The burden caused by alcohol

Transcription

1 The burden caused by alcohol Presentation at REDUCING THE HARM CAUSED BY ALCOHOL: A COORDINATED EUROPEAN RESPONSE Tuesday, November 13 Jürgen Rehm Centre for Addiction and Mental Health, Toronto, Canada University of Toronto, Canada Technische Universität Dresden, Deutschland WHO Collaborating Centre on Substance Abuse, Zürich, Schweiz

2 Alcohol is different from other risk factors Social harm may outweigh the health harm! Acute (e.g. traffic accidents) and chronic (e.g. liver cirrhosis) health consequences Beneficial vs. detrimental impacts More than 70 different disease outcomes related to alcohol Only three important outcomes have beneficial link to alcohol, restricted to certain age groups (40 plus or 50 plus) and patterns Different sign and value of impact by different characteristics of alcohol average volume of alcohol consumption patterns of drinking Quality of alcoholic beverages Alcohol level associated to minimum risk depends on disease Impact of other risk factors (e.g. alcohol impact in undernourished persons is potentiated)

3 Basic causal model of alcohol consumption, intermediate mechanisms, and long-term consequences (from Rehm et al., 2003; Babor et al., 2003) Patterns of drinking Average volume Toxic and benefical biochemical effects* Intoxication Dependence Chronic Disease Accidents/Injuries (acute disease) Acute Social Chronic Social * Independent of intoxication or dependence

4 Conditions with alcohol-attributable fractions of 100% Alcoholic psychoses, Alcohol dependence syndrome, Harmful alcohol use, Alcoholic polyneuropathy, Alcoholic cardiomyopathy, Alcoholic gastritis, Alcoholic fatty liver, Acute alcoholic hepatitis, Alcoholic cirrhosis of liver, Alcoholic liver damage, unspecific, Alcoholic hepatic failure, Fetal alcohol syndrome, Excess blood alcohol, Accidental poisoning and exposure to alcohol, Ethanol and methanol toxicity Practically there may be no reliable data in many countries on some subcategories, and the relation to alcohol may have to be determined based on RR (e.g., for liver cirrhosis as wider category)

5 Relation of alcohol to disease in terms of relative risk for average volume Identification of more than 70 diseases by ICD-10 codes related to alcohol based on epidemiological and biochemical literature (mainly based on relations to average volume of alcohol consumption applying usual causal criteria with more weight on consistency and biological plausibility; in total more than 5000 references checked) Identification of RR for different levels of average volume by sex and age by meta-analyses from different groups of researchers RR can be < 1 (e.g. CHD), depending on the level of alcohol exposure; risk curves for all except injury codes

6 Main chronic disease categories related to average volume and kind of relative risk Cancer: Lip & oropharyngeal cancer, Esophageal cancer, Liver cancer, Laryngeal cancer, Colorectal cancer, Female breast cancer Usual linear risk relationship between average volume of alcohol consumption and risk Other cancers show consistent risk relationships, but do not qualify for other criteria of causality Typical risk curves for cancer (Corrao et al., 2004)

7 Main chronic disease categories related to average volume and kind of relative risk II Diabetes: Curvilinear relationship, partly protective may depend on patterns Gastrointestinal diseases: Esophageal varices, Gastro-esophageal hemorrhage, Liver cirrhosis, Cholelithiasis, Acute pancreatitis, Chronic pancreatitits Often exponential relationship Conditions arising during perinatal period: Spontaneous abortion, Low birth weight, Psoriasis, Prematurity, Intrauterine growth-retardation Deviation from usual model (drinking of mother is causing the disease in children -> different epidemiological model)

8 Influence of pattern 20 grams of pure alcohol per day on average can be achieved by 2dl of wine every day with meals or by 2 bottles of wine every Friday night different impact on disease and injury risk CHD, other CVD conditions (modeled) all kinds of injuries, which are influenced by intoxication and acute drinking before the event (modeled) Liver cirrhosis (not yet modeled) Patterns can be thought of as a weighting factor influencing the outcome of average volume (main effect)

9 Patterns and acute consequences... (one example)

10 Alcohol and injury more public health relevant problems! Relative risk Blood alcohol concentration Relative risk of accident by blood alcohol concentration Source: Hurst et al. (1994) Accident Analysis and prevention, 26(5):

11 Conclusion on patterns and CHD I Alcohol can have detrimental and beneficial effects depending on the pattern and volume of drinking Important considerations: Volume Heavy drinking occasions (Binge drinking is not protective for any heart!) Regularity With or outside of meals The overall relation in one country depends on the mix of drinking patterns

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13 Conclusion on patterns and CHD II CHD is very important cause of disease and thus important in determining health policy (and influencing health policy makers) Alcohol to CHD relation is complex Need to know exactly what proportion of population drinks how to predict outcome Better and standardized pattern measures necessary! But conclusions can tentatively be drawn today: alcohol in many parts of the world is consumed in a way that it is detrimental to CHD How to determine patterns weights for CHD for CRA?

14 Alcohol related disease and injury (major categories) Chronic disease: Cancer: Mouth & oropharyngeal cancer, esophageal cancer, liver cancer, female breast cancer, colorectal cancer Neuropsychiatric diseases: Alcohol use disorders, unipolar major depression, epilepsy Diabetes Cardiovascular diseases: Hypertensive diseases, coronary heart disease, stroke Gastrointestinal diseases: Liver cirrhosis Conditions arising during perinatal period: Low birth weight Injury: Unintentional injury: Motor vehicle accidents, drownings, falls, poisonings, other unintentional injuries Intentional injury: Self-inflicted injuries, homicide, other intentional injuries

15 Drinking pattern hazard score (predominance of intoxication) Volume of drinking Estimation of AAF for different disease categories Injuries Coronary heart disease Other chronic Diseases (except CHD and depression) 100% alcohol-attributable conditions (by definition): e.g. alcohol dependence Depression was estimated differently based on alcohol dependence and temporal sequence from surveys.

16 Adult per capita consumption in litre pure alcohol 2002 Average per capita alcohol consumption in litres pure alcohol,

17 Overall per capita recorded and unrecorded alcohol consumption in litres pure alcohol, Europe, 2002 Alcohol consumption in Europe is comparatively high No systematic East-West differences Differences in unrecorded consumption Source: atlas/default.asp Adult per capita consumption in litres pure alcohol, EU Ltr - 10Ltr 10Ltr - 12Ltr 12Ltr - 14Ltr 14Ltr - 16Ltr 15Ltr - 18Ltr

18 Patterns of drinking 2002 Patterns of drinking

19 Patterns of drinking in Europe Patterns of drinking are different between East and West More irregular binge drinking in EU10 More spirits in EU10, but overall beer being the preferred beverage in EU Drinking Pattern, EU 2002 More problems with quality of beverages in EU

20 Alcohol-attributable global burden of disease Alcohol-attributable mortality DALYs 0.35 to to to to to All numbers are based on net burden!

21 Alcohol-attributable mortality in different countries Alcohol-attributable deaths, males, Alcohol-attributable deaths, females, Russia Estonia Lithuania Hungary Latvia Romania Slovakia EU10 Poland Finland Slovenia Czech Republic Denmark France Bulgaria Luxembourg Germany Portugal Austria EU15 Ireland United Kingdom Belgium Spain Italy Sweden Greece Netherlands Russia Hungary Lithuania Estonia Latvia Denmark Slovakia Finland Romania Slovenia Germany EU10 France Luxembourg Austria EU15 Czech Republic Belgium United Kingdom Portugal Ireland Poland Netherlands Italy Spain Sweden Greece Bulgaria Rates per 100,000 population Rates per 100,000 population 21

22 What are main alcohol-attributable causes of premature death in Europe? 1. Unintentional and intentional injury 2. Liver cirrhosis 3. Cardiovascular diseases (protective effect of regular moderate drinking vs. detrimental effect of binge drinking) 4. Cancer: Mouth & oropharyngeal cancer, esophageal cancer, liver cancer, colorectal cancer, breast cancer Overall 15.3% all premature deaths in Central and Eastern European countries of the EU (19.1% M, 6.6% F), and 12.5% in EU15 are caused by alcohol (15.1% M, 7.5% F). 22

23 Conclusions Alcohol is major risk factor for premature mortality and morbidity in EU, more for men than for women Alcohol-attributable deaths and burden of disease are higher in the Central and Eastern European countries than EU 15 Alcohol-attributable health harm is only one part of overall harm by alcohol

24 Global mortality burden (deaths in 1000s) attributable to alcohol by major disease categories Disease conditions Men Women Total Maternal and perinatal conditions (low birth weight) % of all alcoholattributable deaths % Cancer % Neuro-psychiatric disorders % Cardiovascular diseases % Other non-communicable diseases (diabetes, liver cirrhosis) % Unintentional injuries % Intentional injuries % Alcohol-attributable mortality burden all causes 1, , % All deaths 29,891 27,138 57,029 In comparison: estimate for % of all deaths 6.1% 1.1% 3.7% 2000: 3.2% which are alcohol-attributable

25 Global burden of disease (DALYs in 1000s) attributable to alcohol by major disease categories Disease conditions Men Women Total Maternal and perinatal conditions (low birth weight) % of all alcoholattributable DALYs % Cancer 4,593 1,460 6, % Neuro-psychiatric conditions 19,393 3,722 23, % Cardiovascular diseases 4, , % Other non-communicable diseases (diabetes, liver cirrhosis) 5,190 1,402 6, % Unintentional injuries 14,499 2,647 17, % Intentional injuries 6,366 1,051 7, % Alcohol-attributable disease burden all causes (DALYs) 54,970 10,006 64, % All DALYs 772, ,213 1,490,126 In comparison: estimate for % of all DALYs which are 7.1% 1.4% 4. 4% 2000: 4.0% alcohol-attributable