The Alcohol Harm Paradox

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1 A"World"Health"Organiza2on"Collabora2ng"Centre" Understanding The Alcohol Harm Paradox to focus the development of interventions Professor Mark A. Bellis, Lisa Jones, Michela Morleo Centre for Public Health Liverpool John Moores University

2 Variations in Alcohol Related Mortality and Drinking Patterns with Deprivation! Rate per 100,000 population! 50! 45! 40! 35! 30! 25! 20! 15! 10! 5! 25! 20! 15! 10! 5! %! Alcohol specific mortality (Male) Alcohol specific mortality (Female) Alcohol related mortality (Male) Alcohol related mortality (Female) Liver deaths (Male) Liver deaths (Female) Increasing risk drinkers (%) Increasing and higher risk drinkers (%) alcohol 0! 0! 1! 2! 3! 4! 5! Deprivation quintile! (Local Alcohol Profiles for England (LAPE), Centre for Public Health 2012)!

3 Variations in Alcohol Hospital Admissions and Drinking Patterns with Deprivation! 2500! 25! Alcohol specific admissions (Male)! Alcohol specific admissions (Female)! 2000! 20! Alcohol attributable admissions (Male)! Alcohol attributable admissions (Female)! Rate per 100,000 population! 1500! 1000! 15! 10! %! Increasing risk drinkers (%)! Increasing and higher risk drinkers (%)! 500! 5! 0! 0! 1! 2! 3! 4! 5! Deprivation quintile! (Local Alcohol Profiles for England (LAPE), Centre for Public Health 2012)!

4 What could explain the Paradox?! 1. Under-reporting Deprivation is associated with underreporting through missed units and omitted groups (homeless, military)! 2. Drinking Patterns Similar amounts of alcohol are consumed but current and historical patterns of drinking differ! 3. Compounding Impact of alcohol plus diet, exercise, housing! 4. Health Services Access and uptake of health interventions differ with deprivation! 5. Poverty Gradient Alcohol-related ill health pushes people into poverty causing a concentration of harms in poorer areas!

5 Alcohol Research UK Flagship Grant! Meta-analysis! Measure specific risk estimates associated with deprivation and alcohol consumption! Review of current data! Mortality, Morbidity, Crime, Consumption, Employment! Understand Consumption! Analysis of a new national alcohol consumption dataset! Measure consumption and any impact of very heavy drinkers and abstainers on population averages! Deprivation-specific attributable fractions!

6 Alcohol Research UK Grant Applicants! Professor Mark A. Bellis! Professor Sir Ian Gilmore! Dr Nick Sheron! Ms Lisa Jones! Ms Michela Morleo!!

7 Under-reporting: How much do we really drink? Abstainers = 16.5% adults Survey = 13.7 units Sales = 24.4 units 40 million bottles wine/per week Plus cross border and illicit market +10%? Home brew, food, nett travel, wastage? Bellis et al, Off Measure 2009; HM Revenue and Customs, General Lifestyle Survey 2010

8 Missing and Underrepresented Missing! Homeless! Military (e.g. barracks)! Incarcerated! Under-sampled! Students! In care elderly, those with mental health conditions! Dependent drinkers!

9 N=50,650, Big Drink Debate and Well-Being Survey North West combined, Morleo et al, 2009, Meier et al, 2013! Missing Alcohol Unit Estimation Litres Per Capita Consumption by Drink Type! Drink Type! General Household Survey 2006! HMRC 2006! % in Survey! Beer/Cider! 3.05! 5.56! 54.9! Wine! 2.80! 3.48! 80.5! Spirits! 1.18! 2.35! 50.2! Total! 7.04! 11.39! 61.8! 60%! 50%! Beer! Spirit! Wine! 40%! 30%! 20%! 10%! 1! 2! 3! 4! 5! 6! 7! 8! 9! 10! Deprivation Decile!

10 Hughes, Bellis et al, 2009! Missing Alcohol Holidays Frequency of drunkenness on holiday and at home! year olds visiting Majorca, Cyprus and Crete! 80! Never! Once a week or less! 2-4 days a week! 5+ days a week! 70! 60! 50! 40! 30! 20! 10! 0! Home! Holiday! Home! Holiday! British! German!

11 Drinking Patterns and Cardio-protective Effects?! The impact of occasional Heavy Sessions! Mon$ Tue$ Wed$ Thurs$ Fri$ Sat$ Sun$ Lighter drinking with irregular heavy drinking occasions 45%! Risk of Ischemic Heart Disease Regular drinking Any cardio-protective effects of moderate drinking disappear when mixed with irregular heavy drinking occasions Roerecke & Rehm, 2008!

12 Person aged years drinking 12.5% bottle of wine; From Rehm et al, 2008 Risk of Alcohol-Attributable Injury Related Mortality Annual risk per 10,000 persons Females Males One bottle (750ml) once a week Half a bottle (375ml) twice a week One small glass (125ml) six days a week

13 Index of Multiple Derivation and Violence related attendance at Accident and Emergency in England! Val Upton, Mark Bellis and Clare Perkins, 2012!

14 Interactions between Alcohol and Other Health Harms Relative risks of contributions of BMI and alcohol to liver disease mortality (adjusted for all risk factors) 10 Relative risk (95% CI) Excess risk due to interaction Excess risk due to alcohol Excess risk due to BMI Baseline risk Baseline Baseline + BMI Baseline + alcohol Interaction Alcohol misuse = drink 15 units/wk; Obese = BMI 30 Hart et al, 2010

15 Adult Obesity Prevalence by Equivalised Household Income Quintile 35% 30% 25% 27.4% 29.3% 25.9% 24.0% 21.6% 20% 15% 10% 5% Lowest 0% income quintile Highest income quintile Lowest income Quintile Highest income National Obesity Observatory: Age 16+, BMI >=30kg/m 2 ; Health Survey for England

16 5 Slipping into Deprived Communities? Alcohol-related incapacity benefit* by deprivation quintile Most deprived 4 3?& 2 1 Least deprived Rate per 100,000 population *Incapacity benefit and severe disability allowance. LAPE, 2012!

17 Getting ill less vs. Getting ill better! Cannot afford to be ill! Social support missing Family wealth! Work support missing Employer procedures! Increased mortality! Cannot afford to get better! Remain ill but with assets could get better! Locked into benefit system! Increased morbidity! Alcoholic liver disease patients! Surviving one year after disease! 54% abstinent or drinking in liver safe levels! Response to advice about liver not alcohol therapy! Verrill, Smith, Sheron. 2006; Tom Hennell, Pers. comm. 2013!

18 Patterns of Drinking and Quantities Consumed! Female, aged years Male, aged years Typical units per week Days per week drink 6 4 Special occasions per year 0 55 Non-typical drinking periods Revised units per week Aged started drinking A&E last 12 months No Yes Hospital admission last 12 months No No

19 Patterns of Drinking and Quantities Consumed! Male, aged years Male, aged years Typical units per week Days per week drink 2 4 Non-typical drinking occasions 2 17 Non-typical drinking weeks 27 5 Revised units per week Aged started drinking A&E last 12 months No No Hospital admission last 12 months No No

20 Alcohol Research UK Flagship Grant! Systematic review and meta-analysis - end of October 2013! Analysis of national and booster surveys - end of April 2014! Analysis of secondary datasets - end of March 2014! Final synthesis and report end of August 2014!

21 " A"World"Health"Organiza2on"Collabora2ng"Centre" Study Contacts" Mark Bellis Lisa Jones Michela Morleo

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