Alcoholic beverage types consumed by population subgroups in the United States: Implications for alcohol policy to address health disparities.

INTRODUCTION: We aimed to identify alcoholic beverage types more likely to be consumed by demographic subgroups with greater alcohol-related health risk than others, mainly individuals with low socio-economic status, racial/ethnic minority status and high drinking levels. METHODS: Fractional logit modelling was performed using a nationally representative sample of US adult drinkers (analytic N = 37,657) from the National Epidemiologic Survey on Alcohol and Related Conditions Waves 2 (2004-2005) and 3 (2012-2013). The outcomes were the proportions of pure alcohol consumed as beer, wine, liquor and coolers (defined as wine-/malt-/liquor-based coolers, hard lemonade, hard cider and any prepackaged cocktails of alcohol and mixer). RESULTS: Adults with lower education and low or medium income were more likely to drink beer, liquor and coolers, while those with a 4-year college/advanced degree and those with high income preferred wine. Excepting Asian adults, racial/ethnic minority adults were more likely to drink beer (Hispanics) and liquor (Blacks), compared with White adults. High- or very-high-level drinkers were more likely to consume liquor and beer and less likely to consume wine (and coolers), compared with low-level drinkers. High-level and very-high-level drinkers, who were less than 10% of all drinkers, consumed over half of the total volume of beer, liquor and coolers consumed by all adults. DISCUSSION AND CONCLUSIONS: Individuals with low socio-economic status, racial/ethnic minority status or high drinking level prefer liquor and beer. As alcohol taxes, sales and marketing practices all are beverage-specific, targeted approaches to reduce consumption of these beverages, particularly among individuals with these profiles, are warranted.

Can lifestyle factors explain racial and ethnic inequalities in all-cause mortality among US adults?

BACKGROUND: Racial and ethnic inequalities in all-cause mortality exist, and individual-level lifestyle factors have been proposed to contribute to these inequalities. In this study, we evaluate the extent to which the association between race and ethnicity and all-cause mortality can be explained by differences in the exposure and vulnerability to harmful effects of different lifestyle factors. METHODS: The 1997-2014 cross-sectional, annual US National Health Interview Survey (NHIS) linked to the 2015 National Death Index was used. NHIS reported on race and ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic/Latinx), lifestyle factors (alcohol use, smoking, body mass index, physical activity), and covariates (sex, age, education, marital status, survey year). Causal mediation using an additive hazard and marginal structural approach was used. RESULTS: 465,073 adults (18-85 years) were followed 8.9 years (SD: 5.3); 49,804 deaths were observed. Relative to White adults, Black adults experienced 21.7 (men; 95%CI: 19.9, 23.5) and 11.5 (women; 95%CI: 10.1, 12.9) additional deaths per 10,000 person-years whereas Hispanic/Latinx women experienced 9.3 (95%CI: 8.1, 10.5) fewer deaths per 10,000 person-years; no statistically significant differences were identified between White and Hispanic/Latinx men. Notably, these differences in mortality were partially explained by both differential exposure and differential vulnerability to the lifestyle factors among Black women, while different effects of individual lifestyle factors canceled each other out among Black men and Hispanic/Latinx women. CONCLUSIONS: Lifestyle factors provide some explanation for racial and ethnic inequalities in all-cause mortality. Greater attention to structural, life course, healthcare, and other factors is needed to understand determinants of inequalities in mortality and to advance health equity.

Who benefits from alcohol screening and brief intervention? A mini-review on socioeconomic inequalities with a focus on evidence from the United States.

Alcohol-attributable mortality contributes to growing health inequalities. Addressing hazardous alcohol use and alcohol use disorders through alcohol screening and brief intervention is therefore a promising public health strategy to improve health equity. In this narrative mini-review, we discuss the extent to which socioeconomic differences exist in the alcohol screening and brief intervention cascade, highlighting the example of the United States. We have searched PubMed to identify and summarize relevant literature addressing socioeconomic inequalities in (a) accessing and affording healthcare, (b) receiving alcohol screenings, and/or (c) receiving brief interventions, focusing predominantly on literature from the Unites States. We found evidence for income-related inequalities in access to healthcare in the United States, partly due to inadequate health insurance coverage for individuals with low socioeconomic status. Alcohol screening coverage appears to be generally very low, as is the probability of receiving a brief intervention when indicated. However, research suggests that the latter is more likely to be provided to individuals with low socioeconomic status than those with high socioeconomic status. Individuals with low socioeconomic status also tend to benefit more from brief interventions, showing greater reductions in their alcohol use. Once access to and affordability of healthcare is ensured and high coverage of alcohol screening is achieved for all, alcohol screening and brief interventions have the potential to enhance health equity by reducing alcohol consumption and alcohol-related health harms.

Can lifestyle factors explain racial and ethnic inequalities in all-cause mortality among US adults?

Background: Racial and ethnic inequalities in all-cause mortality exist, and individual-level lifestyle factors have been proposed to contribute to these inequalities. In this study, we evaluate the extent to which the association between race and ethnicity and all-cause mortality can be explained by differences in the exposure and vulnerability to harmful effects of different lifestyle factors. Methods: The 1997-2014 cross-sectional, annual US National Health Interview Survey (NHIS) linked to the 2015 National Death Index was used. NHIS reported on race and ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic/Latinx), lifestyle factors (alcohol use, smoking, body mass index, physical inactivity), and covariates (sex, age, education, marital status, survey year). Causal mediation using an additive hazard and marginal structural approach was used. Results: 465,073 adults (18-85 years) were followed 8.9 years (SD:5.3); 49,804 deaths were observed. Relative to White adults, Black adults experienced 21.7 (men; 95%CI: 19.9, 23.5) and 11.5 (women; 95%CI: 10.1, 12.9) additional deaths per 10,000 person-years whereas Hispanic/Latinx women experienced 9.3 (95%CI: 8.1, 10.5) fewer deaths per 10,000 person-years; no statistically significant differences were identified between White and Hispanic/Latinx men. Notably, these differences in mortality were partially explained by both differential exposure and differential vulnerability to these lifestyle factors among Black women, while different effects of individual lifestyle factors canceled each other out among Black men and Hispanic/Latinx women. Conclusions: Lifestyle factors provide some explanation for racial and ethnic inequalities in all-cause mortality. Greater attention to structural, life course, healthcare, and other factors is needed to understand determinants of inequalities in mortality and advance health equity.

Simulation of Alcohol Control Policies for Health Equity (SIMAH) Project: Study Design and First Results.

Since about 2010, life expectancy at birth in the United States has stagnated and begun to decline, with concurrent increases in the socioeconomic divide in life expectancy. The Simulation of Alcohol Control Policies for Health Equity (SIMAH) Project uses a novel microsimulation approach to investigate the extent to which alcohol use, socioeconomic status (SES), and race/ethnicity contribute to unequal developments in US life expectancy and how alcohol control interventions could reduce such inequalities. Representative, secondary data from several sources will be integrated into one coherent, dynamic microsimulation to model life-course changes in SES and alcohol use and cause-specific mortality attributable to alcohol use by SES, race/ethnicity, age, and sex. Markov models will be used to inform transition intensities between levels of SES and drinking patterns. The model will be used to compare a baseline scenario with multiple counterfactual intervention scenarios. The preliminary results indicate that the crucial microsimulation component provides a good fit to observed demographic changes in the population, providing a robust baseline model for further simulation work. By demonstrating the feasibility of this novel approach, the SIMAH Project promises to offer superior integration of relevant empirical evidence to inform public health policy for a more equitable future.

Trends in mortality from alcohol, opioid, and combined alcohol and opioid poisonings by sex, educational attainment, and race and ethnicity for the United States 2000-2019.

BACKGROUND: The ongoing opioid epidemic and increases in alcohol-related mortality are key public health concerns in the USA, with well-documented inequalities in the degree to which groups with low and high education are affected. This study aimed to quantify disparities over time between educational and racial and ethnic groups in sex-specific mortality rates for opioid, alcohol, and combined alcohol and opioid poisonings in the USA. METHODS: The 2000-2019 Multiple Cause of Death Files from the National Vital Statistics System (NVSS) were used alongside population counts from the Current Population Survey 2000-2019. Alcohol, opioid, and combined alcohol and opioid poisonings were assigned using ICD-10 codes. Sex-stratified generalized least square regression models quantified differences between educational and racial and ethnic groups and changes in educational inequalities over time. RESULTS: Between 2000 and 2019, there was a 6.4-fold increase in opioid poisoning deaths, a 4.6-fold increase in combined alcohol and opioid poisoning deaths, and a 2.1-fold increase in alcohol poisoning deaths. Educational inequalities were observed for all poisoning outcomes, increasing over time for opioid-only and combined alcohol and opioid mortality. For non-Hispanic White Americans, the largest educational inequalities were observed for opioid poisonings and rates were 7.5 (men) and 7.2 (women) times higher in low compared to high education groups. Combined alcohol and opioid poisonings had larger educational inequalities for non-Hispanic Black men and women (relative to non-Hispanic White), with rates 8.9 (men) and 10.9 (women) times higher in low compared to high education groups. CONCLUSIONS: For all types of poisoning, our analysis indicates wide and increasing gaps between those with low and high education with the largest inequalities observed for opioid-involved poisonings for non-Hispanic Black and White men and women. This study highlights population sub-groups such as individuals with low education who may be at the highest risk of increasing mortality from combined alcohol and opioid poisonings. Thereby the findings are crucial for the development of targeted public health interventions to reduce poisoning mortality and the socioeconomic inequalities related to it.

Alcohol-Attributable Deaths Help Drive Growing Socioeconomic Inequalities In US Life Expectancy, 2000-18.

Socioeconomic gaps in life expectancy have widened substantially in the United States since 2000. Yet the contribution of specific causes to these growing disparities remains unknown. We used death records from the National Vital Statistics System and population data from Current Population Surveys to quantify the contribution of alcohol-attributable causes of death to changes in US life expectancy between 2000 and 2018 by sex and socioeconomic status (as measured by educational attainment). During the study period, the gap in life expectancy between people with low (high school diploma or less) compared with high (college degree) levels of education increased by three years among men and five years among women. Between 2000 and 2010 declines in cardiovascular disease mortality among people with high education made major contributions to growing inequalities. In contrast, between 2010 and 2018 deaths from a cause with an alcohol-attributable fraction of 20 percent or more were a dominant driver of socioeconomic divergence. Increased efforts to implement cost-effective alcohol control policies will be essential for reducing health disparities.

The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries.

BACKGROUND: Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals' socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-income countries. We investigated the association between individual and household level socioeconomic status, and alcohol drinking habits in these settings. METHODS: In this pooled analysis of individual-level data, we used available nationally representative surveys-mainly WHO Stepwise Approach to Surveillance surveys-conducted in 55 low-income and middle-income countries between 2005 and 2017 reporting on alcohol use. Surveys from participants aged 15 years or older were included. Logistic regression models controlling for age, country, and survey year stratified by sex and country income groups were used to investigate associations between two indicators of socioeconomic status (individual educational attainment and household wealth) and alcohol use (current drinking and HED amongst current drinkers). FINDINGS: Surveys from 336 287 participants were included in the analysis. Among males, the highest prevalence of both current drinking and HED was found in lower-middle-income countries (L-MICs; current drinking 49·9% [95% CI 48·7-51·2] and HED 63·3% [61·0-65·7]). Among females, the prevalence of current drinking was highest in upper-middle-income countries (U-MIC; 29·5% [26·1-33·2]), and the prevalence of HED was highest in low-income countries (LICs; 36·8% [33·6-40·2]). Clear gradients in the prevalence of current drinking were observed across all country income groups, with a higher prevalence among participants with high socioeconomic status. However, in U-MICs, current drinkers with low socioeconomic status were more likely to engage in HED than participants with high socioeconomic status; the opposite was observed in LICs, and no association between socioeconomic status and HED was found in L-MICs. INTERPRETATION: The findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs. FUNDING: Deutsche Forschungsgemeinschaft and the National Center for Advancing Translational Sciences of the US National Institutes of Health.

Educational Attainment and Lifestyle Risk Factors Associated With All-Cause Mortality in the US.

IMPORTANCE: The US has experienced increasing socioeconomic inequalities and stagnating life expectancy. Past studies have not disentangled 2 mechanisms thought to underlie socioeconomic inequalities in health, differential exposure and differential vulnerability, that have different policy implications. OBJECTIVE: To evaluate the extent to which the association between socioeconomic status (SES) and all-cause mortality can be decomposed into a direct effect of SES, indirect effects through lifestyle factors (differential exposure), and joint effects of SES with lifestyle factors (differential vulnerability). DESIGN SETTING AND PARTICIPANTS: This nationwide, population-based cohort study used the cross-sectional US National Health Interview Survey linked to the National Death Index. Civilian, noninstitutionalized US adults aged 25 to 84 years were included from the 1997 to 2014 National Health Interview Survey and were followed up until December 31, 2015. Data were analyzed from May 1 to October 31, 2021. A causal mediation model using an additive hazard and marginal structural approach was used. EXPOSURES: Both SES (operationalized as educational attainment) and lifestyle risk factors (smoking, alcohol use, obesity, and physical inactivity) were assessed using self-reported questionnaires. MAIN OUTCOMES AND MEASURES: Time to all-cause mortality. RESULTS: Participants included 415 764 adults (mean [SD] age, 49.4 [15.8] years; 55% women; 64% non-Hispanic White), of whom 45% had low educational attainment and 27% had high educational attainment. Participants were followed up for a mean (SD) of 8.8 (5.2) years during which 49 096 deaths (12%) were observed. Low educational attainment (compared with high) was associated with 83.6 (men; 95% CI, 81.8-85.5) and 54.8 (women; 95% CI, 53.4-56.2) additional deaths per 10 000 person-years, of which 66% (men) and 80% (women) were explained by lifestyle factors. Inequalities in mortality were primarily a result of greater exposure and clustering of unhealthy lifestyle factors among low SES groups; with some exceptions among women, little evidence of differential vulnerability was identified. CONCLUSIONS AND RELEVANCE: In this cohort study, differential exposure to lifestyle risk factors was an important mediator of socioeconomic inequalities in mortality. Public health interventions are needed, particularly among low SES groups, to address smoking, physical inactivity, alcohol use, and the socioenvironmental contexts within which these risk factors develop.

Digital Assessment Tools Using Animation Features to Quantify Alcohol Consumption: Systematic App Store and Literature Review.

BACKGROUND: Accurate and user-friendly assessment tools for quantifying alcohol consumption are a prerequisite for effective interventions to reduce alcohol-related harm. Digital assessment tools (DATs) that allow the description of consumed alcoholic drinks through animation features may facilitate more accurate reporting than conventional approaches. OBJECTIVE: This review aims to identify and characterize freely available DATs in English or Russian that use animation features to support the quantitative assessment of alcohol consumption (alcohol DATs) and determine the extent to which such tools have been scientifically evaluated in terms of feasibility, acceptability, and validity. METHODS: Systematic English and Russian searches were conducted in iOS and Android app stores and via the Google search engine. Information on the background and content of eligible DATs was obtained from app store descriptions, websites, and test completions. A systematic literature review was conducted in Embase, MEDLINE, PsycINFO, and Web of Science to identify English-language studies reporting the feasibility, acceptability, and validity of animation-using alcohol DATs. Where possible, the evaluated DATs were accessed and assessed. Owing to the high heterogeneity of study designs, results were synthesized narratively. RESULTS: We identified 22 eligible alcohol DATs in English, 3 (14%) of which were also available in Russian. More than 95% (21/22) of tools allowed the choice of a beverage type from a visually displayed selection. In addition, 36% (8/22) of tools enabled the choice of a drinking vessel. Only 9% (2/22) of tools allowed the simulated interactive pouring of a drink. For none of the tools published evaluation studies were identified in the literature review. The systematic literature review identified 5 exploratory studies evaluating the feasibility, acceptability, and validity of 4 animation-using alcohol DATs, 1 (25%) of which was available in the searched app stores. The evaluated tools reached moderate to high scores on user rating scales and showed fair to high convergent validity when compared with established assessment methods. CONCLUSIONS: Animation-using alcohol DATs are available in app stores and on the web. However, they often use nondynamic features and lack scientific background information. Explorative study data suggest that such tools might enable the user-friendly and valid assessment of alcohol consumption and could thus serve as a building block in the reduction of alcohol-attributable health burden worldwide. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020172825; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172825.

Pilot study to evaluate usability and acceptability of the 'Animated Alcohol Assessment Tool' in Russian primary healthcare.

BACKGROUND AND AIMS: Accurate and user-friendly assessment tools quantifying alcohol consumption are a prerequisite to effective prevention and treatment programmes, including Screening and Brief Intervention. Digital tools offer new potential in this field. We developed the 'Animated Alcohol Assessment Tool' (AAA-Tool), a mobile app providing an interactive version of the World Health Organization's Alcohol Use Disorders Identification Test (AUDIT) that facilitates the description of individual alcohol consumption via culturally informed animation features. This pilot study evaluated the Russia-specific version of the Animated Alcohol Assessment Tool with regard to (1) its usability and acceptability in a primary healthcare setting, (2) the plausibility of its alcohol consumption assessment results and (3) the adequacy of its Russia-specific vessel and beverage selection. METHODS: Convenience samples of 55 patients (47% female) and 15 healthcare practitioners (80% female) in 2 Russian primary healthcare facilities self-administered the Animated Alcohol Assessment Tool and rated their experience on the Mobile Application Rating Scale - User Version. Usage data was automatically collected during app usage, and additional feedback on regional content was elicited in semi-structured interviews. RESULTS: On average, patients completed the Animated Alcohol Assessment Tool in 6:38 min (SD = 2.49, range = 3.00-17.16). User satisfaction was good, with all subscale Mobile Application Rating Scale - User Version scores averaging >3 out of 5 points. A majority of patients (53%) and practitioners (93%) would recommend the tool to 'many people' or 'everyone'. Assessed alcohol consumption was plausible, with a low number (14%) of logically impossible entries. Most patients reported the Animated Alcohol Assessment Tool to reflect all vessels (78%) and all beverages (71%) they typically used. CONCLUSION: High acceptability ratings by patients and healthcare practitioners, acceptable completion time, plausible alcohol usage assessment results and perceived adequacy of region-specific content underline the Animated Alcohol Assessment Tool's potential to provide a novel approach to alcohol assessment in primary healthcare. After its validation, the Animated Alcohol Assessment Tool might contribute to reducing alcohol-related harm by facilitating Screening and Brief Intervention implementation in Russia and beyond.

The dose-response relationship between socioeconomic deprivation and alcohol-attributable mortality risk-a systematic review and meta-analysis.

BACKGROUND: Individuals with low socioeconomic status (SES) experience a higher risk of mortality, in general, and alcohol-attributable mortality in particular. However, a knowledge gap exists concerning the dose-response relationships between the level of socioeconomic deprivation and the alcohol-attributable mortality risk. METHODS: We conducted a systematic literature search in August of 2020 to update a previous systematic review that included studies published up until February of 2013. Quantitative studies reporting on socioeconomic inequality in alcohol-attributable mortality among the general adult population were included. We used random-effects dose-response meta-analyses to investigate the relationship between the level of socioeconomic deprivation and the relative alcohol-attributable risk (RR), by sex and indicator of SES (education, income, and occupation). RESULTS: We identified 25 eligible studies, comprising about 241 million women and 230 million men, among whom there were about 75,200 and 308,400 alcohol-attributable deaths, respectively. A dose-response relationship between the level of socioeconomic deprivation and the RR was found for all indicators of SES. The sharpest and non-linear increase in the RR of dying from an alcohol-attributable cause of death with increasing levels of socioeconomic deprivation was observed for education, where, compared to the most educated individuals, individuals at percentiles with decreasing education had the following RR of dying: women: 25th: 2.09 [95% CI 1.70-2.59], 50th: 3.43 [2.67-4.49], 75th: 4.43 [3.62-5.50], 100th: 4.50 [3.26-6.40]; men: 25th: 2.34 [1.98-2.76], 50th: 4.22 [3.38-5.24], 75th: 5.87 [4.75-7.10], 100th: 6.28 [4.89-8.07]. CONCLUSIONS: The findings of this study show that individuals along the entire continuum of SES are exposed to increased alcohol-attributable mortality risk. Differences in the dose-response relationship can guide priorities in targeting public health initiatives.

Socioeconomic inequality in the risk of intentional injuries among adolescents: a cross-sectional analysis of 89 countries.

INTRODUCTION: In 2015, the elimination of hunger worldwide by 2030 was declared by the United Nations as a Sustainable Development Goal. However, food insecurity remains pervasive, contributing to socioeconomic health inequalities. The overall objective was to investigate the relationship between food insecurity and intentional injuries among adolescents. METHODS: Individual-level data from the Global School-based Student Health Survey from 89 countries were used (370 719 adolescents, aged 12-17 years). Multilevel logistic regressions were used to examine the sex-specific association between the level of food insecurity (none, medium and high) and intentional injuries (interpersonal violence and suicide attempts), accounting for the clustering of observations within surveys. Random-effects meta-analyses were used to analyse dose-response relationships. RESULTS: Medium and high food insecurity were associated with increased odds of reporting an injury from interpersonal violence among both sexes. A positive dose-response relationship was found, where each level increase in food insecurity was associated with a 30% increase in the odds of an injury due to interpersonal violence among boys (1.30; 95% CI 1.26 to 1.34) and a 50% increase among girls (1.53; 95% CI 1.46-1.62). The odds for suicide attempts increased by 30% for both sexes with each level increase in food insecurity (boys: 1.29; 95% CI 1.25-1.32; girls: 1.29; 95% CI 1.25-1.32). DISCUSSION: The findings indicate that socioeconomic inequalities exist in the risk of intentional injuries among adolescents. Although additional studies are needed to establish causality, the present study suggests that the amelioration of food insecurity could have implications beyond the prevention of its direct consequences.

The role of alcohol use and drinking patterns in socioeconomic inequalities in mortality: a systematic review.

BACKGROUND: Individuals with low socioeconomic status (SES) experience disproportionately greater alcohol-attributable health harm than individuals with high SES from similar or lower amounts of alcohol consumption. Our aim was to provide an update of the current evidence for the role of alcohol use and drinking patterns in socioeconomic inequalities in mortality, as well as the effect modification or interaction effects between SES and alcohol use, as two potential explanations of this so-called alcohol-harm paradox. METHODS: We did a systematic review, searching Embase, Medline, PsycINFO, and Web of Science (published between Jan 1, 2013, and June 30, 2019) for studies reporting alcohol consumption, SES, and mortality. Observational, quantitative studies of the general adult population (aged ≥15 years) with a longitudinal study design were included. Two outcome measures were extracted: first, the proportion of socioeconomic inequalities in mortality explained by alcohol use; and second, the effect modification or interaction between SES and alcohol use regarding mortality risks. This study is registered with PROSPERO (CRD42019140279). FINDINGS: Of 1941 records identified, ten met the inclusion criteria. The included studies contained more than 400 000 adults, more than 30 000 deaths from all causes, and more than 3000 100% alcohol-attributable events. Alcohol use explained up to 27% of the socioeconomic inequalities in mortality. The proportion of socioeconomic inequalities explained systematically differed by drinking pattern, with heavy episodic drinking having a potentially significant explanatory value. Although scarce, there was some evidence of effect modification or interaction between SES and alcohol use. INTERPRETATION: To reduce socioeconomic inequalities in mortality, addressing heavy episodic drinking in particular, rather than alcohol use in general, is worth exploring as a public health strategy. FUNDING: Canadian Institutes of Health Research.

National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study.

BACKGROUND: Alcohol use has increased globally, with varying trends in different parts of the world. This study investigates gender, age, and geographical differences in the alcohol-attributable burden of disease from 2000 to 2016. METHODS: This comparative risk assessment study estimated the alcohol-attributable burden of disease. Population-attributable fractions (PAFs) were estimated by combining alcohol exposure data obtained from production and taxation statistics and from national surveys with corresponding relative risks obtained from meta-analyses and cohort studies. Mortality and morbidity data were obtained from the WHO Global Health Estimates, population data were obtained from the UN Population Division, and human development index (HDI) data were obtained from the UN Development Programme. Uncertainty intervals (UIs) were estimated using a Monte Carlo-like approach. FINDINGS: Globally, we estimated that there were 3·0 million (95% UI 2·6-3·6) alcohol-attributable deaths and 131·4 million (119·4-154·4) disability-adjusted life-years (DALYs) in 2016, corresponding to 5·3% (4·6-6·3) of all deaths and 5·0% (4·6-5·9) of all DALYs. Alcohol use was a major risk factor for communicable, maternal, perinatal, and nutritional diseases (PAF of 3·3% [1·9-5·6]), non-communicable diseases (4·3% [3·6-5·1]), and injury (17·7% [14·3-23·0]) deaths. The alcohol-attributable burden of disease was higher among men than among women, and the alcohol-attributable age-standardised burden of disease was highest in the eastern Europe and western, southern, and central sub-Saharan Africa regions, and in countries with low HDIs. 52·4% of all alcohol-attributable deaths occurred in people younger than 60 years. INTERPRETATION: As a leading risk factor for the burden of disease, alcohol use disproportionately affects people in low HDI countries and young people. Given the variations in the alcohol-attributable burden of disease, cost-effective local and national policy measures that can reduce alcohol use and the resulting burden of disease are needed, especially in low-income and middle-income countries. FUNDING: None.

Alcohol use disorders.

Alcohol use disorders consist of disorders characterised by compulsive heavy alcohol use and loss of control over alcohol intake. Alcohol use disorders are some of the most prevalent mental disorders globally, especially in high-income and upper-middle-income countries; and are associated with high mortality and burden of disease, mainly due to medical consequences, such as liver cirrhosis or injury. Despite their high prevalence, alcohol use disorders are undertreated partly because of the high stigma associated with them, but also because of insufficient systematic screening in primary health care, although effective and cost-effective psychosocial and pharmacological interventions do exist. Primary health care should be responsible for most treatment, with routine screening for alcohol use, and the provision of a staggered treatment response, from brief advice to pharmacological treatment. Clinical interventions for these disorders should be embedded in a supportive environment, which can be bolstered by the creation of alcohol control policies aimed at reducing the overall level of consumption.

The global proportion and volume of unrecorded alcohol in 2015.

BACKGROUND: Alcohol consumption is associated with elevated risks of disease and injury, and the best indicator of the level of consumption in a country is total alcohol per capita (APC) consumption among adults which comprises recorded consumption and unrecorded consumption. While recorded consumption can be assessed with small measurement bias via taxation or other governmental records, unrecorded consumption is more difficult to assess. The objectives of this study were to estimate the country-specific proportion and volume of unrecorded APC in 2015, to identify main sources of unrecorded alcohol and to assess to what extent experts perceive unrecorded alcohol as a public health, social, and financial problem. METHODS: Estimates of unrecorded APC were based on a multilevel fractional response regression model using data from World Health Organization's (WHO) STEPwise approach to surveillance surveys (16 countries, 66 188 participants), estimates from the routine WHO reporting on key indicators of alcohol use (189 countries), and a nominal group expert assessment (42 countries, 129 experts). Expert assessments also included data on the sources of unrecorded alcohol and the perception of unrecorded alcohol as a public health, social, and financial problem. RESULTS: The volume of global unrecorded APC was 1.6 L pure alcohol, representing 25% of the total APC. The volume of unrecorded APC was highest in Europe (2.1 L per capita), while the proportion of unrecorded APC was highest in the WHO Eastern Mediterranean region (57% of the total alcohol). In countries with available data, homemade alcohol was identified as a major source of unrecorded alcohol. The majority of experts considered unrecorded alcohol to be a public health (62%), social (60%), and financial problem (54%). CONCLUSIONS: High volumes of unrecorded alcohol are consumed globally; however, the volumes consumed and the sources of the unrecorded alcohol exhibit large geographical variation.

A "buck a beer," but at what cost to public health?

Alcohol use leads to a substantial number of hospitalizations, and to increased health and social harms as well as economic costs in Ontario and across Canada. The effects of alcohol price changes on consumption and resulting harms have been firmly established; changes in the minimum price of alcohol have the greatest effect on consumption among people who for reasons of affordability consume low-priced alcoholic beverages, typically adolescents, people with lower socio-economic status, and people with harmful alcohol use. Decreases in inflation-adjusted minimum pricing in British Columbia from 2002 to 2006 have been associated with increases in deaths wholly attributable to alcohol. Furthermore, decreases in alcohol prices have been previously associated with increases in drink-driving, decreases in life expectancy, increases in road traffic injuries, violence, and alcohol poisonings, and long-term increases in deaths from infectious diseases, circulatory diseases, and digestive diseases. Based on the findings of previous studies, lowering the cost of alcohol will negatively impact the health of Ontarians and further strain a healthcare system with limited resources. Accordingly, Ontario should be strengthening alcohol policies to improve public health, including raising the minimum price of alcohol, rather than weakening alcohol policies.