Burden and cost of alcohol, tobacco andillegal drugs globally and in Europe

Jürgen Rehm 1-4 Kevin D. Shield 1,2,3

1) Centre for Addiction and Mental Health,Toronto, Canada

2) University of Toronto, Canada3) WHO Collaborating Centre for Mental

Health and Addictions4) Technische Universität Dresden, Clinical

Psychology and Psychotherapy, Germany

jtrehm@gmail.com

What will be covered?• Risk factor approach vs. disease approach• Basic methodology for risk factor approach• The 2010 GBD study – the real data (Lim et al., 2012

is unfortunately incorrect)• The situation in the Nordic and Baltic countries• Cost• Conclusions

Addiction (substance use disorders =disease) vs. risk factors• Mortality and morbidity can be attributed to

▫ disease or injury outcomes

▫ preventable risk factors

• However, this distinction gets blurred with substance useand substance use disorders

• How many of the smoking attributable lung cancers aredue to tobacco use disorders?

• But what is written on the cause of death certificate?

Smoking and lung cancer

Below the white linein the red circle:smokers withouttobacco use disorder

Identification of causal relationsExposureQuantification of risk relations

Basic ingredients for a risk factor approach

• First disease and injury categories, where substance usedisorders have causal impact, must be identified• Attributable fraction must be determined, which are a

function of:▫ Prevalence of exposure▫ Risk relations• What does this mean?We need to know the prevalence of alcohol use disorders(or levels of alcohol use as indicator) and the RR foroutcomes for which alcohol use disorders are causal (onlycausal relations count!)

Alcohol consumption

Volume Patterns Quality

Health outcomes

Incidencechronicconditionsincluding AUDs

Incidenceacuteconditions

Mortality bycause

Societal Factors

Drinking culture

Alcohol Policy

Drinkingenvironment

Health caresystem

Populationgroup

Gender

Age

PovertyMarginalization

(individual)

Currently used model for alcohol CRA 2005

Basic formula

where Pa is the prevalence of lifetime abstainersRRa is the relative risk of lifetime abstainers (set to 1)Pex is the prevalence of former drinkers (all types of former

drinkers withno drinking in last year)

RRex is the relative risk of former drinkersx average volume of alcohol consumption per dayP(x) is the prevalence of alcohol with consumption xRR(x) is the relative risk of drinkers with consumption x

Of course, instead of no consumption at all, other counterfactuals could bemodelled.

dxxRRxPRRPRRP

dxxRRxPRRPRRPxAAF x

xexexaa

x

xexexaa

)()(

1-)()()( )max(

)min(

)max(

)min(

Continuousdistribution ofdrinkers

ContinuousRR function

Example of general population distribution of volume ofdrinking => basis for continuous modelling

Log-Normal (red) vs. Gamma (blue) vs. Weibull (green)

German Male ALL AGESVolume (g/day)

Prev

alenc

e

0 20 40 60 80 100

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

Histogram of consumption withestimated consumptiondistributions

Decision was based on comparisonof distributions from 30 countries!

Best overall fit: Weibull & GammaGamma Distribution

f(x; θ, k) = 1/( θk Γ(k)) xk-1 exp{- x / θ}

Mean Estimate for the Gamma Distribution = θkVariance = θ2k

Empirical and theoretical Gamma estimates for mean have to beidentical, and variance estimates were quite similar.

Better properties for transferring results to other populations thanWeibull.

Risk relations• Alcohol has the most disease and injury categories

which are causally impacted (more then 200 ICDthree digit codes) -> mainly not 100% attributable• Tobacco is second -> mainly not 100% attributable• Illicit drugs mainly overdose deaths for mortality

Published in December 2012 in Lancet by Lim et al.ButThe numbers for alcohol are seriously off. What I show in the nextslides is already corrected -> will appear in Lancet soon

One DALY is one year of life lost either due to premature mortality orto disability. If somebody is 20% disabled, living 5 years with thisdisablement will result in one DALY (without age weighting ordiscounting). Total DALYs in 2010 were 2.490 billion.

2010 GBD (% of total burden of disease)

GBD Men 2010 (% of all burden)

GBD women (% of all burden)

Men vs. women in burden of disease• Tobacco: men #1, women #4• Alcohol: men #3, women #12• Illegal drugs #20, women not in top #20• Huge differences between high- and low/middle

income countries• Alcohol consumption varies with emancipation: the

more emancipated, the higher the alcohol-attributable burden of disease!

The worldwide epidemiological transition• Overall improvement in mortality across the world, with near

stagnation in Eastern Europe and parts of sub-Saharan Africa• Large declines in child mortality and in the burden for its key

risk factors, leading to larger share of disease burden fromNCDs (with main risk factors tobacco, alcohol, nutrition, andphysical activity).▫ A great deal more to be done in sub-Saharan Africa and

South Asia.• Shifting burden of smoking from high-income to low-and-

middle-income countries• Worldwide rise in body weight and glycaemia, with rare

regions where it has been stable; higher burden fromoverweight/obesity than undernutrition• Massive harms from alcohol use in Eastern Europe and Latin

America

Western Europe (larger countries)AndorraAustriaBelgiumCyprusDenmarkFinlandFranceGermanyGreeceGreenlandIcelandIrelandIsrael

ItalyLiechtensteinLuxembourgMaltaMonacoNetherlandsNorwayPortugalSan MarinoSpainSwedenSwitzerlandUnited Kingdom

Western Europe 2010

Central EuropeAlbaniaBosnia and HerzegovinaBulgariaCroatiaCzech RepublicHungaryMontenegroPolandRomaniaSerbiaSlovakiaSloveniaThe Former Yugoslav Republic of Macedonia

Central Europe 2010

Eastern EuropeBelarusEstoniaLatviaLithuaniaRepublic of MoldovaRussian FederationUkraine

Eastern Europe 2010

A comparison for the Baltic countries andFinland to global figures – risk factorattributable and total DALYs/100’000

0,00

5000,00

10000,00

15000,00

20000,00

25000,00

30000,00

35000,00

40000,00

Tobacco Alcohol Illegal Drugs All DALYs

Global

Baltic

Finland

A comparison for the Baltic countries andFinland to global figures – risk factorattributable DALYs/100’000

0,00

500,00

1000,00

1500,00

2000,00

2500,00

3000,00

3500,00

4000,00

4500,00

5000,00

Global Baltic Finland

Tobacco

Alcohol

Illegal Drugs

Percent DALYsattributable to SU risk factors

0,00

0,02

0,04

0,06

0,08

0,10

0,12

0,14

Global Baltic Finland

Tobacco

Alcohol

Illegal Drugs

Globally• For tobacco there are 6.30 million deaths in 2010, for

alcohol 2.74 million deaths, and for drugs 0.16million deaths• In total in 2010, there were 52.77 million deaths.• Thus tobacco is causing more than 10% of all deaths

(11.9%), and alcohol for about 5.2% and illegal drugsfor 0.3%

Prevalence, associated burden and economic costs ofsubstance use and substance use disorders in Europe arestaggering. For most of Europe tobacco use disorders causethe most burden and costs, for eastern Europe it is alcohol.Illegal drugs and its attributable burden is far behind, but itscosts depend more on political choices than on burden. Interms of countries, the Baltics are typical for EasternEuropean pattern and the Nordic Countries for westernEuropean patterns.