A 25-year national analysis shows how alcohol misuse fueled record-high fatalities during COVID-19, with women and Native communities hit hardest.
Study: Alcohol-induced deaths in the United States across age, race, gender, geography, and the COVID-19 pandemic. Image credit: Axel Bueckert/Shutterstock.com
Alcohol-induced deaths have sharply increased in the United States between 1999 and 2024, peaking in 2021 during the COVID-19 pandemic. A recent study in PLOS Global Public Health investigated alcohol-induced deaths in the US by race, gender, age, and geography on a yearly and monthly basis.
Alcohol misuse and its health impact
Alcohol use disorder (AUD) is a medical condition that affects both genders, characterized by the inability to stop or control alcohol use despite adverse psychological or physical consequences. An individual with AUD generally drinks more alcohol for a longer duration than intended.
Typically, clinicians categorize AUD as mild to severe. Alcohol misuse may lead to alcoholic hepatitis, cirrhosis, strokes, and heart failure, which could be fatal. Furthermore, high blood alcohol levels could cause respiratory failure. Previous studies have also indicated that, in some cases, alcohol consumption increases suicidal impulses and increases the risk for fatal accidents. An abrupt cessation of heavy drinking may trigger alcohol withdrawal syndrome, which could be lethal.
In the US, alcohol-related mortality has increased in the last two decades. Possible reasons include pandemic-related isolation, stressors, disruption to treatment programs, and difficulties accessing emergency facilities.
Not many studies have assessed alcohol-related mortality with respect to age, gender, geographical, and racial breakdown of fatalities, which is crucial to formulate effective interventions and allocate resources as per requirement across different population subgroups. It is also essential to understand whether alcohol-induced deaths have returned to their pre-pandemic levels.
About the study
The current study conducted an in-depth analysis of alcohol-attributable deaths in the US between 1999 and 2024, particularly during the post-COVID-19 era. Mortality data were obtained from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) was used to identify alcohol-related deaths.
The primary codes associated with alcohol induced mortality were F10 (mental and behavioral disorders from alcohol misuse), K70 (alcoholic liver disease, ALD), and four codes, R78, X45, X65, and Y15 for alcohol poisoning, as well as additional alcohol-related codes including E24.4, G31.2, G62.1, G72.1, I42.6, K29.2, K85.2, and K86.
In addition to mortality data, the CDC WONDER database also provided racial data, including White, Black, American Indian and Alaska Native (AIAN), Asian, Pacific Islander (API), Native Hawaiian, or other Pacific Islander (NHPI), and Mixed race. Because of changes in CDC racial categorization, race-stratified yearly data are comparable only through 2020, while monthly stratifications are available from 2018 onward.
For trend analysis, Bayesian regressions were conducted to assess monthly crude rates between January 2018 and December 2024, although the authors emphasize that 2024 data are provisional and may be updated.
Study findings
Overall, the crude rates for alcohol-induced deaths of all ages increased by 89% between 1999 and 2024. Annual fatality surged in 2021 with 54,258 deaths. The crude rates were higher among males, compared to females, for all ages and races. Males, particularly belonging to the age group of 55 and above, had the highest mortality rates. The male crude rates were roughly stable until 2019 for younger cohorts; they gradually increased around 2010 for older groups, particularly those aged 55–64, and to a lesser degree in those aged 65–74.
Although no definite correlation was observed between specific female age and crude rates, the crude rate for females is also highest between the ages of 55 and 64 and above, starting from the mid-2010s.
Based on race, for both genders, the highest crude rates occur in the AIAN population. In 1999, 34.4 fatalities occurred per 100,000 AIAN males compared to 12.5 fatalities per 100,000 Black males. These numbers increased to 80.8 fatalities per 100,000 AIAN males compared to 25 fatalities per 100,000 White males. Similarly, crude rates of AIAN females were more than four times higher than those of other races in 1999 and more than five times higher in 2020.
Although the overall number of female deaths was lower than that of males for all ages and races, crude rates among females increased at a much higher rate than those of males. In both genders, the highest increases in mortality since 1999 occurred among those aged 25–34. For example, crude rates in this group rose by 291% among males and 381% among females between 1999 and 2021, before declining slightly by 2024.
The mortality rate peaked in 2021 and decreased to 6.5 fatalities per 100,000 in 2024. The male-to-female crude ratio decreased steadily across most age groups and racial categories. This finding highlighted that alcohol-induced mortality is becoming an increasingly significant problem among females. Younger age groups indicated a lower male-to-female ratio, with the gender gap decreasing over time.
For all demographic groups, alcohol-induced deaths were 39,043 in 2019, which increased to 54,258 in 2021. In 2024, there was a 13% increase in alcohol-induced deaths compared to 2019. This finding implies mortality increased significantly during the COVID-19 pandemic, which started to decrease in 2024.
ALD was found to be the leading cause of death, followed by mental and behavioral disorders due to alcohol use, particularly for younger cohorts. Notably, ALD crude rates for cohorts younger than 65 remain above their pre-pandemic values throughout 2024. The study also identified sharp month-to-month increases in spring 2020: AIAN males (+41% between May and June 2020), AIAN and Black females (+32%), males aged 15–34 (+28%), and females aged 35–44 (+28%). These abrupt spikes coincided with the onset of the COVID-19 pandemic.
Although all US states experienced increased crude rates in the 26 years under investigation, the largest increase was in Mississippi (+122%), followed by South Dakota and Alaska. Among all counties, the ones most impacted by alcohol-induced mortality were Oglala Lakota County, McKinley County, Apache County, Rio Arriba County, and Navajo County. Oglala Lakota, McKinley, and Apache Counties reported crude rates exceeding 80 deaths per 100,000 annually since 2020.
Conclusions
The current study highlighted an increase in yearly crude rates for alcohol-related fatalities between 1999 and 2024, with an abrupt rise during the COVID-19 pandemic, across all demographics. Among all races, AIAN males were the most affected group. The authors emphasize that while rates began declining by 2023–2024, they remain above pre-pandemic levels in about half of U.S. states.
In the future, more research is required to understand the impact of COVID-19-related social isolation and disruptions in AUD treatment on the spikes in alcohol-induced mortality. The study also calls for urgent, targeted prevention and treatment policies, particularly for females, youth, and AIAN populations.
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