Methods
For this analysis, we constructed dose-response relative risk curves weighted against 22 health outcomes to estimate the theoretical minimal risk exposure level (TMREL) and the nonconsumer equivalent (NDE), the level of consumption at which the risk for health is equivalent to that of a non-drinker, using disease rates from the Global Burden of Disease, Injury and Risk Factors (GBD) Study 2020 for 21 regions, including 204 countries and territories, by 5-year age group, sex and person-year aged 15–95 years and older from 1990 to 2020. Based on NDE, we quantified the population consuming harmful amounts of alcohol.
Foundings
Weighted relative risk curves for alcohol use differed by region and age. Among individuals aged 15–39 years in 2020, TMREL ranged between 0 (95% CI 0–0) and 0.603 (0.400–1.00) standard drinks per day, and NDE ranged between 0.002 (0–0) and 1.75 (0.698–4.30) standard drinks per day. Among those aged 40 years and older, the weighted relative risk curve was J-shaped for all regions, with 2020 TMRELs ranging from 0.114 (0-0.403) to 1.87 (0.500-3). ·30) standard drinks per day and NDE ranged between 0.193 (0–0.900) and 6.94 (3.40–8.30) standard drinks per day. Among those consuming harmful amounts of alcohol in 2020, 59.1% (54.3–65.4) were aged 15–39 and 76.9% (73.0–81.3) were male.
Interpretation
There is strong evidence to support recommendations about alcohol consumption that vary by age and location. Stronger interventions, particularly those aimed at younger people, are needed to reduce the significant global health loss attributable to alcohol.
Financing
Bill & Melinda Gates Foundation.
Introduction
Alcohol use amounted to 1.78 million (95% CI [UI] 1·39–2·27) deaths in 2020 and was the main risk factor for mortality among men aged 15–49 years (Bryazka D, unpublished). The relationship between moderate alcohol use and health is complex, as shown in many previous studies.1
Griswold MG Fullman N Hawley C et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.2
Shield K Manthey J Raylette M et al.
National, regional and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study.3
Wood AM Kaptoge S Butterworth AS et al.
Risk thresholds for alcohol consumption: pooled analysis of individual participant data for 599 912 current drinkers in 83 prospective studies.4
Rem J Gmail Sr, GE Gmail C et al.
The relationship between different dimensions of alcohol use and disease burden – an update.5
Millwood IY Walters RG Mei XW et al.
Conventional and genetic evidence on the etiology of alcohol and vascular disease: a prospective study of 500,000 men and women in China.6
of Luitgaarden IAT van Oort S Bowman EJ et al.
Alcohol consumption in relation to cardiovascular disease and mortality: a systematic review of Mendelian randomization studies. Alcohol consumption at any level is associated with loss of health from various diseases, including cirrhosis of the liver, breast cancer and tuberculosis, as well as injuries.7
Liu Y Nguyen N Colditz GA
Associations between alcohol consumption and breast cancer: a look at the evidence.8
Imtiaz S KD shield Roerecke M Samokhvalov AV Lönnroth K Rem J
Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease.9
Taylor B Irving HM Canteres F et al.
The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and the risk of injury or crash increase together.10
Roerecke M Vafaii A Hasan OSM et al.
Alcohol consumption and risk of liver cirrhosis: a systematic review and meta-analysis. At the same time, some studies have found that drinking small amounts of alcohol reduces the risk of cardiovascular disease and type 2 diabetes. meta-analysis of the impact of heavy drinking occasions on risk for moderate drinking.12
Pietraszek A. Gregersen S Hermansen K
Alcohol and type 2 diabetes. A review.13
Ding G O’Neill D Bell S Stamatakis E Britton A
Association of alcohol consumption with morbidity and mortality in patients with cardiovascular disease: original data and meta-analysis of 48,423 men and women. As a consequence, the amount of alcohol that minimizes health loss is likely to depend on the distribution of underlying disease burdens in a given population. Since this distribution varies widely by geography, age, sex, and time, the level of alcohol consumption associated with the lowest health risk will depend on the age structure and disease composition of that population.14
Sherk A Gilmore W Churchill S Lensvelt E Stockwell T Chikritzhs T
Implications of cardioprotective hypotheses for national alcohol consumption guidelines and alcohol harm surveillance systems.15
Sherk A Thomas G Churchill S Stockwell T
Does drinking according to low-risk guidelines prevent harm? Implications for high-income countries using the international model of alcohol harm and policies.16 WHO Global Status Report on Alcohol and Health 2018.Two quantities are critical in formulating effective, evidence-based alcohol control guidelines and policies: the theoretical minimum risk exposure level (TMREL), which represents the level of consumption that minimizes health loss from alcohol for a population and non-drinkers; equivalence level (NDE), which measures the level of alcohol consumption at which a drinker’s risk of health loss is equivalent to that of a non-drinker. The majority of studies to date have examined one or a small subset of alcohol-related health outcomes at a time, although several larger systematic meta-analyses have been conducted.1
Griswold MG Fullman N Hawley C et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.4
Rem J Gmail Sr, GE Gmail C et al.
The relationship between different dimensions of alcohol use and disease burden – an update.17
Corrao G Bagnardi V Ham A The old G
A meta-analysis of alcohol consumption and the risk of 15 diseases.18
Xi B Veeranki SP Zhao M My C yan-y Mi J
Association of alcohol consumption with all-cause, cardiovascular, and cancer-related mortality in US adults.19 Levels of alcohol consumption compared with drinking patterns for predicting all-cause and all-cause mortality in current drinkers. Findings from these studies vary in their estimates of TMREL. Several studies have found evidence of a J-shaped relationship between alcohol use and all-cause mortality.3
Wood AM Kaptoge S Butterworth AS et al.
Risk thresholds for alcohol consumption: pooled analysis of individual participant data for 599 912 current drinkers in 83 prospective studies.18
Xi B Veeranki SP Zhao M My C yan-y Mi J
Association of alcohol consumption with all-cause, cardiovascular, and cancer-related mortality in US adults.20
Patra J Buckley C Kerr WC Brennan A RC seller Rem J
Effect of body mass and alcohol consumption on all-cause and liver mortality in 240 000 adults in the United States. However, others have reported that the weighted TMREL of alcohol is zero standard drinks per day.
Griswold MG Fullman N Hawley C et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.21
Habtemichael LH Dzekic D Rosengren AR et al.
Alcohol consumption in young men and risk of heart failure and all-cause mortality – a cohort study. Uncertainty about the effect of alcohol on all-cause health loss arises from differences in the composition of the relevant illness between studies, conflicting studies of individual health outcomes, differences in covariates and study methods, estimation of drinking patterns, and issues that are related to selection bias .22
Fillmore KM Stockwell T Chikritzhs T Bostrom A Kerr W
Moderate alcohol use and reduced risk of mortality: systematic error in prospective studies and new hypotheses.23
Wallach JD Sergiou S Chu et al.
Assessment of confounding in epidemiologic studies assessing alcohol consumption in the risk of ischemic heart disease.Research in context Evidence prior to this study The risks of moderate alcohol use on health outcomes have been widely studied and debated for many years. Studies have examined the health effects associated with alcohol consumption through a variety of approaches, ranging from examining effects on a single disease, examining multiple health outcomes, and using all-cause mortality as the outcome. Several systematic reviews have also been published on this topic, and in recent years several publications have used Mendelian randomization to investigate the relationship between alcohol use and health outcomes. Overall, the findings are mixed, which in part contributes to this topic being controversial and debated. Several studies have found evidence of a J-shaped relationship between alcohol use and all-cause mortality or burden. In other words, at low levels of consumption, alcohol reduces the risk of all-cause mortality, while above a certain threshold it increases the risk. However, other studies, including a publication by the GBD 2016 Alcohol Collaborators in The Lancet in 2018, reported that…
