Determination of lifetime injury mortality risk in Canada in 2002 by drinking amount per occasion and number of occasions

The effectiveness of internet-based group behavioural interventions on lifestyle modifications: A systematic review

OBJECTIVES

To examine the effectiveness of internet-based group interventions incorporating social support elements in addressing behaviours related to smoking, nutrition, alcohol consumption, physical activity, and obesity.

METHODS

A literature search was undertaken in six databases from inception to April 2024. Articles were eligible if they reported on group-based online interventions targeting smoking, nutrition, alcohol consumption, physical activity, and obesity, and included interactive features aimed at promoting social engagement and support. Two reviewers independently screened and assessed the quality of articles using Joanna Briggs Institute Critical Appraisal tools. A narrative analysis was used to synthesize and interpret the data to understand the effects of online interventions on lifestyle modifications.

RESULTS

A total of 4063 citations underwent screening, resulting in 32 articles being deemed eligible and included in this review. Most studies examined physical activity (n = 14), followed by obesity (n = 7) and smoking (n = 6), Most studies were conducted in the USA (n = 14) and Australia (n = 11). Websites were the most utilised mode of intervention delivery (n = 11), followed by Facebook (n = 7) and mobile apps (n = 5). Group-based internet interventions were effective in improving smoking cessation, increasing physical activity and addressing obesity. However, there is insufficient data to determine their effect on promoting healthy nutrition and reducing alcohol intake.

CONCLUSION

Group-based interventions delivered on the internet are effective in changing various health behaviours. This approach can offer large scale and cost-effective means to deliver behavioural interventions. However, the long-term effects and strategies for maintaining the behaviour changes are lacking, underscoring the need for further research.

Canadian Guidelines on Alcohol Use Disorder Among Older Adults

Background

Alcohol use disorder (AUD) is an increasingly common, under-recognized, and under-treated health concern in older adults. Its prevalence is expected to reach unprecedented levels as the Canadian population ages. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of AUD in older adults.

Methods

A systematic review of English language literature from 2008-2018 regarding AUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method by drawing on current literature. Recommendations were created and assessed using the GRADE method.

Results

Twenty-two recommendations were created. Prevention recommendations: Best advice for older adults who choose to drink is to limit intake to well below the national Low-Risk Alcohol Drinking Guidelines. Screening recommendations: Alcohol consumption should be reviewed and discussed on an annual basis by primary care providers. This type of discussion needs to be normalized and approached in a simple, neutral, straight-forward manner. Assessment recommendations: Positive screens for AUD should be followed by a comprehensive assessment. Once more details are obtained an individualized treatment plan can be recommended, negotiated, and implemented. Treatment recommendations: AUD falls on a spectrum of mild, moderate, and severe. It can also be complicated by concurrent mental health, physical, or social issues, especially in older adults. Naltrexone and Acamprosate pharmacotherapies can be used for the treatment of AUD in older adults, as individually indicated. Psychosocial treatment and support should be offered as part of a comprehensive treatment plan.

Conclusion

These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of AUD in older adults within the Canadian context.

Young Adult Unemployment and Later Depression and Anxiety: Does Childhood Neighborhood Matter?

Young adulthood represents a developmental period with disproportionately heightened risk of losing a job. Young adult unemployment has been linked to increased mental health problems, at least in the short term. However, their possible long-term impacts, often referred as "scarring effects," have been understudied, possibly underestimating the magnitude of mental health burden that young adult unemployment generates. This longitudinal study examined whether duration of unemployment during young adulthood is associated with later mental health disorders, after accounting for mental and behavioral health problems in childhood. Furthermore, the current study investigated whether childhood neighborhood characteristics affect this association and if so, in what specific functional ways. Data were drawn from a longitudinal study of developmental outcomes in a community sample in Seattle. Data collection began in 1985 when study participants were elementary students and involved yearly assessments in childhood and adolescence (ages 10-16) and then biennial or triennial assessments (ages 18-39; N = 677 at age 39; 47% European American, 26% African American, 22% Asian American, and 5% Native American; 49% female). The current study findings suggest that duration of unemployment across young adulthood increased mental health problems at age 39, regardless of gender. Childhood neighborhood characteristics, particularly their positive aspect, exerted independent impacts on adult mental health problems beyond unemployment experiences across young adulthood. The current findings indicate a needed shift in service profiles for unemployed young adults-a comprehensive approach that not only facilitates reemployment but also addresses mental health needs to help them to cope with job loss. Further, the present study findings suggest that childhood neighborhoods, particularly positive features such as positive neighborhood involvement, may represent concrete and malleable prevention targets that can curb mental health problems early in life.

Alcohol policy and public health

Alcohol is the most commonly used recreational drug in the world and the third leading cause of preventable death. Alcohol consumption and alcohol problems have increased steadily over the past six decades. Methods likely to reduce alcohol problems (e.g. minimum pricing, restricting licensing hours and increasing the availability of alcohol treatment) tend not to be supported by the drinks industry. Methods favoured by the industry (e.g. public education, industry self-regulation and product warning labelling) are less effective or do not work. The recent history of alcohol policy clearly demonstrates how the financial power of industry can influence governments and undermine effective public health measures, for instance by lobbying, political donations, confusion marketing and creating fnancial vested interests by grants from industry-sponsored 'social aspect organisations'.

Alcohol and drug toxicology screens at time of hospitalization do not predict PTSD or depression after traumatic injury

BACKGROUND

Identifying risk factors for the development of PTSD and depression is critical for intervention and recovery after injury. Given research linking toxicology screens and substance use and the evidenced relationship between substance misuse and distress, the current study aimed to gauge the predictive value of toxicology testing on PTSD and depression.

METHODS

Patients admitted to a Level I Trauma Center (N = 379) completed the PC-PTSD, PCL-C, and PHQ-8 at baseline, 3, 6, and 12 months.

RESULTS

Results showed 52% of tested patients had a positive toxicology test, 51% screened for PTSD, and 54% screened for depression. Positive drug or alcohol toxicology tests were not significantly associated with PTSD or depression.

CONCLUSIONS

Toxicology testing may not meaningful predict depression or PTSD in traumatic injury patients. Future research using validated measures of problematic substance use is needed to better understand how misuse may influence the development of psychological distress.

A systematic review of eHealth behavioral interventions targeting smoking, nutrition, alcohol, physical activity and/or obesity for young adults

A systematic review of randomized control trials (RCT) was undertaken to evaluate the effectiveness of eHealth behavioral interventions aiming to improve smoking rates, nutrition behaviors, alcohol intake, physical activity levels and/or obesity (SNAPO) in young adults. Seven electronic databases were searched for RCTs published in English from 2000 to April 2015 and evaluating eHealth interventions aiming to change one or multiple SNAPO outcomes, and including young adult (18-35years) participants. Of 2,159 articles identified, 45 studies met the inclusion criteria. Most interventions targeted alcohol (n=26), followed by smoking (n=7), physical activity (n=4), obesity (n=4) and nutrition (n=1). Three interventions targeted multiple behaviors. The eHealth interventions were most often delivered via websites (79.5%). Most studies (n=32) compared eHealth interventions to a control group (e.g. waiting list control, minimal intervention), with the majority (n=23) showing a positive effect on a SNAPO outcome at follow-up. Meta-analysis demonstrated a significantly lower mean number of drinks consumed/week in brief web or computer-based interventions compared to controls (Mean Difference -2.43 [-3.54, -1.32], P<0.0001, n=10). Sixteen studies compared eHealth delivery modes, with inconsistent results across target behaviors and technology types. Nine studies compared eHealth to other modes of delivery (e.g. in person) with all finding no difference in SNAPO outcomes between groups at follow-up. This review provides some evidence for the efficacy of eHealth SNAPO interventions for young adults, particularly in the short-term and for alcohol interventions. But there is insufficient evidence for their efficacy in the longer-term, as well as which mode of delivery is most effective.

The association of unemployment from age 21 to 33 with substance use disorder symptoms at age 39: The role of childhood neighborhood characteristics

BACKGROUND

This study examined whether duration of unemployment from ages 21 to 33 was associated with symptoms of alcohol use disorder, nicotine dependence disorder, and cannabis use disorder at age 39, after accounting for childhood and early adult involvement in substance use and other indicators of psychopathology. Analyses also investigated whether dimensions of perceived neighborhood characteristics during childhood and adolescence contributed to the link between unemployment and substance use disorder symptoms during adulthood. Potential gender differences were examined.

METHOD

Using life-course calendar data from a prospective longitudinal study (N=677), participants' unemployment history was measured from ages 21 to 33. General childhood and substance use-specific neighborhood characteristics were assessed at ages 10-18.

RESULTS

Findings from negative binomial regression models showed that duration of unemployment was associated with higher levels of alcohol use disorder and nicotine dependence symptoms, after adjusting for earlier involvement in substance use. Substance use-specific neighborhood factors during childhood were associated with symptoms of nicotine dependence and cannabis use disorder. Findings also suggest that the detrimental impact of unemployment on nicotine dependence symptoms was possibly stronger for women.

CONCLUSIONS

Findings suggest that unemployment may be an important risk factor for alcohol use disorder and nicotine dependence symptoms, indicating that public health efforts providing strategies to cope with unemployment, particularly for women who experience chronic unemployment, may be promising. Additionally, substance use-specific neighborhood characteristics during childhood should be considered as part of a prevention strategy to ameliorate adult nicotine and cannabis use problems.

A Trial-Based Predictive Microsimulation Assessing the Public Health Benefits of Nalmefene and Psychosocial Support for the Reduction of Alcohol Consumption in Alcohol Dependence

BACKGROUND

Alcohol dependence causes considerable harm to patients. Treatment with nalmefene, aiming to reduce consumption rather than maintain complete abstinence, has been licensed based on trials demonstrating a reduction in total alcohol consumption and heavy drinking days. Relating these trial outcomes to harmful events avoided is important to demonstrate the clinical relevance of nalmefene treatment.

METHODS

A predictive microsimulation model was developed to compare nalmefene plus brief psychosocial intervention (BRENDA) versus placebo plus BRENDA for the treatment of patients with alcohol dependence and a high or very high drinking risk level based on three pooled clinical trials. The model simulated patterns and level of alcohol consumption, day-by-day, for 12 months, to estimate the occurrence of alcohol-attributable diseases, injuries and deaths; assessing the clinical relevance of reducing alcohol consumption with treatment.

RESULTS

The microsimulation model predicted that, in a cohort of 100,000 patients, 971 (95 % confidence interval [CI] 904-1038) alcohol-attributable diseases and injuries and 133 (95 % CI 117-150) deaths would be avoided with nalmefene versus placebo. This level of benefit has been considered clinically relevant by the European Medicines Agency.

CONCLUSIONS

This microsimulation model supports the clinical relevance of the reduction in alcohol consumption, and has estimated the extent of the public health benefit of treatment with nalmefene in patients with alcohol dependence and a high or very high drinking risk level.

How economic crises affect alcohol consumption and alcohol-related health problems: a realist systematic review

Economic crises are complex events that affect behavioral patterns (including alcohol consumption) via opposing mechanisms. With this realist systematic review, we aimed to investigate evidence from studies of previous or ongoing crises on which mechanisms (How?) play a role among which individuals (Whom?). Such evidence would help understand and predict the potential impact of economic crises on alcohol consumption. Medical, psychological, social, and economic databases were used to search for peer-reviewed qualitative or quantitative empirical evidence (published January 1, 1990-May 1, 2014) linking economic crises or stressors with alcohol consumption and alcohol-related health problems. We included 35 papers, based on defined selection criteria. From these papers, we extracted evidence on mechanism(s), determinant, outcome, country-level context, and individual context. We found 16 studies that reported evidence completely covering two behavioral mechanisms by which economic crises can influence alcohol consumption and alcohol-related health problems. The first mechanism suggests that psychological distress triggered by unemployment and income reductions can increase drinking problems. The second mechanism suggests that due to tighter budget constraints, less money is spent on alcoholic beverages. Across many countries, the psychological distress mechanism was observed mainly in men. The tighter budget constraints mechanism seems to play a role in all population subgroups across all countries. For the other three mechanisms (i.e., deterioration in the social situation, fear of losing one's job, and increased non-working time), empirical evidence was scarce or absent, or had small to moderate coverage. This was also the case for important influential contextual factors described in our initial theoretical framework. This realist systematic review suggests that among men (but not among women), the net impact of economic crises will be an increase in harmful drinking. Such a different net impact between men and women could potentially contribute to growing gender-related health inequalities during a crisis.

Socioeconomic differences in alcohol-related risk-taking behaviours

INTRODUCTION AND AIMS

There is substantial research showing that low socioeconomic position is a predictor of negative outcomes from alcohol consumption, while alcohol consumption itself does not exhibit a strong social gradient. This study aims to examine socioeconomic differences in self-reported alcohol-related risk-taking behaviour to explore whether differences in risk-taking while drinking may explain some of the socioeconomic disparities in alcohol-related harm.

DESIGN AND METHODS

Cross-sectional data from current drinkers (n = 21 452) in the 2010 wave of the Australian National Drug Strategy Household Survey were used. Ten items on risk-taking behaviour while drinking were combined into two risk scores, and zero-inflated Poisson regression was used to assess the relationship between socioeconomic position and risk-taking while controlling for age, sex and alcohol consumption.

RESULTS

Socioeconomically advantaged respondents reported substantially higher rates of alcohol-related hazardous behaviour than socioeconomically disadvantaged respondents. Controlling for age, sex, volume of drinking and frequency of heavy drinking, respondents living in the most advantaged quintile of neighbourhoods reported significantly higher rates of hazardous behaviour than those in the least advantaged quintile. A similar pattern was evident for household income.

DISCUSSION AND CONCLUSIONS

Socioeconomically advantaged Australians engage in alcohol-related risky behaviour at higher rates than more disadvantaged Australians even with alcohol consumption controlled. The significant socioeconomic disparities in negative consequences linked to alcohol consumption cannot in this instance be explained via differences in behaviour while drinking. Other factors not directly related to alcohol consumption may be responsible for health inequalities in outcomes with significant alcohol involvement.

The cost-effectiveness and public health benefit of nalmefene added to psychosocial support for the reduction of alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels: a Markov model

OBJECTIVES

To determine whether nalmefene combined with psychosocial support is cost-effective compared with psychosocial support alone for reducing alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels (DRLs) as defined by the WHO, and to evaluate the public health benefit of reducing harmful alcohol-attributable diseases, injuries and deaths.

DESIGN

Decision modelling using Markov chains compared costs and effects over 5 years.

SETTING

The analysis was from the perspective of the National Health Service (NHS) in England and Wales.

PARTICIPANTS

The model considered the licensed population for nalmefene, specifically adults with both alcohol dependence and high/very high DRLs, who do not require immediate detoxification and who continue to have high/very high DRLs after initial assessment.

DATA SOURCES

We modelled treatment effect using data from three clinical trials for nalmefene (ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941)). Baseline characteristics of the model population, treatment resource utilisation and utilities were from these trials. We estimated the number of alcohol-attributable events occurring at different levels of alcohol consumption based on published epidemiological risk-relation studies. Health-related costs were from UK sources.

MAIN OUTCOME MEASURES

We measured incremental cost per quality-adjusted life year (QALY) gained and number of alcohol-attributable harmful events avoided.

RESULTS

Nalmefene in combination with psychosocial support had an incremental cost-effectiveness ratio (ICER) of £5204 per QALY gained, and was therefore cost-effective at the £20,000 per QALY gained decision threshold. Sensitivity analyses showed that the conclusion was robust. Nalmefene plus psychosocial support led to the avoidance of 7179 alcohol-attributable diseases/injuries and 309 deaths per 100,000 patients compared to psychosocial support alone over the course of 5 years.

CONCLUSIONS

Nalmefene can be seen as a cost-effective treatment for alcohol dependence, with substantial public health benefits.

TRIAL REGISTRATION NUMBERS

This cost-effectiveness analysis was developed based on data from three randomised clinical trials: ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941).

Acute binge alcohol administration reverses sleep-wake cycle in Sprague Dawley rats

BACKGROUND

Binge alcohol drinking is among the most common pattern of alcohol consumption in our society. Binge alcohol consumption has serious negative consequence on mental and physical health. Although alcohol consumption is known to have profound impact on sleep, it is yet unknown as to how binge alcohol affects/alters sleep-wakefulness. The objective of this study was to examine the effect of acute binge alcohol administration on sleep-wakefulness.

METHODS

Male Sprague Dawley rats were used in the study. Under standard aseptic surgical conditions, rats (N = 7) were implanted with sleep-recording electrodes. After postoperative recovery and habituation, baseline sleep-wakefulness was recorded. Subsequently, rats were exposed to binge alcohol treatment as follows: One hour before light onset, a priming dose of 5 g/kg of alcohol was administered followed by 2 subsequent doses (adjusted based on the intoxication level of the rat) approximately 8 hours apart. Sleep-wakefulness was continuously recorded for 3 days post-binge.

RESULTS

Acute binge alcohol administration had no significant effect on sleep-wakefulness on post-binge Day 1. However, on post-binge Day 2, after blood alcohol concentration (BAC) was 0, sleep disruptions were observed manifested by a reversal of sleep-wakefulness as evident from insomnia-like symptoms (significant increase in wakefulness; significant reduction in nonrapid eye movement [NREM] sleep) during the normal sleep (light) period and excessive sleep (significant increase in NREM sleep) during the normal active (dark) period similar to excessive daytime sleepiness in humans. All sleep-wakefulness changes were normalized on Day 3 post-binge.

CONCLUSIONS

Alcohol hangover is defined as the presence of unpleasant symptoms that peak when BAC is 0. Our results suggest that the reversal of sleep-wakefulness accompanies alcohol hangover after binge alcohol administration.

Association among different measures of alcohol use across adolescence and emerging adulthood

BACKGROUND AND AIMS

The use of alterative alcohol indices in developmental research may generate conflicting findings in the literature. This study examined the longitudinal associations among four indices of alcohol involvement from ages 15 to 25 years and examined their concurrent associations with alcohol-related problems in emerging adulthood.

DESIGN

Data are from the Victoria Healthy Youth Survey, a five-wave multi-cohort study conducted biennially in Victoria, Canada between 2003 and 2011.

SETTING AND PARTICIPANTS

This study included a subsample of 637 randomly recruited Canadian adolescents, aged 15-25 years.

MEASUREMENTS

Four indices of alcohol use were compared using multivariate piecewise growth modeling: frequency, usual quantity, heavy episodic drinking and volume.

FINDINGS

All indices increased on average from ages 15 to 21, peaked at approximately age 21, and gradually declined from ages 21 to 25. Levels of use at age 21 were highly correlated across indices (r = 0.63-0.94, P < 0.001), but correlations among rates of change varied between pairs of indices. Heavy episodic drinking and volume had the strongest correlations over time (r = 0.64-0.81, P < 0.001) and accounted for the greatest variance in alcohol use disorder symptoms (R(2)  = 0.35) and social and health consequences (R(2)  = 16) in emerging adulthood. Frequency and quantity had the weakest associations during adolescence (r = 0.49, P = 0.001) and were uncorrelated during emerging adulthood (r = 0.23, P = 0.09).

CONCLUSIONS

Among Canadian youth aged 15-25 years, measures of heavy episodic drinking and volume are the most strongly correlated over time and account for greater variance in alcohol-related problems in emerging adulthood than either frequency or quantity alone.

Binge drinking in Spain, 2008-2010

BACKGROUND

Most alcohol-related research has focused on northern and eastern Europe and the United States. Data on Mediterranean countries point to drinking patterns approaching the sporadic and excessive patterns found in northern and eastern Europe. This is the first study to estimate the prevalence of binge drinking (BD) and the joint distribution of BD, regular heavy alcohol consumption, and alcohol abuse or dependence (AAD) in a nationally representative sample of the adult population of Spain.

METHODS

Cross-sectional study conducted in 2008 to 2010 with 9,130 persons aged 18 to 64 years. BD was defined as intake of ≥80 g of alcohol in men (≥60 g in women) during any drinking occasion in the previous month, with ≥3 BD episodes discriminating between frequent and sporadic BD. Regular alcohol consumption was measured with a validated diet history, and the threshold between moderate and heavy drinking was ≥40 g of alcohol/d in men (≥24 g in women). AAD was defined by a CAGE score ≥2.

RESULTS

BD prevalence was 10% (95% confidence interval [CI]: 8.8 to 11.2) in men and 4.2% (95% CI: 3.5 to 4.8) in women, and proved highest among 18- to 24-year-olds (19.5% in men and 10.3% in women). During the latest BD episode, men consumed a mean of 114 g of alcohol versus 85.3 g in women; spirits accounted for 65.2 and 66.2% of total intake, respectively. The mean number of monthly BD episodes was 2.3 in men and 2 in women. Among binge drinkers, 61% were 18- to 34-year-olds, over 80% had regular moderate drinking, 25% reported frequent BD, and 22.8% reported AAD. In multivariate analyses, sporadic BD and frequent BD were associated with AAD independently of regular alcohol intake.

CONCLUSIONS

Prevalence of BD in Spain is moderately high. Prevention interventions should consider that the majority of binge drinkers are young men with regular moderate consumption and no AAD traits.

Difficulties with telephone-based surveys on alcohol consumption in high-income countries: the Canadian example

Accurate information concerning alcohol consumption level and patterns is vital to formulating public health policy. The objective of this paper is to critically assess the extent to which survey design, response rate and alcohol consumption coverage obtained in random digit dialling, telephone-based surveys impact on conclusions about alcohol consumption and its patterns in the general population. Our analysis will be based on the Canadian Alcohol and Drug Use Monitoring Survey (CADUMS) 2008, a national survey intended to be representative of the general population. The conclusions of this paper are as follows: (1) ignoring people who are homeless, institutionalized and/or do not have a home phone may lead to an underestimation of the prevalence of alcohol consumption and related problems; (2) weighting of observations to population demographics may lead to a increase in the design effect, does not necessarily address the underlying selection bias, and may lead to overly influential observations; and (3) the accurate characterization of alcohol consumption patterns obtained by triangulating the data with the adult per capita consumption estimate is essential for comparative analyses and intervention planning especially when the alcohol coverage rate is low like in the CADUMS with 34%.

Mortality and potential years of life lost attributable to alcohol consumption in Canada in 2005

BACKGROUND

Alcohol is a substantial risk factor for mortality according to the recent 2010 World Health Assembly strategy to reduce the harmful use of alcohol which outlined the need to characterize and monitor this burden. Accordingly, using new methodology we estimated 1) the number of deaths caused and prevented by alcohol consumption, and 2) the potential years of life lost (PYLLs) attributable to alcohol consumption in Canada in 2005.

METHODS

Mortality attributable to alcohol consumption was estimated by calculating Alcohol-Attributable Fractions (AAFs) (defined as the proportion of mortality that would be eliminated if the exposure was eliminated) using data from various sources. Indicators for alcohol consumption were obtained from the Canadian Alcohol and Drug Use Monitoring Survey 2008 and corrected for adult per capita recorded and unrecorded alcohol consumption. Risk relations were taken from the Comparative Risk Assessment within the current Global Burden of Disease (GBD) study. Due to concerns about the reliability of information specifying causes of death for people aged 65 or older, our analysis was limited to individuals aged 0 to 64 years. Calculation of the 95% confidence intervals (CIs) for the AAFs was performed using Monte Carlo random sampling. Information on mortality was obtained from Statistics Canada. A sensitivity analysis was performed comparing the mortality results obtained using our study methods to results obtained using previous methodologies.

RESULTS

In 2005, 3,970 (95% CI: 810 to 7,170) deaths (4,390 caused and 420 prevented) and 134,555 (95% CI: 36,690 to 236,376) PYLLs were attributable to alcohol consumption for individuals aged 0 to 64 years. These figures represent 7.7% (95% CI: 1.6% to 13.9%) of all deaths and 8.0% (95% CI: 2.2% to 14.1%) of all PYLLs for individuals aged 0 to 64 years. The sensitivity analysis showed that the number of deaths as measured by this new methodology is greater than that if mortality was estimated using previous methodologies.

CONCLUSIONS

The mortality burden attributable to alcohol consumption for Canada is large, unnecessary, and could be substantially reduced in a short period of time if effective public health policies were implemented. A monitoring system on alcohol consumption is imperative and would greatly assist in planning and evaluating future Canadian public health policies related to alcohol consumption.

The basis for Canada's new low-risk drinking guidelines: a relative risk approach to estimating hazardous levels and patterns of alcohol use

ISSUE

Low-risk drinking guidelines have been developed independently in a number of jurisdictions resulting in different sets of advice with different definitions of 'low risk'. This paper discusses some of the fundamental issues addressed by an expert advisory panel during the course of developing national guidelines for Canadians and summarises key sets of evidence that were influential.

APPROACH

The underlying reasoning and connection between the evidence and the guidelines is discussed in relation to: (i) how to minimise risk of long-term illnesses; (ii) how to minimise risk of short-term harms, for example injury; and (iii) alcohol use during pregnancy. Both absolute and relative risks were considered in the development of the guidelines.

FINDINGS

Meta-analyses of all-cause mortality were used to identify upper limits for usual drinking levels where potential benefits and risks were balanced for the average person in comparison with lifetime abstainers (10 standard drinks per week for women, 15 for men). Emergency room studies and situational risk factors were considered for advice on reducing short-term: (i) when not to drink at all; (ii) how to reduce intoxication; and (iii) upper limits for occasional daily consumption by adults aged 25 to 64 years (3 standard drinks for women, 4 for men). Shortcomings in the research data were highlighted.

IMPLICATIONS

It was estimated that total compliance with these guidelines at a national level would result in substantially reduced per capita alcohol consumption and approximately 4600 fewer deaths per year.

Combining best evidence: a novel method to calculate the alcohol-attributable fraction and its variance for injury mortality

BACKGROUND

The alcohol-attributable fraction for injury mortality is defined as the proportion of fatal injury that would disappear if consumption went to zero. Estimating this fraction has previously been based on a simplistic view of drinking and associated risk. This paper develops a new way to calculate the alcohol-attributable fraction for injury based on different dimensions of drinking, mortality data, experimental data, survey research, new risk scenarios, and by incorporating different distributions of consumption within populations. For this analysis, the Canadian population in 2005 was used as the reference population.

METHODS

Binge drinking and average daily consumption were modeled separately with respect to the calculation of the AAF. The acute consumption risk was calculated with a probability-based method that accounted for both the number of binge drinking occasions and the amount of alcohol consumed per occasion. The average daily consumption was computed based on the prevalence of daily drinking at various levels. These were both combined to get an overall estimate. 3 sensitivity analyses were performed using different alcohol consumption parameters to test the robustness of the model. Calculation of the variance to generate confidence limits around the point estimates was accomplished via Monte Carlo resampling methods on randomly generated AAFs that were based on the distribution and prevalence of drinking in the Canadian population.

RESULTS

Overall, the AAFs decrease with age and are significantly lower for women than men across all ages. As binge drinking increases, the injury mortality AAF also increases. Motor vehicle collisions show the largest relative increases in AAF as alcohol consumption is increased, with over a 100% increase in AAF from the lowest to highest consumption category. Among non-motor vehicle collisions, the largest change in total AAF occurred both for homicide and other intentional injuries at about a 15% increase in the AAF from the lowest to the highest binge consumption scenarios.

CONCLUSIONS

This method combines the best available evidence to generate new alcohol-attributable fractions for alcohol-attributable injury mortality. Future research is needed to refine the risk function for non-motor vehicle injury types and to investigate potential interactions between binge drinking and average volume of alcohol consumption.

Alcohol-attributable burden of disease and injury in Canada, 2004

OBJECTIVE

This analysis aimed to estimate the burden of disease and injury caused and prevented by alcohol in 2004 for Canadians aged 0-69 years and compare the effects of different magnitudes of adjustment of survey data on these estimates.

METHODS

Alcohol indicators were obtained from the Canadian Alcohol and Drug Use Monitoring Survey 2008 and were corrected to 80% coverage using adult per capita recorded and unrecorded consumption. Risk relations were taken from meta-analyses. Estimates of burden of disease and injury were obtained from the World Health Organization.

RESULTS

In 2004, 4,721 (95% CI 1,432-8,150) deaths and 274,663 (95% CI 201,397-352,432) disability-adjusted life years lost (DALYs) of Canadians 0-69 years of age were attributable to alcohol. This represented 7.1% (95% CI 2.1-12.2%) of all deaths and 9.3% (95% CI 6.8-11.9%) of DALYs for this age range. The sensitivity analysis showed that the outcome estimates varied substantially based on the adjusted coverage rate.

CONCLUSION

More attention to burden of disease and injury statistics is required to accurately characterize alcohol-related harms. This burden is preventable and could be reduced by implementation of more effective policies.

Epidemiology and alcohol policy in Europe

AIMS

To describe three aspects of the epidemiology of alcohol-attributable deaths in Europe, dose, demography and place, and to illustrate how such knowledge can better be used to inform alcohol policy formulation and implementation.

DESIGN

epidemiological and population health modeling.

SETTING

Europe.

PARTICIPANTS

Based on country-specific aggregate statistics.

EXPOSURE

country-specific adult per capita consumption triangulated with survey data; outcomes: mortality statistics.

FINDINGS

The absolute risk of dying from an alcohol-attributable disease and injury (accounting for a protective effect for ischaemic diseases) increases with increasing daily alcohol consumption beyond 10 g alcohol per day, the first data point. Over 2/3 of all alcohol-attributable deaths occurring amongst the 20-64 year old population of the European Union (minus Cyprus and Malta) occur in the 45-64 year olds. About 25% of the difference in life expectancy between western and eastern Europe for men aged 20-64 years in 2002 can be attributed to alcohol, largely, but not exclusively, as a result of differences in heavy episodic drinking patterns.

CONCLUSIONS

Any reduction in the dose of alcohol consumed, at least down to 10 g/day, will reduce the annual and lifetime risk of an alcohol-related death. There is a need for alcohol policy to focus on measures in reducing alcohol consumption, throughout middle age, with immediacy of impact. Policy should strive to reduce alcohol-related health inequalities, with the specific recommendations for policy depending on the cost-effectiveness of interventions related to the epidemiological profile of the country or region under consideration. Fortunately, there are evidence-based policy options that reduce the amount of alcohol consumed and many alcohol-related harms with immediate effect, that reduce the risk of an alcohol-related death in middle age, and that would help to close the health gap between eastern and western Europe.

The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together

Alcohol consumption causes injury in a dose-response manner. The most common mode of sustaining an alcohol-attributable injury is from a single occasion of acute alcohol consumption, but much of the injury literature employs usual consumption habits to assess risk instead. An analysis of the acute dose-response relationship between alcohol and injury is warranted to generate single occasion- and dose-specific relative risks. A systematic literature review and meta-analysis was conducted to fill this gap. Linear and best-fit first-order model were used to model the data. Usual tests of heterogeneity and publication bias were run. Separate meta-analyses were run for motor vehicle and non-motor vehicle injuries, as well as case-control and case-crossover studies. The risk of injury increases non-linearly with increasing alcohol consumption. For motor vehicle accidents, the odds ratio increases by 1.24 (95% CI: 1.18-1.31) per 10-g in pure alcohol increase to 52.0 (95% CI: 34.50-78.28) at 120 g. For non-motor vehicle injury, the OR increases by 1.30 (95% CI: 1.26-1.34) to an OR of 24.2 at 140 g (95% CI: 16.2-36.2). Case-crossover studies of non-MVA injury result in overall higher risks than case-control studies and the per-drink increase in odds of injury was highest for intentional injury, at 1.38 (95% CI: 1.22-1.55). Efforts to reduce drinking both on an individual level and a population level are important. No level of consumption is safe when driving and less than 2 drinks per occasion should be encouraged to reduce the risk of injury.

Modelling lifetime QALYs and health care costs from different drinking patterns over time: a Markov model

The negative health consequences of alcohol use and its treatment account for significant health care expenditure worldwide. Long-term modelling techniques are developed in this paper to establish a link between drinking patterns, health consequences and alcohol treatment effectiveness and cost-effectiveness. The overall change in health related quality and quantity of life which results from changes in health-related behaviour is estimated. Specifically, a probabilistic lifetime Markov model is presented where alcohol consumption in grams of alcohol per day and drinking history are used for the categorization of patients into four Markov states. Utility weights are assigned to each drinking state using EQ-5D scores. Mortality and morbidity estimates are state, gender and age specific, and are alcohol-related and non-alcohol-related. The methodology is tested in a case study. This represents a major development in the techniques traditionally used in alcohol economic models, in which short-term costs and outcomes are assessed, omitting potential longer term cost savings and improvements in health related quality of life. Assumptions and implications of the approach are discussed.

The relation between different dimensions of alcohol consumption and burden of disease: an overview

AIMS

As part of a larger study to estimate the global burden of disease and injury attributable to alcohol: to evaluate the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injuries; to quantify relationships identified as causal based on published meta-analyses; to separate the impact on mortality versus morbidity where possible; and to assess the impact of the quality of alcohol on burden of disease.

METHODS

Systematic literature reviews were used to identify alcohol-related diseases, birth complications and injuries using standard epidemiological criteria to determine causality. The extent of the risk relations was taken from meta-analyses.

RESULTS

Evidence of a causal impact of average volume of alcohol consumption was found for the following major diseases: tuberculosis, mouth, nasopharynx, other pharynx and oropharynx cancer, oesophageal cancer, colon and rectum cancer, liver cancer, female breast cancer, diabetes mellitus, alcohol use disorders, unipolar depressive disorders, epilepsy, hypertensive heart disease, ischaemic heart disease (IHD), ischaemic and haemorrhagic stroke, conduction disorders and other dysrhythmias, lower respiratory infections (pneumonia), cirrhosis of the liver, preterm birth complications and fetal alcohol syndrome. Dose-response relationships could be quantified for all disease categories except for depressive disorders, with the relative risk increasing with increased level of alcohol consumption for most diseases. Both average volume and drinking pattern were linked causally to IHD, fetal alcohol syndrome and unintentional and intentional injuries. For IHD, ischaemic stroke and diabetes mellitus beneficial effects were observed for patterns of light to moderate drinking without heavy drinking occasions (as defined by 60+ g pure alcohol per day). For several disease and injury categories, the effects were stronger on mortality compared to morbidity. There was insufficient evidence to establish whether quality of alcohol had a major impact on disease burden.

CONCLUSIONS

Overall, these findings indicate that alcohol impacts many disease outcomes causally, both chronic and acute, and injuries. In addition, a pattern of heavy episodic drinking increases risk for some disease and all injury outcomes. Future studies need to address a number of methodological issues, especially the differential role of average volume versus drinking pattern, in order to obtain more accurate risk estimates and to understand more clearly the nature of alcohol-disease relationships.

Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol

This paper reviews the evidence for the effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol, in the areas of education and information, the health sector, community action, driving while under the influence of alcohol (drink-driving), availability, marketing, pricing, harm reduction, and illegally and informally produced alcohol. Systematic reviews and meta-analyses show that policies regulating the environment in which alcohol is marketed (particularly its price and availability) are effective in reducing alcohol-related harm. Enforced legislative measures to reduce drink-driving and individually directed interventions to already at-risk drinkers are also effective. However, school-based education does not reduce alcohol-related harm, although public information and education-type programmes have a role in providing information and in increasing attention and acceptance of alcohol on political and public agendas. Making alcohol more expensive and less available, and banning alcohol advertising, are highly cost-effective strategies to reduce harm. In settings with high amounts of unrecorded production and consumption, increasing the proportion of alcohol that is taxed could be a more effective pricing policy than a simple increase in tax.

Carcinogenicity of acetaldehyde in alcoholic beverages: risk assessment outside ethanol metabolism

AIMS

In addition to being produced in ethanol metabolism, acetaldehyde occurs naturally in alcoholic beverages. Limited epidemiological evidence points to acetaldehyde as an independent risk factor for cancer during alcohol consumption, in addition to the effects of ethanol. This study aims to estimate human exposure to acetaldehyde from alcoholic beverages and provide a quantitative risk assessment.

METHODS

The human dietary intake of acetaldehyde via alcoholic beverages was estimated based on World Health Organization (WHO) consumption data and literature on the acetaldehyde contents of different beverage groups (beer, wine, spirits and unrecorded alcohol). The risk assessment was conducted using the European Food Safety Authority's margin of exposure (MOE) approach with benchmark doses obtained from dose-response modelling of animal experiments. Life-time cancer risk was calculated using the T25 dose descriptor.

RESULTS

The average exposure to acetaldehyde from alcoholic beverages was estimated at 0.112 mg/kg body weight/day. The MOE was calculated to be 498, and the life-time cancer risk at 7.6 in 10,000. Higher risk may exist for people exposed to high acetaldehyde contaminations, as we have found in certain unrecorded alcohol beverages in Guatemala and Russia, for which we have demonstrated possible exposure scenarios, with risks in the range of 1 in 1000.

CONCLUSIONS

The life-time cancer risks for acetaldehyde from alcoholic beverages greatly exceed the usual limits for cancer risks from the environment set between 1 : 10,000 and 1 : 1,000,000. Alcohol consumption has thus been identified as a direct source of acetaldehyde exposure, which in conjunction with other sources (food flavourings, tobacco) results in a magnitude of risk requiring intervention. An initial public health measure could be to reduce the acetaldehyde content in alcoholic beverages as low as technologically possible, and to restrict its use as a food flavour additive.

Method for moderation: measuring lifetime risk of alcohol-attributable mortality as a basis for drinking guidelines

The objective of this paper was to determine separately the lifetime risk of drinking alcohol for chronic disease and acute injury outcomes as a basis for setting general population drinking guidelines for Australia. Relative risk data for different levels of average consumption of alcohol were combined with age, sex, and disease-specific risks of dying from an alcohol-attributable chronic disease. For injury, combinations of the number of drinks per occasion and frequency of drinking occasions were combined to model lifetime risk of death for different drinking pattern scenarios. A lifetime risk of injury death of 1 in 100 is reached for consumption levels of about three drinks daily per week for women, and three drinks five times a week for men. For chronic disease death, lifetime risk increases by about 10% with each 10-gram (one drink) increase in daily average alcohol consumption, although risks are higher for women than men, particularly at higher average consumption levels. Lifetime risks for injury and chronic disease combine to overall risk of alcohol-attributable mortality. In terms of guidelines, if a lifetime risk standard of 1 in 100 is set, then the implications of the analysis presented here are that both men and women should not exceed a volume of two drinks a day for chronic disease mortality, and for occasional drinking three or four drinks seem tolerable.