Perspectives in Disease Prevention and Health Promotion Alcohol-Related Mortality and Years of Potential Life Lost -- United States, 1987

Public health problems associated with alcohol use and misuse include mortality from injuries (an outcome of acute exposure to alcohol) and mortality from chronic diseases (an outcome of long-term misuse of alcohol). In 1985, alcohol-related mortality (ARM) for the United States was estimated at 94,768 deaths (University of California-San Francisco (UCSF), unpublished data), accounting for 4.5% of deaths from all causes. A study of ARM in 1980 estimated 69,180 such deaths in the United States for that year (1); however, that estimate was computed using a smaller number of alcohol-related diagnoses. This report presents estimates of ARM and years of potential life lost (YPLL) for the United States for 1987. These estimates are based on a comprehensive assessment of mortality associated with alcohol use and misuse that employs a structured data-base approach (2).Alcohol-Related Mortality

A comprehensive set of diagnoses that are causally linked to alcohol use and misuse was determined by a literature review, then ranked by International Classification of Diseases, Ninth Revision, Clinical Modification, rubric. Alcohol-attributable fractions (AAFs) were then estimated for each diagnosis. AAFs are estimates of the proportions of deaths from disease or injury diagnoses that are causally linked to alcohol use and misuse. For chronic diseases, AAFs were estimated from clinical case series studies and analytical epidemiologic studies; for injuries, AAFs were estimated from injury surveillance studies that reported alcohol involvement.

For each of these diagnoses, gender- and 5-year-age-group-specific mortality data for 1987 were obtained from CDC's National Center for Health Statistics. For each diagnosis, ARM was calculated as deaths X AAF for each gender and 5-year age group (Table 1). For alcohol-defined diagnoses (e.g., alcoholism, alcohol dependence syndrome, and alcoholic cardiomyopathy), all deaths were ascribed to alcohol use and misuse, and the AAF was set to unity (1.0).

In 1987, an estimated 105,095 persons died from alcohol-related causes (4.9% of total national mortality). Deaths among males predominated (66.8%) (Table 2). Gender disparity was most marked for mental disorders (alcohol dependence and alcohol abuse deaths: male/female ratio=3.7:1) and deaths from intentional injuries attributable to alcohol use (male/female ratio=3.4:1). ARM accounted for 6.3% of deaths among males and 3.4% of deaths among females in 1987.

Certain specific diagnoses were major contributors to ARM: motor vehicle crashes (19.3%), homicide (8.7%), suicide (8.1%), alcoholic cirrhosis of the liver (7.1%), and esophageal cancer (6.5%).Alcohol-Related YPLL

YPLL were calculated to age 65 and to full life expectancy (Table 3) using previously described methods (3). For the calculation of alcohol-related YPLL based on life expectancy, age-specific life expectancy data were U.S. all-races data for 1985 (4). For each diagnosis, alcohol-related YPLL were calculated as deaths X AAF X YPLL by sex and 5-year age group.

In 1987, ARM accounted for more than 1.5 million YPLL before age 65 and more than 2.7 million YPLL before life expectancy (Table 3). Although unintentional injuries caused 28.7% of all ARM, they accounted for 50.8% and 40.8% of YPLL before age 65 and life expectancy, respectively. Intentional injuries (suicide and homicide), which represented 16.8% of all deaths, accounted for 29.1% and 23.7% of YPLL before age 65 and life expectancy, respectively.

On average, each alcohol-related death was associated with 14.6 YPLL before age 65 and 25.9 YPLL before life expectancy (Table 4). For both YPLL measures, deaths caused by intentional and unintentional injuries were associated with the greatest number of YPLL per death. Reported by: JM Shultz, PhD, Dept of Epidemiology and Public Health, Univ of Miami School of Medicine, Miami, Florida. DP Rice, Dept of Social and Behavioral Sciences, Univ of California, San Francisco, California. DL Parker, MD, Park Nicollet Medical Center, Minneapolis, Minnesota.

Editorial Note

Editorial Note: The estimates in this analysis were produced using a structured applications software package (Alcohol-Related Disease Impact (ARDI)) (2) that operates as a set of linked spreadsheets retrieved in response to menu choices. This software adapts epidemiologic and cost-of-illness methodologies developed for U.S. estimates of alcohol-attributable disease impact (UCSF, unpublished data) for use by state and local health departments (5). This approach is time- and cost-efficient; after collection of standard mortality and population data, all analytic procedures (i.e., data entry, disease-impact calculations, table printing, and graph plotting) can be completed in 1 workday.

The development of ARDI software follows the successful use of Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) software (6,7) that produced both national (8) and state-level (9,10) estimates of the disease impact of cigarette smoking. ARDI software can assist state and local health professionals and policy makers in better characterizing the public health impact of alcohol use and misuse, as well as stimulating collaborative research and improvement of alcohol-related research methodologies and health data.

Further epidemiologic studies are needed to allow direct computation of AAFs for most diagnoses. AAFs require a consistent definition of alcohol exposure prevalence and robust, diagnosis-specific relative risk measures. For most alcohol-related diseases and injuries, such measures have not yet been determined by rigorous epidemiologic investigation; quantity, volume, and frequency measures of alcohol consumption vary among studies of alcohol-related chronic diseases. In addition, injury surveillance data are constrained by a lack of standardized units for measuring blood-alcohol concentration and disparities in defining measurement thresholds for intoxication. Finally, consensus must be developed regarding the appropriate comparison population for relative risk calculations--specifically, whether abstinence or moderate drinking provide an optimal baseline.

Despite methodologic concerns, a standardized, structured approach to the analysis of the public health impact of alcohol use and misuse can provide an evaluation tool for monitoring alcohol-intervention efforts.

References

1. Harwood HJ, Napolitano DM, Kristiansen RL, Collins JF.

Economic costs to society of alcohol and drug abuse, and mental illness, 1980. Research Triangle Park, North Carolina: Research Triangle Institute, 1984.

2. Shultz JM, Parker DL, Rice DP. ARDI: Alcohol-Related Disease Impact software. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1989.

3. CDC. Premature mortality in the United States: public health issues in the use of years of potential life lost. MMWR 1986;35(no. 2S).

4. NCHS. Vital statistics of the United States, 1985: life tables. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1988; DHHS publication no. (PHS)88-1104. (Series II, no. 6).

5. CDC. Alcohol-related disease impact--Wisconsin, 1988. MMWR 1990;39:178-80,185-7.

6. Shultz JM. SAMMEC: Smoking-Attributable Mortality, Morbidity, and Economic Costs--computer software and documentation. Minneapolis: Minnesota Department of Health, Center for Nonsmoking and Health, 1986.

7. Shultz JM, Novotny TE, Rice DP. SAMMEC II: Smoking-Attributable Mortality, Morbidity, and Economic Costs--computer software and documentation. US Department of Health and Human Services, Public Health Service, CDC, 1990.

8. CDC. Smoking-attributable mortality and years of potential life lost--United States, 1984. MMWR 1987;36:693-7.

9. CDC. State-specific estimates of smoking-attributable mortality and years of potential life lost--United States, 1985. MMWR 1988;37:689-93. 10. CDC. Smoking and health: a national status report--a report to Congress. Atlanta: US Department of Health and Human Services, Public Health Service, 1990.

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