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. 2022 Jul 16;400(10347):185-235.
doi: 10.1016/S0140-6736(22)00847-9.

Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020

GBD 2020 Alcohol Collaborators
Collaborators

Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020

GBD 2020 Alcohol Collaborators. Lancet. .

Erratum in

  • Department of Error.
    [No authors listed] [No authors listed] Lancet. 2022 Jul 30;400(10349):358. doi: 10.1016/S0140-6736(22)01389-7. Epub 2022 Jul 19. Lancet. 2022. PMID: 35868328 Free PMC article. No abstract available.

Abstract

Background: The health risks associated with moderate alcohol consumption continue to be debated. Small amounts of alcohol might lower the risk of some health outcomes but increase the risk of others, suggesting that the overall risk depends, in part, on background disease rates, which vary by region, age, sex, and year.

Methods: For this analysis, we constructed burden-weighted dose-response relative risk curves across 22 health outcomes to estimate the theoretical minimum risk exposure level (TMREL) and non-drinker equivalence (NDE), the consumption level at which the health risk is equivalent to that of a non-drinker, using disease rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020 for 21 regions, including 204 countries and territories, by 5-year age group, sex, and year for individuals aged 15-95 years and older from 1990 to 2020. Based on the NDE, we quantified the population consuming harmful amounts of alcohol.

Findings: The burden-weighted relative risk curves for alcohol use varied by region and age. Among individuals aged 15-39 years in 2020, the TMREL varied between 0 (95% uncertainty interval 0-0) and 0·603 (0·400-1·00) standard drinks per day, and the NDE varied between 0·002 (0-0) and 1·75 (0·698-4·30) standard drinks per day. Among individuals aged 40 years and older, the burden-weighted relative risk curve was J-shaped for all regions, with a 2020 TMREL that ranged from 0·114 (0-0·403) to 1·87 (0·500-3·30) standard drinks per day and an NDE that ranged between 0·193 (0-0·900) and 6·94 (3·40-8·30) standard drinks per day. Among individuals consuming harmful amounts of alcohol in 2020, 59·1% (54·3-65·4) were aged 15-39 years and 76·9% (73·0-81·3) were male.

Interpretation: There is strong evidence to support recommendations on alcohol consumption varying by age and location. Stronger interventions, particularly those tailored towards younger individuals, are needed to reduce the substantial global health loss attributable to alcohol.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests O M Adebayo reports grants or contracts from Merck Foundation and Servier Nigeria; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Merck Foundation; support for attending meetings or travel from Servier Nigeria; and a leadership or fiduciary role in a board, society, committee or advocacy group, paid or unpaid, with the Nigerian Association of Resident Doctors; all outside the submitted work. S Afzal reports honorary participation on the Institutional Review Board of King Edward Medical University (Lahore, Pakistan), the Quality Enhancement Cell at Fatima Jinnah Medical University (Lahore, Pakistan), and the Corona Expert Advisory Group (Pakistan); an unpaid leadership or fiduciary role in board, society, committee or advocacy group, with the Pakistan Society of Community Medicine & Public Health, Pakistan Association of Medical Editors, and Pakistan Society of Medical Infectious Diseases; all outside the submitted work. R Ancuceanu reports consulting fees from AbbVie; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AbbVie, B. Braun Medical, Sandoz, and Laropharm; all outside the submitted work. P Atorkey reports support for the present manuscript via funding from the School of Medicine and Public Health, The University of Newcastle (Callaghan, NSW, Australia), and infrastructure support from Hunter New England-Population Health and Hunger Medical Research Institute, Australia. M Ausloos reports a research grant from the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI (project number: PN-III-P4-ID-PCCF-2016-0084, title: “Understanding and modelling time-space patterns of psychology-related inequalities and polarization”) outside the submitted work. T Bärnighausen reports grants from the European Union (Horizon 2020 and EIT Health), German Research Foundation (DFG), US National Institutes of Health, German Ministry of Education and Research, Alexander von Humboldt Foundation, Else-Kröner-Fresenius-Foundation, Wellcome Trust, Bill & Melinda Gates Foundation, KfW, Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization; consulting fees from KfW for the OSCAR initiative in Vietnam; participation on a Data Safety Monitoring Board or Advisory Board with National Institutes of Health (US)-funded study “Healthy Options” (PIs: Smith Fawzi, Kaaya) as Chair of the Data Safety and Monitoring Board, with the German National Committee on the “Future of Public Health Research and Education”, as chair of the scientific advisory board to the EDCTP Evaluation, as a member of the UNAIDS Evaluation Expert Advisory Committee, as a National Institutes of Health (US) Study Section Member on Population and Public Health Approaches to HIV/AIDS (PPAH), with the US National Academies of Sciences, Engineering, and Medicine's Committee for the “Evaluation of Human Resources for Health in the Republic of Rwanda under the President's Emergency Plan for AIDS Relief (PEPFAR)”, with the University of Pennsylvania Population Aging Research Center (PARC) as an External Advisory Board Member; leadership or fiduciary role in a board, society, committee or advocacy group, paid or unpaid, with the Global Health Hub Germany (which was initiated by the German Ministry of Health) as a co-chair; all outside the submitted work. S M M Bhaskar reports grants or contracts from the NSW Ministry of Health, Australia; a leadership or fiduciary role in a board, society, committee or advocacy group, paid or unpaid, with the Rotary Club of Sydney as board director, with the International Rotary Fellowship of Healthcare Professionals (UK) as board director, with Global Health & Migration Hub Community, Global Health Hub Germany, Berlin as a chair or manager; all outside the submitted work. J M Castaldelli-Maia reports grants or contracts from Pfizer (Independent Grants for Learning and Change) and the French National Institute for Cancer (INCa); consulting fees from L'Oreal Mental Health Wellness International Board; all outside the submitted work. S Costanzo reports a research grant from the European Foundation for Alcohol Research (ERAB) (ID EA1767; 2018-2020); payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from The Dutch Beer Institute Foundation - The Brewers of Europe as a member of the Organizing Committee and speaker for the 9th European Beer and Health Symposium (Bruxelles 2019), and for giving a lecture at the 13th European Nutrition Conference FENS 2019 (Dublin), sponsored by the Beer and Health Initiative (The Dutch Beer Institute foundation - The Brewers of Europe); all outside the submitted work. I Filip reports financial or non-financial support from the Avicenna Medical and Clinical Research Institute (California, USA). R C Franklin reports leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid with Kidsafe, Farmsafe, Royal Life Saving Society – Australia, and PHAA – Injury Prevention SIG outside the submitted work. C Herteliu reports research grants from the Romanian Ministry of Research Innovation and Digitalization, MCID (ID-585-CTR-42-PFE-2021, Jan 2022-Jun 2023, “Enhancing institutional performance through development of infrastructure and transdisciplinary research ecosystem within socio-economic domain – PERFECTIS”), the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI (PN-III-P4-ID-PCCF-2016-0084, October, 2018, to September, 2022, “Understanding and modelling time-space patterns of psychology-related inequalities and polarization”; PN-III-P2-2.1-SOL-2020-2-0351, June, 2020, to October, 2020, “Approaches within public health management in the context of COVID-19 pandemic”), and the Ministry of Labour and Social Justice, Romania (30/PSCD/2018, September, 2018, to June, 2019, “Agenda for skills Romania 2020-2025”), all outside the submitted work. J J Jozwiak reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Teva Pharmaceuticals, Amgen, Synexus, Boehringer Ingelheim, ALAB Laboratories, and Zentiva, outside the submitted work. M Kivimäki reports support for the present manuscript from the Wellcome Trust (221854/Z/20/Z), the UK Medical Research Council (MR/S011676/1), the US National Institute on Aging (R01AG056477), and the Academy of Finland (350426) in the form of research grants to their institution. K Krishan reports non-financial support from the UGC Centre of Advanced Study (Phase II), Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. S Lorkowski reports grants or contracts paid to his institution from Akcea Therapeutics Germany; consulting fees from Danone, Novartis Pharma, Swedish Orphan Biovitrum (SOBI), and Upfield; payment or honoraria for lectures, presentations, speaker's bureaus, manuscript writing, or educational events from Akcea Therapeutics Germany, Amarin Germany, Amedes Holding, Amgen, Berlin-Chemie, Boehringer Ingelheim, Daiichi Sankyo Deutschland, Danone, Hubert Burda Media Holding, Janssen-Cilag, Lilly Deutschland, Novartis, Novo Nordisk, F Hoffmann-La Roche (Roche), Sanofi-Aventis, SYNLAB Holding Deutschland, and SYNLAB Akademie; support for attending meetings or travel from Amgen; and participation on a data safety monitoring board or advisory board for Akcea Therapeutics Germany, Amgen, Daiichi Sankyo Deutschland, Novartis, and Sanofi-Aventis; all outside the submitted work. A M Madureira-Carvalho reports grants or contracts from Instituto Universitário de Ciências da Saúde (Gandra, Portugal); consulting fees from Albert Labs and Eurox Pharma paid to her and her institution; a leadership or fiduciary role in a board, society, committee or advocacy group, paid or unpaid, with the Portuguese Association of Forensic Sciences (APCF); all outside the submitted work. A-F A Mentis reports grants or contracts from “MilkSafe: A novel pipeline to enrich formula milk using omics technologies”, a research co-financed by the European Regional Development Fund of the European Union and Greek national funds through the Operational Program Competitiveness, Entrepreneurship and Innovation, under the call RESEARCH - CREATE - INNOVATE (project code: T2EDK-02222), as well as from ELIDEK (Hellenic Foundation for Research and Innovation, MIMS-860); stock or stock options in a family winery; and support from BGI Group as a scientific officer; all outside the submitted work. C D H Parry reports grants or contracts from the South African Medical Research Council paid to their institution; consulting fees paid to them from the World Health Organization (WHO) and the University of Cape Town (Cape Town, South Africa); payment or honoraria for a lecture on alcohol & NCDs in 2020 from the University of Cape Town; support for attending meetings or travel from UCT African Union 2022, UN Office on Drugs & Crime 2019, and WHO meeting on alcohol in Uganda 2021; participation on a Data Safety Monitoring Board or Advisory Board with the UK SPECTRUM Project (multi university) Global Advisory Board, and the UN Office on Drugs & Crime WDR Scientific Advisory Board, both unpaid; all outside the submitted work. G A Roth reports support for the present manuscript from the Bill & Melinda Gates Foundation via a research grant to their institution. G A Roth reports grants or contracts from the American Heart Association, the American College of Cardiology, and the National Heart, Lung, and Blood Institute paid to their institution, outside the submitted work V Shivarov reports financial support from ICON plc. J A Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs, Adept Field Solutions, Clinical Care Options, Clearview Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM, Trio Health, Medscape, WebMD, and Practice Point Communications, the National Institutes of Health, and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Simply Speaking; support for attending meetings or travel from the steering committee of OMERACT; participation on a Data Safety Monitoring Board or Advisory Board with the US Food and Drug Administration Arthritis Advisory Committee; leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid, with OMERACT as a steering committee member, with the Veterans Affairs Rheumatology Field Advisory Committee as Chair (unpaid), and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis and editor and director (unpaid); stock or stock options in TPT Global Tech, Vaxart Pharmaceuticals, Aytu BioPharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics, Seres Therapeutics, Tonix Pharmaceuticals and Charlotte's Web Holdings, and previously owned stock options in Amarin, Viking, and Moderna Pharmaceuticals; all outside the submitted work.

Figures

Figure 1
Figure 1
Exemplifying a weighted all-attributable cause alcohol relative risk curve Points mark the theoretical minimum risk exposure level and non-drinker equivalence level. The shaded areas denote consumption levels with a lower risk (green) and greater risk (purple), compared to no consumption. The solid line indicates the mean aggregate relative risk estimate, whereas the shaded area reflects the 95% uncertainty interval of the aggregate relative risk estimate. One standard drink is equivalent to 10 g of pure ethanol.
Figure 2
Figure 2
Relative proportions of DALYs for causes associated with alcohol use, by GBD super-region, age group, and sex, in 2020 The proportions represent the weights associated with each cause-specific relative risk curve when constructing each all-cause relative risk curve. The green shades signify causes with a lower risk at low levels of consumption, compared to no consumption. The red and purple shades signify causes with an entirely harmful effect at all levels of consumption. The black line separates causes for which moderate alcohol use lowers risk from causes with an entirely harmful effect. Diabetes includes only type 2 diabetes. Cancers include lip and oral cavity cancer, nasopharynx cancer, other pharynx cancer, oesophageal cancer, larynx cancer, colon and rectum cancer, breast cancer, and liver cancer. Cirrhosis includes cirrhosis and other chronic diseases of the liver. Infectious disease includes tuberculosis. Injuries includes transport injuries, unintentional injuries, self-harm, and interpersonal violence. Other causes include pancreatitis, idiopathic epilepsy, hypertensive heart disease, and atrial fibrillation and flutter. DALY=disability-adjusted life-year.
Figure 3
Figure 3
Mean theoretical minimum risk exposure levels (A) and non-drinker equivalence levels (B), in units of standard drinks per day, by region, age group, and sex, in 2020 One standard drink is equivalent to 10 g of pure ethanol.
Figure 4
Figure 4
Proportion of the population consuming harmful amounts of alcohol, defined as consumption in excess of the mean non-drinker equivalence level, by sex and age group, in 2020
See this image and copyright information in PMC

Comment in

  • Complex relationship between health and moderate alcohol use.
    Burton R, Sheron N. Burton R, et al. Lancet. 2022 Jul 16;400(10347):141-143. doi: 10.1016/S0140-6736(22)01288-0. Lancet. 2022. PMID: 35843231 No abstract available.
  • Alcohol and health.
    Kivimäki M, Batty GD. Kivimäki M, et al. Lancet. 2022 Nov 19;400(10365):1763-1764. doi: 10.1016/S0140-6736(22)02122-5. Lancet. 2022. PMID: 36403616 No abstract available.
  • Alcohol and health.
    Manthey J, Shield K, Rehm J. Manthey J, et al. Lancet. 2022 Nov 19;400(10365):1764-1765. doi: 10.1016/S0140-6736(22)02123-7. Lancet. 2022. PMID: 36403617 No abstract available.
  • Alcohol and health.
    Schooling CM, Leung GM. Schooling CM, et al. Lancet. 2022 Nov 19;400(10365):1765. doi: 10.1016/S0140-6736(22)02124-9. Lancet. 2022. PMID: 36403618 No abstract available.

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