David Jernigan Center on Alcohol Marketing and Youth Georgetown University dhj@georgetown

1. Estimating alcohol’s role in disease & disability: the alcohol component in WHO’s Global Burden of Disease analysis for 2000 David Jernigan Center on Alcohol Marketing and Youth Georgetown University dhj@georgetown.edu

2. WHO’s Comparative Risk Assessment Collaborating Group • 27 groups: • Core, metholodology, etc. Group • 26 risk factor groups • Alcohol group: • J Rehm, R Room, M Monteiro, G Gmel, K Graham, N Rehn, C T Sempos, U Frick, D Jernigan

3. The 26 risk factors, roughly grouped • Childhood and maternal undernutrition: underweight, iron deficiency, vitamin A deficiency, zinc deficiency; • Other diet-related risks and physical inactivity: blood pressure, cholesterol, overweight, low fruit and vegetable intake, physical inactivity; • Sexual and reproductive health risks: unsafe sex, lack of contraception; • Addictive substance use: tobacco, alcohol, illicit drugs; • Environmental risks: unsafe water, sanitation and hygiene, urban air pollution, indoor smoke from solid fuels, lead exposure, climate change; • Occupational risks: risk factors for injury, carcinogens, airborne particulates, ergonomic stressors, noise; • Other selected risks to health: unsafe health care injections, childhood sexual abuse.

4. Attributable fractions = f(prevalence, pattern weight, relative risk) Defined as: With a given outcome exposure factor, and population, the attributable fraction is the proportion by which the incidence rate of the outcome would be reduced if the distribution of exposure would change to an alternative distribution: “When an exposure is believed to be a cause of a given disease, the attributable fraction is the proportion of the disease in the specific population that would be eliminated in the absence of the exposure.” Four drinking categories (old English et al. terminology: abstainer, moderate, hazardous, harmful) are distinguished. Prevalence for all four categories are taken from surveys Steps to derive at pattern weight: 1. Determine pattern value from survey of key informants, and/or survey data where available. 2. Conduct hierarchical linear analyses on mortality using per capita consumption gross-national product, year (level 1 variables) and pattern values (level 2 variable) as determining factors (separate by age and sex). 3. Construct pattern weight based on intercept and regression weight for patterns. Relative Risk estimates for each drinking category are either taken directly from meta-analyses (chronic diseases) or indirectly from meta-analyses of attributable fractions (injuries) The epidemiological model

5. Patterns of drinking • Countries assigned hazardous drinking scores, a numeric indicator of hazard per litre of alcohol consumed • Information drawn from research literature supplemented by key informant questionnaires • Applied to two areas: injuries and CHD.

6. Dimensions of patterns of drinking • High usual quantity of alcohol per occasion • Festive drinking common – at fiestas or community celebrations • Proportion of drinking occasions when drinkers get drunk • Low proportion of drinkers who drink daily or nearly daily • Less common to drink with meals • Common to drink in public places

7. Pattern of drinking 2000(based on CRA) Patterns ofdrinking 1.00 to 2.00 2.00 to 2.50 2.50 to 3.00 3.00 to 4.00

8. Aspects of alcohol used in estimating alcohol attributable fraction (AAF) for different conditions Volume of drinking Drinking pattern hazard score (predominance of intoxication) Prior alcohol dependence Alcohol- attributable conditions* Physical diseases (except CHD) Coronary heart disease Injuries Depression *AAF = 1 by definition

9. Alcohol-related disorders • Chronic disease: • Conditions arising during perinatal period*: low birth weight • Cancer*: lip & oropharyngeal cancer, esophageal cancer, liver cancer, laryngeal cancer, female breast cancer • Neuropsychiatric diseases: alcohol use disorders, unipolar major depression, epilepsy • Diabetes* • Cardiovascular diseases: hypertension, coronary heart disease, stroke • Gastrointestinal diseases*: liver cirrhosis • Injury: • Unintentional injury: motor vehicle accidents, drownings, falls, poisonings, other unintentional injuries • Intentional injury:self-inflicted injuries, homicide, other intentional injuries * AAF based on volume of drinking only

10. Estimating AAFs • Alcohol-specific categories • Chronic health conditions • CHD • Depression • Injuries

11. Alcohol-attributable mortality 0.35 to 1.00 1.00 to 4.00 4.00 to 6.00 6.00 to 8.00 8.00 to 20.00 Alcohol-related global burden of disease

12. Leading risk factors for disease (WHR 2002) in emerging and established economies (% total DALYS)

13. Disease conditions Males Females Total % of all alcohol-attributable deaths Global mortality burden (deaths in 1000s) attributable to alcohol by major disease categories - 2000 Conditions arising during the perinatal period 2 1 3 0% Malignant neoplasm 269 86 355 20% Neuro-psychiatric conditions 91 19 111 6% Cardiovascular diseases 392 -124 268 15% Other non-communicable diseases (diabetes, liver cirrhosis) 193 49 242 13% Unintentional injuries 484 92 577 32% Intentional injuries 206 42 248 14% Alcohol-related mortality burden all causes 1,638 166 1,804 100.0% All deaths 29,232 26,629 55,861 In comparison: estimate for 1990: 1.5% % of all deaths which are alcohol-attributable 5.6% 0.6% 3.2%

14. Disease conditions Males Females Total % of all alcohol-attributable DALYs Global burden of disease (DALYs in 1000s) attributable to alcohol by major disease categories - 2000 Conditions arising during the perinatal period 68 55 123 0% Malignant neoplasm 3,180 1,021 4,201 7% Neuro-psychiatric conditions 18,090 3,814 21,904 38% Cardiovascular diseases 4,411 -428 3,983 7% Other non-communicable diseases (diabetes, liver cirrhosis) 3,695 860 4,555 8% Unintentional injuries 14,008 2,487 16,495 28% Intentional injuries 5,945 1,117 7,062 12% Alcohol-related disease burden all causes (DALYs) 49,397 8,926 58,323 100% All DALYs 755,176 689,993 1,445,169 In comparison: estimate for 1990: 3.5% % of all DALYs which are alcohol-attributable 6.5% 1.3% 4.0%

15. Future • Increase in alcohol-related burden for two reasons: • The disease categories related to alcohol are relatively increasing: chronic disease, accidents and injuries • Alcohol consumption is increasing in the most populous parts of the world • Patterns are stable if not getting worse • If there are no interventions!!!