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Understanding trends in alcohol consumption via liver disease mortality rates is crucial for targeting resources to reduce alcohol-related harm, writes Associate Professor Michael Livingston.
Alcohol consumption is a key driver of death and ill health in Australia, responsible for an estimated 4.5% of the burden of disease. After peaks in the late 1970s, per-capita alcohol consumption in Australia has declined, with the most recent data available putting average consumption at about 75% of its 1976 peak. These broad changes in drinking hide marked differences across different generations: youth drinking has fallen sharply in the past 20 years, while some older generations have seen increases in consumption (here). Understanding how these broad shifts in population drinking relate to harm rates is crucial for better targeting resources to reduce the negative impacts of alcohol, but long term data on negative outcomes from alcohol are relatively scarce.
Liver disease as a useful indicator
Alcohol-related liver disease is one of the most prevalent negative health impacts of heavy drinking in Australia, with around 400 deaths and 10 000 years of life lost due to its impacts each year (here). Alcohol-related liver disease involves a series of difference conditions, escalating in severity from fatty liver, through alcoholic hepatitis and onto liver cirrhosis, which is the primary driver of deaths 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 the key driver, responsible for around half of cirrhosis deaths globally (here) and in Australia (here).
Since alcohol-related liver disease is well understood and has generally been consistently coded for decades (especially in mortality), even as disease classification systems have changed, it is often used as an indicator of long term trends in harm from alcohol. In our study, we examined trends in alcohol-related liver disease deaths over a 50-year period to explore how overall levels of harm had changed in that period and then to compare mortality trends across generations.
The changing trends
We examined trends in alcohol-related liver disease mortality rates provided by the Australian Institute of Health and Welfare between 1968 and 2020 by age and sex. Death rates for men and women were highest in the late 1970s and early 1980s, before falling steadily (especially for men) through to the early 2000s. For the past 15 years, alcohol-related liver disease mortality has been relatively steady, increasing slightly for women. To unpack these trends, we estimated a series of age–period–cohort models to male and female mortality data. These models break the overall trend down into three components: the overall age distribution of mortality (age), the underlying population-level trend in mortality (period), and the impact of generational differences on mortality trends (cohort).
We found that alcohol-related liver disease mortality peaks around the age of 60 years for both men and women. For men, mortality rates were generally lower at a given age for every generation after those born in the 1930s; thus, for example, controlling for age, a man born around 1980 was around one-third as likely as someone born in 1935 to die of an alcohol-related disease. Generational differences were much less consistent for women, with cohorts born around 1930 and 1965 both experiencing significantly higher mortality rates than those born in between. Adjusting out generational differences, alcohol-related liver disease rates for women had slightly increased overall since the early 2000s. Overall, the data are broadly encouraging: alcohol-related liver disease for men and women is markedly lower now than it was in the early 1980s. However, our analyses suggest that these improvements have stalled and even potentially started to reverse for women. Recently released data showing ongoing increases in alcohol-induced mortality in 2021 and 2022 (here) suggest alcohol-related liver deaths may continue to increase.
Of note in our findings was a narrowing of the gender gap, driven partly by generational peaks in mortality for women born in the 1960s. This narrowing likely reflects long-running (and largely positive) cultural changes towards gender equity that have shifted social norms around women’s drinking. These shifts highlight the need for improved public health responses to alcohol, even in a context where per-capita consumption has been declining.
The need for continued intervention
The evidence for population-level interventions is clear: increasing price via tax or minimum unit pricing, reducing exposure to marketing and reducing the physical availability of alcohol will all lead to reductions in consumption and eventually mortality (here). Alongside these broad interventions, our work suggests that interventions focused on women approaching retirement age now might be especially worthwhile. There remains relatively little research in this area (although see here), and developing appropriate interventions at the general population, primary care and treatment sector levels should be a key priority to prevent ongoing increases in premature mortality among this generation of women. Of course, male rates of alcohol-related liver disease mortality remain higher than women’s and improving brief intervention and treatment access across the entire population is crucial.
The ongoing increases in alcohol deaths seen through the COVID-19 years in the United Kingdom, the United States and Australia point to a potentially overlooked public health challenge, and it is critical that state and federal governments pay attention to this ongoing driver of avoidable early mortality.
Michael Livingston is an Associate Professor at the National Drug Research Institute at Curtin University. He is one of Australia’s leading alcohol policy researchers, with more than 200 articles published.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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