Elsevier

Alcohol

Volume 82, February 2020, Pages 1-10
Alcohol

Is burden of disease differentially linked to spirits? A systematic scoping review and implications for alcohol policy

https://doi.org/10.1016/j.alcohol.2019.06.005Get rights and content

Highlights

  • Estimates of alcohol burden are based on ethanol content without differentiating beverage type.

  • However, epidemiological studies point to differential burden by beverage type.

  • As per our review, often spirits have been associated with higher burden.

  • However, most research has not adequately controlled for confounders (in particular patterns of drinking).

  • There are some indications that favoring lower strength alcohol may result in less harm.

Abstract

Most epidemiological research on alcohol as a risk factor is based on the assumption that outcomes are linked to pattern and level of alcohol exposure, where different beverages are converted into grams of ethanol. This review examines this basic assumption, that alcohol has the same impact, independent of beverage type. We conducted a systematic search on comparative research of beverage-specific alcohol exposure and consequences. Research was divided by methodology (survey, case–control, cohort, time-series analyses, interventional research). Overall, many studies showed higher risks for spirits compared to beer or wine; however, most research was not controlled adequately for confounders such as patterns of drinking. While there is no conclusive evidence for spirits being associated with more harm, given the same pattern and level of alcohol exposure, some evidence supports for certain outcomes such as injuries and poisonings, a potential excess risk with spirits consumption due to rapid ethanol intake and intoxication. Accordingly, encouraging people to opt for beverages with lower alcohol content via taxation strategies has the potential to reduce alcohol-attributable harm. This does not necessarily involve switching beverage type, but also can achieved within the same beverage category, by shifting from higher to lower concentration beverages.

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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