Ralph Hingson, Sc.D., and Jürgen Rehm, Ph.D.
Jürgen Rehm, Ph.D., is director of the Social and Epidemiological Research Department at the Centre for Addiction and Mental Health, chair and professor in the Dalla Lana School of Public Health, University of Toronto, Canada, and section head at the Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany.
Ralph Hingson, Sc.D., is director of the Division of Epidemiology and Prevention Research at the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland.
Measuring the impact of alcohol consumption on morbidity and mortality depends on the accurate measurement of alcohol exposure, risk relationships, and outcomes. A variety of complicating factors make it difficult to measure these elements. This article reviews these factors and provides an overview of the articles that make up this special issue on current research examining alcohol’s role in the burden of disease. These topics include estimating alcohol consumption as well as alcohol-related morbidity and mortality in various demographic groups, and the burden of alcohol use disorders.
Key words: Alcohol use consumption; alcohol use frequency; alcohol use pattern; alcohol burden; public health impact; burden of disease; morbidity; mortality; disease; measurement; outcomes; specificity of measurement; sensitivity of measurement
This issue of Alcohol Research: Current Reviews examines the public health impact of alcohol consumption beyond the role of alcohol use disorders alone (Room et al. 2005)—that is, it looks at the burden of disease. Determining impact hinges on accurate and consistent “measurements.” As demonstrated in the articles in this issue, impact typically is estimated based on three elements (Rehm et al. 2010b; Walter 1976):
- The measurement of exposure (i.e., the relevant dimension of alcohol use) causing the burden (Kehoe et al. 2012; Rehm et al. 2010b);
- The measurement of the risk relations (i.e., what level/pattern of consumption is linked to what outcome) (Rehm et al. 2010a); and
- The measurement of outcomes.
These different measurements are central to this issue of Alcohol Research: Current Reviews.
Numerous challenges exist when measuring the extent and predictors of alcohol-related mortality and morbidity. Those challenges also affect our ability to evaluate the effectiveness of interventions to reduce alcohol-related morbidity and mortality. Different challenges exist for acute alcohol-related mortality and chronic disease mortality and morbidity, although some of the same challenges confront measurement in both areas. The following list of challenges is illustrative but not exhaustive.
Acute Mortality and Morbidity (Injuries and Poisonings)
Postmortem alcohol test data are not consistently available for many types of acute injury or poisoning deaths. The best available U.S. estimates indicate alcohol-attributable acute deaths outnumber chronic disease deaths 44,000 to 35,000 (Centers for Disease Control and Prevention [CDC] 2013). Traffic crashes have been the leading category of alcohol-attributable injury or death over the past 30 years. During that time period, the majority of drivers in fatal crashes (both fatally injured and, to a lesser extent, surviving drivers) have been tested for alcohol. This permits researchers to make accurate estimates of the number of drivers, passengers, and others who die in fatal crashes in which a driver was known to have been drinking.
In addition, by examining the characteristics of crashes and drivers in fatal crashes where alcohol is present, the National Highway Traffic Safety Administration (NHTSA) (Klein 1986; NHTSA 2002) has developed an imputational approach to estimate the proportion of fatal crashes involving alcohol even when the driver is not tested. This approach was verified using data from States with high percentages of drivers involved in fatal crashes that were tested for alcohol use. Researchers used the NHTSA model to predict the percentage of fatal crashes that involved alcohol and then compared those findings with the actual alcohol test results. NHTSA found they could estimate with great accuracy not only the proportion of fatal crashes involving alcohol-positive drivers but also the blood alcohol level (BAL) of the driver at the time of the crash.
Using this approach, researchers have been able to determine annual State and national estimates of alcohol involvement in fatal traffic crashes since 1982. Furthermore, having those accurate direct-test results and imputed results has permitted researchers to make epidemiologic estimates of the increased odds of fatal crashes and other crash involvement at various BALs (Voas et al. 2012). Drivers who were stopped at random in roadside surveys were compared with drivers who were fatally injured in single-vehicle crashes and who were driving in the same States on the same types of roads on the same days of the week and times of day.
Because these data are available monthly on a national, State, and community level, researchers also have been able to monitor trends in fatal crashes involving alcohol relative to fatal crashes where alcohol is not involved over time. In addition, researchers are able to use quasi-experimental and other research designs to evaluate whether State-level traffic safety legislation and community-level education and law enforcement and treatment programs are effective in reducing alcohol-related traffic deaths (Ferguson 2012; Hingson and White 2013).
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