The role of alcohol use in the aetiology and progression of liver disease: A narrative review and a quantification.

ISSUES: Alcohol use has been shown to impact on various forms of liver disease, not restricted to alcoholic liver disease. APPROACH: We developed a conceptual framework based on a narrative review of the literature to identify causal associations between alcohol use and various forms of liver disease including the complex interactions of alcohol with other major risk factors. Based on this framework, we estimate the identified relations for 2017 for the USA. KEY FINDINGS: The following pathways were identified and modelled for the USA for the year 2017. Alcohol use caused 35 200 (95% uncertainty interval 32 800-37 800) incident cases of alcoholic liver cirrhosis. There were 1700 (uncertainty interval 1100-2500) acute hepatitis B and C virus (HBV and HCV) infections attributable to heavy-drinking occasions, and 14 000 (uncertainty interval 5900-19 500) chronic HBV and 1700 (uncertainty interval 700-2400) chronic HCV infections due to heavy alcohol use interfering with spontaneous clearance. Alcohol use and its interactions with other risk factors (HBV, HCV, obesity) led to 54 500 (uncertainty interval 50 900-58 400) new cases of liver cirrhosis. In addition, alcohol use caused 6600 (uncertainty interval 4200-9300) liver cancer deaths and 40 700 (uncertainty interval 36 600-44 600) liver cirrhosis deaths. IMPLICATIONS: Alcohol use causes a substantial number of incident cases and deaths from chronic liver disease, often in interaction with other risk factors. CONCLUSION: This additional disease burden is not reflected in the current alcoholic liver disease categories. Clinical work and prevention policies need to take this into consideration.

Impact of body mass and alcohol consumption on all-cause and liver mortality in 240 000 adults in the United States.

INTRODUCTION: Nationally representative studies of the combined impact of drinking and body mass (BMI) on mortality outcomes are unavailable. We investigate whether both act together to elevate risk of all-cause or liver mortality. METHODS: We obtained self-reported histories of drinking and BMI from 129 098 women (mean age 47.2 years) and 102 568 men (mean age 45.6 years) ≥18 years interviewed from 1997 to 2004 in the National Health Interview Survey and related these data to the deaths that occurred by 31 December 2006 (women = 8486; men = 7819 deaths). Death hazards among current drinkers in different BMI groups were adjusted for age, education, race and smoking. RESULTS: Obese (≥30 kg m-2 ) adults with consumption of >40 g day-1 (women) or >60 g day-1 (men) pure ethanol were at risk of increased mortality from all-cause and chronic liver disease (P trend <0.0001). For heavy drinkers with BMI ≥30 kg m-2 , each 5 kg m-2 higher BMI was associated with an elevated all-cause mortality in men (hazard ratios 1.27, 95% confidence interval [CI]: 1.16-1.40) and women (1.12, [1.02-1.24]). The excess risk due to interaction was more pronounced in men (7.30, [3.60-11.00]) than women (2.90, [0.50-5.30]). DISCUSSION AND CONCLUSIONS: Obesity and excess alcohol are both related to all-cause and liver mortality-the latter with evidence of a supra-additive interaction between the risk factors. The presence of both factors in the same population and their impact should inform treatment, public health policies and research.

Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis of Comparative Studies.

BACKGROUND: Obstructive sleep apnea (OSA) is a common comorbidity in patients undergoing cardiac surgery and may predispose patients to postoperative complications. The purpose of this meta-analysis is to determine the evidence of postoperative complications associated with OSA patients undergoing cardiac surgery. METHODS: A literature search of Cochrane Database of Systematic Reviews, Medline, Medline In-process, Web of Science, Scopus, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL until October 2016 was performed. The search was constrained to studies in adult cardiac surgical patients with diagnosed or suspected OSA. All included studies must report at least 1 postoperative complication. The primary outcome is major adverse cardiac or cerebrovascular events (MACCEs) up to 30 days after surgery, which includes death from all-cause mortality, myocardial infarction, myocardial injury, nonfatal cardiac arrest, revascularization process, pulmonary embolism, deep venous thrombosis, newly documented postoperative atrial fibrillation (POAF), stroke, and congestive heart failure. Secondary outcome is newly documented POAF. The other exploratory outcomes include the following: (1) postoperative tracheal intubation and mechanical ventilation; (2) infection and/or sepsis; (3) unplanned intensive care unit (ICU) admission; and (4) duration of stay in hospital and ICU. Meta-analysis and meta- regression were conducted using Cochrane Review Manager 5.3 (Cochrane, London, UK) and OpenBUGS v3.0, respectively. RESULTS: Eleven comparative studies were included (n = 1801 patients; OSA versus non-OSA: 688 vs 1113, respectively). MACCEs were 33.3% higher odds in OSA versus non-OSA patients (OSA versus non-OSA: 31% vs 10.6%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.38-4.2; P = .002). The odds of newly documented POAF (OSA versus non-OSA: 31% vs 21%; OR, 1.94; 95% CI, 1.13-3.33; P = .02) was higher in OSA compared to non-OSA. Even though the postoperative tracheal intubation and mechanical ventilation (OSA versus non-OSA: 13% vs 5.4%; OR, 2.67; 95% CI, 1.03-6.89; P = .04) were significantly higher in OSA patients, the length of ICU stay and hospital stay were not significantly prolonged in patients with OSA compared to non-OSA. The majority of OSA patients were not treated with continuous positive airway pressure therapy. Meta-regression and sensitivity analysis of the subgroups did not impact the OR of postoperative complications for OSA versus non-OSA groups. CONCLUSIONS: Our meta-analysis demonstrates that after cardiac surgery, MACCEs and newly documented POAF were 33.3% and 18.1% higher odds in OSA versus non-OSA patients, respectively.

Association of STOP-Bang Questionnaire as a Screening Tool for Sleep Apnea and Postoperative Complications: A Systematic Review and Bayesian Meta-analysis of Prospective and Retrospective Cohort Studies.

BACKGROUND: The risk of postoperative complications increases with undiagnosed obstructive sleep apnea (OSA). The high-risk OSA (HR-OSA) patients can be easily identified using the STOP-Bang screening tool. The aim of this systematic review and meta-analysis is to determine the association of postoperative complications in patients screened as HR-OSA versus low-risk OSA (LR-OSA). METHODS: The following data bases were searched from January 1, 2008, to October 31, 2016, to identify the eligible articles: Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Cochrane Databases of Systematic Reviews, Medline-in-Process & other nonindexed citations, Google Scholar, Embase, Web of Sciences and Scopus. The search included studies with adult surgical patients screened for OSA with STOP-Bang questionnaire that reported at least 1 cardiopulmonary or any other complication requiring intensive care unit admission as diagnosis of outcome. We used a Bayesian random-effects analysis to evaluate the existing evidence of STOP-Bang in relation to OSA and to assess the association of postoperative complications with the identified HR-OSA patients by study design and methodologies. RESULTS: This systematic review and meta-analysis was conducted using 10 cohort studies: 23,609 patients (HR-OSA, 7877; LR-OSA, 15,732). The pooled odds of perioperative complications were higher in the HR-OSA versus LR-OSA patients (odds ratio 3.93, 95% credible interval, 1.85-7.77, P= .003; 6.86% vs 4.62%). The length of hospital stay was longer in HR-OSA by 2 days when compared with LR-OSA (5.0 ± 4.2 vs 3.4 ± 2.8 days; mean difference 2.01; 95% credible interval, 0.77-3.24; P= .005). Meta-regression to adjust for baseline confounding factors and subgroup analysis did not materially change the results. CONCLUSIONS: This systematic review and meta-analysis suggests that HR-OSA is related with higher risk of postoperative adverse events and longer length of hospital stay when compared with LR-OSA patients. Our findings support the implementation of the STOP-Bang screening tool for perioperative risk stratification.

Renal failure deaths and their risk factors in India 2001-13: nationally representative estimates from the Million Death Study.

BACKGROUND: Renal failure represents a growing but mostly undocumented cause of premature mortality in low-income and middle-income countries. We investigated changes in adult renal failure mortality and its key risk factors in India using the nationally representative Million Death Study. METHODS: In this cross-sectional analysis of population-based data, two trained physicians independently assigned underlying causes to 150 018 deaths at ages 15-69 years from a nationally-representative mortality survey in India for 2001-03 and 2010-13, using the International Classification of Diseases, 10th version (ICD-10). We applied the age-specific proportion of renal failure deaths for the 2010-13 period to the 2015 UN estimates of total deaths in India and calculated age-standardised death rates for renal failure by rural or urban residence, state, and age group. We used proportional mortality of renal deaths (cases) to injuries (controls) to calculate the odds of renal death in the presence of different comorbidities and stratified risks by decade of birth. FINDINGS: In 2001-03, 2·1% of total deaths among 15-69 year olds were from renal failure (1266 [2·2%] of 58 871; unweighted). By 2010-13, the proportion of deaths from renal failure had risen to 2·9% (2943 [3·2%] of 91 147; unweighted) of total deaths and corresponding to 136 000 renal failure deaths (range 108 000-150 000) of 4 688 000 total deaths nationally in 2015. Age-standardised renal death rates were highest in the southern and eastern states, particularly among adults aged 45-69 years in 2010-13. Diabetes, hypertension, and cardiovascular disease were all significantly associated with increased renal failure deaths, with diabetes the strongest predictor-odds ratio (OR) vs control 9·2 (95% CI 6·7-12·7) in 2001-03, rising to 15·1 (12·6-18·1) in 2010-13. In the 2010-13 study population, the diabetes to non-diabetes OR was twice as large in adults born in the 1970s (25·5, 95% CI 17·6-37·1) as in those individuals born during or before the 1950s (11·7, 9·1-14·9). INTERPRETATION: Renal failure is a growing cause of premature death in India. Poorly treated diabetes is the most probable reason for this increase. Strategies aimed at diabetes prevention, and early detection and treatment are urgently needed in India, as well as greater access to renal replacement therapy. FUNDING: US National Institutes of Health, International Development Research Centre, Centre for Global Health Research, University of Toronto.

Effects of body mass index, tobacco smoking, alcohol drinking and solid fuel use on the risk of asthma: Individual Participant Data (IPD) meta-analysis of 175†000 individuals from 51 nationally representative surveys.

BACKGROUND: We assessed the relationship of body mass index (BMI), smoking, drinking and solid fuel use (r; SFU), and the individual and combined effects of these factors on wheezing symptoms (WS) and on diagnosed asthma (DA). METHODS: We analysed 175 000 individuals from 51 nationally representative surveys, using self-reports of WS and DA as the measures of asthma. The fixed-effects and random-effects estimates of the pooled ORs between asthma and underweight (BMI <18.5 kg/m(2)), obesity (BMI ≥30 kg/m(2)), smoking, drinking and SFU were reported. RESULTS: The pooled risks of all individual risk factors were significantly associated with WS and DA (with the exception of current smoking with DA in women and SFU with DA in both genders). Stronger dose-response relationships were seen in women for smoking amounts and duration; BMI showed stronger quadratic relationships. The combined risks were generally larger in women than in men, with significant risks for underweight (OR=2.73) as well as obese (OR=2.00) smokers for WS (OR=2.13 and OR=1.58 for DA, respectively). The magnitude of the combined effects from low/high BMI, smoking and drinking were also consistently higher among women than among men in WS and DA. SFU among underweight smokers also had positive association with WS (men and women) and DA (women). CONCLUSIONS: BMI, smoking, drinking and SFU-in combination-are associated with double or triple the risk of development of asthma. These risk factors might help explain the wide variation in asthma burden across countries.

Trends in bidi and cigarette smoking in India from 1998 to 2015, by age, gender and education.

OBJECTIVES: Smoking of cigarettes or bidis (small, locally manufactured smoked tobacco) in India has likely changed over the last decade. We sought to document trends in smoking prevalence among Indians aged 15-69 years between 1998 and 2015. DESIGN: Comparison of 3 nationally representative surveys representing 99% of India's population; the Special Fertility and Mortality Survey (1998), the Sample Registration System Baseline Survey (2004) and the Global Adult Tobacco Survey (2010). SETTING: India. PARTICIPANTS: About 14 million residents from 2.5 million homes, representative of India. MAIN OUTCOME MEASURES: Age-standardised smoking prevalence and projected absolute numbers of smokers in 2015. Trends were stratified by type of tobacco smoked, age, gender and education level. FINDINGS: The age-standardised prevalence of any smoking in men at ages 15-69 years fell from about 27% in 1998 to 24% in 2010, but rose at ages 15-29 years. During this period, cigarette smoking in men became about twofold more prevalent at ages 15-69 years and fourfold more prevalent at ages 15-29 years. By contrast, bidi smoking among men at ages 15-69 years fell modestly. The age-standardised prevalence of any smoking in women at these ages was 2.7% in 2010. The smoking prevalence in women born after 1960 was about half of the prevalence in women born before 1950. By contrast, the intergenerational changes in smoking prevalence in men were much smaller. The absolute numbers of men smoking any type of tobacco at ages 15-69 years rose by about 29 million or 36% in relative terms from 79 million in 1998 to 108 million in 2015. This represents an average increase of about 1.7 million male smokers every year. By 2015, there were roughly equal numbers of men smoking cigarettes or bidis. About 11 million women aged 15-69 smoked in 2015. Among illiterate men, the prevalence of smoking rose (most sharply for cigarettes) but fell modestly among men with grade 10 or more education. The ex-smoking prevalence in men at ages 45-59 years rose modestly but was low: only 5% nationally with about 4 current smokers for every former smoker. CONCLUSIONS: Despite modest decreases in smoking prevalence, the absolute numbers of male smokers aged 15-69 years has increased substantially over the last 15 years. Cigarettes are displacing bidi smoking, most notably among young adult men and illiterate men. Tobacco control policies need to adapt to these changes, most notably with higher taxation on tobacco products, so as to raise the currently low levels of adult smoking cessation.

Deaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysis.

BACKGROUND: Few population-based studies quantify mortality from surgical conditions and relate mortality to access to surgical care in low-income and middle-income countries. METHODS: We linked deaths from acute abdominal conditions within a nationally representative, population-based mortality survey of 1·1 million households in India to nationally representative facility data. We calculated total and age-standardised death rates for acute abdominal conditions. Using 4064 postal codes, we undertook a spatial clustering analysis to compare geographical access to well-resourced government district hospitals (24 h surgical and anaesthesia services, blood bank, critical care beds, basic laboratory, and radiology) in high-mortality or low-mortality clusters from acute abdominal conditions. FINDINGS: 923 (1·1%) of 86,806 study deaths at ages 0-69 years were identified as deaths from acute abdominal conditions, corresponding to 72,000 deaths nationally in 2010 in India. Most deaths occurred at home (71%) and in rural areas (87%). Compared with 567 low-mortality geographical clusters, the 393 high-mortality clusters had a nine times higher age-standardised acute abdominal mortality rate and significantly greater distance to a well-resourced hospital. The odds ratio (OR) of being a high-mortality cluster was 4·4 (99% CI 3·2-6·0) for living 50 km or more from well-resourced district hospitals (rising to an OR of 16·1 [95% CI 7·9-32·8] for >100 km). No such relation was seen for deaths from non-acute surgical conditions (ie, oral, breast, and uterine cancer). INTERPRETATION: Improvements in human and physical resources at existing government hospitals are needed to reduce deaths from acute abdominal conditions in India. Full access to well-resourced hospitals within 50 km by all of India's population could have avoided about 50,000 deaths from acute abdominal conditions, and probably more from other emergency surgical conditions. FUNDING: Bill & Melinda Gates Foundation, Dalla Lana School of Public Health, Canadian Institute of Health Research.

Deaths from acute abdominal conditions and geographic access to surgical care in India: a nationally representative population-based spatial analysis.

BACKGROUND: Acute abdominal conditions have high case-fatality rates in the absence of timely surgical care. In India, and many other low-income and middle-income countries, few population-based studies have quantified mortality from surgical conditions and related mortality to access to surgical care. We aimed to describe the spatial and socioeconomic distributions of deaths from acute abdomen (DAA) in India and to quantify potential access to surgical facilities in relation to such deaths. METHODS: We examined deaths from acute abdominal conditions within a nationally representative, population-based mortality survey of 1·1 million Indian households and linked these to nationally representative facility data. Spatial clustering of deaths from acute abdominal conditions was calculated with the Getis-Ord Gi* statistic from about 4000 postal codes. We compared high or low acute abdominal mortality clusters for their geographic access to well-resourced surgical care (24 h surgical and anaesthesia services, blood bank, critical care beds, basic laboratory, and radiology). FINDINGS: 923 (1·1%) of 86 806 study deaths in those aged 0-69 years were identified as deaths from acute abdominal conditions, corresponding to an estimated 72 000 deaths nationally in India in 2010. Most deaths occurred at home (71%), in rural areas (87%), and were caused by peptic ulcer disease (79%). There was wide variation in rates of deaths from acute abdominal conditions. We identified 393 high-mortality geographic clusters and 567 low-mortality clusters. High-mortality clusters of acute abdominal conditions were located significantly further from well-resourced hospitals than were low-mortality clusters. The odds ratio of a postal code area being a high-mortality cluster was 4·4 (99% CI 3·2-6·0) for living 50 km or more from well-resourced district hospitals (rising to an OR of 16·1 for >100 km), after adjustment for socioeconomic status and caste. INTERPRETATION: Improvements in human and physical resources at existing public hospitals are required to reduce deaths from acute abdominal conditions in India. Had all of the Indian population had access to well-resourced hospitals within 50 km, more than 50 000 deaths from acute abdominal conditions could have been averted in 2010, and likely more from other emergency surgical conditions. Our geocoded facility data were limited to public district hospitals. However, noting the high rate of catastrophic health expenditures in India, we chose to focus on publicly provided services which are the only option usually available to the poor. FUNDING: The Bill & Melinda Gates Foundation, Dalla Lana School of Public Health, and Canadian Institute of Health Research.

Exposure to second-hand smoke and the risk of tuberculosis in children and adults: a systematic review and meta-analysis of 18 observational studies.

BACKGROUND: According to WHO Global Health Estimates, tuberculosis (TB) is among the top ten causes of global mortality and ranks second after cardiovascular disease in most high-burden regions. In this systematic review and meta-analysis, we investigated the role of second-hand smoke (SHS) exposure as a risk factor for TB among children and adults. METHODS AND FINDINGS: We performed a systematic literature search of PubMed, Embase, Scopus, Web of Science, and Google Scholar up to August 31, 2014. Our a priori inclusion criteria encompassed only original studies where latent TB infection (LTBI) and active TB disease were diagnosed microbiologically, clinically, histologically, or radiologically. Effect estimates were pooled using fixed- and random-effects models. We identified 18 eligible studies, with 30,757 children and 44,432 adult non-smokers, containing SHS exposure and TB outcome data for inclusion in the meta-analysis. Twelve studies assessed children and eight studies assessed adult non-smokers; two studies assessed both populations. Summary relative risk (RR) of LTBI associated with SHS exposure in children was similar to the overall effect size, with high heterogeneity (pooled RR 1.64, 95% CI 1.00-2.83). Children showed a more than 3-fold increased risk of SHS-associated active TB (pooled RR 3.41, 95% CI 1.81-6.45), which was higher than the risk in adults exposed to SHS (summary RR 1.32, 95% CI 1.04-1.68). Positive and significant exposure-response relationships were observed among children under 5 y (RR 5.88, 95% CI 2.09-16.54), children exposed to SHS through any parent (RR 4.20, 95% CI 1.92-9.20), and children living under the most crowded household conditions (RR 5.53, 95% CI 2.36-12.98). Associations for LTBI and active TB disease remained significant after adjustment for age, biomass fuel (BMF) use, and presence of a TB patient in the household, although the meta-analysis was limited to a subset of studies that adjusted for these variables. There was a loss of association with increased risk of LTBI (but not active TB) after adjustment for socioeconomic status (SES) and study quality. The major limitation of this analysis is the high heterogeneity in outcomes among studies of pediatric cases of LTBI and TB disease. CONCLUSIONS: We found that SHS exposure is associated with an increase in the relative risk of LTBI and active TB after controlling for age, BMF use, and contact with a TB patient, and there was no significant association of SHS exposure with LTBI after adjustment for SES and study quality. Given the high heterogeneity among the primary studies, our analysis may not show sufficient evidence to confirm an association. In addition, considering that the TB burden is highest in countries with increasing SHS exposure, it is important to confirm these results with higher quality studies. Research in this area may have important implications for TB and tobacco control programs, especially for children in settings with high SHS exposure and TB burden.

Tobacco smoking, alcohol drinking, diabetes, low body mass index and the risk of self-reported symptoms of active tuberculosis: individual participant data (IPD) meta-analyses of 72,684 individuals in 14 high tuberculosis burden countries.

BACKGROUND: The effects of multiple exposures on active tuberculosis (TB) are largely undetermined. We sought to establish a dose-response relationship for smoking, drinking, and body mass index (BMI) and to investigate the independent and joint effects of these and diabetes on the risk of self-reported symptoms of active TB disease. METHODS AND FINDINGS: We analyzed 14 national studies in 14 high TB-burden countries using self-reports of blood in cough/phlegm and cough lasting > = 3 weeks in the last year as the measures of symptoms of active TB. The random effect estimates of the relative risks (RR) between active TB and smoking, drinking, diabetes, and BMI<18.5 kg/m2 were reported for each gender. Floating absolute risks were used to examine dyads of exposure. Adjusted for age and education, the risks of active TB were significantly associated with diabetes and BMI<18.5 kg/m2 in both sexes, with ever drinking in men and with ever smoking in women. Stronger dose-response relationships were seen in women than in men for smoking amount, smoking duration and drinking amount but BMI<18.5 kg/m2 showed a stronger dose-response relationship in men. In men, the risks from joint exposures were statistically significant for diabetics with BMI<18.5 kg/m2 (RR = 6.4), diabetics who smoked (RR = 3.8), and diabetics who drank alcohol (RR = 3.2). The risks from joint risk factors were generally larger in women than in men, with statistically significant risks for diabetics with BMI<18.5 kg/m2 (RR = 10.0), diabetics who smoked (RR = 5.4) and women with BMI<18.5 kg/m2 who smoked (RR = 5.0). These risk factors account for 61% of male and 34% of female estimated TB incidents in these 14 countries. CONCLUSIONS: Tobacco, alcohol, diabetes, and low BMI are significant individual risk factors but in combination are associated with triple or quadruple the risk of development of recent active TB. These risk factors might help to explain the wide variation in TB across countries.

Global burden of injuries attributable to alcohol consumption in 2004: a novel way of calculating the burden of injuries attributable to alcohol consumption.

BACKGROUND: Alcohol consumption is a major risk factor for injuries; however, international data on this burden are limited. This article presents new methods to quantify the burden of injuries attributable to alcohol consumption and quantifies the number of deaths, potential years of life lost (PYLL), and disability-adjusted life years (DALYs) lost from injuries attributable to alcohol consumption for 2004. METHODS: Data on drinking indicators were obtained from the Comparative Risk Assessment study. Data on mortality, PYLL, and DALYs for injuries were obtained from the World Health Organization. Alcohol-attributable fractions were calculated based on a new risk modeling methodology, which accounts for average and heavy drinking occasions. 95% confidence intervals (CIs) were calculated using a Monte Carlo simulation method. RESULTS: In 2004, 851,900 (95% CI: 419,400 to 1,282,500) deaths, 19,051,000 (95% CI: 9,767,000 to 28,243,000) PYLL, and 21,688,000 (95% CI: 11,097,000 to 32,385,000) DALYs for people 15 years and older were due to injuries attributable to alcohol consumption. With respect to the total number of deaths, harms to others were responsible for 15.1% of alcohol-attributable injury deaths, 14.5% of alcohol-attributable injury PYLL, and 11.35% of alcohol-attributable injury DALYs. The overall burden of injuries attributable to alcohol consumption corresponds to 17.3% of all injury deaths, 16.7% of all PYLL, and 13.6% of all DALYs caused by injuries, or 1.4% of all deaths, 2.0% of all PYLL, and 1.4% of all DALYs in 2004. CONCLUSIONS: The novel methodology described in this article to calculate the burden of injuries attributable to alcohol consumption improves on previous methodology by more accurately calculating the burden of injuries attributable to one's own drinking, and for the first time, calculates the burden of injuries attributable to the alcohol consumption of others. The burden of injuries attributable to alcohol consumption is large and is entirely avoidable, and policies and strategies to reduce it are recommended.

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.

Strategies for evaluating the economic value of drugs in alcohol dependence treatment.

BACKGROUND: To assess existing health economic strategies, which are used to evaluate the economic value of drugs to treat alcohol dependence (AD) such as acamprosate, naltrexone and any other pharmaceuticals. METHODS: A systematic literature search on AD treatment economic evaluation studies was performed in multiple electronic bibliographic and economic databases. RESULTS: A total of seven studies were found that involved economic evaluations of pharmacotherapy treatment of AD. It was seen that all individual pharmacotherapy treatment programs including acamprosate, naltrexone and combined treatments have resulted in a net benefit or cost savings. However, the examined studies used different methods to estimate the costs, cost savings, and cost effectiveness of the treatments. CONCLUSIONS: Pharmacotherapy treatment of AD produced marked economic benefits. However, the number of studies on the economic evaluation of pharmacotherapy for AD treatment is limited. The gaps in these studies have also been identified as necessitating more research.

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.

Cost of privatisation versus government alcohol retailing systems: Canadian example.

INTRODUCTION AND AIMS: Alcohol retail monopolies have been established in many countries to restrict alcohol availability and thus, minimise alcohol-related harm.The aim of this study was to estimate the impact of the privatisation of alcohol sales on the burden and direct health-care, law enforcement costs and indirect costs (lost productivity due to disability or premature mortality) in Canada. DESIGN AND METHODS: Simulation modelling. International Guidelines for the Estimation of the Avoidable Costs of Substance Abuse were used. All burden and costs were compared with the baseline taken from the aggregate Cost Study on Substance Abuse in Canada 2002. RESULTS: If all Canadian provinces and territories were to privatise alcohol sales we assume that consumption would increase from 10% to 20% based on available Canadian literature. Under the 10% scenario the costs would increase from 6% ($828 million) and under the 20% scenario costs would increase 12% ($1.6 billion).This increase is substantially greater than the tax and mark-up revenue gained from increased sales,and represents a net loss. DISCUSSION AND CONCLUSIONS: Alcohol-attributable burden and associated costs will increase markedly if all Canadian provinces and territories gave up the government alcohol retailing systems.For public health and economic reasons, governments should continue to have a strong role in alcohol retailing.

Different guidelines for different countries? On the scientific basis of low-risk drinking guidelines and their implications.

The scientific evidence for low-risk drinking guidelines was examined in a narrative review focusing on three points: definition of exposure, the best way to select outcomes and risk relations and how to determine thresholds. With respect to exposure, at least two dimensions should be incorporated: average volume of alcohol consumption and patterns of irregular heavy drinking occasions. Mortality should be selected as the most severe outcome, and a disaggregated approach should be adopted incorporating the regional demographic and cause of death structure. Finally, our plea is for establishing a general threshold for acceptable risk on a societal level rather than ad hoc specific committees setting norms for specific risks. Acceptable thresholds will be different if the risk is to oneself or to others.

A literature review of cost-benefit analyses for the treatment of alcohol dependence.

The purpose of this study was to conduct a literature review of cost-benefit studies on pharmacotherapy and psychotherapy treatments of alcohol dependence (AD). A literature search was performed in multiple electronic bibliographic databases. The search identified seven psychotherapy studies from the USA and two pharmacotherapy studies from Europe. In the psychotherapy studies, major benefits are typically seen within the first six months of treatment. The benefit-cost ratio ranged from 1.89 to 39.0. Treatment with acamprosate was found to accrue a net benefit of 21,301 BEF (528 €) per patient over a 24-month period in Belgium and lifetime benefit for each patient in Spain was estimated to be Pta. 3,914,680 (23,528 €). To date, only a few studies exist that have examined the cost-benefit of psychotherapy or pharmacotherapy treatment of AD. Most of the available treatment options for AD appear to produce marked economic benefits.

Alcohol consumption and non-communicable diseases: epidemiology and policy implications.

AIMS: This paper summarizes the relationships between different patterns of alcohol consumption and various on non-communicable disease (NCD) outcomes and estimates the percentage of NCD burden that is attributable to alcohol. METHODS: A narrative review, based on published meta-analyses of alcohol consumption-disease relations, together with an examination of the Comparative Risk Assessment estimates applied to the latest available revision of Global Burden of Disease study. RESULTS: Alcohol is causally linked (to varying degrees) to eight different cancers, with the risk increasing with the volume consumed. Similarly, alcohol use is related detrimentally to many cardiovascular outcomes, including hypertension, haemorrhagic stroke and atrial fibrillation. For other cardiovascular outcomes the relationship is more complex. Alcohol is furthermore linked to various forms of liver disease (particularly with fatty liver, alcoholic hepatitis and cirrhosis) and pancreatitis. For diabetes the relationship is also complex. Conservatively, of the global NCD-related burden of deaths, net years of life lost (YLL) and net disability adjusted life years (DALYs), 3.4%, 5.0% and 2.4%, respectively, can be attributed to alcohol consumption, with the burden being particularly high for cancer and liver cirrhosis. This burden is especially pronounced in countries of the former Soviet Union. CONCLUSIONS: There is a strong link between alcohol and non-communicable diseases, particularly cancer, cardiovascular disease, liver disease, pancreatitis and diabetes, and these findings support calls by the World Health Organization to implement evidence-based strategies to reduce harmful use of alcohol.