Understanding drinking trends through liver disease mortality is critical to identifying resources to reduce alcohol-related harm, writes Associate Professor Michael Livingston.
Alcohol consumption is a key contributor to death and ill-health in Australia, accounting for an estimated 4.5% of the disease burden. After peaking in the late 1970s, Australia’s per capita alcohol consumption has fallen, with the latest figures showing average consumption is about 75% of the 1976 peak. These large changes in drinking hide significant differences between generations: drinking among young people has fallen sharply over the past 20 years, while drinking among some older generations has increased ( here ). Understanding the relationship between broad changes in population drinking and harm rates is critical to better allocating resources to reduce the negative effects of alcohol, but there is relatively little long-term data on the negative effects of alcohol.
Liver disease is a useful indicator
Alcohol-related liver disease is one of the most common negative health effects of alcohol abuse in Australia, killing around 400 people each year and shortening life span by 10,000 years (here). Alcohol-related liver disease involves a spectrum of different conditions, ranging in severity from fatty liver disease to alcoholic hepatitis to cirrhosis, which is the leading cause of death from alcohol-related liver disease. Liver disease has a range of different and interrelated causes and risk factors, including hepatitis C and B, obesity and type 2 diabetes, but alcohol is a key driver, causing around half of cases globally (here) and in Australia (here) Death from cirrhosis of the liver.
Because alcohol-related liver disease is well understood and has generally been coded consistently for decades (especially mortality), it is often used as an indicator of secular trends in alcohol harm, even as disease classification systems have changed. In our study, we looked at trends in alcohol-related liver disease deaths over 50 years to explore how overall harm levels have changed over that period, and then compared mortality trends across generations.
changing trends
We examined trends in alcohol-related liver disease mortality by age and sex between 1968 and 2020 from the Australian Institute of Health and Welfare. Mortality rates for both men and women were highest in the late 1970s and early 1980s, then declined steadily (especially for men) in the early 2000s. Deaths from alcohol-related liver disease have been relatively stable over the past 15 years, with a slight increase in female mortality. To uncover these trends, we estimate a series of age-period-cohort models based on male and female mortality data. These models separate the overall trend into three components: the overall age distribution of mortality (age), the underlying population-level mortality trend (period), and the impact of generational differences on mortality trends (cohort).
We found that alcohol-related liver disease mortality peaked around age 60 in both men and women. For men, age-specific mortality rates are generally lower for each generation born in the 1930s; for example, controlling for age, a man born around 1980 is about One-third of men born in 1935. The intergenerational differences among women are less consistent, with those born around 1930 and 1965 having significantly higher mortality rates than those born in between. After adjusting for generational differences, the overall incidence of alcohol-related liver disease in women has increased slightly since the early 2000s. Overall, the data are generally encouraging: The incidence of alcohol-related liver disease in men and women is significantly lower than it was in the early 1980s. However, our analysis suggests that for women, these improvements have stalled and may even begin to reverse. Recently released data shows a continued increase in alcohol-related mortality in 2021 and 2022 (here), suggesting alcohol-related liver deaths may continue to increase.
What’s noteworthy about our findings is that the gender gap is closing, in part because of an intergenerational peak in mortality among women born in the 1960s. This narrowing may reflect long-standing (and largely positive) cultural changes in gender equality that have altered social norms surrounding women’s drinking. These changes highlight the need to improve the public health response to alcohol, even as per capita consumption has been declining.
Requires ongoing intervention
The evidence for population-level interventions is clear: increasing prices through taxation or minimum unit pricing, reducing marketing opportunities and reducing the physical availability of alcohol will all lead to reduced consumption and ultimately reduced mortality ( here ). In addition to these broad interventions, our work suggests that interventions targeting women who are now approaching retirement age may be particularly worthwhile. There is relatively little research in this area (although see here ) and developing appropriate interventions at the level of the general population, primary care and treatment sectors should be a key priority to prevent continued increases in premature mortality among women in this generation. Of course, alcohol-related liver disease mortality remains higher in men than in women, so improving access to short-term intervention and treatment for the entire population is critical.
The continued rise in alcohol-related deaths during the COVID-19 pandemic in the UK, US and Australia highlights a potentially overlooked public health challenge that state and federal governments must focus on as an ongoing driver of avoidable early alcohol poisoning. die.
Michael Livingston is an Associate Professor at the National Institute of Medicine, Curtin University. He is one of Australia’s leading alcohol policy researchers and has published more than 200 articles.
The statements or opinions expressed in this article reflect the views of the author and do not necessarily represent those of the AMA, Massachusetts JA or Insight+ Unless so stated.
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