Volume of alcohol consumption, patterns of drinking and burden of disease in the Americas 2002 Jürgen Rehm 1,2,3 & Benjamin Taylor 2 1 Institut für Suchtforschung (ISF - Addiction Research Institute), Zurich, Switzerland 2 Centre for Addiction and Mental Health (CAMH), Toronto, Canada 3 University of Toronto, Canada

Causal model of alcohol consumption, intermediate mechanisms, and long-term consequences * Independent of intoxication or dependence

Adult per capita consumption in litre pure alcohol 2000 (based on CRA)

Pattern of drinking 2000 (based on CRA)

Volume of drinking Depression from psychiatric surveys Drinking pattern hazard score (predominance of intoxication) Other chronic Diseases (except CHD and depression) Coronary heart disease Injuries Alcohol- attributable conditions (by definition) Estimation of AAF for different disease categories

Alcohol related disease and injury Chronic disease: Cancer: Mouth & oropharyngeal cancer, Esophageal cancer, Liver cancer, Female breast cancer, other neoplasms Neuropsychiatric diseases: Alcohol use disorders, unipolar major depression, epilepsy Diabetes Cardiovascular diseases: Hypertensive diseases, ischemic heart disease, stroke Gastrointestinal diseases: Liver cirrhosis Conditions arising during perinatal period: Low birth weight Injury: Unintentional injury: Motor vehicle accidents, drownings, falls, poisonings, other unintentional injuries Intentional injury: Self-inflicted injuries, homicide, other intentional injuries

Classification of countries in WHO European regions by childhood and adult mortality (WHO, 2000) America AAmerica BAmerica D very low childhood and very low adult mortality low high childhood and low adult mortality high childhood and high adult mortality USA Canada Cuba Argentina, Barbados, Belize, Brazil, Chile, Colombia, Costa Rica, Dominican republic, El Salvador, Guyana, Honduras, Jamaica, Mexico, Paraguay, Suriname, Trinidad and Tobago, Uruguay, Venezuela Bolivia, Ecuador, Guatemala, Haiti, Nicaragua, Peru Definition of regions*: The regional subgroupings used were defined by WHO (World Health Report 2000) on the basis of high, medium or low levels of adult and of infant mortality.

Estimates of alcohol-related burden in South America Epidemiological developments (i.e. changes in distribution of disease such as chronic disease vs. infectious disease) Changes in drinking (average level and patterns of drinking) => slides with green background

Exposure: Characteristics of adult alcohol consumption in different regions of WHO AMRO: based on CRA 2000 (i.e. no new data on consumption included) (population weighted averages across countries; cf. Rehm et al., 2003b, 2004; Babor et al., 2003)

Adult alcohol consumption in different categories 2000 in % - Americas - males Males Abstainer g/d Cat.I Cat II Cat III 60 + Amro-A Amro-B Amro-D

Adult alcohol consumption in different categories 2000 in % - Americas - females Males Abstainer g/d Cat.I Cat II Cat III 40 + Amro-A Amro-B Amro-D

And after GENACIS and World Health Surveys and new per capita estimates (2002)….? Similar overall consumption rates Different distributions between ages Different distributions between drinking categories: => Higher proportions of people with heavy drinking

Adult alcohol consumption 2002 in % - Americas - Males MalesAbstainer g/d Cat.I Cat II Cat III 60 + Amro-A Amro-B Amro-D

Adult alcohol consumption in 2002 in % - Americas - Females Females Abstainer g/d Cat.I Cat II Cat III 40 + Amro-A Amro-B Amro-D

Changes between 2000 and 2002 estimates in different categories of alcohol consumption femalesmales

Alcohol-attributable deaths in Americas 2002 by disease and region – epidemiological model Amro AAmro BAmro DAll of America MFMFMFBoth Low birth weight Cancer Neuro-psychriatric conditions Vascular conditions Other non- communicable diseases Unintentional injury Intentional Injury All alcohol-related deaths % alcohol- attributable of all deaths

Alcohol-attributable mortality 2002 (number of deaths) – America epidemiological model vs. world America% of all alcohol- attributable World% of all alcohol- attributable Maternal perinatal conditions %3,0570.2% Cancer %377, % Neuro-psychriatric conditions %113,6036.4% Vascular conditions %196, % Other non-communicable diseases %237, % Unintentional injury %585, % Intentional Injury %269, % All alcohol-related deaths %1,783, % % alcohol-attributable of all deaths 4.4%3.1%

Comparison of alcohol-related deaths of 2002 to 2000 – epidemiological model only For all of America, the relative size of mortality of alcohol-related deaths decreased slightly (4.4% in 2002; 4.7% in 2000). The numbers of alcohol-related deaths - decreased in all three regions, with biggest decreases in America Region D. For the world, the relative size of alcohol- related deaths stayed at about the same level (3.2% in 2000; 3.1% in 2002).

Alcohol-attributable deaths 2002 (basis: new alcohol prevalence estimates and epidemiological shifts in COD) Amro AAmro BAmro DAll of America MFMFMFBoth Maternal perinatal conditions Cancer Neuro-psychriatric conditions Vascular conditions Other non- communicable diseases Unintentional injury Intentional Injury All alcohol-related deaths % alcohol- attributable of all deaths

Comparison chart on alcohol- attributable deaths: best estimates 2002 versus 2000 estimates America 2002 best estimates % of all alcohol- attributable America 2000 CRA estimates % of all alcohol- attributable Maternal perinatal conditions %8730.3% Cancer % % Neuro-psychriatric conditions % % Vascular conditions % % Other non-communicable diseases % % Unintentional injury % % Intentional Injury % % All alcohol-related deaths % % % alcohol-attributable of all deaths 4.8%4.7%

Comparison of alcohol-related deaths from 2000 to 2002 – best estimates for 2002 There are no major changes in estimates of alcohol-related mortality from 2000 to 2002 Two developments: –Epidemiological change -> less deaths in alcohol-related categories –More heavy drinking -> more deaths…. Americas continue to have a high mortality burden from alcohol Please note, that this is a net burden, after subtracting cardio-protective effects

Alcohol-attributable BOD in DALYs 2002 (basis: new alcohol prevalence estimates and epidemiological shifts in COD) Amro AAmro BAmro DAll of America MFMFMFBoth Maternal perinatal conditions Cancer Neuro-psychriatric conditions Vascular conditions Other non- communicable diseases Unintentional injury Intentional Injury All alcohol-related deaths % alcohol- attributable of all deaths

Comparison chart on alcohol- attributable DALYs: best estimates 2002 versus 2000 estimates America 2002 best estimates % of all alcohol- attributable America 2000 CRA estimates % of all alcohol- attributable Maternal perinatal conditions % % Cancer % % Neuro-psychriatric conditions % % Vascular conditions % % Other non-communicable diseases % % Unintentional injury % % Intentional Injury % % All alcohol-related deaths % % % alcohol-attributable of all deaths

Comparison of alcohol-related DALYs from 2000 to 2002 – best estimates for 2002 There are no major changes in estimates of alcohol-related burden of disease from 2000 to 2002 Americas continue to have a burden of disease from alcohol Please note, that this is a net burden, after subtracting cardio-protective effects

Relative impact of alcohol for different age groups For all three regions, for both genders, with one small exception, the relative weight of alcohol on deaths is strongest in the age group years of age In this age group, there are no beneficial effects of alcohol on mortality

Age and sex distribution among alcohol-related deaths in WHO America regions and in World for the year 2002 (own calculations) 0 to 1415 to 2930 to 4445 to 5960 to 6970 to Total deaths in 1000 Males AmrA 2.5%28.9%47.7%48.9%9.0%-10.1%-27.0%23.8 Amr B 1.1%24.7%22.6%21.4%13.4%10.0%6.8%203.2 Amr D 2.9%6.5%27.2%22.8%18.8%13.2%8.8%14.7 World 1.2%15.2%20.6%26.1%18.6%12.9%5.3%1636 Females Amr A Not meaningful, as there was a net beneficial effect, but there were no net gains before age 60 Amr B 2.1%9.3%13.4%21.0%17.5%17.0%19.7%37.4 Amr D 15.0%6.8%12.8%17.5%18.0%16.1%13.1%5.5 World 5.4%21.8%31.9%47.1%31.3%11.2%-48.7%165

Conclusion for policy -> main targets based on epidemiology This is the major aim of this conference, but from an epidemiological side, policies to reduce health burden in the following areas should be considered: Heavy drinking occasions Overall level of consumption Youth Injury Alcohol use disorders