Alcohol and Mortality: An Actuarial Issue

Abstract

Despite some favorable global trends in the prevalence of heavy episodic drinking, alcohol-related mortality and morbidity since 2010, and the prevalence of youth drinking in certain developed countries, there has been limited progress in reducing total per-capita alcohol consumption. The burden of disease attributable to alcohol remains high, particularly at pre-retirement ages, and is increasing in some countries and for some causes of death. This article describes the status and trends in alcohol consumption, both worldwide and in the United States. It also describes the adverse consequences of heavy and binge drinking, which are significant to the individual, family and friends, and society. Although the overall effect on mortality of moderate alcohol drinking compared with no drinking at all has generally been viewed to be somewhat favorable due to the effect of certain cardiovascular risks, this view is not shared by all—the arguments involved are examined in this article. The recognition and need for active management of the adverse effects of heavy and binge alcohol consumption, remain essential to favorable health and longevity. Possible public interventions are also described. Actuaries involved in assessing mortality trends and product design need to assess trends in drivers and consequences of historical, current, and expected future alcohol-attributable mortality and morbidity patterns on a regular basis.

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Notes

1 The Volstead Act established Prohibition in America. Prohibition was in effect beginning on January 17, 1920, for 13 years. Liquor was illegal to manufacture or sell, but the purchase, possession, and consumption of legally acquired alcohol was permitted.

2 Ethanol can cause the release in the brain of serotonin, dopamine, and endorphins, all of which are compounds that can make people feel happy and less anxious.

3 The 4.0 million was reported in GBD 2015 Obesity Collaborators (2017); other estimates are by WHO.

4 HED is sometimes referred to as binge drinking, although definitions can differ (e.g., at least 60 grams of pure alcohol during at least one occasion per month).

5 The National Epidemiologic Survey on Alcohol and Related Conditions, with data collected from April 2001 to June 2002, and the National Epidemiologic Survey on Alcohol and Related Conditions III, with data collected from April 2012 to June 2013, in Grant et al. (2017).

6 Alcohol use disorder is the loss of control over alcohol drinking to the point of compulsion—consuming alcohol despite negative consequence. It includes both alcohol abuse and dependence, which can be moderate or severe. Alcohol abusers are those who continue to drink despite recurrent social, interpersonal, health, and legal problems, while those who are alcohol-dependent exhibit some or all of the following characteristics:

Alcohol tolerance: Needing to drink increasing amounts over time to achieve previous effects.

Withdrawal: After a short period without drinking, experiencing physical symptoms, such as tremors and mood swings.

Relieving or avoiding withdrawal symptoms, to “cure” a hangover.

Awareness of the compulsion or craving for alcohol, regardless of whether it is admitted.

Drinking more or over a longer period than intended, with unsuccessful cessation efforts.

7 In 2017, almost 11,000 deaths in the United States were due to alcohol-impaired driving (due to reduced inhibition, increased aggression, compromised motor skills, and blurred vision), although this represented a 63% reduction from the corresponding number of deaths in 1982.

8 According to Bagnardi et al. (2015), excess deaths due to cancers of the oral cavity, pharynx, liver, esophagus, (female) breast, and colorectum, with protection against kidney, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma diseases.

9 These include mental and behavioral disorders, including alcohol dependence and ultimately suicide.

10 22.7% of people who drink alcohol develop a dependence on it (Lopez-Quintero et al. 2011). Although transition from use to dependence was higher for nicotine (67.5%), this rate of transition was higher than for cocaine (20.9%) and cannabis (8.9%) users. Half of the cases of dependence on nicotine, alcohol, cannabis, and cocaine were observed about 27, 13, 5, and 4 years after use onset, respectively.

11 Primary sources of underestimates are (1) legal but unrecorded alcohol products consumed, (2) alcohol products that are recorded but not in the jurisdiction where they are consumed, (3) surrogate alcohol (alcohol not officially intended for consumption), (4) illegal homemade artisanal production, and (5) illegal production and smuggling.

12 Especially in the United States, these may be partly the result of increasingly deadly drugs such as fentanyl used in the overdose epidemic, since many people drink while taking drugs.

13 In 2016, for males, an estimated 2.3 million deaths and 106.5 million DALYs; for females, 0.7 million deaths and 26.1 million DALYs.

14 It is the first leading cause of death for the United Kingdom at those ages.

15 Alcohol consumption has been attributed to as many as one-third of serious falls among the elderly.

16 The study followed 333,247 participants at least 18 years of age with a follow-up period of 8.2 years.

17 It is important to note that if a person is addicted to alcohol use, it is extremely difficult to modify this behavior.

18 Through reduction of plaque deposits in arteries, protection against blood clot formation, and promotion of blood clot dissolution.

19 Mortality-induced deaths are a subset of alcohol-related deaths that are certain to be caused by alcohol consumption, including traffic accidents and cancer.

20 Based on Emerging Risk Factors Collaboration (ERFC), EPIC-CVD in the European Prospective Investigation into Cancer and Nutrition (EPIC) prospective cohort study, and the U.K. Biobank study—599,912 current drinkers with an average age of 57 years who did not have existing cardiovascular disease, adjusted for known confounders.

21 In Bell et al. (2017), clinical research using linked bespoke studies and electronic health records—1.93 million adults without cardiovascular disease at baseline.

22 Based on the Health and Retirement Study (HRS), a nationally representative sample of U.S. adults with mean follow-up of 9.1 years, who had their cognitive functions measured, starting in 1996 until between 2008 and 2019.

23 Although normal testing for alcohol use and patterns is not widely used, Sterling et al. (2020) indicated that 12 million alcohol screenings have been conducted in Kaiser Permanente Northern California annually, capturing alcohol use in the majority (87%) of the patient population. Similarly, the U.S. Veterans Health Administration screens approximately 90% of all outpatients for unhealthy alcohol use annually, resulting in more than 40 million documented screenings in the past 10 years. As demonstrated in the unadjusted analyses by Sterling et al., this information may help clinicians better understand the prevalence of unhealthy alcohol use in key clinical subpopulations at increased risk of alcohol-related harm.

Although a brief alcohol screening test can be used to determine individuals’ alcohol consumption, its accuracy depends on their honesty regarding how much they drink. More advanced technologies, such as epigenetic testing (which enables the identification of structural changes in the genome that occur due to exposure to a wide variety of substances including alcohol, tobacco, and cannabis) or carbohydrate-deficient transferrin (CDT), an alcohol biomarker test, can be used to detect whether someone is a binge drinker or a heavy daily drinker (four or more drinks a day). Their use can also raise a variety of ethical, legal, and social issues that are outside the scope of this article.

An aggregation of such testing results might be used to provide further actuarial insight in the future.