Deaths from alcohol-related liver diseases have been rising for years — and at an accelerated rate for groups including women, young adults, and Indigenous people. New data suggest a surge in deaths in the early months of the pandemic has continued in subsequent years.
The study presents a discouraging picture of the nation’s liver health. Between 2018 and 2022, the most recent year for which mortality data are available, the annual percentage change in alcohol-associated liver disease deaths was nearly 9%, compared to 3.5% between 2006 and 2018.
Men still made up the bulk of these deaths, with 17 deaths per 100,000 people. But women’s death rates sped up, jumping up to 8 deaths from 3 per 100,000 people in the time period studied. On average, the annual percent change in women’s mortality was 4.3% — nearly twice that of men. Researchers also highlight a worsening trend of sudden and dangerous liver inflammation appearing in young people.
While alcohol-associated liver disease (ALD) mortality was relatively stable from 1999 to 2006, it’s been on the rise since then, and has worsened especially since 2018, according to findings published Wednesday in JAMA Network Open. Experts know the pandemic had something to do with that change, since studies suggest people drank more during the Covid era. But new data, and the continuing influx of younger patients with severe illness, further troubles liver doctors and public health researchers.
“It puts numbers to what we’re seeing in the hospital, in the clinic,” said Brian Lee, a hepatologist and liver transplant specialist at Keck Medicine of USC who was not involved with the study.
Some hypothesize that underlying metabolic liver disease is more common due to elevated rates of obesity, hypertension, or other conditions. “That itself can cause liver injury and liver damage. And when you add alcohol on top of that, there is some degree of synergy,” said Robert Wong, the study’s senior author and a clinical associate professor in the gastroenterology and hepatology division at Stanford University School of Medicine.
There is also the matter of gender. Women, specifically cisgender women, have a different biological build that makes it more difficult to metabolize alcohol, and so even relatively small amounts of alcohol tend to have a bigger impact on their bodies as compared to cis men. This is part of the justification for differentiated federal drinking guidelines: They advise women who use alcohol to have at most one drink per day, while men may have up to two per day and still be considered “moderate” drinkers.
“You’d be surprised by how shocked people are when they hear that drinking more than two drinks per day, for example, is considered heavy drinking by federal definitions,” Lee said.
Researchers tracked mortality trends using U.S. death certificates that had alcohol-associated hepatitis or alcohol-associated cirrhosis listed as the underlying cause of death.
The severe form of liver scarring known as cirrhosis was a key driver of ALD deaths. Cirrhosis mortality rates more than doubled between 1999 and 2022, up to 9.5 deaths per 100,000 people. In women, cirrhosis deaths more than tripled, up to almost 6 deaths per 100,000 (men’s were still higher, at 13.3 deaths per 100,000 people).
Some data suggest drinking rates that peaked in 2020 have subsided as the national conversation about alcohol use has picked up. It’s still to be seen if that shift results in lower rates of disease and death — in the near term, but also in years to come.
“Alcohol-related cirrhosis takes time to develop. So we may not see the true extent of the consequences until five, probably 10, years from now, which is very concerning,” said Wong.
Liver disease is perhaps the most well-known complication from heavy drinking. But alcohol use has been linked to dozens of other diseases, including at least a half-dozen types of cancer. This week, the American Medical Association came out publicly in support of awareness campaigns about how alcohol increases the risk of breast cancer in women. The group also threw its support behind other measures, such as adding clearer, front-of-package labeling to alcoholic beverages that tell consumers how many servings are in each container and warn of cancer risks.
The data researchers analyzed did not include information on how much people were drinking before their death, or how long they had used alcohol, whether they had an alcohol use disorder, or what kinds of disease complications they had, among other key points. Their analysis also did not include deaths in which alcohol was a contributing cause.
“It provides a conservative estimate,” said Marissa Esser, who led the alcohol program at the Centers for Disease Control and Prevention until the division was eliminated by federal cuts.
“If somebody has a primary cause of death of heart disease, but then they also had a contributing cause of alcohol-associated liver disease on their death certificate, those individuals wouldn’t be included in this,” said Esser, who was not involved in the study and spoke to STAT in her personal capacity, not on behalf of CDC or the government.
CDC data found that through 2021, more than 12,000 deaths per year from “unspecified liver cirrhosis” were caused by excessive alcohol use, though that wouldn’t be apparent in the death certificate or federal mortality data, Esser said.
The study also analyzed rates of death from alcohol-associated hepatitis (AH), a severe form of liver inflammation that occurs in some people who drink heavily. AH has a high mortality rate, but it is less common than other liver conditions and so appears as a small fraction of the problem across the population. Still, it is the fastest-growing indication for liver transplant, and ALD more broadly is the leading reason for liver transplant in the U.S.
Unlike cirrhosis, which can take years to arise, AH can occur suddenly. Clinicians are seeing younger patients without a long drinking history show up with the hallmark symptoms: tiredness, jaundice, and liver pain.
People between the ages of 25 and 44 had the highest average annual percent change in AH mortality between 1999 and 2022, according to the study. The sharpest increase occurred from 2007 to 2022, when mortality rates from AH changed at 8.4% annually on average.
The rise in ALD mortality didn’t affect all groups evenly: Women’s mortality rates increased more rapidly in that time than men’s, and American Indian or Alaska Native adults had the highest increase in AH mortality and the highest death rates from alcohol-associated cirrhosis among the racial and ethnic groups studied.
Indigenous death rates from hepatitis more than doubled from 2010 to 2022, up to 3.4 deaths per 100,000 people — the highest of all groups. Cirrhosis deaths skyrocketed to 33 deaths per 100,000 people by 2022 (an annual percent change of 18%, compared to half that in white people, and a third that rate in Hispanic and Black Americans). Indigenous communities have long struggled with alcohol-related disease, an issue that worsened during the pandemic.
“The gap and the disparities even became larger, and they still remain,” said Nasim Maleki, an assistant professor of psychiatry at Harvard Medical School who was not involved with the study. “The pandemic itself came under control, but the disparities that came with it continued and lingered.”
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