Burden and cost of alcohol, tobacco and illegal drugs globally and in Europe Jürgen Rehm 1-4 Kevin D. Shield 1,2,3 1) Centre for Addiction and Mental Health, Toronto, Canada 2) University of Toronto, Canada 3) WHO Collaborating Centre for Mental Health and Addictions 4) Technische Universität Dresden, Clinical Psychology and Psychotherapy, Germany jtrehm@gmail.com
What will be covered? Risk factor approach vs. disease approach Basic methodology for risk factor approach The 2010 GBD study the real data (Lim et al., 2012 is unfortunately incorrect) The situation in the Nordic and Baltic countries Cost Conclusions
Diseases vs. risk factors
Addiction (substance use disorders = disease) vs. risk factors Mortality and morbidity can be attributed to disease or injury outcomes preventable risk factors However, this distinction gets blurred with substance use and substance use disorders How many of the smoking attributable lung cancers are due to tobacco use disorders? But what is written on the cause of death certificate?
Smoking and lung cancer Below the white line in the red circle: smokers without tobacco use disorder
The risk factor approach Identification of causal relations Exposure Quantification of risk relations
Basic ingredients for a risk factor approach First disease and injury categories, where substance use disorders have causal impact, must be identified Attributable fraction must be determined, which are a function of: Prevalence of exposure Risk relations What does this mean? We need to know the prevalence of alcohol use
Currently used model for alcohol CRA 2005 Societal Factors (individual) Population group Gender Drinking culture Alcohol Policy Drinking environment Health care system Alcohol consumption Volume Patterns Quality Incidence chronic conditions including AUDs Incidence acute conditions Health outcomes Age Poverty Marginalization Mortality by cause
Basic formula Continuous distribution of drinkers Continuous RR function P a RR P RR AAF( x) max( x) P RR P RR P( x) RR( x) dx a a a ex ex min( x) where Pa is the prevalence of lifetime abstainers RRa is the relative risk of lifetime abstainers (set to 1) Pex is the prevalence of former drinkers (all types of former drinkers with no drinking in last year) RRex is the relative risk of former drinkers x average volume of alcohol consumption per day P(x) is the prevalence of alcohol with consumption x RR(x) is the relative risk of drinkers with consumption x Of course, instead of no consumption at all, other counterfactuals could be modelled. ex ex max( x) min( x) P( x) RR( x) dx -1
Volume (g/day) German Male ALL AGES Example of general population distribution of volume of drinking => basis for continuous modelling Log-Normal (red) vs. Gamma (blue) vs. Weibull (green) P re v a le n c e 0.0 0 0.0 1 0.0 2 0.0 3 0.0 4 0.0 5 0.0 6 0.0 7 Histogram of consumption with estimated consumption distributions Decision was based on comparison of distributions from 30 countries! 0 20 40 60 80 100
Best overall fit: Weibull & Gamma Gamma Distribution f(x; θ, k) = 1/( θk Γ(k)) xk-1 exp{- x / θ} Mean Estimate for the Gamma Distribution = θk Variance = θ2k Empirical and theoretical Gamma estimates for mean have to be identical, and variance estimates were quite similar. Better properties for transferring results to other populations than Weibull.
Risk relations Alcohol has the most disease and injury categories which are causally impacted (more then 200 ICD three digit codes) -> mainly not 100% attributable Tobacco is second -> mainly not 100% attributable Illicit drugs mainly overdose deaths for mortality
Risk factor assessment within GBD 2010 Published in December 2012 in Lancet by Lim et al. But The numbers for alcohol are seriously off. What I show in the next slides is already corrected -> will appear in Lancet soon
Burden of disease in DALYs One DALY is one year of life lost either due to premature mortality or to disability. If somebody is 20% disabled, living 5 years with this disablement will result in one DALY (without age weighting or discounting). Total DALYs in 2010 were 2.490 billion.
2010 GBD (% of total burden of disease)
GBD Men 2010 (% of all burden)
GBD women (% of all burden)
Men vs. women in burden of disease Tobacco: men #1, women #4 Alcohol: men #3, women #12 Illegal drugs #20, women not in top #20 Huge differences between high- and low/middle income countries Alcohol consumption varies with emancipation: the more emancipated, the higher the alcoholattributable burden of disease!
Worldwide rise in body weight and glycaemia, with rare regions where it has been stable; higher burden from overweight/obesity than undernutrition The worldwide epidemiological transition Overall improvement in mortality across the world, with near stagnation in Eastern Europe and parts of sub-saharan Africa Large declines in child mortality and in the burden for its key risk factors, leading to larger share of disease burden from NCDs (with main risk factors tobacco, alcohol, nutrition, and physical activity). A great deal more to be done in sub-saharan Africa and South Asia. Shifting burden of smoking from high-income to low-andmiddle-income countries
Western Europe (larger countries) Andorra Austria Belgium Cyprus Denmark Finland France Germany Greece Greenland Iceland Ireland Israel Italy Liechtenstein Luxembourg Malta Monaco Netherlands Norway Portugal San Marino Spain Sweden Switzerland United Kingdom
Western Europe 2010
Central Europe Albania Bosnia and Herzegovina Bulgaria Croatia Czech Republic Hungary Montenegro Poland Romania Serbia Slovakia Slovenia The Former Yugoslav Republic of Macedonia
Central Europe 2010
Eastern Europe Belarus Estonia Latvia Lithuania Republic of Moldova Russian Federation Ukraine
Eastern Europe 2010
A comparison for the Baltic countries and Finland to global figures risk factor attributable and total DALYs/100 000 12 10 8 6 4 2 0
A comparison for the Baltic countries and Finland to global figures risk factor attributable DALYs/100 000 12 10 8 6 4 2 0
Percent DALYs attributable to SU risk factors 12 10 8 6 4 2 0
Globally For tobacco there are 6.30 million deaths in 2010, for alcohol 2.74 million deaths, and for drugs 0.16 million deaths In total in 2010, there were 52.77 million deaths. Thus tobacco is causing more than 10% of all deaths (11.9%), and alcohol for about 5.2% and illegal drugs for 0.3%
Conclusion Prevalence, associated burden and economic costs of substance use and substance use disorders in Europe are staggering. For most of Europe tobacco use disorders cause the most burden and costs, for eastern Europe it is alcohol. Illegal drugs and its attributable burden is far behind, but its costs depend more on political choices than on burden. In terms of countries, the Baltics are typical for Eastern European pattern and the Nordic Countries for western European patterns.