they were not directly estimated in the WHO’s Global Health Estimates. The WHO’s road traffic death database [18] was used to determine the fractions of alcohol-attributable motor vehicle deaths which involved a driver and those traffic deaths which involved people other than the driver.

Population data by age, sex, country, and year were obtained from the UN Population Division [19]. Deaths, YLLs, YLDs, and DALYs lost were aggregated into five-year age groups, beginning at 0 years until 84 years, followed by the category of 85 years and older; alcohol PAFs were applied to these age groupings.

Data were aggregated by GBD region (see: http://ghdx.healthdata.org (accessed on 1 January 2021) for regional groupings) and by Human Development Index (HDI) region (see Figure S1 in the Supplementary Materials for HDI groupings). HDI categories were obtained from the United Nations Development Programme [20]. The HDI is based on having a long and healthy life (i.e., life expectancy at birth), being knowledgeable (i.e., expected years of schooling and mean years of schooling for adults 25 years of age and older), and having a decent standard of living (i.e., Gross National Income per capita) [20].

The 95% uncertainty intervals (see Tables S2–S14 in Supplementary Materials) were based on a set of 1000 simulations of all lowest level parameters (i.e., parameters sampled from their respective error distributions). These parameters were then used to estimate 1000 simulated estimates of the alcohol-attributable burden of disease. From these simulations, the 2.5th and 97.5th percentiles were utilized for the 95% uncertainty intervals.

Analyses were performed using the statistical software package R [21].

3. Results

In 2016, there were 2.0 million premature deaths and 117.2 million DALYs lost globally due to alcohol use, representing 7.1% of all premature deaths and 5.5% of all DALYs lost in that year (see Table 1 and Table 2). In contrast, 3.2% of all deaths and 3.0% of all DALYs lost among people 70 years of age and older were attributable to alcohol consumption. An estimated 70.7% of all alcohol-attributable deaths and 89.2% of all alcohol-attributable DALYs lost globally in 2016 were premature, i.e., among those 69 years of age and younger. In comparison, 52.0% of all deaths and 81.8% of all DALYs lost globally in 2016 were premature. The alcohol-attributable deaths and DALYs lost among those 69 years of age and younger were greater among men (1.6 million deaths and 90.9 million DALYs lost) compared to women (0.5 million deaths and 26.3 million DALYs lost). The largest proportion of premature deaths that were attributable to alcohol occurred among people 30–39 years of age (13.3%) and 20–29 years of age (13.0%). See Tables S2 to S17 for data on sex-specific alcohol-attributable deaths, YLL, YLD, and DALYs lost.

Table 1.

Alcohol-attributable deaths globally in 2016, by cause and age.

Cause of Disease or Injury Alcohol-Attributable Deaths Population Attributable Fraction (%)
0 to 14 15 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 ≥70 0 to 14 15 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 ≥70
All Causes 33,939 47,719 248,762 317,457 396,552 510,448 542,012 870,937 0.5 6.9 13.0 13.3 12.0 9.2 5.9 3.2
Communicable, maternal, perinatal and nutritional conditions 0 3073 30,471 50,497 58,869 60,646 55,847 102,481 0.0 1.5 5.4 6.8 8.5 9.1 6.5 4.0
Tuberculosis 0 2299 23,738 34,975 42,291 46,097 40,121 46,762 0.0 8.5 22.0 24.7 25.4 22.0 17.5 12.7
HIV AIDS 0 269 3444 10,566 10,220 4352 1284 302 0.0 1.0 3.0 3.5 3.8 3.5 3.1 2.3
Lower respiratory infections 0 505 3289 4956 6358 10,197 14,442 55,417 0.0 2.2 6.2 8.4 8.5 7.4 5.1 4.1
Noncommunicable diseases 0 5997 42,304 111,176 203,371 330,932 392,643 656,706 0.0 3.2 7.7 11.2 9.8 7.6 5.0 2.8
Malignant neoplasms 0 0 1094 9183 30,653 73,936 102,619 150,215 0.0 0.0 0.9 3.4 4.5 5.2 4.8 3.6
Lip and oral cavity cancer 0 0 224 2542 6678 13,732 14,915 14,085 0.0 0.0 7.9 30.2 32.2 35.4 33.7 27.8
Other pharynx cancers 0 0 63 975 4250 11,026 12,356 9922 0.0 0.0 7.3 28.5 34.6 39.9 38.1 29.6
Oesophagus cancer 0 0 53 712 4519 16,516 27,076 34,070 0.0 0.0 3.5 12.8 18.6 22.4 21.7 17.2
Colon and rectum cancers 0 0 248 1754 4823 12,582 22,287 50,866 0.0 0.0 3.9 9.6 10.8 12.4 12.8 11.4
Liver cancer 0 0 507 3199 10,383 20,080 25,985 41,273 0.0 0.0 5.6 11.5 11.8 12.4 12.6 12.4
Breast cancer 0 0 178 3003 6743 10,445 9238 12,415 0.0 0.0 2.4 7.1 7.4 8.1 7.4 6.5
Larynx cancer 0 0 13 210 1418 4753 6849 7283 0.0 0.0 4.2 17.9 21.7 24.6 24.0 20.3
Diabetes mellitus 0 −41 −362 −681 −1958 −4474 −7816 −19,753 0.0 −1.1 −2.8 −2.7 −2.6 −2.3 −2.0 −2.2
Alcohol use disorders 0 967 7748 21,406 31,222 38,315 28,103 17,804 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Epilepsy 0 694 3278 3019 2651 2177 1844 2751 0.0 5.9 15.2 17.3 18.7 16.9 14.4 11.7
Cardiovascular diseases 0 680 4328 13,070 30,099 65,934 107,708 347,811 0.0 1.8 3.2 4.2 4.1 3.8 3.1 3.0
Hypertensive heart disease 0 40 457 1260 3204 7079 12,846 41,571 0.0 3.1 9.1 10.2 10.4 9.4 8.2 6.8
Ischaemic heart disease 0 85 139 1195 3027 12,654 32,002 201,657 0.0 0.8 0.3 0.8 0.8 1.3 1.8 3.3
Ischaemic stroke 0 −11 −75 −174 −838 −2823 −10,280 −45,068 0.0 −0.7 −1.3 −1.5 −2.2 −2.1 −2.0 −2.1
Haemorrhagic stroke 0 476 3044 7768 20,968 43,205 68,579 142,988 0.0 5.7 10.4 11.3 11.8 10.8 9.7 9.2
Cardiomyopathy, myocarditis, endocarditis 0 89 763 3021 3738 5819 4562 6662 0.0 1.9 5.0 12.3 11.5 12.3 7.5 3.8
Digestive diseases 0 3697 26,027 61,967 102,541 139,846 144,097 138,180 0.0 12.8 28.4 37.8 39.9 35.6 27.9 13.9
Cirrhosis of the liver 0 3593 24,369 58,145 97,529 134,702 139,105 130,695 0.0 28.8 49.6 54.0 55.3 52.5 47.8 38.9
Pancreatitis 0 104 1658 3822 5012 5144 4993 7485 0.0 11.0 27.3 32.2 31.6 28.3 23.2 18.5
Injuries 33,939 38,649 175,987 155,784 134,313 118,870 93,522 111,750 5.3 12.8 21.9 24.0 25.2 23.2 18.4 12.1
Unintentional injuries 33,939 28,303 116,260 101,421 94,461 87,006 73,167 94,404 5.9 16.0 26.1 27.3 27.6 24.6 19.1 12.0
Road injury 33,939 20,533 78,740 62,508 56,129 48,048 37,797 33,073 23.1 20.2 29.1 30.0 30.0 27.5 24.7 20.8
Poisonings 0 409 2543 2273 2342 1969 1718 1480 0.0 10.0 20.7 22.9 21.8 19.3 13.9 9.5
Falls 0 809 5398 7347 9340 11,524 12,814 32,138 0.0 10.3 22.4 24.6 25.4 20.9 13.5 8.8
Fire, heat and hot substances 0 531 2813 3106 2614 2773 2362 2960 0.0 6.7 14.7 17.5 20.9 20.1 15.5 10.4
Drowning 0 2708 8553 7214 5983 5109 4223 4320 0.0 11.6 23.4 26.0 26.1 22.6 17.3 11.5
Exposure to mechanical forces 0 786 4655 4573 4114 3443 2311 1635 0.0 10.8 23.0 24.9 25.8 23.1 17.7 10.5
Other unintentional injuries 0 2526 13,558 14,400 13,940 14,141 11,942 18,798 0.0 10.4 22.0 24.4 25.1 22.9 16.8 11.3
Intentional injuries 0 10,346 59,726 54,363 39,851 31,863 20,355 17,346 0.0 8.2 16.6 19.7 20.8 20.0 16.2 12.3
Self-harm 0 4491 29,477 31,085 26,207 23,767 16,508 15,484 0.0 8.5 18.4 23.0 23.8 21.9 17.1 12.8
Interpersonal violence 0 5855 30,249 23,278 13,645 8096 3847 1862 0.0 11.1 20.7 22.4 22.0 20.1 16.6 11.1
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Table 2.

Alcohol-attributable disability adjusted life years lost globally in 2016, by cause for people 0 to 69 years of age.

Cause of Disease or Injury Alcohol-Attributable DALYs (100,000 s) Population Attributable Fraction (%)
0 to 14 15 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 ≥70 0 to 14 15 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 ≥70
All Causes 302.5 451.5 2189.8 2348.6 2349.6 2297.1 1783.2 1419.4 0.5 5.0 9.8 9.9 9.0 7.4 5.1 3.0
Communicable, maternal, perinatal and nutritional conditions 0.0 24.4 215.6 302.8 293.1 238.9 167.2 148.9 0.0 1.1 4.0 5.4 6.7 7.4 5.9 3.9
Tuberculosis 0.0 18.5 168.5 210.4 210.8 182.6 122.0 78.6 0.0 8.5 22.0 24.6 25.4 22.1 18.0 13.0
HIV AIDS 0.0 2.1 24.9 64.0 52.1 18.1 4.2 0.7 0.0 1.0 3.0 3.5 3.8 3.5 3.1 2.2
Lower respiratory infections 0.0 3.8 22.1 28.5 30.2 38.2 41.0 69.6 0.0 2.2 6.2 8.4 8.5 7.4 5.3 4.0
Noncommunicable diseases 6.3 111.5 657.4 975.5 1208.1 1405.3 1191.1 982.8 0.0 2.6 6.0 7.2 6.6 5.6 4.0 2.4
Malignant neoplasms 0.0 0.0 8.4 70.9 184.2 337.5 338.7 263.9 0.0 0.0 1.1 4.6 5.7 6.3 5.5 4.2
Lip and oral cavity cancer 0.0 0.0 1.5 14.5 31.8 52.2 43.1 22.8 0.0 0.0 7.7 30.0 32.2 35.4 33.8 28.7
Other pharynx cancers 0.0 0.0 0.4 5.5 20.0 41.6 35.4 16.6 0.0 0.0 7.1 28.4 34.6 39.9 38.2 30.9
Oesophagus cancer 0.0 0.0 0.3 4.0 21.0 61.6 76.1 53.9 0.0 0.0 3.4 12.8 18.5 22.4 21.7 17.8
Colon and rectum cancers 0.0 0.0 1.6 10.1 23.0 47.9 63.9 75.8 0.0 0.0 3.8 9.6 10.8 12.4 12.8 11.7
Liver cancer 0.0 0.0 3.3 18.2 48.8 75.4 73.3 63.5 0.0 0.0 5.5 11.5 11.8 12.4 12.6 12.4
Breast cancer 0.0 0.0 1.2 17.4 32.9 40.8 27.3 19.2 0.0 0.0 2.4 7.1 7.5 8.2 7.4 6.7
Larynx cancer 0.0 0.0 0.1 1.2 6.7 18.1 19.7 12.0 0.0 0.0 4.1 17.9 21.7 24.6 24.1 20.8
Diabetes mellitus 0.0 −0.7 −7.4 −13.2 −27.2 −37.3 −40.7 −40.2 0.0 −1.3 −3.1 −3.0 −3.1 −2.6 −2.4 −2.2
Alcohol use disorders 6.3 68.0 407.7 451.8 389.3 304.5 157.4 60.6 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Epilepsy 0.0 9.2 39.3 30.9 24.5 17.7 12.1 9.5 0.0 5.8 14.4 16.0 17.1 15.6 13.9 11.4
Cardiovascular diseases 0.0 5.2 29.2 75.1 142.0 244.7 303.4 462.0 0.0 1.6 2.8 3.9 3.8 3.6 2.9 2.8
Hypertensive heart disease 0.0 0.3 3.0 7.5 16.2 28.1 38.4 58.5 0.0 3.1 9.1 10.0 10.2 9.3 8.3 6.8
Ischaemic heart disease 0.0 0.7 1.1 7.1 14.7 47.5 91.8 252.0 0.0 0.8 0.3 0.8 0.7 1.3 1.8 3.1
Ischaemic stroke 0.0 −0.2 −1.2 −2.4 −8.3 −19.5 −40.0 −71.5 0.0 −1.1 −2.0 −2.3 −3.1 −2.8 −2.3 −2.2
Haemorrhagic stroke 0.0 3.7 21.2 45.5 101.5 166.5 199.6 213.7 0.0 5.8 10.5 11.3 11.9 10.8 9.9 9.0
Cardiomyopathy, myocarditis, endocarditis 0.0 0.7 5.1 17.4 17.9 22.1 13.4 9.3 0.0 1.8 4.7 11.9 11.3 11.9 7.5 3.8
Digestive diseases 0.0 29.8 180.2 360.1 495.3 538.1 420.2 227.0 0.0 12.4 26.6 34.7 36.1 33.2 26.6 14.6
Cirrhosis of the liver 0.0 29.0 169.1 338.1 471.3 518.6 405.8 215.7 0.0 28.9 49.5 53.9 55.3 52.5 48.3 39.5
Pancreatitis 0.0 0.8 11.1 22.0 23.9 19.5 14.4 11.3 0.0 11.1 27.2 32.1 31.5 28.2 23.5 18.8
Injuries 296.2 315.7 1316.8 1070.3 848.4 652.9 425.0 287.7 4.9 12.7 21.8 23.7 24.8 22.8 19.0 13.2
Unintentional injuries 296.2 236.1 904.5 744.6 645.8 522.1 359.6 256.8 5.6 15.6 25.6 26.5 26.8 24.0 19.7 13.4
Road injury 296.2 158.6 557.9 403.0 325.7 241.0 153.7 88.0 23.1 20.3 29.1 30.0 30.2 28.0 25.8 22.4
Poisonings 0.0 3.3 18.2 14.1 12.2 8.2 5.5 2.6 0.0 10.2 20.7 22.9 21.9 19.5 14.6 9.8
Falls 0.0 14.4 76.6 95.2 109.1 113.2 95.6 97.9 0.0 11.9 23.0 24.6 25.2 21.8 16.4 10.7
Fire, heat and hot substances 0.0 5.5 25.9 26.7 21.5 18.1 11.7 7.4 0.0 7.6 15.8 18.4 21.2 20.0 16.7 11.6
Drowning 0.0 20.3 58.0 42.0 29.1 19.8 12.6 7.1 0.0 11.6 23.3 25.9 26.0 22.4 17.6 11.6
Exposure to mechanical forces 0.0 8.1 43.6 43.0 40.1 32.2 20.2 11.0 0.0 11.5 23.4 25.1 26.0 23.6 19.8 13.9
Other unintentional injuries 0.0 25.9 124.3 120.5 108.2 89.6 60.4 42.9 0.0 10.2 21.0 22.5 23.0 20.7 16.5 11.3
Intentional injuries 0.0 79.5 412.3 325.7 202.7 130.8 65.3 30.9 0.0 8.2 16.4 19.1 20.0 19.0 16.0 12.0
Self-harm 0.0 33.7 198.1 180.0 125.9 90.9 48.6 24.7 0.0 8.5 18.4 23.0 23.7 21.9 17.5 12.8
Interpersonal violence 0.0 45.9 214.2 145.7 76.8 39.9 16.7 6.2 0.0 10.9 20.5 22.1 21.8 20.2 17.3 12.0
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The leading causes of the burden of premature alcohol-attributable deaths were cirrhosis of the liver (457,000 deaths), road injuries (338,000 deaths), and tuberculosis (190,000 deaths) (see Figure 1). Road injuries and cirrhosis of the liver were the leading causes of alcohol-attributable deaths among those aged 0 to 39 and 40 to 69 years of age, respectively. The proportion of alcohol-attributable deaths due to road injuries decreased with age from 100% of all alcohol-attributable deaths among those aged 0–14 years to 7.0% among those aged 60–69 years. The proportion of alcohol-attributable deaths due to cirrhosis of the liver increased with age, peaking at 26.4% of all alcohol-attributable deaths among those 50–59 years of age. The proportion of alcohol-attributable deaths due to tuberculosis increased with age, peaking at 10.7% of all alcohol-attributable deaths among those 40–49 years of age.

Figure 1.

Figure 1

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Alcohol-attributable deaths and disability adjusted life years (DALYs) lost by age.

3.1. Alcohol-Attributable Burden of Disease by Region

The numbers of premature alcohol-attributable deaths and DALYs lost per 100,000 people showed large variations globally (see Figure 2 and Figure 3). The numbers of premature alcohol-attributable deaths were highest in Eastern Europe (155.8 deaths per 100,000), Central Europe (52.3 deaths per 100,000 people), and Western sub-Saharan Africa (48.7 deaths per 100,000). In 2016, the two leading contributors to alcohol-attributable deaths among all regions were either cirrhosis of the liver or road injuries, except for three regions: Asia Pacific with self-harm, Southern sub-Saharan Africa with tuberculosis, and Eastern Europe with ischaemic heart disease being the largest contributors, respectively (see Figure 3). The second largest contributors to alcohol-attributable deaths in Southern sub-Saharan Africa and Eastern Europe were HIV/AIDS and alcohol use disorders, respectively. Figure S2 outlines the burden of alcohol-attributable premature YLL and YLD globally. Figure S3 outlines the burden of alcohol-attributable premature YLL and YLD by GBD region.

Figure 2.

Figure 2

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Alcohol-attributable deaths and disability adjusted years of life lost globally in 2016 among people 0 to 69 years of age.

Figure 3.

Figure 3

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Alcohol-attributable deaths and disability adjusted life years (DALYs) lost among people 0 to 70 years of age by global burden of disease region.

3.2. Alcohol-Attributable Burden of Disease by Human Development Index

The burden of premature alcohol-attributable deaths and DALYs lost varied by HDI region (see Figure 4). The number of alcohol-attributable deaths was highest in countries with a very high HDI (43.3 deaths and 2339.9 DALYs lost per 100,000), followed by low HDI countries (33.7 deaths and 1966.1 DALYs lost per 100,000), high HDI countries (26.8 deaths and 1502.3 DALYs lost per 100,000) and medium HDI countries (24.8 deaths and 1392.5 DALYs lost per 100,000). The leading cause of death was cirrhosis of the liver in very high HDI countries (8.2 deaths per 100,000), low HDI countries (7.4 deaths per 100,000), and medium HDI countries (6.6 deaths per 1,000,000), and was road injuries in high HDI countries (5.9 deaths per 100,000). For DALYs lost, the leading contributor to the premature alcohol-attributable burden of disease was alcohol use disorders for very-high HDI countries (449.3 DALYs lost per 100,000), liver cirrhosis for medium HDI countries (297.3 DALYs lost per 100,000 people), and road injuries for low HDI countries (431.2 DALYs lost per 100,000 people) and high HDI countries (354.4 DALYs lost per 100,000). Figure S4 outlines the burden of premature YLL and YLD by HDI region.

Figure 4.

Figure 4

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Alcohol-attributable deaths and disability adjusted life years (DALYs) lost among people 0 to 70 years of age by human development index region.

4. Discussion

The results of this study indicate that alcohol-attributable deaths and health loss occurred among people relatively young in age. The proportions of alcohol-attributable deaths and DALYs lost that were premature were greater than the proportions of all-cause deaths and DALYs lost that were considered premature. This indicates that alcohol use disproportionately affects the health of people who are younger in age. The cause composition of the premature alcohol-attributable burden is unique when compared to the burden among people 70 years of age and older, with cirrhosis of the liver, road injuries, and tuberculosis being the primary contributors to this burden. Furthermore, regional and societal development-based variations in the magnitude of the premature alcohol-attributable burden of disease and the cause composition of this burden were observed.

This study modelled both the detrimental and protective effects of alcohol consumption on health. Specifically, alcohol consumed at low amounts, and not on HED occasions has a protective effect on diabetes, ischemic heart disease, and ischemic stroke [13]. This study found that for the premature disease burden, the detrimental effects of alcohol at the population level outweighed the protective effects. At the individual level, the net effect of alcohol consumption on overall health is unknown; however, a recent modelling study found no level of alcohol consumption that provided a net health benefit [10].

The premature burden of disease attributable to alcohol consumption was characterized by tuberculosis, liver cirrhosis, and injuries. Liver cirrhosis is mainly linked to the overall volume of drinking, while injuries attributable to alcohol are mostly related to intoxication (i.e., binge alcohol consumption) [13]. Tuberculosis risk (i.e., the impact of alcohol on the immune system) is related both to the overall volume of alcohol consumed and binge drinking; however, due to the lack of studies, the impact of alcohol use on tuberculosis was modelled based only on the overall volume of alcohol consumed [13]. Therefore, both overall volume of alcohol consumed and drinking to intoxication are factors leading to the premature burden of disease attributable to alcohol consumption.

Tuberculosis remains an enormous public health concern globally, especially in low and medium HDI countries [22]. The treatment of tuberculosis and the interaction between HIV/AIDS and tuberculosis are key public health priorities [23]. Alcohol use is a key risk factor for both diseases (Morojele et al., this issue), which if addressed can substantially reduce the health burden of tuberculosis and HIV/AIDS. The burden of disease due to liver cirrhosis was high in all HDI categories and in most GBD regions. The burden of alcoholic liver cirrhosis is affected by multiple risk factors which interact with alcohol, including hepatitis B and C infections, obesity, and socio-economic status [24]. The burden of alcohol-related injuries is problematic as investment in preventing mortality from injury has fallen behind other causes of death, such as HIV/AIDS and reproductive health [21]. Furthermore, mental health concerns have been overlooked in terms of public health programming, especially in young people [10] where injuries and neuropsychiatric conditions are greatly impacted by alcohol consumption [22].

The burden of premature disease attributable to alcohol consumption was highest in Eastern Europe, Central Europe, and Western sub-Saharan Africa. The Central and Eastern Europe region have a high overall volume of alcohol consumption and a high prevalence of HED [5,6]. Alcohol control policy measures, including increases in alcohol prices and decreases in availability, have been implemented in the Eastern Europe region and have resulted in marked downward shifts in mortality and the burden of disease [25]. The Western sub-Saharan Africa region has a relatively low overall volume of alcohol consumption. The burden of alcohol-attributable premature disease in this region was driven mainly by infectious diseases, liver cirrhosis, and injuries. Cirrhosis-related deaths doubled in the sub-Saharan Africa region between 1980 and 2010, with hepatitis B virus, hepatitis C virus, and alcohol use being contributing factors to this increase [26]. Furthermore, treatment of liver cirrhosis is unavailable in most parts of sub-Saharan Africa, due to a shortage of hepatologists and gastroenterologists, interventional radiologists, hepatobiliary surgeons, and pathologists [27].

4.1. Limitations

The methods used in this paper are limited by several factors. Firstly, estimates of alcohol consumption came from surveys which are susceptible to numerous biases which lead to an underestimation of alcohol use. Per capita consumption of alcohol is utilized to estimate the volume of alcohol use among drinkers to avoid bias; however, no correction exists for the prevalence of HED. This study did not fully account for the interaction between alcohol use and other risk factors, such as smoking (increased risk of cancer [28]), hepatitis B and C (increased risk of liver cirrhosis [29]), and obesity (increased risk of liver cirrhosis [24,30]). Furthermore, the study did not account for the differential alcohol RRs by socio-economic status. Furthermore, although depression has been shown to be causally related to alcohol consumption, it was not included in the estimates of the alcohol-attributable burden of disease due to depression also causally increasing alcohol consumption [13].

This study is also limited as deaths and health loss due to interpersonal harm are based on the alcohol consumption of the person who experiences the harm and not the alcohol consumption of the person who inflicts the harm. This is due to the relative risks of injuries from assault being based on the person who experiences the harm and not the person who is inflicting the harm [13]. Therefore, estimates of intentional harm are likely underestimated for children and women who are often victims of alcohol-related violence [31]. It is important to note that violence against women and children is a major public health, social policy, and human rights concern that spans disciplines and geographical boundaries [32,33,34,35]. Globally, domestic violence is one of the largest sources of non-fatal injuries to women and children [36], resulting in avoidable inequities in health status, and increases in the risk of mental health and physical conditions [37].

4.2. Health Policies

The health harms and inequities outlined in the paper should be considered in the context of population-level interventions which can reduce the alcohol-attributable burden of disease and are sustainable, scalable, and politically, economically, and technically feasible [38]. Several alcohol interventions have been designated as “best buys” by the WHO as they are more cost-effective than most other interventions designed for other risk factors [39]. These include increases in taxation and restrictions on availability and marketing. Other policies include WHO cost-effective “very good buys,” such as enactment and enforcement of impaired-driving laws and blood-alcohol-concentration limits [39,40].

The need to intervene to reduce the burden of premature health loss attributable to alcohol consumption can be viewed under the framework of utilitarian ageism. The framework of utilitarian ageism, which is often observed in medical practice, states that there should be prioritization of treatments and interventions for health loss among the young (as the old have lived longer) [41,42].

Despite the majority of the burden of disease attributable to alcohol consumption occurring among people 0 to 69 years of age, alcohol leads to a substantial burden of disease among people 70 years of age and older. Interventions such as the WHO best buys and very best buys should also be prioritized to reduce the burden among people 70 years of age and older. Furthermore, these policies should apply equally to beer, wine, spirits, and other alcoholic beverages as the harm caused by alcohol is based on ethanol content regardless of whether the ethanol is consumed in the form of beer, wine, or spirits (with the exception of alcohol poisonings which are caused predominately by the consumption of spirits) [13].

5. Conclusions

Alcohol consumption remains a leading risk factor for the burden of disease, especially among people younger in age. Given the high global alcohol-attributable burden of disease, the development and implementation of cost-effective alcohol control policies can further reduce in the near future the social, economic, and health burdens resulting from the use of alcohol.

Acknowledgments

The authors would like to thank the World Health Organization as well as the regional and country level offices of the World Health Organization for providing data on alcohol consumption and the burden of disease. In particular, the authors thank Alexandra Fleischmann, Vladimir Poznyak, Maristela Monteiro, and Carina Ferreira-Borges for coordinating this data collection.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/nu13093145/s1: the supplemental methodology and supplemental results (Figures S1–S4, and Tables S1–S17).

Click here for additional data file. (1.3MB, zip)

Author Contributions

Conceptualization, I.S., A.F., J.R. and K.S.; methodology, A.F., J.R. and K.S.; software, K.S.; validation A.F. and J.R.; formal analysis, I.S. and K.S.; investigation, I.S. and K.S.; data curation, A.W., A.F. and K.S.; writing—original draft preparation, I.S.; writing—reviewing and editing, I.S., A.F., J.R., B.C, A.W. and K.S.; visualization, B.C., K.S.; supervision, K.S.; project administration, K.S.; funding acquisition, J.R. and K.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the World Health Organization.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

All statistical code (i.e., R code) and input files used to produce the results presented in this paper are available to the general public. To obtain the code and input files, please contact the author, Kevin Shield (Kevin.Shield@camh.ca).

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study, in the collection, analyses, or interpretation of data, in the writing of the manuscript, or in the decision to publish the results.

Footnotes

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

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

Supplementary Materials

Click here for additional data file. (1.3MB, zip)

Data Availability Statement

All statistical code (i.e., R code) and input files used to produce the results presented in this paper are available to the general public. To obtain the code and input files, please contact the author, Kevin Shield (Kevin.Shield@camh.ca).

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