What does research tell us about alcohol related health risks

www.rarha.euPia.makela@thl.fi
Helsinki
17 February 2016
Expert Meeting
What does research tell us
about alcohol related health
risks:
RARHA work to summarize the
evidence to inform the setting of
low-risk drinking guidelines

www.rarha.eu
Setting guidelines and science
Marjatta.Montonen@thl.fi
Setting up guidelines always includes some type of review of
the science
- Narrative review
- Quantitative estimates of risk in various levels of alcohol
intake
Recent low-risk drinking guidelines based on sophisticated
quantitative summaries of risk: Australia (2009), Canada
(2012), UK (2016)
- Heavy work requiring a lot of resources
- Not (easily) an option for smaller and poorer countries
- Could this work be done for EU countries together?

www.rarha.eu
Problems in determining guidelines from risk data
Problem 1: where to draw
the line? ?
(Canada)?
Di Castelnuovo et al. (2006) Arch Intern Med. .
??

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Problem 2: how to take into account different diseases?
Source: Holmes et al. 2016

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Country 1: 20%
Country 2: 5%
Each curve is a meta-analytic
review of literature on the risk
of one disease by the level of
drinking. To derive drinking
guidelines, a summary of these
summaries is needed

www.rarha.eu
Country 1: 20%
Country 2: 5%
Country 1: 10%
Country 2: 30%
You cannot rely on estimates of overall mortality
or do one calculation for all countries combined.
Different cause-of-death distributions in
different populations need to be taken into account

www.rarha.eu
Work in Joint Action RARHA to summarize science
unerpinnings
- Aim: to provide this type of summarizing risk
quantification for 7 countries selected to represent the
variation of drinking patterns and mortality patterns in the
EU.
- Estonia, Finland, Germany, Hungary, Ireland, Italy,
Poland

www.rarha.eu
Work in Joint Action RARHA to summarize science
unerpinnings
Work carried out by
Jürgen Rehm’s team
at the Canadian
Centre forAddiction
and Mental Health
(CAMH), also
responsible for
calculations for the
Canadian and the
Australian guidelines.
http://www.camh.ca/en/research/new
s_and_publications/reports_and_book
s/Documents/Lifetime%20Risk%20of
%20Alcohol-
Attributable%20Mortality.pdf

www.rarha.eu
Method (problems to be solved, continued)
Mortality vs. morbidity?
- Robust estimates of risk curves for
morbidity by cause not available
-> based on mortality only
- Canada: mainly mortality;
Australia: mortality; UK: mainly
mortality

www.rarha.eu
Method: what risk & “where to draw the line?”
Canada: relative risk approach = risk at a
given drinking level relative to abstainers
Australia: absolute risk approach = life
time risk of dying due to alcohol if you
drink at a given level your whole life. E.g.
risk of 1/100.
- Same approach as with environmental
hazards (risk 1/1000 000)
- What criterion? 1/10, 1/100, 1/1000 (or
1/274)?
UK: both
RARHA: Rehm’s report used the Australian approach (1/100
and 1/1000); results fed into the Delphi survey on “low risk”
drinking

www.rarha.eu
Method / problems to solve: men vs. women
Typical pattern:
women’s
RELATIVE risk
(of chronic
diseases)
increases more
strongly with
increasing
consumption…

www.rarha.eu
But men have
higher ABSOLUTE
risk, with or
without alcohol
Should men drink
less than women,
because they
reach 1/100 risk
faster -- because
of their higher
baseline risk?
0
5
10
15
20
25
30
35
40
0 10 20 30 40 50 60
%
Mean consumption
(Units per week)
Male
Female
(Hypothetical data)

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-> Australia & UK: same limits for men and women
Calculations made for RARHA: baseline risk (risk at
no alcohol consumption) assumed to be common for
men and women in order to not ‘punish’ men for
their higher baseline risk (+ sensitivity analysis)
- Delphi survey: experts asked for their opinion

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How to decide what diseases and injuries are alcohol-
attributable & which risk functions to use?
• Based on WHO
Global Status Report
on Alcohol and
Health and on the
Global Burden of
Disease work

www.rarha.eu
What do the RARHA calculation results look like –
combined risk curves for two countries
Xx
-0,05
0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0,4
0,45
0,5
0 10 20 30 40 50 60 70 80 90 100
A
l
c
o
h
o
l
l
i
f
e
t
i
m
e
m
o
r
t
a
l
i
t
y
r
i
s
k
Population consumption in g/day
Risk M
Risk W
-0,05
0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0,4
0,45
0,5
0 10 20 30 40 50 60 70 80 90 100
A
l
c
o
h
o
l
l
i
f
e
t
i
m
e
m
o
r
t
a
l
i
t
y
r
i
s
k
Population consumption in g/day
Risk M
Risk W
Hungary Italy
Differences are due to
differences in cause-of death
distribution

www.rarha.eu
Combined EU-results / table format
Risk:
Average
Drinking
Average across all seven countries
M W Total
10g -0.0019 0.0009 -0.0005
20g 0.0043 0.0199 0.0121
30g 0.0138 0.0471 0.0305
40g 0.0269 0.0804 0.0536
50g 0.0444 0.1267 0.0855
60g 0.0664 0.1726 0.1195
<1/1000
<1/100
>1/100

www.rarha.eu
Combined EU-results / table format
Avera
ge
Drinki
ng
Estonia Finland Germany Hungary Ireland Italy Poland
M W M W M W M W M W M W M W
10g 0.003 0.005 -0.002 0.004 -0.000 0.002 -0.006 -0.002 -0.001 0.001 0.000 0.002 -0.007 -0.006
20g 0.014 0.038 0.003 0.019 0.004 0.015 0.003 0.027 0.003 0.013 0.005 0.013 -0.000 0.015
30g 0.030 0.084 0.010 0.040 0.011 0.033 0.017 0.070 0.008 0.029 0.010 0.028 0.010 0.047
<1/1000 <1/100 >1/100

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Role of these calculations?
The risk calculations might help individual
countries in assessing risks and in deriving
guidelines
In Joint Action RARHA the risk calculations were
one point of departure in the Delphi survey to
explore consensus and differing views

This presentation was produced for a meeting organized within
Joint Action on Reducing Alcohol Related Harm (RARHA) which has
received funding from the European Union, in the framework of the
Health Programme (2008-2013).
The content of this presentation represents the views of the
author/s and it is their sole responsibility; it can in no way be taken
to reflect the views of the European Commission or of the
Consumers, Health, Agriculture and Food Executive Agency or any
other body of the European Union. The European Commission and
the Executive Agency do not accept responsibility for any use that
may be made of the information it contains.

What does research tell us about alcohol related health risks

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