Correspondence
1
2
3
Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009; 373: 2223–33. Rehm J, Room R. A case study in how harmful alcohol consumption can be. Lancet 2009; 373: 2176–77. US Department of Health and Human Services. National health expenditure accounts. http:// www.cms.hhs.gov/NationalHealthExpendData/ (accessed July 7, 2009).
Authors’ reply Damian Mole and colleagues argue that more focus should be placed on pancreatitis as a factor in global health, stressing the high costs of treatment of pancreatitis in high-income countries such as the UK and USA. Although such considerations are important, the Global Burden of Disease (GBD) study uses a different metric—one that focuses on mortality and burden of disease, the latter as a composite measure of years of life lost either to premature mortality or to disability.1 Burden of disease and costs are associated, but they are not the same. Moreover, the GBD has to restrict itself to major disease categories that can be assessed or estimated reliably in all parts of the world. As a result, the 2004 GBD update did not have a separate disease category for pancreatitis.1 The ongoing GBD 2005 study, to be finalised in 2010, tries to overcome these limitations with a substantially enlarged disease and injury cause list, which will now include pancreatitis (International Classification of Disease [ICD] categories K85 and K86). This will allow for the inclusion of pancreatitis in the next round of the comparative risk assessment for alcohol and other potentially relevant risk factors. Additionally, a meta-analysis to establish relative risks of alcohol and pancreatitis has been done.2 Attributable fractions for alcohol and pancreatitis have to be established via combining exposure prevalence with risk estimates, since the more detailed ICD categories such as alcohol-induced acute (K85.2) and alcohol-induced chronic pancreatitis (K86.0) cannot be assessed or estimated reliably on www.thelancet.com Vol 374 September 19, 2009
a global level. With the exception of alcohol-use disorders and fetal alcohol syndrome, all disease categories that are by definition alcohol-attributable3 have to be estimated as part of a larger category via this method. Finally, we roughly estimated the effect of omitting pancreatitis from our Lancet study, which resulted in less than a 0·1% increase in the total alcohol-attributable global burden of disease and injury. Similarly, estimates based on the findings of Zaridze and colleagues4 showed that about 1% of all alcohol-attributable mortality in Russia is due to pancreatitis. More detailed numbers based on fewer assumptions will be available in 2010. We declare that we have no conflicts of interest.
*Jürgen Rehm, Colin Mathers
[email protected] *Public Health and Regulatory Policies, Centre for Addiction and Mental Health, Toronto, ON M5S 2S1, Canada (JR); Dalla Lana School of Public Health, University of Toronto, ON, Canada (JR); Epidemiological Research Unit, Klinische Psychologie & Psychotherapie, Technische Universität Dresden, Dresden, Germany (JR); and WHO, Geneva, Switzerland (CM) 1 2
3
4
WHO. The global burden of disease: 2004 update. Geneva: World Health Organization, 2008. Irving HM, Samokhvalov A, Rehm J. Alcohol as a risk factor for pancreatitis: a systematic review and meta-analysis. J Pancreas 2009; 10: 387–92. Rehm J, Room R, Graham K, Monteiro M, Gmel G, Sempos C. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease—an overview. Addiction 2003; 98: 1209–28. Zaridze D, Brennan P, Boreham J, et al. Alcohol and cause-specific mortality in Russia: a retrospective case-control study of 48 557 adult deaths. Lancet 2009; 373: 2201–14.
Reducing harm from alcohol: what about unrecorded products? Your Editorial (June 27, p 2171)1 accompanying The Lancet Series on alcohol and global health2–4 correctly points out that a major part of global alcohol consumption is unrecorded. Global strategies to reduce harm from alcohol must therefore consider this important part of alcohol consumption. However, the strategies mentioned sound rather naive.
The demand for “stronger enforcement of legal sales—eg, tax stamps on legal products”5 does not seem to be an effective measure, considering that home production of alcohol (eg, samogon in Russia or local brews in Asia or Africa) constitutes a major part of unrecorded consumption. The implementation of policies on unrecorded consumption, therefore, not only means confrontation with organised criminals and corrupt officials1 but also reaching out to every alcoholproducing household—a very complex issue. Alcohol policy should consider the balance between recorded and unrecorded consumption, since the possibility that certain policy measures might lead to the substitution of recorded with unrecorded alcohol, which could be good for the statistics but not for public health, cannot be excluded. Alcohol research must not only gather better knowledge on exposure (rather than estimation2), including the different subgroups of unrecorded alcohol, but also information on chemical composition. Finally it seems that research and policy alike have treated unrecorded alcohol a bit like a “rotten apple” in the past, perhaps from fear of “supporting” the alcohol industry. Hopefully this will change in the future, since it is clear that the holistic view of global alcohol-related problems must include the unrecorded market. I declare that I have no conflicts of interest.
Dirk W Lachenmeier
[email protected] Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe, 76187 Karlsruhe, Germany 1 2
3
4
5
The Lancet. Alcohol and harm reduction in Russia. Lancet 2009; 373: 2171. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009; 373: 2223–33. Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009; 373: 2234–46. Casswell S, Thamarangsi T. Reducing harm from alcohol: call to action. Lancet 2009; 373: 2247–57. Beaglehole R, Bonita R. Alcohol: a global health priority. Lancet 2009; 373: 2173–74.
977
