No level of alcohol consumption improves health

By use of methodological enhancements of previous iterations, 1Forouzanfar MH Alexander L Anderson HR et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015; 386: 2287-2323Summary Full Text Full Text PDF PubMed Scopus (1612) Google Scholar the systematic analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 for 195 countries and territories, 1990–2016, 2GBD 2016 Alcohol CollaboratorsAlcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018; (published online Aug 23. ) http: //dx. doi. org/10. 1016/S0140-6736 (18) 31310-2Google Scholar is the most comprehensive estimate of the global burden of alcohol use to date. The GBD 2016 Alcohol Collaborators clearly demonstrate the substantial, and larger than previously estimated, contribution of alcohol to death, disability, and ill health, globally. In 2016, alcohol use was the seventh leading risk factor for both deaths and disability-adjusted life-years (DALYs), accounting for 2·2% (95% uncertainty interval UI 1·5–3·0) of female deaths and 6·8% (5·8–8·0) of male deaths. The burden is particularly borne among those aged 15–49 years, for whom alcohol ranks as the leading cause of DALYs. In this population, alcohol use was the leading risk factor globally in 2016, with 3·8% (3·2–4·3) of female deaths and 12·2% (10·8–13·6) of male deaths attributable to alcohol use. The study considers the extent to which moderate levels of consumption are protective for some health conditions. 3Ronksley PE Brien SE Turner BJ Mukamal KJ Ghali WA Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. 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Addiction. 2017; 112: 218-219Crossref PubMed Scopus (11) Google Scholar, 7Naimi TS Stockwell T Zhao J et al. Selection biases in observational studies affect associations between ‘moderate’ alcohol consumption and mortality. Addiction. 2017; 112: 207-214Crossref PubMed Scopus (81) Google Scholar However, the emerging literature can account for some of these issues, enabling more reliable estimates of the disease burden attributable to alcohol. 8Holmes MV Dale CE Zuccolo L et al. Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data. BMJ. 2014; 349: g4164Crossref PubMed Scopus (384) Google Scholar, 9Stockwell T Zhao J Panwar S Roemer A Naimi T Chikritzhs T Do “moderate” drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality. J Stud Alcohol Drugs. 2016; 77: 185-198Crossref PubMed Scopus (230) Google Scholar By implementing a novel method to establish a counterfactual level of exposure across varied relative risks that does not need to assume zero exposure, the authors present tangible evidence for low-risk drinking recommendations. The level of consumption that minimises an individual's risk is 0 g of ethanol per week, largely driven by the fact that the estimated protective effects for ischaemic heart disease and diabetes in women are offset by monotonic associations with cancer. This latest GBD analysis applies state-of-the-art epidemiology to produce a definitive understanding of alcohol-related harm. More work remains to be done in calculating the impact of unrecorded alcohol consumption and the importance of patterns of drinking and binge drinking, particularly on young people. Furthermore, the harmful impact of alcohol extends beyond health into families, crime and disorder, and the workplace. 10Burton R Henn C Lavoie D et al. A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective. Lancet. 2017; 389: 1558-1580Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar Evidence demonstrating the range and magnitude of the harm of alcohol to those other than the drinker is increasingly emerging. 11Laslett Room R Ferris J Wilkinson C Livingston M Mugavin J Surveying the range and magnitude of alcohol's harm to others in Australia. Addiction. 2011; 106: 1603-1611Crossref PubMed Scopus (149) Google Scholar, 12Ferris JA Laslett A-M Livingston M Room R Wilkinson C The impacts of others' drinking on mental health. Med J Aust. 2011; 195: 22PubMed Google Scholar This additional array of harms is a necessary consideration at both national and local levels, when aiming to understand the full range of alcohol-related harm and ensuring adequate provision of public health policy with a wider impact than on health alone. The conclusions of the study are clear and unambiguous: alcohol is a colossal global health issue and small reductions in health-related harms at low levels of alcohol intake are outweighed by the increased risk of other health-related harms, including cancer. There is strong support here for the guideline published by the Chief Medical Officer of the UK who found that there is “no safe level of alcohol consumption”. 13UK Department of HealthUK Chief Medical Officers' Low Risk Drinking Guidelines. https: //www. gov. uk/government/uploads/system/uploads/attachmentdata/file/545937/UKCMOs_ᵣeport. pdfDate: August, 2016Date accessed: March 16, 2018Google Scholar The findings have further ramifications for public health policy, and suggest that policies that operate by decreasing population-level consumption should be prioritised. The most effective and cost-effective means to reduce alcohol-related harms are to reduce affordability through taxation or price regulation, including setting a minimum price per unit (MUP), closely followed by marketing regulation, and restrictions on the physical availability of alcohol. 10Burton R Henn C Lavoie D et al. A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective. Lancet. 2017; 389: 1558-1580Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar These approaches should come as no surprise because these are also the most effective measures for curbing tobacco-related harms, another commercially mediated disease, with an increasing body of evidence showing that controlling obesity will require the same measures. 14Kickbusch I Allen L Franz C The commercial determinants of health. Lancet Glob Health. 2016; 4: e895-e896Summary Full Text Full Text PDF PubMed Scopus (160) Google Scholar These diseases of unhealthy behaviours, facilitated by unhealthy environments and fuelled by commercial interests putting shareholder value ahead of the tragic human consequences, are the dominant health issue of the 21st century. The solutions are straightforward: increasing taxation creates income for hard-pressed health ministries, and reducing the exposure of children and adolescents to alcohol marketing has no downsides. The outlook is promising: the UK has just embarked on a huge controlled natural experiment with a progressive evidence-based alcohol strategy in place in Scotland, and with similar measures planned in Northern Ireland and Wales, with England as the placebo control. MUP in Scotland was introduced in May, 2018, without so much as a whisper of complaint from the media, the public, and politicians. Mortality and morbidity rates might be expected to diverge dramatically within just a few years, and pressures to extend these measures across Europe and elsewhere will start to rise. RB is employed full-time at Public Health England (PHE), is a visiting researcher at King's College London, and declares no other competing interests. NS is employed part-time at PHE. NS has received research grants from the British Liver Trust, Alcohol Education Research Council, and various other funding bodies. NS has undertaken paid consultancy work and received travelling expenses from Gilead (who develop drugs for the treatment of inflammatory bowel disease, liver disease, and viral hepatitis), and has been paid for medicolegal work in the area of hepatitis C and alcohol-related liver disease. NS is a clinical adviser to PHE, a scientific adviser to the European Public Health Alliance, and Royal College of Physicians representative on European Union (EU) Alcohol Policies, EU Alcohol Forum, Alcohol Health Alliance UK, UK Department of Health, Home Office, Department of Transport, National Institute for Health and Care Excellence (NICE), Southampton City Council, British Liver Trust, European Association for the Study of the Liver, British Association for the Study of the Liver, and British Society of Gastroenterology. One of the GBD authors (F Greaves) is affiliated with PHE but had no involvement in or knowledge of the Comment. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016Alcohol use is a leading risk factor for global disease burden and causes substantial health loss. We found that the risk of all-cause mortality, and of cancers specifically, rises with increasing levels of consumption, and the level of consumption that minimises health loss is zero. These results suggest that alcohol control policies might need to be revised worldwide, refocusing on efforts to lower overall population-level consumption. Full-Text PDF Open Access