Charlotte Probst

The relationship between different dimensions of alcohol use and the burden of disease-an update.

Abstract Background and aims Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs). Methods Systematic review of reviews and meta‐analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others. Results In total, 255 reviews and meta‐analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD‐10 three‐digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in‐depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently. Conclusions Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

Socioeconomic differences in alcohol-attributable mortality compared with all-cause mortality: a systematic review and meta-analysis

BACKGROUND Factors underlying socioeconomic inequalities in mortality are not well understood. This study contributes to our understanding of potential pathways to result in socioeconomic inequalities, by examining alcohol consumption as one potential explanation via comparing socioeconomic inequalities in alcohol-attributable mortality and all-cause mortality. METHODS Web of Science, MEDLINE, PsycINFO and ETOH were searched systematically from their inception to second week of February 2013 for articles reporting alcohol-attributable mortality by socioeconomic status, operationalized by using information on education, occupation, employment status or income. The sex-specific ratios of relative risks (RRRs) of alcohol-attributable mortality to all-cause mortality were pooled for different operationalizations of socioeconomic status using inverse-variance weighted random effects models. These RRRs were then combined to a single estimate. RESULTS We identified 15 unique papers suitable for a meta-analysis; capturing about 133 million people, 3 741 334 deaths from all causes and 167 652 alcohol-attributable deaths. The overall RRRs amounted to RRR = 1.78 (95% confidence interval (CI) 1.43 to 2.22) and RRR = 1.66 (95% CI 1.20 to 2.31), for women and men, respectively. In other words: lower socioeconomic status leads to 1.5-2-fold higher mortality for alcohol-attributable causes compared with all causes. CONCLUSIONS Alcohol was identified as a factor underlying higher mortality risks in more disadvantaged populations. All alcohol-attributable mortality is in principle avoidable, and future alcohol policies must take into consideration any differential effect on socioeconomic groups.

Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis

BACKGROUND Alcohol use during pregnancy is the direct cause of fetal alcohol syndrome (FAS). We aimed to estimate the prevalence of alcohol use during pregnancy and FAS in the general population and, by linking these two indicators, estimate the number of pregnant women that consumed alcohol during pregnancy per one case of FAS. METHODS We began by doing two independent comprehensive systematic literature searches using multiple electronic databases for original quantitative studies that reported the prevalence in the general population of the respective country of alcohol use during pregnancy published from Jan 1, 1984, to June 30, 2014, or the prevalence of FAS published from Nov 1, 1973, to June 30, 2015, in a peer-reviewed journal or scholarly report. Each study on the prevalence of alcohol use during pregnancy was critically appraised using a checklist for observational studies, and each study on the prevalence of FAS was critically appraised by use of a method specifically designed for systematic reviews addressing questions of prevalence. Studies on the prevalence of alcohol use during pregnancy and/or FAS were omitted if they used a sample population not generalisable to the general population of the respective country, reported a pooled estimate by combining several studies, or were published in iteration. Studies that excluded abstainers were also omitted for the prevalence of alcohol use during pregnancy. We then did country-specific random-effects meta-analyses to estimate the pooled prevalence of these indicators. For countries with one or no empirical studies, we predicted prevalence of alcohol use during pregnancy using fractional response regression modelling and prevalence of FAS using a quotient of the average number of women who consumed alcohol during pregnancy per one case of FAS. We used Monte Carlo simulations to derive confidence intervals for the country-specific point estimates of the prevalence of FAS. We estimated WHO regional and global averages of the prevalence of alcohol use during pregnancy and FAS, weighted by the number of livebirths per country. The review protocols for the prevalence of alcohol use during pregnancy (CRD42016033835) and FAS (CRD42016033837) are available on PROSPERO. FINDINGS Of 23 470 studies identified for the prevalence of alcohol use, 328 studies were retained for systematic review and meta-analysis; the search strategy for the prevalence of FAS yielded 11 110 studies, of which 62 were used in our analysis. The global prevalence of alcohol use during pregnancy was estimated to be 9·8% (95% CI 8·9-11·1) and the estimated prevalence of FAS in the general population was 14·6 per 10 000 people (95% CI 9·4-23·3). We also estimated that one in every 67 women who consumed alcohol during pregnancy would deliver a child with FAS, which translates to about 119 000 children born with FAS in the world every year. INTERPRETATION Alcohol use during pregnancy is common in many countries and as such, FAS is a relatively prevalent alcohol-related birth defect. More effective prevention strategies targeting alcohol use during pregnancy and surveillance of FAS are urgently needed. FUNDING Centre for Addiction and Mental Health (no external funding was sought).

General Practitioners Recognizing Alcohol Dependence: A Large Cross-Sectional Study in 6 European Countries

PURPOSE Although alcohol dependence causes marked mortality and disease burden in Europe, the treatment rate is low. Primary care could play a key role in reducing alcohol-attributable harm by screening, brief interventions, and initiating or referral to treatment. This study investigates identification of alcohol dependence in European primary care settings. METHODS Assessments from 13,003 general practitioners, and 9,098 interviews (8,476 joint number of interviewed patients with a physician’s assessment) were collected in 6 European countries. Alcohol dependence, comorbidities, and health service utilization were assessed by the general practitioner and independently using the Composite International Diagnostic Interview (CIDI) and other structured interviews. Weighted regression analyses were used to compare the impact of influencing variables on both types of diagnoses. RESULTS The rate of patients being identified as alcohol dependent by the CIDI or a general practitioner was about equally high, but there was not a lot of overlap between cases identified. Alcohol-dependent patients identified by a physician were older, had higher rates of physicial comorbidity (liver disease, hypertension), and were socially more marginalized, whereas average consumption of alcohol and mental comorbidity were equally high in both groups. CONCLUSION General practitioners were able to identify alcohol dependence, but the cases they identified differed from cases identified using the CIDI. The role of the CIDI as the reference standard should be reexamined, as older alcohol-dependent patients with severe comorbidities seemed to be missed in this assessment.

People with Alcohol Use Disorders in Specialized Care in Eight Different European Countries

AIM To provide a description of patients receiving alcohol treatment in eight different European countries, including the level of comorbidities and functional limitations. METHODS Drinking behaviours, DSM-IV alcohol use disorder (AUD), mental and somatic comorbidities, disability and health services utilization of 1767 patients from various specialized treatment settings were assessed as representative for regions of eight European countries. Severity of alcohol dependence (AD) in terms of drinking level was compared with a large representative US sample. RESULTS Patients in specialized care for AUDs showed high levels of consumption [average level of daily ethanol intake: 141.1 g, standard deviation (SD): 116.0 g], comorbidity [e.g. liver problems: 19.6%, 95% confidence interval (CI): 17.5-21.6%; depression: 43.2%, 95% CI: 40.7-45.8%; anxiety: 50.3%, 95% CI: 47.8-52.9%], disability and health services utilization (average number of nights spent in hospital(s) during the last 6 months: 8.8, SD: 19.5 nights). Severity of AD was similar to the US sample, but European men consumed on average more alcohol daily. CONCLUSIONS High levels of consumption, somatic and mental comorbidities, disability and functional losses were found in this representative treatment sample, indicating that treatment was initiated only at severe stages of AUDs. Earlier initiation of treatment could help avoid some of the health and social burden.

Global Prevalence of Fetal Alcohol Spectrum Disorder Among Children and Youth: A Systematic Review and Meta-analysis

Importance Prevalence estimates are essential to effectively prioritize, plan, and deliver health care to high-needs populations such as children and youth with fetal alcohol spectrum disorder (FASD). However, most countries do not have population-level prevalence data for FASD. Objective To obtain prevalence estimates of FASD among children and youth in the general population by country, by World Health Organization (WHO) region, and globally. Data Sources MEDLINE, MEDLINE in process, EMBASE, Education Resource Information Center, Cumulative Index to Nursing and Allied Health Literature, Web of Science, PsychINFO, and Scopus were systematically searched for studies published from November 1, 1973, through June 30, 2015, without geographic or language restrictions. Study Selection Original quantitative studies that reported the prevalence of FASD among children and youth in the general population, used active case ascertainment or clinic-based methods, and specified the diagnostic guideline or case definition used were included. Data Extraction and Synthesis Individual study characteristics and prevalence of FASD were extracted. Country-specific random-effects meta-analyses were conducted. For countries with 1 or no empirical study on the prevalence of FASD, this indicator was estimated based on the proportion of women who consumed alcohol during pregnancy per 1 case of FASD. Finally, WHO regional and global mean prevalence of FASD weighted by the number of live births in each country was estimated. Main Outcomes and Measures Prevalence of FASD. Results A total of 24 unique studies including 1416 unique children and youth diagnosed with FASD (age range, 0-16.4 years) were retained for data extraction. The global prevalence of FASD among children and youth in the general population was estimated to be 7.7 per 1000 population (95% CI, 4.9-11.7 per 1000 population). The WHO European Region had the highest prevalence (19.8 per 1000 population; 95% CI, 14.1-28.0 per 1000 population), and the WHO Eastern Mediterranean Region had the lowest (0.1 per 1000 population; 95% CI, 0.1-0.5 per 1000 population). Of 187 countries, South Africa was estimated to have the highest prevalence of FASD at 111.1 per 1000 population (95% CI, 71.1-158.4 per 1000 population), followed by Croatia at 53.3 per 1000 population (95% CI, 30.9-81.2 per 1000 population) and Ireland at 47.5 per 1000 population (95% CI, 28.0-73.6 per 1000 population). Conclusions and Relevance Globally, FASD is a prevalent alcohol-related developmental disability that is largely preventable. The findings highlight the need to establish a universal public health message about the potential harm of prenatal alcohol exposure and a routine screening protocol. Brief interventions should be provided, where appropriate.

Gender differences in socioeconomic inequality of alcohol‐attributable mortality: A systematic review and meta‐analysis

INTRODUCTION AND AIMS The present analysis contributes to understanding the societal distribution of alcohol-attributable harm by investigating socioeconomic inequality and related gender differences in alcohol-attributable mortality. DESIGN AND METHODS A systematic literature search was performed on Web of Science, MEDLINE, PsycINFO and ETOH from their inception until February 2013. Articles were included when they reported data on alcohol-attributable mortality by socioeconomic status (SES), operationalised as education, occupation, employment status or income. Gender-specific relative risks (RR) comparing low with high SES were pooled using random effects meta-analyses. Gender differences were additionally investigated in random effects meta-regressions. RESULTS Nineteen articles from 14 countries were included. For women, significant RRs across all measures of SES, except employment status, were found, ranging between 1.75 [95% confidence interval (CI) 1.21-2.54; occupation] and 4.78 (95% CI 2.57-8.87; income). For men, all measures of SES showed significant RRs ranging between 2.88 (95% CI 2.45-3.40; income) and 12.25 (95% CI 11.45-13.10; employment status). While RRs for men were in general slightly higher, only for occupation this gender difference was above chance (P = 0.01). Results refer to deaths 100% attributable to alcohol. DISCUSSION AND CONCLUSIONS The results are predominantly based on data from high-income countries, limiting generalisability. Alcohol-attributable mortality is strongly distributed to the disadvantage of persons with a low SES. Marked gender differences in this inequality were found for occupation. Possibly male-dominated occupations of low SES were more strongly related to risky drinking cultures compared with female-dominated occupations of the same SES.

Prevalence of alcohol consumption during pregnancy and Fetal Alcohol Spectrum Disorders among the general and Aboriginal populations in Canada and the United States.

Prenatal alcohol exposure may cause a number of health complications for the mother and developing fetus, including Fetal Alcohol Spectrum Disorders (FASD). This study aimed to estimate the pooled prevalence of i) alcohol use (any amount) and binge drinking (4 or more standard drinks on a single occasion) during pregnancy, and ii) Fetal Alcohol Syndrome (FAS) and FASD among the general and Aboriginal populations in Canada and the United States, based on the available literature. Comprehensive systematic literature searches and meta-analyses, assuming a random-effects model, were conducted. It was revealed that about 10% and 15% of pregnant women in the general population consume alcohol in Canada and the United States, respectively, and that about 3% of women engage in binge drinking during pregnancy in both countries. However, the prevalence of alcohol use during pregnancy in the Aboriginal populations of the United States and Canada were found to be approximately 3-4 times higher, respectively, compared to the general population. Even more alarmingly, it was estimated that approximately one in five women in the Aboriginal populations in both countries engage in binge drinking during pregnancy. Further, among the general population of Canada, the pooled prevalence was estimated to be about 1 per 1000 for FAS and 5 per 1000 for FASD. However, compared to the general population, the prevalence of FAS and FASD among the Aboriginal population in Canada was estimated to be 38 times and 16 times higher, respectively. With respect to the United States, the pooled prevalence of FAS and FASD was estimated to be about 2 per 1000 and 15 per 1,000, respectively, among the general population, and 4 per 1000 and 10 per 1,000, respectively, among the Aboriginal population. The FAS and FASD pooled prevalence estimates presented here should be used with caution due to the limited number of existing studies and their methodological limitations. Based on the results of the current study, it is evident that there is an urgent need for implementing more effective national prevention and surveillance strategies to monitor and lower the prevalence of alcohol consumption during pregnancy and FASD.

Alcohol use disorders in Europe: A comparison of general population and primary health care prevalence rates

Abstract Aims. Alcohol use disorders (AUDs) are prevalent in Europe but occurrence in primary care and the proportion of treated cases are understudied. This study reports prevalence of AUDs and their treatment in European primary health care settings and compares them with general population estimates. Procedure. We sampled 358 general practitioners (GPs, refusal rate: 56.4%) across six European countries (Germany, Hungary, Italy, Latvia, Poland, and Spain) who assessed 13,003 patients including providing AUD diagnoses. A subsample of 8,476 patients (refusal rate: 17.8%) was interviewed subsequently, assessing DSM-IV AUD diagnoses via the Composite International Diagnostic Interview. Final AUD diagnoses combined GP and patient interview information. Findings. Past year AUDs were prevalent with 11.8% (95% CI: 11.2–12.5%) across all regions, which is 1.6 times the European general population AUD estimate. Of those diagnosed with AUDs, 17.7% (95% CI: 15.4–20.0%) received professional help. Compared to general population estimates, AUDs and their treatment were more prevalent in primary care settings in most countries, with disproportionally high AUD rates in Italy and Spain and unexpectedly low AUD rates in Hungary. Conclusions. We found higher prevalence and treatment rates of AUDs in primary health care compared to general population surveys, with large variability between the observed countries.

Alcohol use, smoking and their co-occurrence during pregnancy among Canadian women, 2003 to 2011/12

INTRODUCTION The co-occurrence of alcohol use and smoking during pregnancy has been shown to have a negative synergistic effect on fetal and perinatal risks. The objectives were to: 1) obtain an estimate of the prevalence of smoking during pregnancy in Canada by province and territory from 2003 to 2011/12; 2) determine if the prevalence of smoking during pregnancy has increased or decreased over time; 3) investigate whether smoking status is differentially associated with alcohol use during pregnancy; and 4) examine the risk factors predictive of alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy. METHODS Secondary data analysis was conducted using five cycles of the Canadian Community Health Survey (CCHS; 2003, 2005, 2007/08, 2009/10 and 2011/12). The prevalence of smoking during pregnancy, and 95% confidence interval (CI) was calculated by province and territory and by year. The likelihood ratio test was used to determine if the prevalence of smoking during pregnancy has increased or decreased over time. The relationship between smoking status and alcohol use during pregnancy was explored using a quasi-Poisson regression model. A multinomial logistic regression model was utilized to determine which factors were predictive of alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy. RESULTS In Canada, between 2003 and 2011/12, the weighted pooled prevalence of smoking during pregnancy was 14.3% (95% CI: 13.6%-15.0%). Women who smoked daily during pregnancy, occasionally during pregnancy, or had a lifetime history of smoking (but did not smoke while pregnant) were 2.54 (95% CI: 2.11-3.06, P < 0.0001), 2.71 (95% CI: 2.25-3.27, P < 0.0001), and 2.09 (95% CI: 1.85-2.37, P < 0.0001), respectively, times more likely to have consumed alcohol during pregnancy, compared to pregnant women who were lifetime non-smokers when controlling for age, household income, ethnicity and CCHS cycle. Risk factors that predicted alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy differed. CONCLUSION It is apparent that smoking in any capacity, whether during pregnancy or not, increases the likelihood that a woman consumed alcohol while pregnant. Ascertaining smoking status among pregnant women and women of childbearing age could be a useful screening method for identifying those at-risk of consuming alcohol during pregnancy, and vice versa.