Drinking to death: the changing face of liver disease

Abstract

According to a recent study, annual deaths from liver cirrhosis in the USA increased by 65% between 1999 and 2016, with deaths from hepatocellular carcinoma doubling during the same period. The investigators note an inflection point in 2009, particularly in people aged 25–34 years, who saw an average annual increase in cirrhosis-related mortality of 10·5% between 2009 and 2016. Strikingly, this rise was driven entirely by alcohol-related liver disease (ARLD). ARLD is typically thought to progress over many years, so the emergence of advanced liver disease in adults in their 20s and 30s is particularly alarming, and implies a drastic change in the ways that people consume alcohol. The authors of the US study hypothesise that the 2008 economic crisis and subsequent rise in unemployment might be behind the change. However, others have blamed changes in drinking patterns, including regular binge drinking, combined with the increased popularity of drinks with a high alcohol content, such as craft beer and cocktails. Also unclear is whether altered genetics or the rise in obesity and NAFLD could be compounding the problem, accelerating the progression of liver disease at an unprecedented rate. At the other end of the spectrum, low and moderate alcohol use—long posited to confer health benefits—is increasingly associated with increased mortality. On Aug 23, The GBD Alcohol Collaborators reported that, globally, alcohol use led to 2·8 million deaths in 2016 and was the leading risk factor for premature death and disability among people aged 15–49 years. The GBD report echoes earlier advice that there is no beneficial—or even safe—level of alcohol consumption. Alcohol is emerging as a public health problem comparable to that of smoking in previous generations. And, like smoking, attitudes towards alcohol will not change without policy change. Increased taxation and controlling the physical availability and advertising of alcohol products would likely have protective effects. Data from Scotland, where minimum unit pricing was introduced in May, are eagerly awaited. Beyond this, guidelines should be updated to reflect current evidence. With the reasons behind this silent epidemic still unclear, research is needed to define the aetiology and natural history of ARLD in young adults, to reverse these trends for future generations. Minimum alcohol pricing in ScotlandOn Oct 15, 2017, the UK's Supreme Court rejected an appeal by the Scotch Whisky Association against the Alcohol Minimum Pricing Act, which had been approved by Scottish Members of Parliament in 2012. This landmark ruling brings an end to years of appeals and legal challenges against the Act, and paves the way for Scotland to become the first country in the world to introduce a minimum price on alcohol. Full-Text PDF