REVISTA PAN AMERICAN PANAMERICANA JOURNAL OF DE SALUD PÚBLICA PUBLIC HEALTH Supplementary material to: Shield KD, Monteiro M, Roerecke M, Smith B, Rehm J. Alcohol consumption and burden of disease in the Americas in 2012: implications for alcohol policy. Rev Panam Salud Publica. 2015;38(6):442-9. This material formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Material suplementario / Supplementary material / Material supplementar
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REVISTA PAN AMERICANPANAMERICANA JOURNAL OFDE SALUD PÚBLICA PUBLIC HEAL TH
Supplementary material to: Shield KD, Monteiro M, Roerecke M, Smith B,Rehm J. Alcohol consumption and burden ofdisease in the Americas in 2012: implications foralcohol policy. Rev Panam Salud Publica.2015;38(6):442-9.
This material formed part of the original submission and has been peer reviewed.We post it as supplied by the authors.
Material suplement ario / Supplement ary material / Material supplement ar
Web Appendix. Inf ormation on alcohol consumption data, and methods used to calculate the
Methods
Alcohol exposure estimates
Total, recorded, unrecorded and tourist adult per capita consumption (in litres of pure alcohol)
were obtained by country from 1961 to 2012 (beverage specific data on recorded alcohol
consumption was available from 1961 to 2010). Recorded consumption is alcohol that is tracked
by governments through production, sales and taxation statistics, market research firms serving
the alcoholic beverage industry, and the United Nations Food and Agriculture Organization.
Unrecorded consumption is alcohol that is not tracked through the statistics of recorded
consumption, and can originate from a variety of sources, including, for example, surrogate
alcohol (alcohol not officially intended for consumption) (see (1) for the sources of unrecorded
alcohol consumption). Data for unrecorded alcohol consumption are usually obtained from a
variety of sources, including government-monitoring data, surveys and expert judgments (2).
Tourist per capita consumption of alcohol represents both cross-border trade and the amount of
alcohol consumed by foreign tourists (accounting for the amount of alcohol consumed by the
countries’ inhabitants when they travel outside their own country). Data on tourist consumption is
estimated using tourist visa data and data from special sales taxes or measures of alcoholic
beverages sold to tourists (if implemented in a country).
Prevalence of both current abstainers (made up of both lifetime abstainers (people who have
never consumed a standard drink of alcohol) and former drinkers (people who have consumed a
standard drink of alcohol but have not done so in the past year) and of current drinkers (those who
have consumed alcohol in the past year) were obtained by triangulating survey data with data
obtained from a regression analysis of all published survey data found through a systematic
review (3).
SUPPLEMENTARY MATERIAL Shield et al. • Alcohol consumption and burden of disease in the Americas
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alcohol - population- attributable f ractions
The pattern of alcohol consumption was measured through the prevalence of heavy episodic
drinking and the pattern of drinking (POD) scores. The POD scores capture six different aspects
of drinking: (i) the usual quantity of alcohol consumed per drinking occasion; (ii) the prevalence
and frequency of festive drinking; (iii) the proportion of drinking events when drinkers become
intoxicated; (iv) the proportion of drinkers who drink daily or nearly every day; (v) the frequency
of drinking with meals and outside of meals; and (vi) the prevalence of drinking in public places.
Data on these variables were collected through a key informant survey, with the POD scores
being validated from previous pattern of drinking scores measured at the global level (3).
Specifically, the data from the key informant survey are aggregated and scaled from 1 to 5 (1
representing the least risky drinking pattern and 5 representing the most risky drinking pattern)
and missing information is then imputed by expert opinion.
Alcohol consumption among current drinkers was modelled by triangulating total adult per capita
consumption data with survey data to correct for the inconsistent and severe undercoverage of
population alcohol consumption when measured by population alcohol surveys (as compared to a
more accurate source of adult per capita consumption data). The distribution of alcohol
consumption was modelled using a Gamma distribution, which Rehm and colleagues and Kehoe
and colleagues found best describes the population distribution of alcohol consumption (4, 5). To
describe the distribution of alcohol consumption by age and sex, the relative alcohol consumption
amounts by age and sex (as obtained from population surveys (3)) were combined with
population data and per capita consumption of alcohol data to estimate the mean alcohol
consumption by age and sex. The standard deviation of the alcohol consumption distribution was
modelled according to Rehm and colleagues, who observed that the standard deviation of a
population alcohol consumption distribution could be predicted using the mean of the alcohol
consumption distribution (4).
Shield et al. • Alcohol consumption and burden of disease in the Americas SUPPLEMENTARY MATERIAL
38(6), 2015Rev Panam Salud Publica 3
Alcohol-attributable burden calculations for 2012
For diseases and injuries where alcohol is a component cause (i.e. alcohol increases the risk for
the disease or injury, but is not a necessary cause), the alcohol population-attributable fraction
(PAF) combines information on the prevalence of current drinkers, former drinkers and lifetime
abstainers, the distribution of alcohol consumption among current drinkers, and the relative risk
(RR) for a disease for current drinkers and former drinkers as compared to lifetime abstainers. For
most diseases casually related to alcohol, the alcohol PAF is estimated using the formula:
In the above formulae, Pdayatrisk represents the proportion of a day at risk, and RRinjury is the
relative risk for injury given an amount of alcohol consumed (xbinge alcohol consumption during
heavy episodic drinking occasions and xaverage-non-binge alcohol consumption during average non-
heavy episodic drinking days). Pdayatrisk is calculated based on the average rate at which alcohol is
metabolized, thereby corresponding to the time during which the blood alcohol level is
sufficiently elevated to increase the risk of injury. Pbinge_days and Pnon-binge_days represent the
proportion of heavy episodic drinking days and non-binge drinking days among binge drinkers
respectively.
The above-presented alcohol PAFs were determined based on injury RR estimates that were
calculated using samples of emergency room patients. In the case of injury mortality alcohol
PAFs, the alcohol PAF for morbidity from non-motor vehicle accidents was multiplied by 9/4 and
the alcohol PAF for morbidity from motor vehicle accidents was multiplied by 3/2. These
multiplication factors were based on two studies that compared blood alcohol levels of
emergency room patients with blood alcohol levels obtained from coroners’ reports of patients
who died from an injury (34, 35).
Shield et al. • Alcohol consumption and burden of disease in the Americas SUPPLEMENTARY MATERIAL
9Rev Panam Salud Publica 38(6), 2015
For women, the alcohol PAF for motor vehicle accidents was calculated by multiplying the
alcohol PAF for motor vehicle accidents for men by the product of the per capita consumption of
alcohol for women divided by the per capita consumption of alcohol for men. This imputation
method was performed since the RR function for motor vehicle accidents is considered valid for
men only (36).
Regions
Table A2. World Health Organization (WHO) sub-regional classification of countries in the Americas according to childhood and adult mortality WHO sub-region* Countries A (Very low childhood and very low adult mortality rates) Canada, Cuba, United States of America
B (Low childhood and low adult mortality rates)
Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Brazil, Chile, Colombia, Costa Rica, Dominica, Dominican Republic, El Salvador, Grenada, Guyana, Honduras, Jamaica, Mexico, Panama, Paraguay, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Uruguay, Venezuela (Bolivarian Republic of)
D (High childhood and high adult mortality)
Bolivia (Plurinational State of), Ecuador Guatemala, Haiti, Nicaragua, Peru
* Regional subgroups defined by the World Health Organization (37) based on the rates of childhood and adult mortality
SUPPLEMENTARY MATERIAL Shield et al. • Alcohol consumption and burden of disease in the Americas
Rev Panam Salud Publica 38(6), 2015 10
Results
Figure A1. Recorded adult per capita consumption of alcohol (litres of pure alcohol) in the Americas for sub-regions A, B, and D from 1961 to 2010
Figure A2. Alcohol-attributable DALYs lost per 1,000 people for (A) women and (B) men in the Americas in 2012
Shield et al. • Alcohol consumption and burden of disease in the Americas SUPPLEMENTARY MATERIAL
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