Global mortality attributable to alcoholic cardiomyopathy

Introduction: Globally, around 2.6 billion people have consumed alcohol in 2017. In the same year, nearly 3 million or 5% of all deaths were attributable to alcohol consumption, the majority of which were non-communicable diseases, such as cancer, digestive and cardiovascular diseases. Chronic heavy alcohol consumption in particular causes harm to the cardiovascular system and is linked to an elevated risk on the occurrence of ischemic heart diseases and cardiomyopathies. The latter constitutes a heterogeneous group of cardiovascular diseases, which can generally be characterized by a weakened heart muscle. The causal link between chronic heavy alcohol consumption and cardiomyopathy has long been recognized, with the Tenth Revision of the International Classification of Diseases (ICD-10) listing alcoholic cardiomyopathy (ACM) as a fully alcohol-attributable diagnosis. For a few, predominately high-income countries, civil registries provide valuable information of ACM mortality. However, for the majority of countries and global population, the cardiomyopathy burden attributable to alcohol consumption needs to estimated. Established methods for estimating alcohol-attributable fractions (AAF), i.e. proportion of an outcome which could be avoided in a scenario of zero alcohol consumption, could not be applied for cardiomyopathy as the link between alcohol consumption levels and risk of cardiomyopathy could not be specified. Accordingly, a global assessment of the contribution of alcohol consumption to the disease burden from cardiomyopathy was lacking. Aims and objectives: First, to develop methods for estimating the contribution of alcohol consumption to cardiomyopathy that can be used globally (study I). Second, to apply the method developed in study I to estimate the global mortality from ACM (study II). Third, to assess differences between this method and an alternative method for estimating the contribution of alcohol consumption to cardiomyopathy proposed during pursuit of these aims (study III). Design: Statistical modelling study with country-level data as unit of analyses. Study I. Based on mortality data from civil registries, the proportion of deaths from ACM among deaths from any cardiomyopathy (=AAF) was used as proxy for the link between alcohol consumption and cardiomyopathy. To generalize this link to countries without available civil registry data, associations of population alcohol exposure and registered AAF were established. Cardiomyopathy deaths that are attributable to alcohol use were quantified in those countries with available registry data. Study II. For countries without available civil registry data, ACM mortality was estimated using population alcohol exposure data based on the methods from study I. As a result, national, regional and global estimates of the mortality attributable to ACM were obtained for the year 2015. Study III. In the alternative method developed by the Global Burden of Disease (GBD) study team, the contribution of alcohol consumption to cardiomyopathy was estimated taking into account that actual ACM deaths may be incorrectly coded as so-called garbage codes (disease codes that do not accurately describe the underlying cause of death). In the alternative method, garbage codes were redistributed to both cardiomyopathy and ACM using statistical procedures. The underlying assumptions for the redistribution of garbage codes were examined by comparing registered and estimated ACM mortality data taking into account the distribution of alcohol exposure. Data sources: Data on population alcohol exposure (alcohol per capita consumption, prevalence of heavy episodic drinking, prevalence of alcohol use disorders) were sourced from publicly available World Health Organization (WHO) data bases. As outcome data, sex-specific mortality counts from different disease groups (ACM, any cardiomyopathy, and selected garbage codes) were obtained at the country level from three different sources: First, WHO mortality data base, which provide civil registry mortality data on nearly half of all member states, coded according to the ICD-10. Second and third, ‘Global Health Estimates’ and ‘GBD Results Tool’ data bases, which provide complete and consistent mortality estimates aggregated into larger disease groups for all WHO member states. Data on covariates were obtained from the United Nations and the World Bank. Statistical analyses: In study I, the dependent variable – AAF for cardiomyopathy – was calculated by dividing deaths from ACM by deaths from any cardiomyopathy, based on civil registry data from N=52 countries. Taking into account country-specific crude mortality rates of ACM, AAF were modeled in two-step sex-specific regression analyses using population alcohol exposure as covariate. AAF were estimated for the same set of N=52 countries, in addition to N=43 countries without civil registry data. Estimated AAF were compared to registered AAF available for N=52 countries. In study II, the global mortality of ACM was estimated by combining civil registry ACM mortality data for N=91 countries and estimated ACM mortality for N=99 countries without available civil registry data. For the latter set of countries, ACM mortality data were calculated by estimating AAF based on the methodology outlined in the first study and subsequently applied to all cardiomyopathy deaths. As a proxy for under-reporting of ACM in civil registries, estimated ACM deaths were compared to registered ACM deaths for N=91 countries. In study III, ACM mortality estimates from the GBD study were compared against registered ACM mortality data for N=77 countries, aiming to test underlying assumptions for redistribution of garbage-coded deaths in the alternative method. For this purpose, descriptive statistics and Pearson correlations were used to assess the association of estimated and registered deaths and to examine consistency of estimates with population alcohol exposure. Results: In study I, population alcohol exposure and ACM mortality were closely linked (spearman correlation=0.7), supporting the proposed modelling strategy. For N=95 countries, the AAF for cardiomyopathy was estimated at 6.9% (95% confidence interval (CI): 5.4-8.4%), indicating that one in 14 of all cardiomyopathy deaths were attributable to alcohol in the year 2013 or the last available year. The findings were robust, with 78% of all estimated AAF deviating less than 5% from registered AAF. In study II, it was estimated that 25,997 (95% CI: 17,385-49,096) persons died from ACM in 2015 globally, with 76.0% of ACM deaths being located in Russia. Globally, 6.3% (95% CI: 4.2-11.9%) of all deaths from cardiomyopathy were estimated to be caused by alcohol. Furthermore, indications of underreporting in civil registration mortality data were found, with two out of three global ACM deaths being possibly misclassified. In study III, findings suggested that only one in six ACM deaths were correctly coded in civil registries of N=77 countries. However, the algorithm accounting for misclassifications in the GBD study was not aligned with population alcohol exposure, which has led to implausibly high ACM mortality estimates for people aged 65 years or older. Specifically, registered and estimated ACM mortality rates diverged in the elderly, which was corroborated with decreasing correlations in these age groups. Conclusions: For countries without civil registry data, the contribution of alcohol consumption to mortality from cardiomyopathy could be quantified using population alcohol exposure and estimated mortality data for any cardiomyopathy. The proposed method was adapted by the WHO in 2018, allowing for a more complete picture of the alcohol-attributable global disease burden for nearly 200 countries. Notably, ACM mortality was hardly present in countries with low to moderate alcohol consumption levels, corroborating that ACM is the result of sustained and very high alcohol consumption levels. In civil registries, at least two out of three ACM deaths are misclassified, thus, presented mortality figures are likely underestimated. As with other alcohol-attributable diseases, misclassification of ACM mortality is a systematic phenomenon, which may be caused by low resources, lacking standards and severe stigma associated with alcohol use disorders. With transition from ICD-10 to ICD-11, new methods will be required as ACM will not remain a unique diagnosis in the new classificatory system. Future methods should account for mortality misclassifications by redistributing garbage codes while taking into consideration the distribution of alcohol exposure. Further, measures to reduce stigma may improve diagnostic accuracy for ACM and other alcohol-attributable diseases. This will not only improve public health statistics but also – and more importantly – improve health prospects of persons with heavy alcohol consumption.:Statement for a publication-based dissertation I Contents II List of tables IV List of figures V Abbreviations VI Abstract VII 1 Introduction 10 1.1 Global extent of alcohol use 10 1.2 Alcohol-attributable disease burden 11 1.3 Estimating the alcohol-attributable burden 12 1.4 Cardiomyopathy 18 1.5 Alcohol and cardiomyopathy 19 2 Aims and objectives 21 3 Study design and methodology 21 3.1 Study design 21 3.2 Data sources 22 4 Study I - Quantifying the global contribution of alcohol consumption to cardiomyopathy 25 4.1 Background 26 4.2 Methods 27 4.3 Results 32 4.4 Discussion 38 4.5 Conclusion 41 5 Study II - National, regional and global mortality due to alcoholic cardiomyopathy in 2015 42 5.1 Introduction 43 5.2 Methods 44 5.3 Results 45 5.4 Discussion 51 6 Study III - Mortality from alcoholic cardiomyopathy: Exploring the gap between estimated and civil registry data 57 6.1 Introduction 58 6.2 Experimental section 59 6.3 Results 62 6.4 Discussion 67 7 General discussion 72 7.1 Summary of the findings 72 7.2 Strengths and limitations 72 7.3 Implications for future research 75 7.4 Implications for alcohol policy 79 7.5 Outlook 80 7.6 Conclusion 81 8 References 83 9 Appendix A (study I) 97 10 Appendix B (study II) 99 10.1 Methods 99 10.2 Results 103 11 Appendix C (study III) 119 11.1 Methods 119 11.2 Results 124 12 Erklärung gemäß § 5 der Promotionsordnung 12

Alcohol consumption in India: a systematic review and modelling study for sub-national estimates of drinking patterns

Background and Aims: In India, alcohol per capita consumption (APC) has substantially increased over the past 2 decades. Although consumption does vary across the country, consistent state-level data are lacking. We aimed to identify all state-level alcohol exposure estimates since 2000 to (i) model consistent current drinking (CD) (12 months) prevalence estimates for all 36 states/union territories (UT) in 2019 and (ii) compare state-level CD trends with national-level APC trends. Design: A systematic review for studies on the Indian state-level prevalence of CD, lifetime abstinence (LA), alcohol use disorders (AUD) or the quantity of alcohol consumed among current drinkers (QU) was conducted. Subsequently, statistical modelling was applied. Setting: Data were collected and modelled for all Indian states/UTs. Participants: Studies since 2000 referring to the general adult population (≥15 years) of at least one Indian state/UT were eligible. The total sample size covered was 29 600 000 (males: females, 1:1.6). Measurements: Results on LA, AUD and QU were summarized descriptively. For (i) the state-, sex- and age-specific CD prevalence was estimated using random intercept fractional response models. For (ii) random intercept and slope models were performed. Findings: Of 2870 studies identified, 30 were retained for data extraction. LA, AUD and QU data were available for 31, 36 and 12 states/UTs, respectively. CD model estimates ranged from 6.4% (95% CI = 2.1%–18.1%; males) in Lakshadweep and 1.3% (95% CI = 0.7%–2.6%; females) in Delhi to 76.1% (95% CI = 68.1%–82.6%; males) and 63.7% (95% CI = 49.4%–75.7%; females) in Arunachal Pradesh. Over time, CD decreased in most states/UTs in the observed data, contradicting increasing national-level APC trends. Conclusions: Alcohol use (measured as consistent current drinking) in India has large regional variations, with alcohol consumption being most prevalent in the North-East, Chhattisgarh, Telangana, Himachal Pradesh, Punjab and Jharkhand

Alcohol Consumption Levels and Health Care Utilization in Germany: Results from the GEDA 2014/2015-EHIS Study

Abstract:Aims: Due to large inconsistencies in previous studies, it remains unclear how alcohol use is related to health care utilization. The aim of this study was to examine associations between alcohol drinking status with utilization of outpatient and inpatient health care services in Germany. Methodology: Survey data of the GEDA 2014/2015-EHIS study with n = 23,561 German adults were analyzed (response rate: 27 %). Respondents were categorized as lifetime abstainers, former drinkers, and non-weekly drinkers, as well as weekly low-risk drinkers and risky drinkers. Outpatient services included GP, specialist, and hospital visits; inpatient services included hospital overnight stays in the last 12 months. For both settings, binary logistic regression models were applied, adjusted for possible confounders. Results: For specialist visits, elevated odds were found among former drinkers (odds ratio (OR) = 1.93, 95 % confidence interval (95 % CI) = 1.50-2.49), non-weekly drinkers (OR = 1.24, 95 % CI = 1.05-1.47), weekly low-risk drinkers (OR = 1.39, 95 % CI = 1.17-1.67), and risky drinkers (OR = 1.28, 95 % CI = 1.04-1.57) compared to lifetime abstainers. In contrast, lower odds for inpatient service use were found among non-weekly drinkers (OR = 0.76, 95 % CI = 0.62-0.93), low-risk drinkers (OR = 0.66, 95 % CI = 0.53-0.81), and risky drinkers (OR = 0.65, 95 % CI = 0.51-0.84). No differences were observed for GP and outpatient hospital visits. Conclusions: While the increased odds of consulting a specialist are consistent with higher health care needs among former and current drinkers, the lower use of inpatient care among current drinkers is contrary to known health risks associated with alcohol consumption and evidence from hospitalized populations. The findings also highlight the need to differentiate between lifetime abstainers and former drinkers in their use of health services

The Impact of Raising Alcohol Taxes on Government Tax Revenue : Insights from Five European Countries

Publisher Copyright: © The Author(s) 2024.Background and Objective: Reducing the affordability of alcoholic beverages by increasing alcohol excise taxation can lead to a reduction in alcohol consumption but the impact on government alcohol excise tax revenue is poorly understood. This study aimed to (a) describe cross-country tax revenue variations and (b) investigate how changes in taxation were related to changes in government tax revenue, using data from Estonia, Germany, Latvia, Lithuania and Poland. Methods: For the population aged 15 years or older, we calculated the annual per capita alcohol excise tax revenue, total tax revenue, gross domestic product and alcohol consumption. In addition to descriptive analyses, joinpoint regressions were performed to identify whether changes in alcohol excise taxation were linked to changes in alcohol excise revenue since 1999. Results: In 2022, the per capita alcohol excise tax revenue was lowest in Germany (€44.2) and highest in Estonia (€218.4). In all countries, the alcohol excise tax revenue was mostly determined by spirit sales (57–72% of total alcohol tax revenue). During 2010–20, inflation-adjusted per capita alcohol excise tax revenues have declined in Germany (− 22.9%), Poland (− 19.1%) and Estonia (− 4.2%) and increased in Latvia (+ 56.8%) and Lithuania (+ 49.3%). In periods of policy non-action, alcohol consumption and tax revenue showed similar trends, but tax level increases were accompanied by increased revenue and stagnant or decreased consumption. Conclusions: Increasing alcohol taxation was not linked to decreased but increased government revenue. Policymakers can increase revenue and reduce alcohol consumption and harm by increasing alcohol taxes.Peer reviewe

Potenzielle Auswirkungen erhöhter Alkoholsteuern auf die alkoholbedingte Krankheitslast in Deutschland: Eine Modellierungsstudie

Hintergrund. Deutschland gehörte im Jahr 2019 zu den Ländern mit dem weltweit höchsten Pro-Kopf-Alkoholkonsum, welcher wesentlich zur Krankheitslast beiträgt. Fragestellung. In dieser Modellierungsstudie schätzen wir, wie viele alkoholbedingte inzidente Krankheits- sowie Todesfälle in Deutschland im Jahr 2019 hätten vermieden werden können, wenn die derzeitigen Verbrauchssteuern auf Alkohol um 20%, 50% und 100%erhöht worden wären. Methodik. Ausgangspunkt für die Modellierung sind die spezifischen Verbrauchssteuern auf alkoholische Getränke in Deutschland. Drei Szenarien wurden unter der Annahme, dass die resultierende Steuererhöhung vollständig in den Verkaufspreis übertragen wird, und unter Verwendung von getränkespezifischen Preiselastizitäten modelliert. Mittels des sich daraus ergebenden Rückgangs im jährlichen Pro-Kopf-Konsum und der krankheitsspezifischen Risikofunktionen wurde die vermeidbare alkoholbedingte Inzidenz bzw. Mortalität geschätzt. Berücksichtigt wurden alkoholbedingte Erkrankungen des Herz-Kreislauf- und Verdauungssystems, Alkoholabhängigkeit, Epilepsie, Infektionskrankheiten sowie Verletzungen und Unfälle. Ergebnisse. Insgesamt hätten durch eine Verdoppelung der spezifischen Verbrauchssteuern auf Alkohol im Jahr 2019 bis zu 200.400 alkoholbedingte Erkrankungs- und Verletzungsfälle sowie 2800 Todesfälle vermieden werden können. Dies entspricht knapp 7% der berücksichtigten alkoholbedingten Krankheits- bzw. Todesfälle in Deutschland. Diskussion. Alkoholbedingte Erkrankungen und Verletzungen sind vermeidbar und eine Erhöhung der spezifischen Verbrauchssteuern auf alkoholische Getränke in Deutschland könnte die alkoholbedingte Krankheitslast substanziell reduzieren.Background. In 2019, Germany was among the countries with the highest alcohol per capita consumption in the world, which contributes significantly to the burden of disease. Aim. In this modelling study, we estimate how many alcohol-attributable diseases and deaths in Germany could have been avoided in 2019 if current alcohol excise taxes were increased by 20%, 50%, and 100%. Methods. The starting point for the modelling was the national beverage-specific alcohol taxes. Three scenarios were modelled under the assumption that the resulting tax increase would be fully transferred to the retail prices. Beverage-specific price elasticities were used. Based on the estimated resulting decline in annual per capita consumption and the disease-specific risk functions, we modelled the avoidable incidence and mortality for alcohol-attributable diseases for 2019. Alcohol-attributable diseases of the cardiovascular and digestive systems, alcohol dependence, epilepsy, and infectious diseases as well as injuries and accidentswere considered. Results. Overall, doubling the beveragespecific alcohol taxes could have avoided up to 200,400 alcohol-attributable cases of disease and injury as well as 2800 deaths in Germany in 2019. This corresponds to just under 7% of the modelled new alcohol-attributable cases of disease and death in Germany. Discussion. Alcohol-attributable diseases and injuries are preventable and an increase in the alcohol taxes could substantially reduce the alcohol-attributable burden of disease in Germany

Early, Chronic, and Acute Cannabis Exposure and Their Relationship With Cognitive and Behavioral Harms

Background: Cannabis is the third most consumed drug worldwide. Thus, healthcare providers should be able to identify users who are in need for an intervention. This study aims to explore the relationship of acute, chronic, and early exposure (AE, CE, and EE) to cannabis with cognitive and behavioral harms (CBH), as a first step toward defining risky cannabis use criteria. Methods: Adults living in Spain who used cannabis at least once during the last year answered an online survey about cannabis use and health-related harms. Cannabis use was assessed in five dimensions: quantity on use days during the last 30 days (AE), frequency of use in the last month (AE), years of regular use (YRCU) (CE), age of first use (AOf) (EE), and age of onset of regular use (AOr) (EE). CBH indicators included validated instruments and custom-made items. Pearson correlations were calculated for continuous variables, and Student’s t-tests for independent samples were calculated for categorical variables. Effect sizes were calculated for each of the five dimensions of use (Cohen’s d or r Pearson correlation) and harm outcome. Classification and Regression Trees (CART) analyses were performed for those dependent variables (harms) significantly associated with at least two dimensions of cannabis use patterns. Lastly, logistic binary analyses were conducted for each harm outcome. Results: The mean age of participants was 26.2 years old [standard deviation (SD) 8.5]. Out of 2,124 respondents, 1,606 (75.6%) reported at least one harm outcome (mean 1.8 and SD 1.5). In our sample, using cannabis on 3 out of 4 days was associated with an 8-fold probability of scoring 4+ on the Severity Dependence Scale (OR 8.33, 95% CI 4.91–14.16, p < 0.001), which is indicative of a cannabis use disorder. Also, a start of regular cannabis use before the age of 25 combined with using cannabis at least once per month was associated with a higher probability of risky alcohol use (OR 1.33, 95% CI 1.12–1.57, p = 0.001). Besides, a start of regular cannabis use before the age of 18 combined with a period of regular use of at least 7.5 years was associated with a higher probability of reporting a motor vehicle accident (OR 1.81, 95% CI 1.41–2.32, p < 0.0001). Results were ambiguous regarding the role that age of first use and milligrams of THC per day of use might play regarding cannabis-related harms. Conclusions: The relationship among AE, CE, and EE with CBH indicators is a complex phenomenon that deserves further studies. The pattern of cannabis use should be carefully and widely evaluated—(not just including frequency but also other dimensions of pattern of use)—in research (preferably in longitudinal studies) to assess cannabis-related harms

Alcohol dependence and treatment utilization in Europe - a representative cross-sectional study in primary care

Alcohol dependence (AD) in Europe is prevalent and causes considerable health burden. Recognition by general practitioners (GPs) and provision of or referral to treatment may contribute to reduce this burden. This paper studied AD prevalence in varying European primary care settings and examined who received treatment

Changes in Alcoholic Beverage Choice and Risky Drinking among Adolescents in Europe 1999–2019

This paper explores trends in beverage preference in adolescents, identifies related regional differences, and examines cluster differences in key drinking measures. Data were obtained from the European School Survey Project on Alcohol and Other Drugs (ESPAD), covering 24 European countries between 1999 and 2019. Trends in the distribution of alcoholic beverages on the participants’ most recent drinking occasion were analysed by sex and country using fractional multinomial logit regression. Clusters of countries based on trends and predicted beverage proportions were compared regarding the prevalence of drinkers, mean alcohol volume and prevalence of heavy drinking. Four distinct clusters each among girls and boys emerged. Among girls, there was not one type of beverage that was preferred across clusters, but the proportion of cider/alcopops strongly increased over time in most clusters. Among boys, the proportion of beer decreased, but was dominant across time in all clusters. Only northern European countries formed a geographically defined region with the highest prevalence of heavy drinking and average alcohol volume in both genders. Adolescent beverage preferences are associated with mean alcohol volume and heavy drinking at a country-level. Future approaches to drinking cultures need to take subpopulations such as adolescents into account

Changes in Alcohol Consumption during the COVID-19 Pandemic Are Dependent on Initial Consumption Level: Findings from Eight European Countries

Evidence suggests that changes in alcohol consumption during the first months of the COVID-19 pandemic were unevenly distributed over consumer groups. We investigated possible inter-country differences in how changes in alcohol consumption are contingent on initial consumption (before or at the start of the pandemic), and how changes in consumption translate into possible changes in the prevalence of heavy drinking. We used data from the European Survey on Alcohol use and COVID-19 (ESAC) conducted in Czechia, Denmark, Finland, Germany, Norway, Poland, Spain, and the UK (N = 31921). Past-year alcohol consumption and changes in consumption were measured by AUDIT-C. Drinking habits were compared according to percentiles of pre-pandemic consumption levels, below versus above the 90th percentile. Across countries, drinkers in the highest 10% for pre-pandemic consumption increased their drinking during the pandemic, whereas absolute changes among those initially drinking below this level were modest. The percentage of people reporting >28 alcohol units/week increased significantly in seven of eight countries. During the first months of the COVID-19 pandemic, alcohol consumption in the upper decile of the drinkers increased as did the prevalence of heavy drinkers, in contrast with a declining consumption in other groups in the sample

Cross-sectional study on the characteristics of unrecorded alcohol consumption in nine newly independent states between 2013 and 2017

Objectives: As unrecorded alcohol use contributes to a substantial burden of disease, this study characterises this phenomenon in newly independent states (NIS) of the former Soviet Union with regard to the sources of unrecorded alcohol, and the proportion of unrecorded of total alcohol consumption. We also investigate associated sociodemographic characteristics and drinking patterns. Design: Cross-sectional data on overall and unrecorded alcohol use in the past 7 days from WHO STEPwise Approach to NCD Risk Factor Surveillance (STEPS) surveys. Descriptive statistics were calculated at the country level, hierarchical logistic and linear regression models were used to investigate sociodemographic characteristics and drinking patterns associated with using unrecorded alcohol. Setting: Nine NIS (Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkmenistan and Uzbekistan) in the years 2013–2017. Participants: Nationally representative samples including a total of 36 259 participants. Results: A total of 6251 participants (19.7%; 95% CI 7.9% to 31.5%) reported alcohol consumption in the past 7 days, 2185 of which (35.1%; 95% CI 8.2% to 62.0%) reported unrecorded alcohol consumption with pronounced differences between countries. The population-weighted average proportion of unrecorded consumption in nine NIS was 8.7% (95% CI 5.9% to 12.4%). The most common type of unrecorded alcohol was home-made spirits, followed by home-made beer and wine. Older (45–69 vs 25–44 years) and unemployed (vs employed) participants had higher odds of using unrecorded alcohol. More nuanced sociodemographic differences were observed for specific types of unrecorded alcohol. Conclusions This contribution is the first to highlight both, prevalence and composition of unrecorded alcohol consumption in nine NIS. The observed proportions and sources of unrecorded alcohol are discussed in light of local challenges in policy implementation, especially in regard to the newly formed Eurasian Economic Union (EAEU), as some but not all NIS are in the EAEU