Gerhard Gmel

The Global Distribution of Average Volume of Alcohol Consumption and Patterns of Drinking

Aims: To make quantitative estimates on a global basis of exposure of disease-relevant dimensions of alcohol consumption, i.e. average volume of alcohol consumption and patterns of drinking. Design: Secondary data analysis. Measurements: Level of average volume of drinking was estimated by a triangulation of data on per capita consumption and from general population surveys. Patterns of drinking were measured by an index composed of several indicators for heavy drinking occasions, an indicator of drinking with meals and an indicator of public drinking. Average volume of consumption was assessed by sex and age within each country, and patterns of drinking only by country; estimates for the global subregions were derived from the population-weighted average of the countries. For more than 90% of the world population, per capita consumption was known, and for more than 80% of the world population, survey data were available. Findings: On the country level, average volume of alcohol consumption and patterns of drinking were independent. There was marked variation between WHO subregions on both dimensions. Average volume of drinking was highest in established market economies in Western Europe and the former Socialist economies in the Eastern part of Europe and in North America, and lowest in the Eastern Mediterranean region and parts of Southeast Asia including India. Patterns were most detrimental in the former Socialist economies in the Eastern part of Europe, in Middle and South America and parts of Africa. Patterns were least detrimental in Western Europe and in developed countries in the Western Pacific region (e.g., Japan). Conclusions: Although exposure to alcohol varies considerably between regions, the overall exposure by volume is quite high and patterns are relatively detrimental. The predictions for the future are not favorable, both with respect to average volume and to patterns of drinking.

Measuring Alcohol Consumption

This article is an overview of different approaches to measuring alcohol consumption: self-reports and objective measures such as blood alcohol concentration (BAC) and aggregate level measures. These approaches are evaluated as regards their ability to capture quantity, frequency, volume and variability of drinking. This review focuses on self-report measures and on the current knowledge of undercoverage error when compared with sales data. In the comparative evaluation of measures, two analytical aims are examined: a) description and testing of differences across groups for which ordinal information is sufficient and b) establishment of cutoff points and risk relationships for which unbiased interval scale level is required. First, minimal differences were found between self-report measures when the recall period was sufficiently long enough. Second, prospective diaries appear to be stronger measures than retrospective recalls. However, prospective diaries commonly cover only short reporting periods and should be combined with simple retrospective measures to capture rare and infrequent drinking episodes. In regard to undercoverage, the discrepancy cannot be fully explained by non-response or concealment of consumption by drinkers. It is argued that undercoverage of sales data may be more related to sample frame defects–-e.g., the non-inclusion of particular subpopulations such as the homeless or institutionalized.

Alcohol as a Risk Factor for Global Burden of Disease

Aim: To make quantitative estimates of the burden of disease attributable to alcohol in the year 2000 on a global basis. Design: Secondary data analysis. Measurements: Two dimensions of alcohol exposure were included: average volume of alcohol consumption and patterns of drinking. There were also two main outcome measures: mortality, i.e. the number of deaths, and disability-adjusted life years (DALYs), i.e. the number of years of life lost to premature mortality or to disability. All estimates were prepared separately by sex, age group and WHO region. Findings: Alcohol causes a considerable disease burden: 3.2% of the global deaths and 4.0% of the global DALYs in the year 2000 could be attributed to this exposure. There were marked differences by sex and region for both outcomes. In addition, there were differences by disease category and type of outcome; in particular, unintentional injuries contributed most to alcohol-attributable mortality burden while neuropsychiatric diseases contributed most to alcohol-attributable disease burden. Discussion/Conclusions: The underlying assumptions are discussed and reasons are given as to why the estimates should still be considered conservative despite the considerable burden attributable to alcohol globally.

Gender and alcohol consumption: patterns from the multinational GENACIS project.

AIMS To evaluate multinational patterns of gender- and age-specific alcohol consumption. DESIGN AND PARTICIPANTS Large general-population surveys of mens and womens drinking behavior (ns > 900) in 35 countries in 1997-2007 used a standardized questionnaire (25 countries) or measures comparable to those in the standardized questionnaire. MEASUREMENTS Data from men and women in three age groups (18-34, 35-49, 50-65) showed the prevalence of drinkers, former drinkers, and lifetime abstainers; and the prevalence of high-frequency, high-volume, and heavy episodic drinking among current drinkers. Analyses examined gender ratios for prevalence rates and the direction of changes in prevalence rates across age groups. FINDINGS Drinking per se and high-volume drinking were consistently more prevalent among men than among women, but lifetime abstention from alcohol was consistently more prevalent among women. Among respondents who had ever been drinkers, women in all age groups were consistently more likely to have stopped drinking than men were. Among drinkers, the prevalence of high-frequency drinking was consistently greatest in the oldest age group, particularly among men. Unexpectedly, the prevalence of drinking per se did not decline consistently with increasing age, and declines in high-volume and heavy episodic drinking with increasing age were more typical in Europe and English-speaking countries. CONCLUSIONS As expected, men still exceed women in drinking and high-volume drinking, although gender ratios vary. Better explanations are needed for why more women than men quit drinking, and why aging does not consistently reduce drinking and heavy drinking outside Europe and English-speaking countries.

Relation between Average Alcohol Consumption and Disease: An Overview

Objective: To conduct an overview of alcohol-related health consequences and to estimate relative risk for chronic consequences and attributable fractions for acute consequences. Methods: Identification of alcohol-related consequences was performed by means of reviewing and evaluating large-scale epidemiological studies and reviews on alcohol and health, including epidemiological contributions to major social cost studies. Relative risks and alcohol-attributable fractions were drawn from the international literature and risk estimates were updated, whenever possible, by means of meta-analytical techniques. Results: More than 60 health consequences were identified for which a causal link between alcohol consumption and outcome can be assumed. Conclusions: Future research on alcohol-related health consequences should focus on standardization of exposure measures and take into consideration both average volume of consumption and patterns of drinking.

How stable is the risk curve between alcohol and all-cause mortality and what factors influence the shape? A precision-weighted hierarchical meta-analysis

Objective: To determine the influence of six determining variables on the shape of the risk curve between alcohol and all-cause mortality. Methods: Data: Based on a systematic search with clear inclusion criteria, all articles on alcohol and all-cause mortality until 2000 were included. Statistical methods: Precision-weighted pooling of relative risks (RRs); precision-weighted hierarchical analysis. Variables: For pooling: RRs for different categories of average volume of drinking, lifetime abstainers and ex-drinkers. For hierarchical analysis: on first level: consumption in grams of pure alcohol per day; on second level: length of follow-up time in months; per capita consumption; average age, proportion of abstainers, average volume of drinking, and variability of average volume of drinking at baseline. Outcomes measures: RR of former and current drinkers for all-cause mortality compared to abstainers. Results: The main hypotheses could be confirmed for males: Ex-drinkers had a higher mortality risk than lifetime abstainers; the higher and the more diverse the average volume of alcohol consumption, the wider the dip of the curve; the older the persons at baseline, the more pronounced the protective effect; and the longer the follow-up time, the less pronounced the protective effect. Except for average volume of drinking effects for females went in the same direction but with one exception did not reach significance. Conclusions: There are systematic influences on the shape of the risk curve between alcohol and all-cause mortality. The overall beneficial effect of light to moderate drinking remained under all scenarios, indicating a high validity of the overall shape despite the heterogeneity between studies.

Risky single‐occasion drinking: bingeing is not bingeing

AIMS To review the concept of binge drinking as a measure of risky single occasion drinking (RSOD), to illustrate its differential impact on selected health outcomes and to identify research gaps. METHODS Narrative literature review with focus on conceptual and methodological differences, trajectories of RSOD and effects of RSOD on fetal outcomes, coronary heart disease (CHD) and injuries. RESULTS Effects ascribed commonly to RSOD may often be the effects of an undifferentiated mixture of risky single occasions and regular heavy volume drinking, constituted by frequent, successive RSOD. This leads to the problem that additional risks due to RSOD are mis-specified and remain unidentified or underestimated in some cases, such as for injuries or CHD, but are probably overstated for some chronic consequences or for effects of maternal drinking on newborns. CONCLUSION A stronger focus should be placed upon methods that can differentiate the effects of RSOD from those due to frequent occasions of heavy drinking that result in heavy volume drinking.

Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the US example

BackgroundAlcohol consumption is a major risk factor in the global burden of disease, with overall volume of exposure as the principal underlying dimension. Two main sources of data on volume of alcohol exposure are available: surveys and per capita consumption derived from routine statistics such as taxation. As both sources have significant problems, this paper presents an approach that triangulates information from both sources into disaggregated estimates in line with the overall level of per capita consumption.MethodsA modeling approach was applied to the US using data from a large and representative survey, the National Epidemiologic Survey on Alcohol and Related Conditions. Different distributions (log-normal, gamma, Weibull) were used to model consumption among drinkers in subgroups defined by sex, age, and ethnicity. The gamma distribution was used to shift the fitted distributions in line with the overall volume as derived from per capita estimates. Implications for alcohol-attributable fractions were presented, using liver cirrhosis as an example.ResultsThe triangulation of survey data with aggregated per capita consumption data proved feasible and allowed for modeling of alcohol exposure disaggregated by sex, age, and ethnicity. These models can be used in combination with risk relations for burden of disease calculations. Sensitivity analyses showed that the gamma distribution chosen yielded very similar results in terms of fit and alcohol-attributable mortality as the other tested distributions.ConclusionsModeling alcohol consumption via the gamma distribution was feasible. To further refine this approach, research should focus on the main assumptions underlying the approach to explore differences between volume estimates derived from surveys and per capita consumption figures.

Steps towards Constructing a Global Comparative Risk Analysis for Alcohol Consumption: Determining Indicators and Empirical Weights for Patterns of Drinking, Deciding about Theoretical Minimum, and Dealing with Different Consequences

In order to conduct a comparative risk analysis for alcohol within the Global Burden of Disease Study (GBD 2000), several questions had to be answered. (1) What are the appropriate dimensions for alcohol consumption and how can they be categorized? The average volume of alcohol and patterns of drinking were selected as dimensions. Both dimensions could be looked upon as continuous but were categorized for practical purposes. The average volume of drinking was categorized into the following categories: abstention; drinking 1 (>0–19.99 g pure alcohol daily for females, >0–39.99 g for males); drinking 2 (20–39.99 g for females, 40–59.99 g for males), and drinking 3 (≧40 g for females, ≧60 g for males). Patterns of drinking were categorized into four levels of detrimental impact based on an optimal scaling analysis of key informant ratings. (2) What is the theoretical minimum for both dimensions? A pattern of regular light drinking (at most 1 drink every day) was selected as theoretical minimum for established market economies for all people above age 45. For all other regions and age groups, the theoretical minimum was set to zero. Potential problems and uncertainties with this selection are discussed. (3) What are the health outcomes for alcohol and how do they relate to the dimensions? Overall, more than 60 disease conditions were identified as being related to alcohol consumption. Most chronic conditions seem to be related to volume only (exceptions are coronary heart disease and ischemic stroke), and most acute conditions seem to be related to volume and patterns. In addition, using methodology based on aggregate data, patterns were relevant for attributing harms for men but not women.

Global alcohol exposure estimates by country, territory and region for 2005—a contribution to the Comparative Risk Assessment for the 2010 Global Burden of Disease Study

AIMS This study aimed to estimate the prevalence of life-time abstainers, former drinkers and current drinkers, adult per-capita consumption of alcohol and pattern of drinking scores, by country and Global Burden of Disease region for 2005, and to forecast these indicators for 2010. DESIGN Statistical modelling based on survey data and routine statistics. SETTING AND PARTICIPANTS A total of 241 countries and territories. MEASUREMENTS Per-capita consumption data were obtained with the help of the World Health Organizations Global Information System on Alcohol and Health. Drinking status data were obtained from Gender, Alcohol and Culture: An International Study, the STEPwise approach to Surveillance study, the World Health Survey/Multi-Country Study and other surveys. Consumption and drinking status data were triangulated to estimate alcohol consumption across multiple categories. FINDINGS In 2005 adult per-capita annual consumption of alcohol was 6.1 litres, with 1.7 litres stemming from unrecorded consumption; 17.1 litres of alcohol were consumed per drinker, 45.8% of all adults were life-time abstainers, 13.6% were former drinkers and 40.6% were current drinkers. Life-time abstention was most prevalent in North Africa/Middle East and South Asia. Eastern Europe and Southern sub-Saharan Africa had the most detrimental pattern of drinking scores, while drinkers in Europe (Eastern and Central) and sub-Saharan Africa (Southern and West) consumed the most alcohol. CONCLUSIONS Just over 40% of the worlds adult population consumes alcohol and the average consumption per drinker is 17.1 litres per year. However, the prevalence of abstention, level of alcohol consumption and patterns of drinking vary widely across regions of the world.