Based on CDC's Behavioral Risk Factor Surveillance System, Wisconsin is among the leading states nationally in estimates of alcohol-related risk factors: in 1988, 25.3% of the adult population reported binge drinking (consuming five or more drinks on one occasion during the last month), 8.6% reported heavier drinking (consuming greater than or equal to 60 drinks per month), and 6.2% reported drinking and driving (driving after having "too much to drink" at least once in the last month). Alcohol sales data for 1984 indicate that Wisconsin ranked sixth among all states in per capita sales of ethanol (3.2 gallons of ethanol sold per Wisconsin resident aged greater than or equal to 14 years). To characterize the public health impact of alcohol use and misuse in Wisconsin, the Wisconsin Department of Health and Social Services used 1988 mortality data and population estimates and a structured data-base approach to estimate alcohol-related mortality (ARM),* years of potential life lost (YPLL),** and economic costs (1,2).

In 1988, a total of 1949 alcohol-related deaths occurred in Wisconsin, accounting for 4.5% of all deaths (Table 1). Intentional (suicide and homicide) and unintentional injuries accounted for 857 (44%) of these. The contribution of injury deaths to ARM varied inversely with age: injuries accounted for 97% of ARM among persons aged less than 35 years, 38% among persons aged 35-64 years, and 24% among persons aged greater than or equal to 65 years (Figure 1, page 185). ARM due to digestive diseases and mental disorders was more prevalent in the 35-64-year age group; ARM from neoplasms and cardiovascular diseases in persons aged greater than or equal to 65 years was substantial. The absolute number of alcohol-associated deaths increased with age. In contrast, ARM as a proportion of total mortality peaked at ages 15-24 years and declined with age thereafter (Figure 2, page 185).

Males accounted for nearly twice as many alcohol-associated deaths as females (1263, compared with 686); the greatest differential (3:1) occurred in the less than 35-year age group. Sixty-one percent (417/686) of alcohol-related deaths in females occurred in the greater than or equal to 65-year age group, compared with 41% (521/1263) in males. Of the 857 alcohol-related deaths due to injury, 604 (70%) occurred in males, 311 (51%) of whom were less than 35 years of age. For males less than 35 years of age, 159 deaths (50% of ARM in this group) were from motor-vehicle injuries.

The 1949 deaths related to alcohol use and misuse accounted for an estimated 46,052 YPLL to full life expectancy (23.6 YPLL per death). Injuries accounted for 30,023 (65%) YPLL; 14,458 of these YPLL were due to motor-vehicle injuries. Males less than 35 years of age accounted for 16,011 YPLL, more than one third the total.

Alcohol-related economic costs were prorated from national figures (national per capita alcohol-related costs multiplied by Wisconsin population), except for indirect mortality costs, which were calculated using expected lifetime earnings and Wisconsin mortality data (1). In 1988, alcohol-related economic costs in Wisconsin were estimated to be $1.47 billion (Table 2, page 186). Direct costs (i.e., those for which actual expenditures are made) were estimated at $344 million. Direct health-care costs for the detection, treatment, and rehabilitation of alcohol-related diseases and injuries were $152 million, of which $65 million (43%) represented short-stay hospital costs. Direct costs of fetal alcohol syndrome (FAS) were estimated at $34 million; 80% of these costs were for residential care and support services for mentally retarded adults greater than 21 years of age whose impairment was considered to be caused by FAS. Indirect costs (i.e., potential goods and services not produced because of lost or diminished productivity) were estimated at $1.13 billion. In 1988, the alcohol-related economic cost per resident in Wisconsin was $305. Reported by: NA Akgulian, ME Moss, DDS, PL Remington, MD, HA Anderson, MD, Div of Health, Wisconsin Dept of Health and Social Svcs. JM Shultz, PhD, Dept of Epidemiology and Public Health, Univ of Miami School of Medicine, Miami, Florida. Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The structured data-base analysis described in this report (1) can be used by state health departments to estimate the magnitude of the health and economic impact of alcohol use and misuse across many disease categories. Previous experience has shown that analyses that attribute costs and disease outcomes to specific risk factors can be used to support public-health interventions (3). This analysis determined that in Wisconsin in 1988, alcohol use and misuse was responsible for 4.5% of all deaths, an estimated 46,052 YPLL, and approximately $1.47 billion of direct and indirect costs. A substantial proportion of the health and economic impact was related to alcohol-attributable injuries among persons in younger age groups.

Although this assessment of alcohol-attributable disease and injury impact is based on the most current cost-of-illness methodologies, at least four restrictions apply to the interpretation of the results. First, the lack of well-established relative risks for alcohol use and misuse by age, sex, and drinking pattern limit the precision of the alcohol-attributable fractions (AAFs). All calculations of ARM, YPLL, and mortality-related economic costs depend on these AAFs. Second, indirect costs were calculated by a methodology (4) in which the value of human life is estimated to be the lifetime earnings of a person, with future earnings discounted to present value (a 4% discounting rate was used in this study). Although this method is commonly used to place a dollar value on human life, it may underestimate the relative economic value of women and minorities (4). Third, for costs other than those due to mortality, national estimates are prorated to the state's population. Although proration is necessary because state-level data are not available, this method is insensitive to possible differences between the state and the nation in patterns of alcohol use and associated costs. Finally, the psychosocial effects of alcohol use and misuse (e.g., pain and suffering) are difficult to convert into economic terms and were not included in this analysis.

Despite these limitations, this analysis illustrates the magnitude of the health and economic costs of alcohol use and misuse across many disease and injury categories and may provide a framework for public health initiatives to reduce alcohol-related morbidity and mortality.

Revenues from excise taxes on alcohol are lower than the economic costs associated with alcohol use and misuse (5). Increasing state alcohol tax rates represents one potential approach for reducing alcohol consumption while simultaneously generating revenue to offset the costs associated with alcohol use and misuse. These funds could be used to support mass media campaigns, school-based health education programs, and alcohol treatment programs to reduce the burden of alcohol-related morbidity and mortality.

This report also demonstrates that injuries--particularly those caused by motor vehicle crashes--were a substantial cause of alcohol-related premature mortality in Wisconsin. State-based options for reducing the public health impact of drinking and driving include raising the minimum drinking age, lowering legal blood-alcohol concentration limits, increasing the enforcement of "drunk driving" laws, and enacting mandatory motor vehicle safety-restraint laws.

References

1. Shultz JM, Parker DL, Rice DP. ARDI: Alcohol-Related Disease Impact software. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1989.

2. CDC. Alcohol-related mortality and years of potential life lost--United States, 1987. MMWR 1990;39:173-8.

3. CDC. Smoking-attributable mortality, morbidity, and economic costs--California, 1985. MMWR 1989;38:272-5.

4. Hodgson TA. State of the art of cost-of-illness estimates. Adv Health Econ Health Serv Res 1983;4:129-64.

5. Manning WC, Keeler EB, Newhouse JP, Sloss EM, Wasserman J. The taxes of sin: do smokers and drinkers pay their way? JAMA 1989;261:1604-9. *ARM was calculated by multiplying the number of deaths by the fraction determined to be alcohol-related for each International Classification of Diseases, Ninth Revision, Clinical Modification, rubric.

**YPLL were calculated by adding YPLL (age-adjusted life expectancy minus age at death) for each of the alcohol-related deaths.

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