Alcohol, Other Drugs, and Health: Current Evidence Journal Club Alcohol, Other Drugs, and Health: Current Evidence September-October 2018 www.aodhealth.org

GBD 2016 Alcohol Collaborators. Lancet. Featured Article Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016 GBD 2016 Alcohol Collaborators. Lancet. 2018;392(10152):1015–1035.

Study Objective To examine the global impact of alcohol use and estimate the levels of consumption that minimize an individual’s total attributable risk on health. www.aodhealth.org

Study Design Systematic review and meta-analysis following the comparative risk assessment framework developed in previous iterations of GBD. www.aodhealth.org

Assessing an Overview Article (Systematic Reviews and Meta-Analyses) Are the results of the study valid? What are the results? Will the results help me in caring for my patients? Based on the Users’ Guide to Evidence-Based Practice; for more information, see the following: http://www.cche.net/usersguides/main.asp http://pubs.ama-assn.org/misc/usersguides.dtl www.aodhealth.org

Are the Results of the Study Valid? Did the overview address a focused clinical question? Were the criteria used to select articles for inclusion appropriate? Is it unlikely that important, relevant studies were missed? Was the validity of the included studies appraised? Were assessments of studies reproducible? Were the results similar from study to study? www.aodhealth.org

Did the overview address a focused clinical question? Yes. Study aimed to estimate global alcohol consumption and associated health burden, addressing the limitations of previous studies. Seeks to control for “sick quitter” confounding. Adjusts analyses of sales data to account for “tourism and unrecorded consumption.” “Proposes a new method for the use of available evidence to establish a counterfactual level of exposure across varied relative risks, which provides tangible evidence for low-risk drinking recommendations.” www.aodhealth.org

Were the criteria used to select articles for inclusion appropriate? Yes. Data sources: Global Health Data Exchange (GHDx), PubMed. Exposure estimates from 694 total sources. Relative risk estimates from 592 studies for a combined study population of 28 million individuals and 649,000 cases of outcomes. www.aodhealth.org

Is it unlikely that important, relevant studies were missed? Yes. www.aodhealth.org

Was the validity of the included studies appraised? Yes. Authors included “nationally representative survey data sources that captured information on alcohol use among individuals age 15 and above. We included only self-reported drinking data and excluded data from questions asking about others’ drinking behaviors. We included data that was collected between 1 January 1990 and 31 December 2016 in any of the 195 locations included in this study.” www.aodhealth.org

Were assessments of studies reproducible? Yes. The authors state their specific criteria for searching and study quality assessment. www.aodhealth.org

Were the results similar from study to study? There was a wide variety of studies. Authors conducted “a new systematic review for each associated outcome to incorporate new findings on risk and to improve upon existing approaches. This strategy allowed [the authors] to systematically control for reference category confounding in constituent studies across associated outcomes.” www.aodhealth.org

What Are the Results? What are the overall results of the review? How precise were the results? www.aodhealth.org

What are the overall results of the review? In 2016, alcohol was the seventh leading risk factor for death and disability worldwide. Among those aged 15–49, alcohol use was the leading risk factor, accounting for 2.3% of disability-adjusted life-years (DALYs) and 3.8% of deaths among women, and 8.9% of DALYs and 12.2% of deaths among men. The burden changed over the lifespan: tuberculosis, road injuries, and self-harm were leading causes of death attributable to alcohol among 15-49 year-olds, while cancer was the leading cause among people over 50. A J-shaped curve showing positive effects for lower levels of alcohol use was found only for ischemic heart disease, with a minimum relative risk at 0.86 standard drinks (10g ethanol) per day for men and 0.92 standard drinks for women. For all other outcomes (including all cancers), risk increased with any alcohol consumption. www.aodhealth.org

How precise were the results? Globally, alcohol accounted for 2.2% (95% confidence interval [CI] 1.5–3.0) of age-standardized female deaths and 6.8% (5.8–8.0) of age-standardized male deaths. The level of alcohol consumption that minimized harm across health outcomes was zero (95% CI 0.0–0.8) standard drinks per week. www.aodhealth.org

Will the Results Help Me in Caring for My Patients? Can the results be applied to my patient care? Were all clinically important outcomes considered? www.aodhealth.org

Can the results be applied to my patient care? Yes. Study participants were drawn from countries all over the world. www.aodhealth.org

Were all clinically important outcomes considered? Yes. www.aodhealth.org