Is burden of disease differentially linked to spirits? A systematic scoping review and implications for alcohol policy
Introduction
Alcohol-attributable burden of disease is usually calculated under the assumption that beverage type does not matter; risk relations are based on level and pattern of use of pure alcohol (ethanol) rather than differentially by beverage type (GBD Risk Factors Collaborators et al., 2018, Rehm et al., 2001, World Health Organization, 2018). This practice has been applied in all comparative risk assessments of alcohol to date, either as part of the Global Burden of Disease studies or independent from them (Rehm and Imtiaz, 2016, World Health Organization, 2018), mostly based on epidemiological cohort studies, where the risk of alcohol exposure for disease outcomes was also based on the assumption that ethanol has the same impact, regardless of the underlying beverage type (e.g., see the meta-analyses for the various incidence and mortality endpoints summarized in Rehm, Gmel et al., 2017). However, this assumption is challenged by many ecological studies, which point to a higher impact of spirits consumption compared to the same ethanol content in the form of beer or wine (e.g., Kerr and Ye, 2011, Korotayev et al., 2018, Razvodovsky, 2010b; see below for an overview). For example, Kerr and colleagues compared the beverage-specific and the total alcohol per capita consumption's associations with cirrhosis mortality rates in multiple countries, using pooled cross-sectional time-series analysis (Kerr, Fillmore, & Marvy, 2000). They only found significant associations for both total ethanol and spirits consumption, but not for beer or wine. Thus, spirits consumption was found to make up the majority of the effect of alcoholic beverage consumption on cirrhosis mortality.
This contribution will first review the evidence for a larger contribution of spirits, and will develop recommendations not only for future handling in science, but also for practical applications such as alcohol control policy measures (Room, 2010).
Section snippets
Materials and methods
This scoping review has been conducted according to the PRISMA guidelines (Moher, Liberati, Tetzlaff, Altman, & Group, 2015). A systematic search was carried out on January 8, 2019, with no date or language restrictions, using OVID to search MEDLINE® and Embase®. Studies pertaining to beverage-specific alcohol exposure and harm were identified using a combination of keywords and MESH terms related to alcohol use, morbidity, and mortality. Table in the Appendix provides the exact search strategy.
Overview
Table 1 gives an overview of the individual papers on differential effects of beverage types after 1995. The year 1995 was selected because the last comprehensive narrative review of Smart was published in 1996 (Smart, 1996), and included publications up to 1994. Our systematic search also yielded only one relevant publication prior to 1995, indicating that wine drinking was associated with higher incidence of functional disability compared to beer or spirits drinking or to abstention; however,
Discussion
Consumption of spirits was more closely associated with a number of outcomes where patterns of drinking played a crucial role, most prominently unintentional and intentional injuries (Rehm et al., 2017, Rehm et al., 2003). However, there is no general rule that spirits consumption is associated with more harm than consumption of wine and beer. What are the implications for alcohol control policy?
In a situation where spirits consumption is more closely associated with a major outcome of alcohol
Competing interests
The authors confirm that no competing interests exist.
Funding
JR acknowledges funding from the Canadian Institutes of Health Research, Institute of Neurosciences, Mental Health and Addiction (CRISM Ontario Node grant no. SMN-13950).
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